please make me a summary for narrative literature review based on these data:1. Introduction

Spinal cord injury (SCI) is a severe condition that results in theimpairment of the spinal cord and associated nerves, causing various sensory,motor, and autonomic dysfunctions [1]. The causes of SCI are eithertraumatic like accidents, falls, or violence, or non-traumatic like infections,tumors, or degenerative diseases [1]. The World Health Organization(WHO) reports that SCI affects 13 to 33 million people globally every year, with250,000 to 500,000 new cases each year [2]. SCI profoundly influences anindividual’s physical, psychological, and social well-being as well as theirfamilies, healthcare systems, and society. The incidence of traumatic SCI inIran is estimated to be 9 per 100,000. The prevalence of SCI in Iran, accordingto PubMed research, is 318.45 per million [3]. 

SCI comorbidities often lead to long-term disabilities that requiremultiple treatments. The aim of this review is to analyze the morbidity in SCIpatients in Iran by summarizing and synthesizing existing data. Morbidityrefers to health conditions like diseases or disabilities that affect anindividual’s health status and quality of life [4]. There are two classifications of morbidityin SCI patients, the primary and secondary type. Primary morbidity results fromthe direct consequences of SCIs on the nervous system, including paralysis,neuropathic pain, bladder, and bowel dysfunctions. Whereas, secondary morbidityrefers to the indirect effects of SCIs on other body systems, like pressureulcers, infections, cardio vascular diseases, osteoporosis, and depression.Several factors affect morbidity in SCI patients, and they include the leveland completeness of injury, time since injury, patient’s age and gender,availability, and access to healthcare, and socio-cultural contexts [5].

This review aims to achieve four objectives, which includedescribing various morbidities’ prevalence, risk factors, correlation, andconsequences in SCI patients in Iran. Moreover, the review compares andcontrasts research findings conducted in Iran and other countries, identifiesstrengths and weaknesses of the current literature, and provides implications,recommendations for education, clinical practice, policy-making, and research.The inclusion and exclusion criteria are explained in the review’s methodsection, and we only reviewed up-to-date studies published in English orPersian from 2010 to 2023, primarily focusing on morbidity in SCI patients inIran. 

2. Methods

This narrative review followed a four-step process to select,extract, analyze and synthesize the relevant literature on morbidity in SCIpatients in Iran. The steps were as follows: 

We conducted a comprehensive literature search in four electronicdatabases: PubMed, Scopus, Science direct, Semantic scholar and SID (ScientificInformation Database). We used a combination of keywords and MeSH terms relatedto SCI (e.g., spinal cord injury, spinal cord trauma, paraplegia, tetraplegia)and morbidity (e.g., morbidity, complication, comorbidity, disability). We alsoused the term "Iran" to limit the search to studies conducted inIran. We applied the following inclusion criteria: (1) published in English orPersian; (2) published between 2000 and 2023; (3) focused on morbidity in SCIpatients in Iran; and (4) used a quantitative or qualitative design. Weexcluded studies that: (1) were not original research articles (e.g., reviews,editorials, letters); (2) did not report data on morbidity in SCI patients inIran. The literature search was performed in February 2023 and updated in May2023.

 

We screened the titles and abstracts of the retrieved records usingthe inclusion and exclusion criteria. We obtained the full texts of thepotentially eligible articles and assessed them for eligibility. We alsochecked the reference lists of the included articles for additional relevantstudies. We resolved any disagreements or uncertainties by discussion orconsultation with a third reviewer. We recorded the reasons for exclusion andreported the selection process using a PRISMA flow diagram.

We extracted the following data from each included article using astandardized data extraction form: (1) author(s); (2) year of publication; (3)title; (4) journal; (5) study design; (6) sample size; (7) mean age; (8) malepercentage; (9) comorbidity percentage; (10) type of morbidity; (11) prevalenceof morbidity; (12) risk factors of morbidity; (13) correlates of morbidity; and(14) consequences of morbidity. We also assessed the quality of each articleusing appropriate quality assessment tools based on the study design. Forquantitative studies, we used the Joanna Briggs Institute Critical AppraisalChecklist for Analytical Cross-Sectional Studies. For qualitative studies, weused the Critical Appraisal Skills Programmed Qualitative Checklist. We ratedeach article as high, moderate or low quality based on the number and severityof methodological flaws. 

The literaturesearch yielded a total of 750 records from the five databases. After removingduplicates and screening titles and abstracts, 25 articles met the inclusioncriteria and were included in the review. The selection process is illustratedin Figure 1. The characteristics and quality ratings of the included articlesare presented in Table 1. The articles were published between 2000 and 2020.The articles used either a cross-sectional (n=16), qualitative(n=3) or cohort (n=2) design. The sample size ranged from 21 to 5901. Themean age ranged from 29.57 to 49.62 years. The male percentage ranged from 0%to 100%. The comorbidity percentage ranged from 15% to 74%. The quality ratingswere high (n=5), moderate (n=17) or low (n=3). 

 

   Table 1: Characteristics and quality ratings of the included articles

 
 
   Study

 
  Authors

 
  Year

 
  Journal

 
  Design

 
  Quality Score

 
  Quality Rating

 
 
   1

 
  Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries [6]

 
  Farahbakhsh et al.

 
  2023

 
  Journal of Tissue Viability

 
  Cross-sectional

 
  9/12

 
  Moderate

 
 
   2

 
  Sexual matters of couples with spinal cord injury attending a sexual health clinic in Tehran, Iran [7]

 
  Salmani et al.

 
  2019

 
  Sexual Medicine

 
  Qualitative

 
  8/10

 
  High

 
 
   3

 
  Depression in patients with spinal cord injury referred to the specialized centers in Tehran, Iran [8]

 
  Dezfoly et al.

 
  2018

 
  Archives of Neuroscience

 
  qualitative study

 
  7/10

 
  Moderate

 
 
   4

 
  Development of a sexual needs rehabilitation framework in women post–spinal cord injury: a study from Iran [9]

 
  Maasoumi et al.

 
  2018

 
  Archives of Physical Medicine and Rehabilitation

 
  Qualitative 

 
  7/10

 
  Moderate 

 
 
   5

 
  Association of pain, social support and socioeconomic indicators in patients with spinal cord injury in Iran [10]

 
  Khazaeipour et al

 
  2017

 
  Spinal Cord

 
  Descriptive cross-sectional study

 
  8/10

 
  High

 
 
   6

 
  Psychological defense mechanisms among individuals with SCI with adjustment disorder [11]

 
  Ghazwin et al.

 
  2017

 
  Journal of Spinal Cord Medicine

 
  Cross-sectional

 
  9/12

 
  Moderate

 
 
   7

 
  Prevalence of Androgen Deficiency in Chronic SCI Patients Suffering from Erectile Dysfunction [12]

 
  Behnaz

 
  2017

 
  Spinal Cord

 
  Cross-sectional

 
  8/12

 
  Moderate

 
 
   8

 
  Evaluation of sexual function and its contributing factors in men with spinal cord injury using a self-administered questionnaire [13]

 
  Khak, et al. 

 
  2016

 
  American Journal of Men's Health

 
  Cross-sectional survey 

 
  6/10

 
  Low

 
 
   9

 
  Assessment of passive knee stiffness and viscosity in individuals with spinal cord injury using pendulum test [14]

 
  Joghtaei et al.

 
  2015

 
  The Journal of Spinal Cord Medicine

 
  Cross-sectional study

 
   

 
   

 
 
   10

 
  Prevalence of overweight and obesity in spinal cord injury patients [15]

 
  Hanzai, et al.

 
  2015

 
  Journal of Spinal Cord Medicine

 
  Analytical cross-sectional study

 
  8/10

 
  High

 
 
   11

 
  Subjective Sleep Quality in Iranian Patients with Spinal Cord Injury: Results of

 Pittsburgh Sleep Quality Index in a Referral Center [16]

 
  Matin, et al. 

 
  2014

 
  Journal of Sleep Disorders and Therapy 

 
  Cross-sectional survey 

 
  7/10

 
  Moderate

 
 
   12

 
  Depressive mood and fatigue in Iranian patients with spinal cord injury and spared walking ability [17]

 
  Matin et al.

 
  2015

 
  Topics in Spinal Cord Injury Rehabilitation

 
  Cross-sectional

 
  8/12

 
  Moderate

 
 
   13

 
  Does religious coping and spirituality have a moderating role on depression and anxiety in patients with spinal cord injury? A study from Iran [18]

 
  Rahnama, et al.

 
  2015

 
  Spinal Cord

 
  Cross-sectional

 
  10/12

 
  High

 
 
   14

 
  Calcium and vitamin D plasma concentration and nutritional intake status in patients with chronic spinal cord injury: A referral center report [19]

 
  Javidan, et al.

 
  2014

   

 
  Journal of Research in Medical Sciences

 
  Cross-sectional

 
   

 
   

 
 
   15

 
  Medical complications and patient outcomes in Iranian veterans with spinal cord injury (SCI) [20] 

 
  Javadi, et al.

 
  2014

 
  Advances in Clinical and Experimental Medicine

 
  Retrospective cohort study

 
  8/10 

 
  High

 
 
   16

 
  Health status of veterans with spinal cord injury during screening program in Tehran 2013: investigating the pulmonary function-a preliminary report [21]

 
  Azimi, et al.

 
  2014

 
  Iranian Journal of War and Public Health

 
  Cross-sectional

 
  5/12

 
  Low

 
 
   17

 
  Psychosocial outcomes following spinal cord injury (SCI) in Iran and to identify the factors associated with them [22] 

 
  Khazaeipour, et al.

 
  2014

 
  Journal of Spinal Cord Medicine

 
  Cross-sectional survey

 
  7/10

 
  Moderate

 
 
   18

 
  Female sexual dysfunction in patients with spinal cord injury: a study from Iran [23]

 
  Hajiaghababaei et al.

 
  2014

 
  Spinal Cord

 
  Cross-sectional

 
  9/12

 
  Moderate

 
 
   19

 
  Evaluation of bone mineral loss in patients with chronic traumatic spinal cord injury in Iran [9]

 
  Javidan, et al.

 
  2014

   

 
  The Journal of Spinal Cord Medicine

 
  Cross-sectional 

 
  8/12

 
  Moderate

 
 
   20

 
  Cardiometabolic risk factors in Iranians with spinal cord injury: analysis by injury-related variables [24]

 
  Sabour et al.

 
  2013

 
  Spinal Cord

 
  Cross-sectional

 
  8/12

 
  Moderate

 
 
   21

 
  Health-related quality of life among individuals with long-standing spinal cord injury: a comparative study of veterans and non-veterans [25]

 
  Saadat et al.

 
  2010

 
  BMC Public Health

 
  Cross-sectional

 
  10/12

 
  High

 
 
   22

 
  Renal transplant in patients with spinal cord injuries [26]

 
  Basiri et al.

 
  2009

 
  Experimental and Clinical Transplantation

 
  Cohort

 
  8/11

 
  Moderate

 
 
   23

 
  Factors associated with pressure ulcers in patients with complete or sensory-only preserved spinal cord injury: Is there any difference between traumatic and nontraumatic causes? Clinical article

 
  Taghipoor et al.

 
  2009

 
  Journal of Neurosurgery: Spine

 
  Cross-sectional

 
  9/12

 
  Moderate

 
 
   24

 
  Spinal cord injury-induced osteoporosis in veterans [27]

 
  Shojaei et al.

 
  2006

 
  Journal of Spinal Disorders and Techniques

 
  Cohort

 
  8/11

 
  Moderate

 
 
   25

 
  Epididymo-orchitis risk factors in traumatic spinal cord injured patients [28]

 
  Mirsadraee et al.

 
  2003

 
  Spinal Cord

 
  Cross-sectional

 
  8/12

 
  Moderate

 
 

 

3. Comorbidity in SCI 

This narrative literature review presents the findings from 25articles that examined the prevalence, risk factors, and consequences ofvarious comorbidities among people with spinal cord injury (SCI). The articleswere categorized into four themes based on the type of morbidity: physical,sexual, psychological, and metabolic. The table 2 summarize the sample size,mean age, male percentage, prevalence of morbidity, risk factors of morbidity,and consequences of morbidity for each article that focused on physicalmorbidity.

3.1. Physical Morbidity

Physical morbidity refers to any medical condition or complicationthat affects the body functions or structures of people with SCI. The mostcommon physical morbidities reported in this literature were pressure ulcers,pain, osteoporosis, fracture, pulmonary function impairment, renal failure, andobesity. 

Pressure ulcers were the mostprevalent physical morbidity among people with SCI, affecting more than half of thetraumatic SCI subgroup and more than one-third of all SCI patients. Pressure ulcers were associated withincreased morbidity, mortality, and cost of care. Risk factors for pressure ulcersinclude marital status, having SCI, urinary incontinence, level ofeducation, treating center, number of days in ICU, age, Glasgow coma scale score, traumatic cause,interval less than 1 year since onset of SCI, male sex, single status, andlower education level [6]. Other studies have identifiedadditional risk factors such as incontinence, smoking, hypoalbuminemia,drinking alcohol, diabetes [29], immobility, vascular disease,impaired nutrition, perfusion issues, mechanical ventilation and surgery[30]. Proper implementation ofmonitoring, education and care programs can help reduce the occurrence of theseulcers [31].

Pain is another common physical morbidity among people with SCI. Itcan be classified into nociceptive or neuropathic pain depending on the sourceand mechanism of pain generation. Pain is associated with lower quality oflife, depression, anger and poor adjustment as well as anxiety and sleep andmood disorders. The only risk factor for pain identified in one study waseconomic situation [10]. have been linked to pain intensityand pain-related factors such as pain interference and depressive symptomsamong individuals with SCI [32]. Neuropathic pain is generallyregarded as the most frequent type of pain after SCI [33].

Osteoporosis is a frequent physical morbidity among people with SCIthat results from bone mineral density loss in spine and hip regions due toreduced mechanical loading on bones after SCI [27]. Osteoporosis increased the risk offragility fractures which could lead to infections, pain disability andmortality [27, 34]. Risk factors for osteoporosisinclude age, sex, body mass index (BMI), injury completeness and level as wellas ASIA score and serum calcium levels [34] SCI duration level, immobilization,hormonal changes, nutritional deficiencies, inflammation, oxidative stressaltered bone metabolism [34].

Pulmonary function impairment is a physical morbidity among peoplewith SCI that affected respiratory function and health status [21]. It is caused by reduced lungvolumes impaired cough reflex decreased chest wall compliance increased airwayresistance. Risk factors for pulmonary function impairment include injury leveland duration as well as age gender and smoking [21].

Renal failure is a rare but serious physical morbidity among peoplewith SCI that may require renal transplantation as a treatment option [26]. Renal failure is caused by chronickidney disease due to neurogenic bladder dysfunction urolithiasis urinary tractinfection. Renal transplantation reduces the risk of urolithiasis upper urinarytract infection but increases the risk graft rejection [26].

Obesity is a prevalent physical morbidity among people with SCI thataffects more than one-tenth of the sample in one study. Obesity is defined ashaving a BMI greater than 30 kg/m2. Obesity increases the risk cardiovasculardiseases reduced functional level increased risk injury during nursing care.Risk factors for obesity include age and BMI [15].

3.2. Metabolic Morbidity

Vitamin D deficiency is a prevalent metabolic morbidity amongpeople with SCI that affects more than half of the sample in one study. VitaminD deficiency is defined as having a serum 25-hydroxyvitamin D level less than20 ng/ml. Vitamin D deficiency is associated with calcium and vitamin Dinsufficiency in Iranian patients with SCI [19].

Cardiometabolic risk factors are common metabolic morbidities amongpeople with SCI that affect various aspects of the metabolic and cardiovascularsystem such as glucose, lipid, blood pressure and body weight. Cardiometabolicrisk factors are associated with increased risk of coronary heart disease,stroke and mortality. Risk factors for cardiometabolic risk factors includediabetes mellitus, dyslipidemia, hypertension obesity and smoking [24]. Recent studies have suggested thatvitamin D deficiency is associated with cardiometabolic risk factors, includingobesity, autoimmune diseases, cancer and insulin resistance [35]

 

 

 

 

 

 

 

 

3.3. Psychological Morbidity

3.3.1. Depression

Depression is a common morbidity reported in SCI patients. Theprevalence of depression in SCI patients in Iran ranges from 15% to 74%,depending on the study. Depression is associated with several factors such asage, gender, level and completeness of injury, time since injury, pain,anxiety, quality of life and functional status.  Depression has negative consequences onphysical, psychological and social well-being such as reduced motivation,self-esteem, coping skills, social support and sexual satisfaction. Pain is oneof the consistent and significant risk factors for depression in SCI patientsin Iran. Other risk factors for depression include anxiety, low education,unemployment, low income, low self-esteem, low self-efficacy, low life satisfaction,low social support and negative religious coping. Depression has a negativeimpact on SCI patients' quality of life across all domains [8, 16-18, 22]. 

 

3.3.2. Anxiety

Anxiety is another psychological morbidity among SCI patients.Anxiety is associated with lower quality of life, increased pain anddepression, impaired sleep and cognitive function. Risk factors for anxietyinclude gender education employment negative religious coping existentialspiritual well-being [16, 18, 22]. A study fromIran found that 30% of SCI patients had anxiety [18]. The findings indicated thatreligion and spiritual well-being have a moderating role on the occurrence ofanxiety [36]. 

 

3.3.3. Defense mechanisms

One study found that individualswith SCI who have adjustment disorder, a condition characterized by emotionaldistress and difficulty adapting to a changed situation, used more immaturedefense mechanisms such as denial, projection and acting out than those withoutadjustment disorder. On the other hand, individuals with SCI who used moremature defense mechanisms such as humor, sublimation and altruism had higherlevels of self-esteem and lower levels of depression. The most prevalent defensestyle was neurotic and the dominant used defense mechanism was idealization.The role of demographic and injury-related variables in determining the useddefense mechanisms was found to be insignificant [11].

3.4. SexualMorbidity

Sexual morbidity refers to anycondition or complication that affects the sexual function or satisfaction ofpeople with SCI. Some of the most common sexual morbidities reported inliterature include sexual dysfunction, erectile dysfunction, ejaculationdysfunction, orgasm dysfunction, sexual satisfaction dysfunction and impairedsexual quality life satisfaction [7, 9, 12, 13, 23].

 

 

 

 

   Table 2: Characteristics of the included articles based on comorbidity

 
 
   Study

 
  Sample Size

 
  Mean Age

 
  Male %

 
  Type of Morbidity

 
  Prevalence of Morbidity %

 
  Risk Factors of Morbidity

 
  Consequences of Morbidity

 
 
   1

 
  2785

 
  N/A

 
  N/A

 
  Pressure ulcers

 
  16.1 for the SCI subgroup 

 
  Marital status, having SCI, urinary incontinence, level of education, treating center, number of days in ICU, age, and Glasgow coma scale score

 
  Increased morbidity, mortality, and cost of care 

 
 
   2

 
  60

 
  38.3 men; 35.8 women

 
  50

 
  Sexual dysfunction

 
  N/A

 
  Injury level, injury duration, age, gender, and marital status

 
  Reduced sexual function, intimacy, and well-being

 
 
   3

 
  51

 
  35.8

 
  84.3

 
  Depressed mood

 
  74%

 
  Gender, education, lesion type, and duration since the injury

 
  Reduced quality of life, increased pain, and anxiety

 
 
   4

 
  31

 
  N/A

 
  0

 
  Sexual dysfunction 

 
  N/A

 
  Spinal injury type and level, lack of sexual knowledge and awareness post-SCI, lack of sexual and reproductive education/counseling in the rehabilitation process 

 
  Reduced sexual quality of life and satisfaction

 
 
   5

 
  334

 
  34.9

 
  81.4

 
  Pain (nociceptive or neuropathic)

 
  50.7

 
  Economic situation

 
  Lower quality of life, depression, anger and poor adjustment, anxiety and sleep and mood disorders

 
 
   6

 
  114

 
  29.57

 
  84.3

 
  Adjustment disorder

 
  28

 
  N/A

 
  | Reduced rehabilitation, quality of life, and increased morbidity and mortality

 
 
   7

 
  319

 
  34.6

 
  100

 
  Androgen deficiency and erectile dysfunction

 
  29.1 androgen deficiency; 32.6 low total testosterone level, 

 
  Injury level, injury duration, age, gender, and opioid use

 
  Reduced sexual function and well-being

 
 
   8

 
  100

 
  36.6 

 
  100

 
  Impaired sexual function such as erectile dysfunction, ejaculation dysfunction, orgasm dysfunction, sexual satisfaction dysfunction, etc.

 
  N/A

 
  Injury level, age, marital status, education level, employment status, income level, duration of injury, medication use 

 
  Reduced quality of life, impaired sexual health and intimacy 

 
 
   9

 
   

 
  33.44

 
  53.3

 
  Passive knee stiffness and viscosity

 
  N/A

 
  N/A

 
  SCI have significantly greater joint stiffness compared to able-bodied subjects

 
 
   10

 
  850

 
  36.5

 
  98

 
  Obesity

 
  42

 
  Age, body mass index

 
  Increased risk of cardiovascular diseases, reduced functional level, increased risk of injury during nursing care

 
 
   11

 
  100

 
  38.8 

 
  87

 
  Poor sleep quality 

 
  77

 
  Injury level, pain, spasticity, depression, anxiety, medication use, smoking, alcohol consumption, caffeine intake, physical activity, environmental factors

 
  Reduced quality of life, impaired cognitive function, increased mortality risk, cardiovascular diseases, metabolic disorders, immune dysfunction, psychiatric disorders

 
 
   12

 
  60

 
  34.6 SCI; 33.9 control group

 
  100

 
  Depressive mood and fatigue

 
  26.7 and 40 for SCI group

 
  Injury level, injury duration, age, gender, and pain

 
  Reduced physical and mental function and well-being

 
 
   13

 
  213

 
  34.8

 
  67.4

 
  Depression and anxiety

 
  15 Depression; 30 anxiety

 
  Gender, education, employment, negative religious coping, and existential spiritual well-being

 
  Reduced recovery, quality of life, and increased morbidity and mortality

 
 
   14

 
  160 

 
  38.8

 
  81.9

 
  Vitamin D deficiency

 
  53.1

 
  N/A

 
  Calcium, and Vitamin D insufficiency in Iranian patients with SCI

 
 
   15

 
  200 

 
  49.9

 
  100

 
  Medical complications such as urinary tract infection, pressure ulcer, osteoporosis, fracture, spasticity, pain, etc. 

 
  N/A

 
  Injury level, age, duration of injury, smoking status, BMI, marital status, education level, employment status

 
  Increased mortality rate, decreased quality of life, increased health care costs 

 
 
   16

 
  368

 
  49.62

 
  100

 
  Pulmonary function

 
  N/A

 
  Injury level, injury duration, age, gender, and smoking status

 
  Reduced respiratory function and health status

 
 
   17

 
  100 

 
  38.8

 
  87

 
  Poor psychosocial outcomes such as depression, anxiety, stress, coping strategies, social support, life satisfaction, etc. 

 
  N/A

 
  Injury level, age, gender, marital status, education level, employment status, income level, duration of injury 

 
  Reduced quality of life, impaired mental health, increased suicide risk 

 
 
   18

 
  105

 
  41.0 SCI; 33.9 control group

 
  0

 
  Sexual dysfunction

 
  88

 
  Injury level, injury duration, age, education, symptoms of depression and anxiety

 
  Reduced sexual function and satisfaction

 
 
   19

 
  148

 
  51

 
  78.4

 
  Bone mineral density (BMD) loss in spine and hip

 
  N/A

 
  Age, sex, BMI, injury completeness, injury level, ASIA score,

 
  serum calcium, phosphor, and vitamin D levels Osteoporosis and pathological fractures

 
 
   20

 
  162

 
  34.6

 
  100

 
  Cardiometabolic risk factors such as diabetes mellitus, dyslipidemia, hypertension, obesity, and smoking

 
  N/A

 
  16.7diabetes mellitus, 22.2 dyslipidemia, 2.5 hypertension, 13.6 obesity, and 8 smoking

 
  Increased risk of coronary heart disease, stroke, and mortality

 
 
   21

 
  123 (39 veterans: 84 non-veterans)

 
  46.8 veterans: 41.4 non-veterans

 
  100

 
  Health-related quality of life measured by SF-36 questionnaire

 
  N/A

 
  Veteran status, age, marital status, education level, employment status, and income level

 
  Reduced well-being and satisfaction

 
 
   22

 
  21

 
  43.8

 
  100

 
  Renal failure

 
  N/A

 
  Spinal cord injury status, age, sex, injury level, injury duration, and time since injury

 
  Reduced risk of urolithiasis and upper urinary tract infection; increased risk of graft rejection

 
 
   23

 
  5901 (3791 traumatic, 2110 nontraumatic)

 
  37.8 traumatic; 48.8 women

 
  81.4% (traumatic), 63.5% (nontraumatic)

 
  Pressure ulcer

 
  39.2% (all), 71.8% (traumatic), 28.2% (nontraumatic)

 
  Traumatic cause, older age, interval less than 1 year since onset of SCI, male sex, single status, lower education level

 
  Negative impact on quality of life, rehabilitation set-backs, hospitalization, death

 
 
   24

 
  100

 
  38

 
  100

 
  Osteoporosis

 
  N/A

 
  SCI duration, level and completeness of injury, immobilization, hormonal changes, nutritional deficiencies, inflammation, oxidative stress, altered bone metabolism

 
  Increased risk of fragility fractures, infections, pain and disability

 
 
   25

 
  169

 
  N/A

 
  100

 
  Epididymo-orchitis

 
  38.5

 
  N/A

 
  Azoospermia and infertility in paraplegic patients

 
 

 

 

4. Conclusion

First, the review revealed that SCI patients in Iran face multiplechallenges and difficulties in their daily lives due to physical,psychological, social, and environmental factors. The results of study showedthat physical health problems secondary to SCI are extremely common worldwide [37]. SCI patients reported lowerquality of life [25], higher levels of depression [8, 16-18, 22], anxiety [16, 18, 22], pain [10], sexual dysfunction [7, 9, 12, 13, 23], andosteoporosis [27]. These problems were influenced byvarious factors such as age, gender, level and duration of injury, maritalstatus, education level, employment status, income level, access to health careservices, social support, coping strategies, and spirituality.

Second, the review showed that there are some protective factorsthat can enhance the psychosocial well-being of SCI patients in Iran. Theseinclude social support, religious coping, spirituality, positive attitude,self-efficacy, and sexual satisfaction [18]. These factors can help SCIpatients to cope with stress, reduce negative emotions, increase self-esteem,improve interpersonal relationships, and find meaning and purpose in life.Therefore, interventions that target these factors may be beneficial for SCIpatients.

Third, the review highlighted some gaps and limitations in theexisting literature on SCI in Iran. Most of the studies were cross-sectional ordescriptive in nature, which limits the causal inference and generalizabilityof the findings. There was a lack of longitudinal or experimental studies thatcould examine the changes and effects of SCI over time or test the efficacy ofinterventions. There was also a lack of standardized or validated instrumentsto measure some of the psychosocial outcomes such as quality of life, coping,or spirituality. Moreover, there was a lack of diversity and representation inthe samples of SCI patients, as most of them were male veterans with traumaticinjuries. There was also a lack of comparison groups or control groups tocontrast the outcomes of SCI patients with other populations.

Therefore, future research on SCI in Iran should address these gapsand limitations by using more rigorous designs, methods, instruments, andsamples. Future research should also explore other psychosocial aspects thathave not been adequately studied such as resilience, post-traumatic growth,stigma, discrimination, or empowerment. Furthermore, future research shoulddevelop and evaluate culturally appropriate and evidence-based interventionsthat can improve the psychosocial outcomes of SCI patients in Iran.

In conclusion, this narrative literature review provided acomprehensive overview of multiple aspects of SCI in Iranian patients. Thereview identified several challenges and difficulties that SCI patients face intheir lives as well as some protective factors that can enhance theirwell-being. The review also pointed out some gaps and limitations in thecurrent literature and suggested some directions for future research. Thefindings of this review can inform policy makers, health care providers,researchers, and SCI patients and resources of this population.