People with SCI are more likely than the general population to experience difficulties with mental health (Craig et al, 2009) and cognitive functioning (Sandalic et al, 2022).
NHS England brought together a working group to develop a set of recommended standards for SCI patients with psychological and mental health needs, published in January 2023 in collaboration with BASCIS, BSPRM, and MASCIP.
Psychological screening
National standards recommend screening for psychological distress and alcohol/substance use at the following time points:
- Four weeks post-injury (please contact the network or SCI Centre Acute Outreach team for a copy of the questionnaire)
- (If admitted to an SCI centre for rehab) Within four weeks of admission to the SCI centre and within the final four weeks prior to discharge
- At outpatient review by SCI centre
Where routine screening identifies psychological needs, the patient should be referred onwards to local or national services (or signposted to self-refer if appropriate).
Patients can self-refer to any of the following services:
- Spinal Injuries Association counselling
- Back Up mentoring and peer support
- Cauda Equina Champions peer support and psychological and psychosexual therapy
- NHS Talking Therapies
The Spinal Injuries Association have developed a series of virtual training sessions on psychological health for healthcare professionals working with SCI patients. See their website for more information and available dates:
Spinal Injuries Association – Training for Healthcare Professionals
Cognitive screening
People with SCI experience reduced cognitive functioning compared to able-bodied people, with deficits particularly in attention and executive functioning (Sandalic et al, 2022). This can impact on engagement with rehab, length of stay, and long term outcomes.
The aetiology of poor cognitive performance in SCI can be varied, including but not limited to the following factors:
- Pre-existing cognitive impairment that may or may not have been diagnosed prior to SCI eg. dementia, age-related degeneration, learning disability, previous head injury or stroke/TIA
- Co-morbid brain injury
- Post-traumatic inflammation
- Fatigue (acute and chronic)
- Autonomic dysfunction, cardiac regulation problems
- Alcohol/substance use (historical or current)
- Side effects and polypharmacy
- Anxiety, depression, PTSD
- Pain (acute and chronic)
- Sleep disorders (including sleep disordered breathing)
- PICS (post intensive care syndrome) – delirium as risk factor
National standards recommend the use of a brief screen such as the 6CIT, AMTS or MoCA if there are concerns regarding cognition, with a more thorough neuropsychological assessment to be requested if screen is positive for cognitive impairment.
The MoCA (Montreal Cognitive Assessment) is one of the more commonly used screening tools. Please note that the MoCA should only be administered and scored by those who have completed the official training and certification module, which can be accessed for free as an employee of a public healthcare institution (see https://mocacognition.com/training-certification/ for more details).
A note of caution:
Most existing cognitive screening tools have been developed to detect dementia in the general population, with the relevant published norms and cut-offs. None have been validated for the SCI population and therefore should be interpreted with caution.
Assessing cognition in tetraplegic patients:
In cases of impaired upper limb function, you may need to adapt the administration of screening tools and therefore should exercise caution in interpretation. For the MoCA, it is possible to administer the standard MoCA without the drawing tasks, then pro rata the scores – e.g. scoring 20/25 would correspond to 24/30 and could then be interpreted in comparison to population norms (N.B. This conversion has not been validated). If the person is able to trace with a finger/hand or use a writing tool/stylus with a grip aid, the first visuospatial task may be included. The MoCA-blind could be used as an alternative, however this also leaves out the picture naming task.
Further resources and recommended reading
- Contact the Network team for access to a series of informational videos on topics related to psychosocial care of patients with spinal cord injury, developed by the Network Clinical Psychologist
- Psychological Adjustment after Spinal Cord Injury: Useful strategies for health professionals – Agency for Clinical Innovation, 2014
- Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury: Clinical Practice Guideline for Healthcare Providers – Bombardier et al, 2021
- SCI pathway and transformation recommendations for adults with SCI who have psychological and mental health needs– Duff et al, 2023
- The Spinal Injuries Association have developed a series of virtual training sessions on psychological health for healthcare professionals working with SCI patients. See their website for more information and available dates: https://spinal.co.uk/get-informed/healthcare-professionals/courses/