Psychosocial Impact and Anxiety Determinants in Individuals with Spinal Cord Injury Following the April 2025 Istanbul Earthquake: Perceptions of Safety and Early Post-Disaster Experience

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Objective : This study aimed to assess the earthquake experiences, perceived safety, and psychological impact—specifically anxiety and post-traumatic stress levels—among individuals with SCI following the 6.2-magnitude Istanbul earthquake on April 23, 2025. Setting : A tertiary referral hospital in Istanbul, Turkey, where hospitalized and community-dwelling individuals with spinal cord injury (SCI) were evaluated on the fifth day following the April 2025 earthquake. Methods : A total of 64 participants, including hospitalized SCI patients (n = 19), community-dwelling SCI patients (n = 22), and healthy controls (n = 23), were evaluated within five days of the disaster. Demographic data, housing characteristics, and disaster experiences were recorded. Psychological assessment included the Beck Anxiety Inventory (BAI), the Impact of Event Scale-Revised (IES-R), and a 10-item perceived safety scale. Results : SCI participants had significantly higher BAI scores compared to healthy individuals (p < 0.05). Hospitalized SCI patients reported lower anxiety levels than their community-dwelling counterparts. No significant differences were found regarding mobility level, location (European vs. Asian side), building age, or number of floors. A strong correlation was observed between anxiety and post-traumatic stress symptoms (r = 0.770, p < 0.001). Conclusion : SCI individuals are more psychologically affected by earthquakes than healthy peers, regardless of functional independence or physical environment. Hospitalization during disaster may offer protective psychological benefits. These findings highlight the importance of integrating psychosocial support and tailored disaster preparedness strategies for individuals with SCI. Health sciences/Anatomy/Musculoskeletal system/Skeleton Health sciences/Neurology/Neurological disorders/Spinal cord diseases Introduction Spinal cord injury (SCI) is a permanent and multifaceted neurological condition that causes significant loss of motor, sensory, and autonomic functions, profoundly affecting not only physical but also psychosocial life [ 1 ]. While the prevalence of SCI is increasing worldwide, it has been reported that the risks faced by these individuals in sudden and large-scale disasters are also significantly increasing, in addition to their everyday challenges [ 2 ]. While natural disasters such as earthquakes pose a threat to the entire community, the magnitude of this threat can be far more devastating for individuals with spinal cord injuries. Individuals with SCI experience significant limitations in perceiving environmental hazards, evacuating safely, and requesting assistance during disasters [ 3 ]. Additionally, factors such as physical mobility limitations, environmental access difficulties, and increased cognitive load can lead to a decrease in safety perception and an intensification of psychological effects during sudden and uncontrollable events like earthquakes. In this context, it is crucial to assess not only emotional responses such as anxiety, but also the individual perception of security, expectations of social support, and evacuation possibilities. Factors such as the environment in which SCI individuals find themselves during an earthquake (home, hospital, etc.), the physical characteristics of the dwelling (building type, number of floors, accessibility), and the ability to receive assistance during a disaster can directly affect the stress experienced by the individual and the post-disaster recovery process. The assessment of these multidimensional factors is a critical requirement for the individualization of disaster preparedness processes and psychosocial support approaches for individuals with SCI. It is known that the individual's social support network and self-efficacy perception play a decisive role in psychological resilience. Previous studies have shown that strong social support systems and high self-efficacy in individuals with spinal cord injuries who encounter large-scale stressors such as disasters reduce the level of psychological distress and increase the individual's capacity for post-disaster recovery [ 4 ]. These findings clearly demonstrate that, in the post-disaster process, not only physical rehabilitation but also the strengthening of individuals' psychosocial resources is of critical importance. Unlike studies that focus on individuals who sustain spinal cord injuries as a direct result of earthquakes, this study investigates how people already living with SCI experience and perceive such disasters [ 5 – 8 ]. While the existing literature largely concentrates on acute trauma care and the rehabilitation of newly injured individuals, little attention has been given to the psychological impact and perceived safety among those with pre-existing SCI during and after natural disasters [ 9 ]. Addressing this gap, the present study offers a comprehensive evaluation of the disaster experiences, emotional responses, and safety perceptions of individuals with SCI following the earthquake that occurred in Istanbul—an urban center with a high seismic risk. Understanding the unique needs of this vulnerable population is essential for developing individualized disaster preparedness, psychosocial support, and rehabilitation strategies. To better contextualize these outcomes, a healthy control group was included to enable comparison across key psychological and environmental variables. Methods Study Design and Participants This study was conducted using a cross-sectional descriptive design to evaluate the disaster moment experiences, perceived safety levels, and psychological impact of individuals diagnosed with SCI following an earthquake in Istanbul. Participants were selected on a voluntary basis from individuals who had been diagnosed with SCI for at least six months and were present in Istanbul during the earthquake. Inclusion criteria were: being 18 years of age or older, having mental capacity sufficient to independently complete the questionnaires, and providing written informed consent to participate in the study. Exclusion criteria included mental disability or inability to communicate. Additionally, a healthy control group was included to allow comparative analysis. Healthy individuals aged 18 years or older, without any neurological or psychiatric diagnoses, who were present in Istanbul during the earthquake and consented to participate voluntarily, were selected. The healthy group was matched with the SCI group based on age and gender distribution to minimize demographic differences. A priori power analysis was conducted based on the effect size reported by Bhattarai et al. [ 4 ]. Assuming a medium effect size (d = 0.5), a significance level of α = 0.05, and a statistical power of 80% (1-β = 0.80), it was calculated that a minimum of 32 participants per group (SCI and healthy control) would be required. Accordingly, the total minimum sample size was determined to be 64 participants, which was achieved in this study. Data Collection Tools The following data were collected from participants: Demographic and Clinical Information : Participants’ age, gender, educational status, residential area (Asian or European side), and environment at the time of the earthquake (home, hospital, or other) were recorded for all individuals. Additionally, for participants with spinal cord injury, SCI level, ASIA grade, level of independence in daily living activities, mobility status (walking, wheelchair use, or bedridden), and other basic clinical characteristics were collected. Housing Characteristics and Disaster Experience : Environmental and structural information such as housing type (apartment, detached house, site, container, etc.), building age, number of floors, floor of residence, elevator availability, entrance accessibility (flat ground or not), and whether assistance was received during the disaster were inquired. Additionally, whether participants were alone during the earthquake and their ability to reach emergency response teams during the disaster were assessed. Psychological Assessment Scales a) Beck Anxiety Inventory (BAI) Participants’ anxiety levels were assessed using the BAI [ 10 ], a widely used self-report instrument designed to evaluate the severity of anxiety symptoms in clinical and research settings. b) Impact of Event Scale-Revised (IES-R) The level of psychological distress experienced by participants following the earthquake was evaluated using the IES-R [ 11 ], which measures intrusion, avoidance, and hyperarousal symptoms related to trauma. c) Safety Perception Assessment Form A 10-item Likert-type form developed for this study to assess perceived environmental safety, evacuation possibility, and expectations of help. Environmental and Individual Risk Factors : Participants were also asked about evacuation conditions, the process of receiving assistance, and their perception of social support. Statistical Analysis The collected data will be analyzed using SPSS 25.0 (IBM Corp., Armonk, NY, USA) software. Descriptive statistics (mean, standard deviation) will be calculated for continuous variables, and frequency and percentage distributions will be calculated for categorical variables. For subgroup comparisons, Student's t-test will be used for normally distributed data, and the Mann-Whitney U test will be used for non-normally distributed data. Relationships between categorical variables will be analyzed using the chi-square test or Fisher's exact test.Comparative analyses will also be conducted between the SCI group and the healthy control group in terms of disaster experiences, perceived safety, and psychological impact. Statistical significance will be set at p < 0.05. Results In this study, the experiences of individuals with SCI and healthy individuals were evaluated multidimensionally after the earthquake that occurred in Istanbul on April 23, 2025. Many variables such as demographic characteristics of the participants (age, gender, education level, continent, marital status), living conditions (type of building, age of the building, floor of the apartment), physical independence levels (mobility status, independence in daily life activities), their experiences during the earthquake (with whom they were caught, with whom they lived, evacuation possibilities, elevator status) and their perceptions of disaster safety (10-item Likert-type safety scale) were taken into consideration. In addition, the psychological effects of the earthquake were assessed through BAI and IES-R, and the relationships between anxiety level and post-traumatic stress symptoms were analyzed. A total of 64 individuals, including hospitalized SCI individuals (n = 19), community-dwelling SCI individuals (n = 22), and healthy individuals (n = 23), participated in the study. The mean ages were 41.4 ± 16.2 years for the hospitalized SCI group, 43.9 ± 11.5 years for the community-dwelling SCI group, and 43.5 ± 12.8 years for the healthy group, respectively. The mean difference in age between SCI participants and healthy individuals was minimal (mean difference = 1.9 years, 95% CI − 5.1 to 8.9), indicating no substantial age-related group differences. Gender distribution was predominantly male across all groups: 84.2% in the hospitalized SCI group, 72.7% in the community-dwelling SCI group, and 73.9% in the healthy group. In terms of education level, primary and high school education were more common among SCI individuals, while 60.8% of healthy individuals had university education and 39.1% had postgraduate education. Most participants resided in Asia (hospitalized SCI: 73.7%; community-dwelling SCI: 68.2%; healthy: 78.3%). Regarding mobility, the majority of both SCI groups used a wheelchair (hospitalized SCI: 84.2%, community-dwelling SCI: 86.3%). Paraplegia was more prevalent than tetraplegia in both SCI subgroups (Table 1). The majority of participants lived in apartment-type buildings. Living in housing estates or detached buildings was rare. Previous earthquake experience was reported by 89.5% of the hospitalized SCI group, 86.4% of the community-dwelling SCI group, and 73.9% of the healthy group. Being alone during the earthquake showed similar distribution across groups. The proportion of those who received help during the earthquake differed notably: 47.4% of the hospitalized SCI group and 22.7% of the community-dwelling SCI group reported receiving help, while none of the healthy individuals reported receiving assistance. This reflects a moderate difference in help received between SCI and healthy individuals (difference: ~35 percentage points, 95% CI 14–56%). Regarding location during the earthquake, all SCI individuals were in the hospital, while most healthy individuals were at home (47.8%) or outside (34.8%). Evacuation patterns also differed: SCI individuals mostly stayed in place with or without assistance (42.1% and 21.1%, respectively), whereas all healthy individuals evacuated independently (100%) (Table 2). On the 10-item Likert-type disaster safety scale, statistically significant group differences were found on several items (Table 3): Question 1 ("The environment I was in at the time of the earthquake was safe"): healthy individuals scored, on average, 2,4 points higher (95% CI 0.8–4.0) than the hospitalized SCI group, and 1.9 points higher (95% CI 0.5–3.3) than the community-dwelling SCI group (p = 0.021). Question 2 ("The structural condition of the building I was in was sound"): the healthy group scored 1.6 points higher (95% CI 0.1–3.1) than the community-dwelling SCI group (p = 0.044). Question 5 ("People around me helped me during the earthquake"): the hospitalized SCI group reported significantly more support than the community-dwelling SCI group, with a mean difference of 2.7 points (95% CI 1.8–3.6) (p < 0.001). Question 8 ("I felt safe after the disaster"): the healthy group scored 2.3 points higher (95% CI 1.0–3.6) than the community-dwelling SCI group (p = 0.001). There was also a statistically significant difference in total BAI score between the hospitalized and community-dwelling SCI groups. Community-dwelling SCI participants scored points higher (95% CI 0.7–11.7), indicating greater acute anxiety levels in hospitalized individuals following the earthquake (p = 0.027) (Table 4). In contrast, no significant differences were observed between groups in terms of other items on the safety perception scale or in the total IES-R scores. The mean difference in total IES-R scores between the highest and lowest scoring groups was small (mean difference = 3.5, 95% CI − 2.5 to 9.5), indicating similar levels of post-traumatic stress symptoms across groups (p > 0.05) (Table 4). BAI and IES-R scores did not differ meaningfully according to the continent of residence (BAI: mean difference = 2.3 points, 95% CI − 0.4 to 5.1; IES-R: mean difference = 2.8 points, 95% CI − 2.1 to 7.6) (p = 0.088 and p = 0.250, respectively). A strong positive correlation was found between BAI and IES-R scores among individuals with SCI (Pearson’s r = 0.770, 95% CI 0.62–0.87), suggesting that individuals with higher anxiety were also more likely to exhibit post-traumatic stress symptoms (p < 0.001). Prior earthquake experience did not substantially affect BAI or IES-R scores among individuals with SCI. For example, BAI scores differed by only 0.9 points (95% CI − 3.0 to 4.8) between those with and without prior earthquake experience (p > 0.05). Likewise, no meaningful differences were found in BAI or IES-R scores between SCI participants grouped by mobility status (bedridden, wheelchair users, ambulatory), nor were these scores associated with building age or apartment floor number (all confidence intervals for mean differences included zero). Discussion This study evaluated anxiety and stress levels in individuals with spinal cord injury (SCI) fifth days following the 6.2 magnitude earthquake centered in Silivri, Istanbul, on April 23, 2025. Comparisons were made between SCI patients hospitalized during the earthquake, those residing at home, and healthy controls. Findings indicated that SCI patients exhibited significantly higher anxiety levels compared to healthy individuals, aligning with existing literature that suggests individuals with disabilities are more psychologically vulnerable following disasters [ 12 , 13 , 14 ]. SCI entails not only physical dependence but also lifelong neurological dysfunctions and complications. Sudden, uncontrollable events like natural disasters can exacerbate existing psychological vulnerabilities in SCI patients, facilitating the emergence of anxiety and stress-related issues [ 15 , 16 ]. Our findings corroborate this, demonstrating markedly elevated anxiety levels in SCI patients relative to healthy controls. Interestingly, SCI patients hospitalized during the earthquake reported lower anxiety levels than those residing at home during the event. This may be attributed to the perceived safety of hospital environments, easier access to medical personnel, and the general belief in the structural resilience of hospital buildings. Previous research indicates that professional support during disasters can mitigate psychological impacts [ 17 , 18 ]. Additionally, SCI patients often undergo multiple rehabilitation sessions in the same hospital, making the hospital environment a familiar and routine setting, potentially contributing to psychological stability [ 19 ]. No significant differences were observed in anxiety and stress levels among SCI patients based on functional mobility levels (bedridden, wheelchair-mobile, or ambulatory). This suggests that factors such as disaster perception, psychological resilience, and social support may play more critical roles in psychological outcomes than physical capacity [ 20 ]. While some studies propose that physical disability may lead to psychological issues [ 21 ], others have found no direct correlation between mobility levels and anxiety [ 22 ]. Therefore, we as physiatrist should adopt a holistic approach, addressing not only physical recovery but also psychosocial support during inpatient rehabilitation. Despite the earthquake being more intensely felt on Istanbul's European side, no significant differences in anxiety and stress levels were found between SCI patients residing on the European and Asian sides. This underscores that the development of anxiety is influenced more by individual perceptions, cognitive evaluations, and coping mechanisms than by the physical intensity of the event [ 23 , 15 ]. Similarly, no significant correlations were found between building age or number of floors and anxiety or post-traumatic stress scores. Literature suggests that post-disaster psychological responses are more closely related to subjective threat perception, the nature of trauma exposure, feelings of isolation or helplessness during the event, and the strength of social support systems [ 15 , 17 ]. For instance, individuals in high-rise apartments may perceive greater structural risk but benefit from increased social interactions, whereas those in single-family homes may feel safer structurally but more socially isolated, potentially leading to higher emotional stress [ 18 ]. These findings highlight the need to consider both structural and psychosocial factors when assessing post-disaster psychological outcomes. This study contributes to the limited body of research systematically examining the mental health of SCI individuals following disasters. Most existing studies focus on the general population, often overlooking the unique needs of individuals with disabilities [ 24 ]. The World Report on Disability emphasizes the importance of prioritizing individuals with disabilities in disaster preparedness and response plans [ 25 ]. Based on our findings, we propose the following recommendations for SCI patients in disaster contexts: Enhancing the Protective Role of Hospitals : Given the observed protective effect of hospitalization during disasters, ensuring priority access to hospital care for SCI patients during such events is crucial. Structural Adaptations in Rehabilitation Clinics : Physical medicine and rehabilitation clinics should be designed to facilitate rapid evacuation, preferably located on ground floors or equipped with features that allow swift patient transfers during emergencies. Provision of Psychosocial Support Post-Disaster : Patients with SCI should be identified as a priority group to whom psychosocial support should be provided after the disaster and this support should be provided by the state at the earliest. In this context, in order to reach patients with this diagnosis immediately, information such as their residence and telephone number should be recorded in the database by the Ministry of Health. Community-Based Support Centers : Local authorities should register SCI patients living alone or receiving home care, ensuring regular social support and check-ins. Organizing the Physical and Environmental Structure : Residences of SCI patients should be structurally adapted to allow easy evacuation, with a preference for ground-floor accommodations or features that enable quick exits during emergencies. One of the key strengths of this study is the early assessment of a specific patient population—individuals with spinal cord injury (SCI)—in the immediate aftermath of a distinct disaster (an earthquake), with all participants evaluated on the fifth day following the event. The study also accounts for both clinical and demographic variables, allowing for a more comprehensive analysis of factors influencing psychological outcomes. However, several limitations should be considered. The relatively small sample size limits the generalizability of the findings and precludes the establishment of causal relationships. Furthermore, the psychological assessment was restricted to anxiety and stress measures, potentially overlooking other relevant mental health conditions such as depression. Lastly, the study focused exclusively on the acute phase following the disaster, which prevents us from evaluating the long-term trajectory of anxiety and stress levels induced by the event. Conclusion This study is among the first to investigate anxiety and stress levels in SCI patients following a moderate earthquake. Results indicate that SCI patients experience significantly higher anxiety levels compared to healthy individuals. Notably, those hospitalized during the earthquake reported lower anxiety levels than their counterparts residing at home. Factors such as mobility level, geographic location during the earthquake, building age, and number of floors did not significantly impact anxiety and stress levels. These findings suggest that post-disaster psychological outcomes are influenced more by environmental perceptions, social support systems, and psychosocial resilience than by physical exposure or structural factors. Ensuring safe and organized environments, like hospitals, may offer protective effects against psychological distress in disaster contexts. Declarations Ethical Approval This study was conducted with the approval of the Ethics Committee of Başakşehir Çam and Sakura City Hospital (approval number: 2025 / 160). Written informed consent was obtained from all participants prior to their participation in the study. The study adhered to the principles outlined in the Declaration of Helsinki. Competing Interests The authors declare no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contributions All authors contributed substantially to the study. [Author 1,2,3,8,9] conceptualized and designed the study, [Author 4,5,6] collected patients’ data, [Author 7] performed statistical analyses, [Author 1] drafted the manuscript. All authors critically reviewed and approved the final manuscript. Acknowledgements None Data avaibality The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. References Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clin Epidemiol. 2014;6:309–331. Post MW, van Leeuwen CM. Psychosocial issues in spinal cord injury: a review. Spinal Cord. 2012;50(5):382–389. 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NeuroRehabilitation. 2014;35(1):99–109. Peter C, Müller R, Cieza A. Determinants of quality of life in people with spinal cord injury: a review of the literature. Spinal Cord. 2012;50(8):587–595. Chan RCK, Lee TMC, Lieh-Mak F. Cognitive and emotional disturbances after spinal cord injury: a review of recent literature. Clin Neuropsychol. 2009;23(6):1064–1081. Peter C, Müller R, Post MWM, van Leeuwen CMC. Impact of physical and psychosocial factors on functioning in persons with spinal cord injury in the Netherlands. Arch Phys Med Rehabil. 2014;95(6):1023–1030. Tartakovsky E. Psychological well-being and social support among immigrants from the former Soviet Union in Israel. Int J Psychol. 2016;51(5):325–333. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020;383(6):510–512. World Health Organization. World Report on Disability. Geneva: WHO Press; 2011. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations There is no duality of interest Supplementary Files tables.docx table 1, table 2, table 3, table 4 Cite Share Download PDF Status: Published Journal Publication published 04 Oct, 2025 Read the published version in Spinal Cord → Version 1 posted Editorial decision: revise 26 Jun, 2025 Review # 1 received at journal 12 Jun, 2025 Review # 2 received at journal 11 Jun, 2025 Reviewer # 2 agreed at journal 11 Jun, 2025 Reviewer # 1 agreed at journal 08 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Submission checks completed at journal 23 May, 2025 First submitted to journal 21 May, 2025 Unknown event 21 May, 2025 Editor assigned by journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:05:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":684510,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6709953/v1/37c73217-2614-4f88-a339-4dd460927e83.pdf"},{"id":84161064,"identity":"e37f1cea-4d3a-4ed5-b278-3d92fbc068d3","added_by":"auto","created_at":"2025-06-08 14:04:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":126276,"visible":true,"origin":"","legend":"table 1, table 2, table 3, table 4","description":"","filename":"tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6709953/v1/3b5ad7e8377b1ce0bdd58839.docx"}],"financialInterests":"There is no duality of interest","formattedTitle":"Psychosocial Impact and Anxiety Determinants in Individuals with Spinal Cord Injury Following the April 2025 Istanbul Earthquake: Perceptions of Safety and Early Post-Disaster Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpinal cord injury (SCI) is a permanent and multifaceted neurological condition that causes significant loss of motor, sensory, and autonomic functions, profoundly affecting not only physical but also psychosocial life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While the prevalence of SCI is increasing worldwide, it has been reported that the risks faced by these individuals in sudden and large-scale disasters are also significantly increasing, in addition to their everyday challenges [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile natural disasters such as earthquakes pose a threat to the entire community, the magnitude of this threat can be far more devastating for individuals with spinal cord injuries. Individuals with SCI experience significant limitations in perceiving environmental hazards, evacuating safely, and requesting assistance during disasters [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, factors such as physical mobility limitations, environmental access difficulties, and increased cognitive load can lead to a decrease in safety perception and an intensification of psychological effects during sudden and uncontrollable events like earthquakes.\u003c/p\u003e \u003cp\u003eIn this context, it is crucial to assess not only emotional responses such as anxiety, but also the individual perception of security, expectations of social support, and evacuation possibilities. Factors such as the environment in which SCI individuals find themselves during an earthquake (home, hospital, etc.), the physical characteristics of the dwelling (building type, number of floors, accessibility), and the ability to receive assistance during a disaster can directly affect the stress experienced by the individual and the post-disaster recovery process. The assessment of these multidimensional factors is a critical requirement for the individualization of disaster preparedness processes and psychosocial support approaches for individuals with SCI.\u003c/p\u003e \u003cp\u003eIt is known that the individual's social support network and self-efficacy perception play a decisive role in psychological resilience. Previous studies have shown that strong social support systems and high self-efficacy in individuals with spinal cord injuries who encounter large-scale stressors such as disasters reduce the level of psychological distress and increase the individual's capacity for post-disaster recovery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These findings clearly demonstrate that, in the post-disaster process, not only physical rehabilitation but also the strengthening of individuals' psychosocial resources is of critical importance.\u003c/p\u003e \u003cp\u003eUnlike studies that focus on individuals who sustain spinal cord injuries as a direct result of earthquakes, this study investigates how people already living with SCI experience and perceive such disasters [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While the existing literature largely concentrates on acute trauma care and the rehabilitation of newly injured individuals, little attention has been given to the psychological impact and perceived safety among those with pre-existing SCI during and after natural disasters [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAddressing this gap, the present study offers a comprehensive evaluation of the disaster experiences, emotional responses, and safety perceptions of individuals with SCI following the earthquake that occurred in Istanbul\u0026mdash;an urban center with a high seismic risk. Understanding the unique needs of this vulnerable population is essential for developing individualized disaster preparedness, psychosocial support, and rehabilitation strategies. To better contextualize these outcomes, a healthy control group was included to enable comparison across key psychological and environmental variables.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Participants\u003c/p\u003e \u003cp\u003eThis study was conducted using a cross-sectional descriptive design to evaluate the disaster moment experiences, perceived safety levels, and psychological impact of individuals diagnosed with SCI following an earthquake in Istanbul. Participants were selected on a voluntary basis from individuals who had been diagnosed with SCI for at least six months and were present in Istanbul during the earthquake. Inclusion criteria were: being 18 years of age or older, having mental capacity sufficient to independently complete the questionnaires, and providing written informed consent to participate in the study. Exclusion criteria included mental disability or inability to communicate.\u003c/p\u003e \u003cp\u003eAdditionally, a healthy control group was included to allow comparative analysis. Healthy individuals aged 18 years or older, without any neurological or psychiatric diagnoses, who were present in Istanbul during the earthquake and consented to participate voluntarily, were selected. The healthy group was matched with the SCI group based on age and gender distribution to minimize demographic differences.\u003c/p\u003e \u003cp\u003eA priori power analysis was conducted based on the effect size reported by Bhattarai et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Assuming a medium effect size (d\u0026thinsp;=\u0026thinsp;0.5), a significance level of α\u0026thinsp;=\u0026thinsp;0.05, and a statistical power of 80% (1-β\u0026thinsp;=\u0026thinsp;0.80), it was calculated that a minimum of 32 participants per group (SCI and healthy control) would be required. Accordingly, the total minimum sample size was determined to be 64 participants, which was achieved in this study.\u003c/p\u003e \u003cp\u003eData Collection Tools\u003c/p\u003e \u003cp\u003eThe following data were collected from participants:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDemographic and Clinical Information\u003c/b\u003e: Participants\u0026rsquo; age, gender, educational status, residential area (Asian or European side), and environment at the time of the earthquake (home, hospital, or other) were recorded for all individuals. Additionally, for participants with spinal cord injury, SCI level, ASIA grade, level of independence in daily living activities, mobility status (walking, wheelchair use, or bedridden), and other basic clinical characteristics were collected.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eHousing Characteristics and Disaster Experience\u003c/b\u003e: Environmental and structural information such as housing type (apartment, detached house, site, container, etc.), building age, number of floors, floor of residence, elevator availability, entrance accessibility (flat ground or not), and whether assistance was received during the disaster were inquired. Additionally, whether participants were alone during the earthquake and their ability to reach emergency response teams during the disaster were assessed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePsychological Assessment Scales\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003ea) \u003cb\u003eBeck Anxiety Inventory (BAI)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; anxiety levels were assessed using the BAI [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], a widely used self-report instrument designed to evaluate the severity of anxiety symptoms in clinical and research settings.\u003c/p\u003e \u003cp\u003eb) \u003cb\u003eImpact of Event Scale-Revised (IES-R)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe level of psychological distress experienced by participants following the earthquake was evaluated using the IES-R [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which measures intrusion, avoidance, and hyperarousal symptoms related to trauma.\u003c/p\u003e \u003cp\u003ec) \u003cb\u003eSafety Perception Assessment Form\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA 10-item Likert-type form developed for this study to assess perceived environmental safety, evacuation possibility, and expectations of help.\u003c/p\u003e \u003cp\u003e \u003col start=\"4\"\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEnvironmental and Individual Risk Factors\u003c/b\u003e: Participants were also asked about evacuation conditions, the process of receiving assistance, and their perception of social support.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe collected data will be analyzed using SPSS 25.0 (IBM Corp., Armonk, NY, USA) software. Descriptive statistics (mean, standard deviation) will be calculated for continuous variables, and frequency and percentage distributions will be calculated for categorical variables. For subgroup comparisons, Student's t-test will be used for normally distributed data, and the Mann-Whitney U test will be used for non-normally distributed data. Relationships between categorical variables will be analyzed using the chi-square test or Fisher's exact test.Comparative analyses will also be conducted between the SCI group and the healthy control group in terms of disaster experiences, perceived safety, and psychological impact. Statistical significance will be set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, the experiences of individuals with SCI and healthy individuals were evaluated multidimensionally after the earthquake that occurred in Istanbul on April 23, 2025. Many variables such as demographic characteristics of the participants (age, gender, education level, continent, marital status), living conditions (type of building, age of the building, floor of the apartment), physical independence levels (mobility status, independence in daily life activities), their experiences during the earthquake (with whom they were caught, with whom they lived, evacuation possibilities, elevator status) and their perceptions of disaster safety (10-item Likert-type safety scale) were taken into consideration. In addition, the psychological effects of the earthquake were assessed through BAI and IES-R, and the relationships between anxiety level and post-traumatic stress symptoms were analyzed.\u003c/p\u003e \u003cp\u003eA total of 64 individuals, including hospitalized SCI individuals (n\u0026thinsp;=\u0026thinsp;19), community-dwelling SCI individuals (n\u0026thinsp;=\u0026thinsp;22), and healthy individuals (n\u0026thinsp;=\u0026thinsp;23), participated in the study. The mean ages were 41.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 years for the hospitalized SCI group, 43.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years for the community-dwelling SCI group, and 43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 years for the healthy group, respectively. The mean difference in age between SCI participants and healthy individuals was minimal (mean difference\u0026thinsp;=\u0026thinsp;1.9 years, 95% CI \u0026minus;\u0026thinsp;5.1 to 8.9), indicating no substantial age-related group differences. Gender distribution was predominantly male across all groups: 84.2% in the hospitalized SCI group, 72.7% in the community-dwelling SCI group, and 73.9% in the healthy group. In terms of education level, primary and high school education were more common among SCI individuals, while 60.8% of healthy individuals had university education and 39.1% had postgraduate education. Most participants resided in Asia (hospitalized SCI: 73.7%; community-dwelling SCI: 68.2%; healthy: 78.3%). Regarding mobility, the majority of both SCI groups used a wheelchair (hospitalized SCI: 84.2%, community-dwelling SCI: 86.3%). Paraplegia was more prevalent than tetraplegia in both SCI subgroups (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe majority of participants lived in apartment-type buildings. Living in housing estates or detached buildings was rare. Previous earthquake experience was reported by 89.5% of the hospitalized SCI group, 86.4% of the community-dwelling SCI group, and 73.9% of the healthy group. Being alone during the earthquake showed similar distribution across groups.\u003c/p\u003e \u003cp\u003eThe proportion of those who received help during the earthquake differed notably: 47.4% of the hospitalized SCI group and 22.7% of the community-dwelling SCI group reported receiving help, while none of the healthy individuals reported receiving assistance. This reflects a moderate difference in help received between SCI and healthy individuals (difference: ~35 percentage points, 95% CI 14\u0026ndash;56%).\u003c/p\u003e \u003cp\u003eRegarding location during the earthquake, all SCI individuals were in the hospital, while most healthy individuals were at home (47.8%) or outside (34.8%). Evacuation patterns also differed: SCI individuals mostly stayed in place with or without assistance (42.1% and 21.1%, respectively), whereas all healthy individuals evacuated independently (100%) (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eOn the 10-item Likert-type disaster safety scale, statistically significant group differences were found on several items (Table\u0026nbsp;3):\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eQuestion 1\u003c/b\u003e (\"The environment I was in at the time of the earthquake was safe\"): healthy individuals scored, on average, 2,4 points higher (95% CI 0.8\u0026ndash;4.0) than the hospitalized SCI group, and 1.9 points higher (95% CI 0.5\u0026ndash;3.3) than the community-dwelling SCI group (p\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eQuestion 2\u003c/b\u003e (\"The structural condition of the building I was in was sound\"): the healthy group scored 1.6 points higher (95% CI 0.1\u0026ndash;3.1) than the community-dwelling SCI group (p\u0026thinsp;=\u0026thinsp;0.044).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eQuestion 5\u003c/b\u003e (\"People around me helped me during the earthquake\"): the hospitalized SCI group reported significantly more support than the community-dwelling SCI group, with a mean difference of 2.7 points (95% CI 1.8\u0026ndash;3.6) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eQuestion 8\u003c/b\u003e (\"I felt safe after the disaster\"): the healthy group scored 2.3 points higher (95% CI 1.0\u0026ndash;3.6) than the community-dwelling SCI group (p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThere was also a statistically significant difference in total BAI score between the hospitalized and community-dwelling SCI groups. Community-dwelling SCI participants scored points higher (95% CI 0.7\u0026ndash;11.7), indicating greater acute anxiety levels in hospitalized individuals following the earthquake (p\u0026thinsp;=\u0026thinsp;0.027) (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003eIn contrast, no significant differences were observed between groups in terms of other items on the safety perception scale or in the total IES-R scores. The mean difference in total IES-R scores between the highest and lowest scoring groups was small (mean difference\u0026thinsp;=\u0026thinsp;3.5, 95% CI \u0026minus;\u0026thinsp;2.5 to 9.5), indicating similar levels of post-traumatic stress symptoms across groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003eBAI and IES-R scores did not differ meaningfully according to the continent of residence (BAI: mean difference\u0026thinsp;=\u0026thinsp;2.3 points, 95% CI \u0026minus;\u0026thinsp;0.4 to 5.1; IES-R: mean difference\u0026thinsp;=\u0026thinsp;2.8 points, 95% CI \u0026minus;\u0026thinsp;2.1 to 7.6) (p\u0026thinsp;=\u0026thinsp;0.088 and p\u0026thinsp;=\u0026thinsp;0.250, respectively).\u003c/p\u003e \u003cp\u003eA strong positive correlation was found between BAI and IES-R scores among individuals with SCI (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.770, 95% CI 0.62\u0026ndash;0.87), suggesting that individuals with higher anxiety were also more likely to exhibit post-traumatic stress symptoms (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003ePrior earthquake experience did not substantially affect BAI or IES-R scores among individuals with SCI. For example, BAI scores differed by only 0.9 points (95% CI \u0026minus;\u0026thinsp;3.0 to 4.8) between those with and without prior earthquake experience (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eLikewise, no meaningful differences were found in BAI or IES-R scores between SCI participants grouped by mobility status (bedridden, wheelchair users, ambulatory), nor were these scores associated with building age or apartment floor number (all confidence intervals for mean differences included zero).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated anxiety and stress levels in individuals with spinal cord injury (SCI) fifth days following the 6.2 magnitude earthquake centered in Silivri, Istanbul, on April 23, 2025. Comparisons were made between SCI patients hospitalized during the earthquake, those residing at home, and healthy controls. Findings indicated that SCI patients exhibited significantly higher anxiety levels compared to healthy individuals, aligning with existing literature that suggests individuals with disabilities are more psychologically vulnerable following disasters [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSCI entails not only physical dependence but also lifelong neurological dysfunctions and complications. Sudden, uncontrollable events like natural disasters can exacerbate existing psychological vulnerabilities in SCI patients, facilitating the emergence of anxiety and stress-related issues [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our findings corroborate this, demonstrating markedly elevated anxiety levels in SCI patients relative to healthy controls.\u003c/p\u003e \u003cp\u003eInterestingly, SCI patients hospitalized during the earthquake reported lower anxiety levels than those residing at home during the event. This may be attributed to the perceived safety of hospital environments, easier access to medical personnel, and the general belief in the structural resilience of hospital buildings. Previous research indicates that professional support during disasters can mitigate psychological impacts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, SCI patients often undergo multiple rehabilitation sessions in the same hospital, making the hospital environment a familiar and routine setting, potentially contributing to psychological stability [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo significant differences were observed in anxiety and stress levels among SCI patients based on functional mobility levels (bedridden, wheelchair-mobile, or ambulatory). This suggests that factors such as disaster perception, psychological resilience, and social support may play more critical roles in psychological outcomes than physical capacity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While some studies propose that physical disability may lead to psychological issues [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], others have found no direct correlation between mobility levels and anxiety [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, we as physiatrist should adopt a holistic approach, addressing not only physical recovery but also psychosocial support during inpatient rehabilitation.\u003c/p\u003e \u003cp\u003eDespite the earthquake being more intensely felt on Istanbul's European side, no significant differences in anxiety and stress levels were found between SCI patients residing on the European and Asian sides. This underscores that the development of anxiety is influenced more by individual perceptions, cognitive evaluations, and coping mechanisms than by the physical intensity of the event [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, no significant correlations were found between building age or number of floors and anxiety or post-traumatic stress scores. Literature suggests that post-disaster psychological responses are more closely related to subjective threat perception, the nature of trauma exposure, feelings of isolation or helplessness during the event, and the strength of social support systems [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor instance, individuals in high-rise apartments may perceive greater structural risk but benefit from increased social interactions, whereas those in single-family homes may feel safer structurally but more socially isolated, potentially leading to higher emotional stress [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These findings highlight the need to consider both structural and psychosocial factors when assessing post-disaster psychological outcomes.\u003c/p\u003e \u003cp\u003eThis study contributes to the limited body of research systematically examining the mental health of SCI individuals following disasters. Most existing studies focus on the general population, often overlooking the unique needs of individuals with disabilities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The World Report on Disability emphasizes the importance of prioritizing individuals with disabilities in disaster preparedness and response plans [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Based on our findings, we propose the following recommendations for SCI patients in disaster contexts:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEnhancing the Protective Role of Hospitals\u003c/b\u003e: Given the observed protective effect of hospitalization during disasters, ensuring priority access to hospital care for SCI patients during such events is crucial.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStructural Adaptations in Rehabilitation Clinics\u003c/b\u003e: Physical medicine and rehabilitation clinics should be designed to facilitate rapid evacuation, preferably located on ground floors or equipped with features that allow swift patient transfers during emergencies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProvision of Psychosocial Support Post-Disaster\u003c/b\u003e: Patients with SCI should be identified as a priority group to whom psychosocial support should be provided after the disaster and this support should be provided by the state at the earliest. In this context, in order to reach patients with this diagnosis immediately, information such as their residence and telephone number should be recorded in the database by the Ministry of Health.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCommunity-Based Support Centers\u003c/b\u003e: Local authorities should register SCI patients living alone or receiving home care, ensuring regular social support and check-ins.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOrganizing the Physical and Environmental Structure\u003c/b\u003e: Residences of SCI patients should be structurally adapted to allow easy evacuation, with a preference for ground-floor accommodations or features that enable quick exits during emergencies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eOne of the key strengths of this study is the early assessment of a specific patient population\u0026mdash;individuals with spinal cord injury (SCI)\u0026mdash;in the immediate aftermath of a distinct disaster (an earthquake), with all participants evaluated on the fifth day following the event. The study also accounts for both clinical and demographic variables, allowing for a more comprehensive analysis of factors influencing psychological outcomes.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be considered. The relatively small sample size limits the generalizability of the findings and precludes the establishment of causal relationships. Furthermore, the psychological assessment was restricted to anxiety and stress measures, potentially overlooking other relevant mental health conditions such as depression. Lastly, the study focused exclusively on the acute phase following the disaster, which prevents us from evaluating the long-term trajectory of anxiety and stress levels induced by the event.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is among the first to investigate anxiety and stress levels in SCI patients following a moderate earthquake. Results indicate that SCI patients experience significantly higher anxiety levels compared to healthy individuals. Notably, those hospitalized during the earthquake reported lower anxiety levels than their counterparts residing at home. Factors such as mobility level, geographic location during the earthquake, building age, and number of floors did not significantly impact anxiety and stress levels.\u003c/p\u003e \u003cp\u003eThese findings suggest that post-disaster psychological outcomes are influenced more by environmental perceptions, social support systems, and psychosocial resilience than by physical exposure or structural factors. Ensuring safe and organized environments, like hospitals, may offer protective effects against psychological distress in disaster contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003e This study was conducted with the approval of the Ethics Committee of Başakşehir \u0026Ccedil;am and Sakura City Hospital (approval number: 2025 / 160). Written informed consent was obtained from all participants prior to their participation in the study. The study adhered to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting Interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003eAll authors contributed substantially to the study. [Author 1,2,3,8,9] conceptualized and designed the study, [Author 4,5,6] collected patients\u0026rsquo; data, [Author 7] performed statistical analyses, [Author 1] drafted the manuscript. All authors critically reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\n\u003ch3\u003eData avaibality\u003c/h3\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSingh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clin Epidemiol. 2014;6:309\u0026ndash;331.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePost MW, van Leeuwen CM. Psychosocial issues in spinal cord injury: a review. Spinal Cord. 2012;50(5):382\u0026ndash;389.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep. 2012;6(1):44\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhattarai M, Maneewat K, Sae-Sia W. Psychosocial factors affecting resilience in Nepalese individuals with earthquake-related spinal cord injury: a cross-sectional study. BMC Psychiatry. 2018;18(1):60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroves C, Poudel M, Baniya M, Rana C, House D. Descriptive study of earthquake-related spinal cord injury in Nepal. Spinal Cord. 2017;55(8):705\u0026ndash;710.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaissi G, Mokhtari A, Mansouri K. Reports from spinal cord injury patients: eight months after the 2003 earthquake in Bam, Iran. Am J Phys Med Rehabil. 2007;86(10):912\u0026ndash;917.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathore MF, Rashid P, Butt AW, Malik AA, Gill ZA, Haig AJ. Epidemiology of spinal cord injuries in the 2005 Pakistan earthquake. Spinal Cord. 2007;45(10):658\u0026ndash;663.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Reinhardt JD, Gosney JE, Zhang X, Hu X, Chen S, Ding M, Li J. Evaluation of functional outcomes of physical rehabilitation and medical complications in spinal cord injury victims of the Sichuan earthquake. J Rehabil Med. 2012;44(7):534\u0026ndash;540.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathore MF, Farooq F, Muzammil S, New PW, Ahmad N, Haig AJ. Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan. Arch Phys Med Rehabil. 2008;89(3):579\u0026ndash;585.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893\u0026ndash;897.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiss DS. The impact of event scale: revised. In: Wilson JP, Tang CS, editors. Cross-cultural assessment of psychological trauma and PTSD. Boston, MA: Springer US; 2007. p. 219\u0026ndash;238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStough LM, Kang D, Lee C. The SEND Project: engaging students with disabilities in emergency preparedness. J Emerg Manag. 2016;14(4):259\u0026ndash;269.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig A, Tran Y, Middleton J, Cameron I. Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord. 2015;53(8):650\u0026ndash;657.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy P, Lude P, Taylor N. Quality of life, social participation, appraisals and coping post spinal cord injury: a review. Spinal Cord. 2010;48(5):255\u0026ndash;265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonanno GA, Brewin CR, Kaniasty K, La Greca AM. Weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities. Psychol Sci Public Interest. 2010;11(1):1\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePost MWM, van Leeuwen CMC. Psychological factors and quality of life after spinal cord injury: a review of literature. Spinal Cord. 2012;50(8):597\u0026ndash;604.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalea S, Nandi A, Vlahov D. The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev. 2005;27(1):78\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: part II. Summary and implications of the disaster mental health research. Psychiatry. 2002;65(3):240\u0026ndash;260.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTate DG, Forchheimer MB, Krause JS. Psychological health and resilience in people with spinal cord injury: a narrative review of the literature. NeuroRehabilitation. 2014;35(1):99\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeter C, M\u0026uuml;ller R, Cieza A. Determinants of quality of life in people with spinal cord injury: a review of the literature. Spinal Cord. 2012;50(8):587\u0026ndash;595.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan RCK, Lee TMC, Lieh-Mak F. Cognitive and emotional disturbances after spinal cord injury: a review of recent literature. Clin Neuropsychol. 2009;23(6):1064\u0026ndash;1081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeter C, M\u0026uuml;ller R, Post MWM, van Leeuwen CMC. Impact of physical and psychosocial factors on functioning in persons with spinal cord injury in the Netherlands. Arch Phys Med Rehabil. 2014;95(6):1023\u0026ndash;1030.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTartakovsky E. Psychological well-being and social support among immigrants from the former Soviet Union in Israel. Int J Psychol. 2016;51(5):325\u0026ndash;333.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020;383(6):510\u0026ndash;512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World Report on Disability. Geneva: WHO Press; 2011.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6709953/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6709953/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eStudy design\u003c/b\u003e: A cross sectional study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective\u003c/b\u003e: This study aimed to assess the earthquake experiences, perceived safety, and psychological impact\u0026mdash;specifically anxiety and post-traumatic stress levels\u0026mdash;among individuals with SCI following the 6.2-magnitude Istanbul earthquake on April 23, 2025.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSetting\u003c/b\u003e: A tertiary referral hospital in Istanbul, Turkey, where hospitalized and community-dwelling individuals with spinal cord injury (SCI) were evaluated on the fifth day following the April 2025 earthquake.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: A total of 64 participants, including hospitalized SCI patients (n\u0026thinsp;=\u0026thinsp;19), community-dwelling SCI patients (n\u0026thinsp;=\u0026thinsp;22), and healthy controls (n\u0026thinsp;=\u0026thinsp;23), were evaluated within five days of the disaster. Demographic data, housing characteristics, and disaster experiences were recorded. Psychological assessment included the Beck Anxiety Inventory (BAI), the Impact of Event Scale-Revised (IES-R), and a 10-item perceived safety scale.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: SCI participants had significantly higher BAI scores compared to healthy individuals (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Hospitalized SCI patients reported lower anxiety levels than their community-dwelling counterparts. No significant differences were found regarding mobility level, location (European vs. Asian side), building age, or number of floors. A strong correlation was observed between anxiety and post-traumatic stress symptoms (r\u0026thinsp;=\u0026thinsp;0.770, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: SCI individuals are more psychologically affected by earthquakes than healthy peers, regardless of functional independence or physical environment. Hospitalization during disaster may offer protective psychological benefits. These findings highlight the importance of integrating psychosocial support and tailored disaster preparedness strategies for individuals with SCI.\u003c/p\u003e","manuscriptTitle":"Psychosocial Impact and Anxiety Determinants in Individuals with Spinal Cord Injury Following the April 2025 Istanbul Earthquake: Perceptions of Safety and Early Post-Disaster Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-08 14:04:18","doi":"10.21203/rs.3.rs-6709953/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-06-26T14:43:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-06-12T05:58:00+00:00","index":1,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-06-11T11:56:16+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-06-11T07:23:15+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-06-09T00:54:04+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-06-04T17:27:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T16:25:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Spinal Cord","date":"2025-05-21T16:01:41+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2025-05-21T14:12:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-20T17:10:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9dcff8d7-1828-49d7-9c66-2dea6fdeacd5","owner":[],"postedDate":"June 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":49540839,"name":"Health sciences/Anatomy/Musculoskeletal system/Skeleton"},{"id":49540840,"name":"Health sciences/Neurology/Neurological disorders/Spinal cord diseases"}],"tags":[],"updatedAt":"2025-10-04T07:05:49+00:00","versionOfRecord":{"articleIdentity":"rs-6709953","link":"https://doi.org/10.1038/s41393-025-01122-9","journal":{"identity":"spinal-cord","isVorOnly":false,"title":"Spinal Cord"},"publishedOn":"2025-10-04 04:00:00","publishedOnDateReadable":"October 4th, 2025"},"versionCreatedAt":"2025-06-08 14:04:18","video":"","vorDoi":"10.1038/s41393-025-01122-9","vorDoiUrl":"https://doi.org/10.1038/s41393-025-01122-9","workflowStages":[]},"version":"v1","identity":"rs-6709953","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6709953","identity":"rs-6709953","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}