An Integrative Review of Factors Associated With Resilience Post-Spinal Cord Injury

Resilience in SCI

Resilience is a psychological construct within the positive psychology research paradigm that emphasizes the strengths or positive characteristics of a person (Seligman & Csikszentmihalyi, 2000). Resilience is defined as the personal ability to cope with adversity (Connor & Davidson, 2003), or the process of adapting well while confronting adversities or stressful events (American Psychological Association, 2010). Richardson (2002) states that a person’s reaction to a stressful event is determined by his or her level of resilience. Following an event, the person may undergo four different paths as follows: (a) resilient integration characterized by finding new interests and meaning in life; (b) reintegration to homeostasis (balance in life; c) reintegration with loss (e.g., unemployment or social isolation); or (d) dysfunctional reintegration characterized by depression or low quality of life. A longitudinal study found that 68% and 66% of participants with SCI reported high resilience at discharge and after 6 months of living in the community, respectively. Other participants demonstrated low resilience, which is likely to interfere with successful integration into the community (Guest, Craig, Tran, & Middleton, 2015).

The current literature suggests that higher resilience among persons with SCI is associated with adaptive adjustment, effective coping, and better quality of life (Bonanno et al., 2012; Tansey et al., 2017). Resilience appears to mitigate the negative effects of pain on adaptation outcomes and to buffer the occurrence of depressive symptoms among persons with SCI (Bonanno et al., 2012; Min et al., 2014). On the contrary, low resilience is likely to result in poor adjustment, behavioral disengagement, and psychological distress, including depression (Bonanno et al., 2012; Kilic et al., 2013). A resilient individual possesses a strong sense of self-efficacy, perceived social support, and stable mood which can help them to adapt successfully despite the disability-related consequences of SCI (Guest, Craig, Tran, & Middleton, 2015; Kilic et al., 2013). Resilience has a vital role in achieving adjustment following SCI (Kornhaber et al., 2017). Overall, the current evidence suggests that persons with SCI who have greater resilience overcome adversity more successfully than those who have lower resilience (Guest, Craig, Tran, & Middleton, 2015; Tansey et al., 2017; White et al., 2010).

Research on Factors Associated With Resilience in SCI

The literature shows that resilience in people with SCI is influenced by multiple psychosocial, demographics, and injury-related variables (Bhattarai et al., 2018; Bonanno et al., 2012; Guest, Craig, Tran, & Middleton, 2015; Kilic et al., 2013). Kumpfer (1999) stresses that resilience results from the interaction of personal, environmental, and situational factors. Richardson (2002) pointed out that a person can be moved from dysfunctional reintegration to resilient integration with appropriate interventions. Consideration of factors related to resilience is essential while planning or designing interventions in rehabilitation settings. To date, a few systematic reviews have been conducted which examine personal psychological factors that influence the quality of life and adjustment in persons with SCI (e.g., Peter et al., 2012; van Leeuwen et al., 2012). Several outcomes have been analyzed in terms of adjustment to SCI, such as quality of life, life satisfaction, well-being, physical health, mental health, activity and participation, anxiety, depression, post-traumatic stress, and emotional distress (Peter et al., 2012; van Leeuwen et al., 2012). However, none have investigated resilience as an outcome.

Although resilience has not yet been systematically reviewed as a measurement outcome in persons with SCI, a systematic review was conducted to explore factors related to resilience among people with chronic physical illnesses (Stewart & Yuen, 2011). The review included 52 studies that were carried out among people with cardiovascular diseases, stroke, HIV/AIDS, diabetes, cancers, rheumatoid arthritis, hip fracture, and multiple sclerosis. The outcomes in the review were resilience and related constructs such as hardiness, benefit-finding, positive adaptation, and positive behavior. Psychosocial factors including self-efficacy, self-esteem, internal locus of control, optimism, mastery, hope, self-empowerment, social support, spirituality, and active coping were found to be associated with resilience (Stewart & Yuen, 2011). SCI is a chronic disability that can have a substantial impact similar to some other chronic illnesses such as dementia, multiple sclerosis, cerebral palsy, and diabetes (WHO, 2013), and as such factors of resilience are important to explore in SCI as well.

The understanding of factors contributing to resilience will help rehabilitation researchers and practitioners to develop effective rehabilitation programs to enhance resilience in persons with SCI. Improving overall well-being by utilizing one’s resources, including resilience, is one of the major goals of rehabilitation services. As rehabilitation counselors have a central role in the rehabilitation process of persons with SCI, their understanding of how they can support their clients in developing and strengthening resilience is fundamental. Although people with SCI may not recover from their physical condition (e.g., paralysis), assisting them to enhance resilience may enable those individuals to achieve optimum functioning.

Therefore, the present review was conducted to analyze the available evidence regarding demographic, injury-related, and psychosocial factors that are associated with resilience in persons who have sustained a SCI. The review question addressed in the present analysis is: What demographic, injury-related, and psychosocial factors are associated with resilience in persons with SCI? A summary of current findings on factors can provide a basis for a better understanding of how persons with SCI can effectively adjust to the negative consequences of SCI.

Method

An integrative review was undertaken, as this approach allows for the combination of diverse methodologies to provide a comprehensive understanding of a particular phenomenon (Whittemore & Knafl, 2005). The stages of the integrative review include problem identification, literature search, data evaluation, data analysis, and presentation/results (Whittemore & Knafl, 2005).

Results

The search strategy revealed a total of 291 studies (see Figure 1). After removing duplicates and irrelevant studies, a total of 11 studies were included for the final review. Of the 11, nine were quantitative studies and two were qualitative phenomenology studies.

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Figure 1.

Search process and search result.

Characteristics of the Selected Studies

All of the studies were conducted in developed countries, including Australia (Guest, Craig, Nicholson Perry, et al., 2015; Guest, Craig, Tran, & Middleton, 2015; Kilic et al., 2013), the United States (Dodd et al., 2015; Driver et al., 2015; Machida et al., 2013; Monden et al., 2014; White et al., 2010), Canada (Catalano et al., 2011), and South Korea (Min et al., 2014), with the exception of one study conducted among people with earthquake-related SCI in Nepal (Bhattarai et al., 2018). The studies were carried out in community settings, rehabilitation centers, or both. All quantitative studies used bivariate or multivariate statistical analyses. Sample sizes ranged from 12 to 28 in the qualitative studies and 37 to 255 in the quantitative studies. Of the nine quantitative studies, five were descriptive cross-sectional in design. All of the studies used convenience sampling techniques to recruit participants. The characteristics of these studies are presented in Table 1.

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Table 1.

Characteristics of the Selected Studies.

No.	Authors, country	Study design	Setting	Sample size	Male/female
1.	Bhattarai et al. (2018), Nepal	Cross-sectional	Rehabilitation unit and community	82	48/34
2.	Guest, Craig, Tran, and Middleton (2015), Australia	Longitudinal	Rehabilitation unit	88	62/26
3.	Driver et al. (2015), USA	Longitudinal	Rehabilitation unit and community	44	26/16
4.	Dodd et al. (2015), USA	Cross-sectional	Rehabilitation unit	106	68/38
5.	Guest, Craig, Nicholson Perry, et al. (2015), Australia	Quasi-experimental	Rehabilitation unit	88	62/26
6.	Min et al. (2014), Korea	Cross-sectional	Community	37	20/8
7.	Monden et al. (2014), USA	Qualitative, phenomenology	Rehabilitation unit and community	28	29/8
8.	Kilic et al. (2013), Australia	Cross-sectional	Community	60	41/19
9.	Machida et al. (2013), USA	Qualitative, phenomenology	Community	12	12/0
10.	Catalano et al. (2011), Canada	Cross-sectional	Community	225	173/52
11.	White et al. (2010), USA	Longitudinal	Rehabilitation unit	42	33/9

The nine quantitative studies analyzed for this review were homogeneous in terms of the measurement of resilience. All of these studies used the Connor-Davidson Resilience Scale (CD-RISC), either the 25-item original version (Bhattarai et al., 2018; Catalano et al., 2011; Guest, Craig, Nicholson Perry, et al., 2015; Guest, Craig, Tran, & Middleton, 2015; Min et al., 2014; White et al., 2010) or the 10-item short version (Dodd et al., 2015; Driver et al., 2015; Kilic et al., 2013). The instruments that were used to measure resilience and resilience factors identified in the selected studies are presented in Table 2. From the review of the 11 studies, a total of 26 independent variables were identified which can be considered as factors of resilience based on the resilience literature. Factors identified from the review were grouped into two primary categories: psychosocial factors and demographic and injury-related factors, as most of the reviewed studies categorized and investigated factors in terms of these two groups. The factors that showed significant associations with resilience are presented in Table 3.

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Table 2.

Measurement Instruments of Resilience and Factors in the Selected Studies.

Variable	Number of studies	Instrument used
Resilience	6	Connor-Davidson Resilience Scale-25
	3	Connor-Davidson Resilience Scale-10
Self-efficacy	4	Moorong Self-Efficacy Scale
	1	Chronic Disease/Disability Self-efficacy Scale
Social support	2	Social Support Questionnaire
	1	Social Provision Scale
	2	Multidimensional Scale of Perceived Social Support
Stress	1	Perceived Stress Questionnaire
	1	Depression, Anxiety, and Stress Scale-21
Anxiety	2	Hospital Anxiety and Depression Scale
	1	Experience in Close Relationship
	1	Depression, Anxiety, and Stress Scale-21
Depression	3	Depression, Anxiety, and Stress Scale-21
	5	Patient Health Questionnaire-9
	1	Center for Epidemiologic Studies Depression Scale
Spirituality	2	Intrinsic Spirituality Scale
Coping	1	Brief-COPE
Post-traumatic growth	1	Post-Traumatic Growth Inventory
Locus of control	1	Locus of Control of Behavior Scale
Satisfaction with life	1	Satisfaction With Life Scale
Avoidance	1	Experience in Close Relationship
Social and recreation activities limitation	1	Social Role/Activities Limitation Scale
Functional independence	3	Functional Independence Measure
Pain	1	SCI Pain Basic Data Set
	1	Numerical Rating Scale-11
	1	EuroQol Dimension Questionnaire
	1	Visual Analog Scale

Note. SCI = spinal cord injury.

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Table 3.

Factors and Their Associations With Resilience in Persons With Spinal Cord Injury.

Factor	Correlation (r) or regression (β)	Study reference
1. Psychosocial factors
Self-efficacy	r = .50** to .68**	Bhattarai et al. (2018), Driver et al. (2015), Guest, Craig, Nicholson Perry, et al. (2015), Guest, Craig, Tran, and Middleton (2015), Kilic et al. (2013)
Social support	r = .28** to .58** β = .15*	Bhattarai et al. (2018), Catalano et al. (2011), Driver et al. (2015), Guest, Craig, Nicholson Perry, et al. (2015), Guest, Craig, Tran, and Middleton (2015), Monden et al. (2014)
Spirituality	r = .35*	Monden et al. (2014), White et al. (2010)
Coping strategies	β = .43*	Catalano et al. (2011), Machida et al. (2013), Monden et al. (2014)
Post-traumatic growth	r = .59**	Min et al. (2014)
Satisfaction with life	r = .54*	White et al. (2010)
Being a role model	Qualitative	Machida et al. (2013), Monden et al. (2014)
Stress	r = –.43** to –.67**	Catalano et al. (2011), Kilic et al. (2013)
Anxiety	r = –.35** to –.55**	Dodd et al. (2015), Driver et al. (2015), Guest, Craig, Nicholson Perry, et al. (2015), Kilic et al. (2013)
Depression/depressed mood	r = –.27** to –.68** β = –.29**	Catalano et al. (2011), Dodd et al. (2015), Driver et al. (2015), Guest, Craig, Nicholson Perry, et al., (2015), Guest, Craig, Tran, and Middleton (2015), Kilic et al. (2013), Min et al. (2014), White et al. (2010)
External locus of control	r = –.52**	Kilic et al. (2013)
Attachment avoidance	r = –.35**	Dodd et al. (2015)
2. Demographic and injury-related factors
Age of participants	r = .33*	Driver et al. (2015)
Sex	r = .47*	Bhattarai et al. (2018)
Employment	r = .27**	Bhattarai et al. (2018), Min et al. (2014)
Current living location	r = .24*	Bhattarai et al. (2018)
Pain	r = –.26* to –.41* β = –.47*	Driver et al. (2015), Guest, Craig, Tran, and Middleton (2015), Min et al. (2014)
Functional independence	β = .22*

Note. *p < .05; **p < .01.

Discussion

The purpose of this review was to examine the existing evidence related to factors associated with resilience in persons with SCI. The empirical studies reviewed suggested that resilience is an attribute that can be enhanced or diminished. Those who have high resilience are generally more able to cope with the negative consequences of SCI and have a good quality of life (Driver et al., 2015; Kilic et al., 2013; Tansey et al., 2017). Numerous factors associated with resilience in persons with SCI were identified in this review. Most of these factors are consistent with factors that were previously explored in a systematic review of studies related to chronic physical illnesses (Stewart & Yuen, 2011). The present review revealed some consistent and inconsistent factors related to the resilience of people with SCI.

Self-efficacy and social support were found to be the most consistent factors associated with resilience. A sense of self-confidence to perform a particular behavior is likely to enhance resilience (Guest, Craig, Tran, & Middleton, 2015; Kilic et al., 2013). Similarly, perceived support from family, friends, or others helps an individual to change negative thoughts and seek resources to manage stress (Catalano et al., 2011; Guest, Craig, Tran, & Middleton, 2015). The incongruent findings related to spirituality in one study could be due to the different context in which the study was conducted. The study was conducted in a developing Asian country and included participants who faced dual traumatic events: earthquake and SCI. The authors argued that the traumatic events could lead to an alteration in participants’ spiritual beliefs and that the dynamic nature of spirituality is difficult to capture in a cross-sectional study (Bhattarai et al., 2018).

Depression or depressive symptoms were found to be associated with lower resilience among people with SCI in almost all of the reviewed studies (Bhattarai et al., 2018; Catalano et al., 2011; Dodd et al., 2015; Guest, Craig, Nicholson Perry, et al., 2015; Guest, Craig, Tran, & Middleton, 2015; Kilic et al., 2013; Min et al., 2014; White et al., 2010). Immediate and long-term consequences of SCI such as immobility, functional limitations, dependency, chronic pain, unemployment, and other medical complications could result in depression. Furthermore, depression is likely to reduce self-efficacy to manage daily life stressors and seek social support. Therefore, people with SCI who have depression or depressive symptoms are likely to experience lower resilience (Bhattarai et al., 2018).

There were inconclusive findings regarding the contribution of demographic and injury-related factors to resilience. Age of participants, gender, pain, and functional independence were inconsistent determinants of resilience. The discrepancies in the findings could be attributed to different reasons such as study setting, cultural differences, measures of constructs, characteristics of samples, sample size, and operational definitions of some variables. For example, Kilic et al. (2013) measured neuropathic pain using a 10-point scale, and Driver et al. (2015) measured overall pain (could be either neuropathic or musculoskeletal pain) using a 10-point scale. However, Min et al. (2014) used a 3-point scale to measure pain. In terms of characteristics of participants, some studies included only people with traumatic SCI (Driver et al., 2015), whereas others included people with traumatic as well as nontraumatic SCI (Kilic et al., 2013; Min et al., 2014). In a study conducted by Kilic et al. (2013), 98% of the participants were Caucasian, whereas other studies included different ethnic groups.

With regard to gender, the study conducted in Nepal, a developing Asian country, found that male participants were likely to have higher resilience scores than female participants. The authors argued that the cultural context of the country could have resulted in this discrepancy. In a patriarchal society, males, even those with a disability, are considered to be authority figures; whereas, females are considered to be subordinates. Males are also more likely to obtain higher levels of education and employment as compared with females. Consequently, males in these contexts may have higher self-esteem or confidence which could contribute to greater resilience. A study conducted in India also supported the finding that males with SCI were more resilient than their female counterparts (Ahum et al., 2016). Bhattarai et al. (2018) also found that the people living in rural areas with inaccessible health care, rehabilitation services, and transportation facilities reported lower resilience scores than those living in urban areas.

A number of design strengths and weaknesses were identified. All of the studies were similar in terms of the measurement outcome and measurement tool for resilience. Some of the studies included an adequate sample size (Catalano et al., 2011; Dodd et al., 2015; Monden et al., 2014) and longitudinal design (Driver et al., 2015; Guest, Craig, Tran, & Middleton, 2015; White et al., 2010). However, weaknesses such as small sample sizes (Driver et al., 2015; Min et al., 2014; White et al., 2010), lack of clear inclusion/exclusion criteria (Monden et al., 2014), and inclusion of only male participants (Machida et al., 2013) were noted in some studies. Furthermore, participants were recruited using convenience sampling techniques in all of the studies.

Conclusion

This review summarized and synthesized the factors that have been found to be associated with resilience among people with SCI. Many factors were identified. Some of those factors are modifiable; hence, rehabilitation counselors can design intervention strategies to promote the resilience of people with SCI. The review also revealed that resilience can be influenced by individuals’ cultural or social environments. Therefore, these factors need to be considered while developing interventions. Research on determinants of resilience is mostly limited to developed countries; future studies to explore this issue among persons with SCI in developing and/or Eastern countries are indicated. Overall, the current review serves as a guide for rehabilitation counselors to include factors contributing to resilience in clients’ rehabilitation plans. This will help to promote the effectiveness of rehabilitation services and effectively reintegrate the persons with SCI into their communities. Further intervention studies considering these factors are also needed.