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Secondary Complications of Multiple Systems

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Most individuals with SCI will develop a variety of secondary complications (Jensen et al. 2013). Common complications include pain, bowel and bladder regulation problems, muscle spasms, fatigue, esophageal symptoms, osteoporosis, cardiovascular disease, diabetes, and respiratory complications or infections (Jensen et al. 2013). As secondary health conditions negatively affect community re-integration and quality of life, the influence of the aging process on these conditions is important to consider in their management. While specific conditions have been described in previous sections (e.g. pain, bowel and bladder regulation, genitourinal and gastrointestinal problems, bone, cardiovascular disease and endocrine problems, and respiratory complications) the below section describes studies with general measures of secondary health complications or multiple health conditions, including physical and mental health (e.g. depression, fatigue and spasticity).

In this section, 1 systematic review (see Table 10) and 5 longitudinal studies (see Table 11) on secondary health complications after SCI are reviewed.

Table 10: Systematic Review of Secondary Complications of Multiple Systems

In this scoping review that examined the association between age and secondary health complications post SCI, Jensen et al. (2013) report seven key findings (i.e. evidence that is reported in at least two studies): 1) bladder problems are not associated with duration of injury; 2) spasms are not associated with duration of injury; 3) cardiovascular disease is more prevalent in older individuals; 4) diabetes is more prevalent in older individuals; 5) bone mineral density loss is higher in both older individuals and in individuals with longer duration of injury; 6) fatigue is more commonly reported by older individuals; and 7) respiratory complications/infections are more prevalent in older individuals.

The authors concluded that older age and longer SCI duration are associated with more frequent and severe health conditions. These findings support the belief that premature aging may be occurring in individuals with SCI.

The following reviews additional papers studying aging and secondary health complications after SCI.

Table 11: Aging and Secondary Health Complications after SCI

Discussion

Premature aging with a number of different organ systems appears to lead to the higher prevalence of a number of secondary health conditions compared to the normative population (Jensen et al. 2013).  Of concern is that more medical attention is required over time to address these secondary health complications (Krause et al. 2013).  As with the general population (Roy & Thomas 1986; Gaston-Johansson et al. 1996; Poluri et al. 2005), issues of fatigue and pain can limit the independence of a person with SCI.  Fatigue can be defined as an overwhelming sense of tiredness, lack of energy and often a feeling of total exhaustion (Herlofson & Larsen, 2002). Fatigue after SCI is a prevalent issue (Gerhart et al. 1999; McColl et al. 2003; McColl et al. 2004; Fawkes-Kirby et al. 2008). The findings on the associations between age and fatigue after SCI have been somewhat conflicting. For example, one study found that males with SCI reported an increased fatigue with increasing age (Pentland et al., 1995), whereas some have found greater reports of fatigue in younger persons with SCI with short duration of injury (McColl et al. 2003).

Both pain and fatigue have been both found to negatively impact on several domains of function and QoL (Rintala et al. 1998; Ingles et al. 1999; Herlofson & Larsen 2002). As well, there is some evidence of a relationship between fatigue and pain after SCI (Fawkes-Kirby et al. 2008). When examined together, the study by Charlifue and colleagues (1999) and by Putzke and colleagues (2002a) highlight chronological age as a factor that mediates the expression and/or onset of change. In the study by Charlifue et al. (1999), the youngest and oldest group reported no significant changes in fatigue between Time 1 and Time 2. Similarly, in the study by Putzke et al. (2002a) the youngest and oldest group reported the least amount of pain interference between Year 1 and Year 2; however, overall, older individuals were significantly more likely to report pain in both years than younger individuals with SCI. In terms of the influence of pain and the interference of pain on QoL over time, Putzke et al. (2002a) found that those individuals who experienced increased interference over time had decreased life satisfaction scores, whereas those whose interference subsided had increased life satisfaction. Similarly, Stensman (1994) observed over 5 years that individuals with variable pain experienced fluctuating global QoL, those with constant pain experience consistently low QoL, and those with no or little pain had consistently high or improvements to an initially low QoL over time.

The finding by Charlifue and colleagues (1999) that increasing age is associated with increased fatigue and additional physical assistance is congruent with other studies examining the effects of long-term SCI (e.g. Gerhart et al. 1993; Thompson, 1999; Liem et al. 2004). A limitation noted by Charlifue et al. (1999) was that their sample was relatively ‘young’ (M= 37.1 years), and none having lived with their SCI for more than 20 years (M= 9.3), and may not have aged enough to significantly affect overall health and functional status. However, the consistent findings for increased fatigue between Time 1 and Time 2 do highlight that there is a consistent physical decline occurring. Charlifue and colleagues (1999) recognized the systematic changes in their sample (i.e. improved health but declining functionality) but attributed them to external factors such as less contact with the healthcare system, funding changes, which lead to fewer participants reporting particular outcomes. As well, they noted the need for increased physical assistance over time in their sample may have reflected attitude changes in rehabilitation practice where maintaining functionality is preferred over complete physical independence. Although the strength of the study is its provision of several perspectives to aging with a SCI, an alternative analysis strategy might have helped to provide a more cohesive model of how the factors assessed related to one another. For instance, the increases in physical assistance between Time 1 and Time 2 were often accompanied with improvements in health but also with increases in fatigue. Reporting on associations (or lack of) between these variables may have provided additional support for their conclusions.

Conclusions

There is Level 3 evidence (Jensen et al. 2013) from a scoping review that cardiovascular disease, diabetes, bone mineral density loss, fatigue and respiratory complications or infections occur with higher frequency in older individuals or those with longer SCI duration, relative to younger individuals or those with shorter SCI duration.

There is Level 4 evidence (Ullrich et al. 2013) from one longitudinal study that co-occurrence of pain and depression is common among persons who have lived with SCI for many years and remains stable over time. There is also evidence that comorbid pain and depression are associated with higher severity of conditions, more persistent conditions over time, and more utilization of SCI specialty health-care services.

There is Level 4 evidence (Hitzig et al. 2010; Pershouse et al. 2012) that secondary health complications increase over time in persons with SCI, (with the exception of bowel problems, which decrease).

There is Level 4 evidence from a longitudinal study (Charlifue et al. 1999) that fatigue and the need for physical assistance increases over time with SCI.

  • Fatigue and the need for physical assistance may increase over time with SCI.

    The number of secondary health complications increase with more years post injury.

    The incidence and severity of UTIs decrease over time in persons with SCI and prevalence of pressure sores remain stable.

    The co-occurrence of pain and depression is common in persons who have lived with SCI for many years.