create the summary of the findings " Objectives
Our purpose was to evaluate fatigue, depressive mood,
and pain in Iranian individuals with spinal cord injury
with high SCIM score and spared walking ability, using
Matin M et al.
2 Arch Neurosci. 2015;2(2):e20180
modified fatigue impairment scale (MFIS) for SCI (MFISSCI), Beck depression inventory, and 0-10 numerical rating scale (NRS), respectively.
3. Patients and Methods
3.1. Study Design
This was a cross-sectional study for people with chronic
traumatic SCI. This investigation was based on obtaining
information using standard questionnaires within faceto-face interviews. These interviews were held during patients’ routine visits and participation was voluntary. The
study was approved by the Research Ethics Committee of
Tehran University of Medical Sciences. Data was collected
during September 2012 to October 2013 in the Brain and
Spinal Injury Research Center (BASIR). The study protocol
was confirmed by the ethical guidelines of the 1975 Declaration of Helsinki.
3.2. Participants
Patients with traumatic SCI who had spared walking
ability (whether nonassisted or assisted with canes,
walker or orthoses), referred to BASIR from September
2012 to October 2013 were selected. Informed consents
were obtained before the enrollment. The inclusion criteria were: acceptable ability to walk (assisted or nonassisted), post-injury duration longer than one year,
traumatic SCI, SCIM score higher than 65. The exclusion criteria were: nontraumatic SCI, disability to stand
or walk, SCIM score lower than 65, previous history of
psychological disorders before the injury incidence including major depressive disorder, bipolar mood disorder, psychosis, schizophrenia, generalized anxiety
disorders, obsessive compulsive disorder, and sleep
problems. None of the patients and their family members stated the mentioned psychological disorders during their interviews with a psychiatrist. By considering
the depressive phase which mostly occurs in the acute
phase of SCI and may continue up to one year (13), we excluded patients with post-injury durations of less than
one year to omit the bias effect of acute phase depression development.
3.3. Measurements
3.3.1. Spinal Cord Independence Measure
We used spinal cord independence measure III to evaluate the patients’ independency and ability for conventional daily activities. This measure has especially been
designed for individuals with SCI to assess their ability
in performing routine tasks (14). Among the three published versions of SCIM, the third edition has been shown
to have adequate reliability and validity for spinal cord
injured patients (15, 16). This instrument consists of three
subscales: self-care (0-20), mobility (0-40 scores), and
respiration and sphincter management (0-40 scores),
which comes to a maximum score of 100. Higher scores
illustrate more independency.
3.3.2. Modified Fatigue Impairment Scale With Modification for Spinal Cord Independence
The modified fatigue impact scale (MFIS) is a reliable
tool in measuring fatigue, especially in multiple sclerosis
(MS) (17). The Persian version of this questionnaire had
an acceptable reliability and reproducibility (18). However, an MFIS with modifications for SCI has been introduced recently (19). MFIS-SCI is a 21-item questionnaire,
including three main domains: cognition (11 items; score:
0-44), physical (seven items; score: 0-28) and psychosocial (three items; score: 0-12). The scores range from 0 to
84 and higher scores illustrate a higher impact of fatigue.
Items are summarized in Table 1.
3.3.3. Beck Depression Inventory
Beck depression inventory consists of 21 items and the
score ranges from 0 to 63 (20). Higher scores indicate
more severe depressive moods. Interpretations of the
scores are as follows: 1-10: normal, 11-16: mild mood disturbance, 17-20: borderline clinical depression, 21-30: moderate depressive mood, 31-40: severe depressive mood, over
40: extreme depression.
3.3.4. Pain Determination
Numerical rating scale (NRS), ranging from 0 to 10, is
the most common subjective assessment method for
pain determination, in which patients give scores to their
pain levels. Score 0 indicates no pain, 1-3 show mild pain
(nagging, annoying and slightly interfering with daily
living activities), 4-6 illustrates moderate pain (interfering significantly with daily life activities), and 7-10 are
related to severe pain (disabling and being unable to perform daily life activities, requiring analgesics). Although
this scale is the most commonly used technique for neuropathic pain determination in clinical practices, it only
has modest accuracy (21).
4. Results
Thirty patients with spinal cord injuries with spared
abilities to walk (assisted and nonassisted) were entered
to this study. It is noticeable that the ratio of patients
with SCI who had spared mobility ability was less than
the wheelchair-dependent patients. Population of patients with SCI in our referral center, to which patients
from all over the country are referred, mostly consists
of individuals dependent to wheelchairs and only a minority of patients with SCI have spared ability to walk.
Hence, although 30 patients may seem low number, it
can present the population of individuals with SCI with
walking ability.
Matin M et al.
Arch Neurosci. 2015;2(2):e20180 3
Table 1. Items of Modified Fatigue Impairment Scale With Modification for Spinal Cord Independence With Their Scoring Systems
Domain and Item Score
Never Rarely Sometimes Often Almost Always
Cognitive
I have been less alert 0 1 2 3 4
I have had difficulty paying attention for long periods of time 0 1 2 3 4
I have been unable to think clearly 0 1 2 3 4
I have been forgetful 0 1 2 3 4
I have had difficulty paying attention for short periods of time 0 1 2 3 4
I have had difficulty making decisions 0 1 2 3 4
I have been less motivated to do anything that requires thinking 0 1 2 3 4
I have had trouble finishing tasks that require thinking 0 1 2 3 4
I have had difficulty organizing my thoughts when doing things 0 1 2 3 4
My thinking has slowed down 0 1 2 3 4
I have had trouble concentrating 0 1 2 3 4
Physical
I have had to pace myself in my physical activities 0 1 2 3 4
I have been less motivated to do anything that requires physical effort 0 1 2 3 4
I have had trouble maintaining physical effort for long periods 0 1 2 3 4
I have had trouble maintaining physical effort for short periods 0 1 2 3 4
I have been physically uncomfortable 0 1 2 3 4
I have been less able to complete tasks that require physical effort 0 1 2 3 4
I have needed to rest more often or for longer periods 0 1 2 3 4
Psychosocial
I have avoided/eliminated certain tasks, activities and lifestyles 0 1 2 3 4
I have been less motivated to participate in social activities 0 1 2 3 4
I have been limited in my ability to do things 0 1 2 3 4
Table 2. Baseline Characteristics of Individuals With Spinal
Cord Injury With Spared Walking Ability a,b
Variable Value
Age 35.03 ± 13.34
Gender
Male 24 (80%)
Female 6 (20%)
Injury level
Cervical 2 (6.7%)
Thoracic 8 (26.7%)
Lumbar 20 (66.7%)
Beck depression inventory
score
Normal Mood 20 (66.7%)
Mild Mood Disturbance 5 (16.7%)
Borderline Clinical Depression
2 (6.7%)
Moderate Depression 2 (6.7%)
Severe Depression 1 (3.3%)
Pain (based on NRS)
No pain 11 (36.7%)
Mild pain 5 (16.7%)
Moderate pain 3 (10.0%)
Severe pain 11 (36.7%)
SCIM 80.03 ± 10.88
a Abbreviations: NRS, Numerical Rating Scale; SCIM, Spinal Cord
Independence Measure; SD, Standard Deviation.
b Data are presented as Frequency (%) or mean ± SD.
The examined population consisted of 24 (80%) males
and 6 (20%) females. The mean age was 35.03 ± 13.34
(range: 18-60). The mean SCIM score was 80.03 ± 10.88
(range: 65-99). The mean BDI score was 9.46 ± 9.05 (range:
0-38). Baseline characteristics are shown in Table 2.
Among patients with SCI with spared ability to walk,
66.7% (n = 20) had BDI scores < 10, considered as normal,
16.7% (n = 5) had mild mood disturbances, 6.7% (n = 2)
showed borderline clinical depressive moods, 6.7% (n =
2) revealed moderate depressive moods and only 1 (3.3%)
showed severe depression. No case of extreme depression (BDI score > 40) was detected.
The obtained mean scores in cognitive, physical and
psychosocial domains of MFIS-SCI were 6.87 ± 6.96, 10.73 ±
7.75 and 4.87 ± 3.28, respectively. The mean total score was
22.46 ± 15.76. Higher scores in BDI were significantly associated with higher scores of MFIS-SCI in all domains of
cognitive (P < 0.0001, r = 0.81), physical (P = 0.001, r = 0.58)
and psychosocial (P: 0.001, r = 0.57). This positive correlation between the results of BDI and the total MFIS-SCI score
showed that patients with disturbed moods and higher
depressive levels experienced higher fatigue impacts (P <
0.0001, r = 0.76). The cutoff point to define fatigue patient
by MFIS-SCI was 24.50 according to Imam et al. study (19).
Based on this cutoff point, 53.3% of our patients (n = 16)
were fatigued and 46.7% (n = 14) did not reveal fatigue.
Although it is assumed that patients with higher levels
of pain severity may experience higher fatigue impacts
Matin M et al.
4 Arch Neurosci. 2015;2(2):e20180
and depression, no significant association between the
pain score and the BDI score was detected (P = 0.63). The
correlations between the pain score and the MFIS-SCI
score in all three domains of cognitive, physical and psychosocial were statistically insignificant as well (P = 0.42,
0.34 and 0.39, respectively). Age was not related to the BDI
and MFIS-SCI scores (P = 0.60 and 0.98, respectively).
Injury level was another factor that showed a significant influence on the MFIS-SCI scores. It is well described
that some patients with incomplete injury to spinal cord
at cervical level may spare walking ability; but, still, it
seems that patients with injury at cervical level experience more disability. In our study, patients with SCI at
cervical level showed significantly higher MFIS scores in
all the three domains, while no correlation was observed
between the injury level and the BDI score (Table 3).
Table 3. Effect of Injury Level and Pain Severity on Modified Fatigue Impairment Scale With Modification for Spinal Cord Injury and
Beck Depression Inventory Scores a,b
Variable MFIS-SCI BDI
Cognitive Physical Psychosocial Total
Injury level
Cervical 20.0 ± 8.48 17.50 ± 3.53 9.0 ± 1.41 46.50 ± 13.43 23.50 ± 6.36
Thoracic 7.00 ± 5.50 9.38 ± 8.94 5.63 ± 3.54 24.0 ± 16.21 7.12 ± 5.98
Lumbar 5.50 ± 6.24 9.80 ± 7.45 4.15 ± 3.03 19.45 ± 14.19 9.0 ± 9.29
P value 0.015 0.040 0.043 0.036 0.19
Pain
No pain 5.55 ± 7.00 10.09 ± 8.37 4.55 ± 3.47 20.18 ± 17.34 8.90 ± 10.80
Mild pain 7.60 ± 4.61 8.80 ± 7.05 4.40 ± 4.09 20.80 ± 14.66 7.60 ± 7.95
Moderate pain 4.0 ± 6.92 4.00 ± 3.606 2.00 ± 2.0 10.00 ± 9.53 8.66 ± 10.96
Severe pain 8.64 ± 7.52 14.09 ± 7.30 6.18 ± 2.67 28.90 ± 14.7 11.09 ± 8.14
P value 0.38 0.26 0.30 0.25 0.56
a Abbreviations: BDI: beck depression inventory, MFIS-SCI: modified fatigue impairment scale with modification for spinal cord injury, SD: standard
deviation.
b Data are presented as mean ± SD. P values stand for comparison of means between the groups with one-way analysis of variances (ANOVA)."