The interrelationship between pain, life satisfaction and mental health in adults with traumatic spinal cord injury, in the context of a developing country

Traumatic spinal cord injury (TSCI) substantially impairs quality of life (QOL), which encompasses physical, psychological, social, and environmental domains. In South Africa’s Western Cape, TSCI incidence is high and often linked to violent etiologies, with affected individuals experiencing lower life satisfaction than the general population. In developing contexts, life satisfaction is further shaped by employment, income, living environment, and education. Chronic pain is highly prevalent after SCI and adversely affects life satisfaction. The study investigates how pain (intensity and interference) relates to life satisfaction and psychological distress (depression, anxiety) in adults with TSCI in South Africa, hypothesizing that depression, anxiety, and pain would be negatively related to life satisfaction.

Prior work shows people with SCI in developing countries report poorer QOL than those in developed settings, with higher education, employment, and longer time since injury associated with better QOL. Life satisfaction, a cognitive–affective appraisal of one’s life, is influenced by socioecological factors and chronic pain. Chronic pain (neuropathic and nociceptive) is common after SCI and linked to lower life satisfaction and higher psychological distress. Acceptance-based strategies and CBT have shown benefits for chronic pain and psychological outcomes. In TSCI, demographic and injury-related factors (e.g., time since injury, gender) and pain relate to anxiety and depression, with longer time since injury often associated with lower distress. Resilience may buffer distress, with some evidence of sex differences. There is limited research in developing contexts on how life satisfaction relates to mental health in TSCI, motivating the present examination of its potential protective/mediating role between pain and psychological distress.

Design: Cross-sectional, analytical study with convenience sampling. Setting and recruitment: Adults with TSCI living in the City of Cape Town Metropolitan region were identified from medical records at the Western Cape Rehabilitation Center. Healthcare professionals and peer supporters assisted recruitment. Inclusion/exclusion: Adults with TSCI; excluded if unable to provide informed consent or comprehend questions. Data collection: Telephonic interviews (20–30 minutes) conducted by the first author and assistants; a translator administered Xhosa versions where needed. Sample: n=70; predominantly men (87.1%); largely unemployed (94.3%); most had secondary schooling (88.6%); common injury etiologies were gunshot wounds (40.0%) and motor vehicle accidents (27.1%); most injuries within past 1–5 years (84.3%); thoracic injuries were most common (60.0%). Measures: • Life satisfaction: 10 satisfaction items from WHOQOL-BREF (1=very dissatisfied to 5=very satisfied). • Depression: CESD-10 (0–3 scale). • Anxiety: STAI-T5 (1–4 scale). • Pain intensity: single VAS item (0–10) from ISCIPBDS. • Pain interference: 7-item BPI interference scale (0–10). Demographics and injury background collected. Psychometrics: Reported internal consistencies included alpha and omega; prior evidence supports measure reliability/validity in SCI populations. Statistical analysis: SPSS v28 used for descriptive statistics, reliability (alpha and omega via OMEGA macro), and Pearson correlations. Mediation analyses used PROCESS v3.5 (Hayes) with life satisfaction as mediator; significance of direct/indirect effects evaluated via bootstrapped 95% CIs (5000 samples). Normality assessed by skewness and kurtosis (observed skewness −0.38 to 0.20; kurtosis −1.44 to 0.93), indicating approximate normality.

- Sample characteristics: Mean age 35.48 years (SD 9.34); 87.1% men; 94.3% unemployed; thoracic injuries 60.0%; gunshot etiology 40.0%. 83% reported chronic pain; most prevalent pain types were below-level neuropathic pain (BL-NEUP) and musculoskeletal nociceptive pain (MNP). Common pain locations included lower limbs, lower back, and shoulder. - Descriptive statistics (means, SD): Pain intensity 5.55 (3.61); Pain interference 31.22 (24.33); Life satisfaction 30.97 (7.25); Depression 11.30 (5.74); Anxiety 11.94 (4.23). - Reliability: Internal consistencies generally acceptable to excellent (α or ω=0.77–0.96). CESD-10 α was just below 0.70 but ω=0.72. - Correlations (Pearson r): Pain interference and life satisfaction r=−0.45, p<0.001; Pain intensity and life satisfaction r=−0.36, p=0.003. Pain intensity and depression r=0.31, p=0.012; pain interference and depression r=0.32, p=0.010. Pain intensity and anxiety r=0.25, p=0.042; pain interference and anxiety r=0.32, p=0.010. Life satisfaction correlated negatively with depression r=−0.45, p<0.001 and anxiety r=−0.34, p=0.005. - Mediation: Life satisfaction significantly mediated: • Pain intensity → depression (β=0.15; 95% CI 0.07–0.46). • Pain intensity → anxiety (β=0.10; 95% CI 0.01–0.30). • Pain interference → depression (β=0.17; 95% CI 0.01–0.08). It did not significantly mediate pain interference → anxiety (β=0.11; 95% CI −0.00 to 0.05). - Direct effects in mediation models: Life satisfaction → depression β=−0.42, p<0.001; Life satisfaction → anxiety β=−0.29, p=0.022. In the presence of the mediator, direct effects of pain on depression and anxiety were non-significant, indicating full mediation of pain effects on psychological well-being by life satisfaction.

Findings confirm that higher pain intensity and interference are associated with lower life satisfaction and higher depression and anxiety in adults with TSCI in a developing country context. Life satisfaction was directly and beneficially associated with lower depression and anxiety and functioned as a mediator of pain’s impact on psychological distress—fully mediating links from pain intensity to both depression and anxiety and from pain interference to depression. These results extend evidence from developed settings to a South African cohort characterized by high rates of violent injury etiology and socioeconomic adversity. The results underscore life satisfaction as a potentially modifiable protective factor that may buffer the psychological impact of chronic pain in TSCI. Interventions that enhance life satisfaction (e.g., CBT, mindfulness, acceptance-based strategies), alongside comprehensive pain management and social support, may improve mental health outcomes in this population.

Pain intensity and interference are linked to higher depression and anxiety and lower life satisfaction among adults with TSCI in a developing context. Life satisfaction is beneficially associated with psychological well-being and mediates the impact of pain on depression and, in part, on anxiety. Interventions that improve life satisfaction may reduce pain-related interference and psychological distress. Future research should test measures and therapies (e.g., CBT and acceptance-based interventions) that enhance life satisfaction in TSCI and examine longitudinal trajectories of pain, life satisfaction, and mental health to enable early, targeted treatment.

- Cross-sectional design limits causal inference. - Restricted access to participants (data protection constraints) resulted in a smaller sample size than planned. - Reliance on self-reported measures may introduce social desirability and recall bias. - Telephonic administration and translation may contribute to measurement variability. - Single-center sample from one metropolitan region may limit generalizability to other settings in developing countries.