Secondary Complications of Multiple Systems
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 and 5 longitudinal studies on secondary health complications after SCI are reviewed.
Author Year; Country Date included in the review Total Sample Size Level of Evidence Type of study Score |
Methods | Outcome |
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Jensen et al. 2013; USA Reviewed published articles from 1986 to 2011 N=92 Methodological quality not assessed Type of study: Systematic Review AMSTAR: 3 |
Method: Searches of electronic databases for studies published in English from 1986–2011 that provided information regarding the prevalence, course or associations with age and duration of secondary health conditions in human adults (>18 yrs of age) with SCI. No interventions studied. Outcome Measures: frequency or prevalence, severity, time course, and/or age and duration of effects of a health condition. Databases: PubMed, CINAHL, PsycINFO. |
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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.
Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
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Adriaansen et al. 2016; The Netherlands Level 5 Cross-sectional N=282 |
Population: 282 participants with SCI acquired between 18-35 years of age and ≥10 YPI, current age 28-65 years; 74% male, 26% female; 3 groups: TSI 10-19 years n=107, TSI 20-29 years n=96, TSI ≥30 years n=79 Age (years), mean (SD): 48.3 (8.9); mean TSI (years): 22.0 (range 16.8-30.3); Cervical 41%, thoracic 53%, lumbar 6%; AIS A 69%, AIS B 14%, AIS C 10%, AIS D 8% Methodology: Random samples of eligible participants were drawn from 8 Dutch rehabilitation centers. Participants completed a self-report questionnaire about secondary health conditions. Outcome Measures: Occurrence of 13 secondary health conditions (SHCs): neuropathic pain, musculoskeletal pain, pressure ulcers, problematic spasticity, autonomic dysreflexia (AD), hypotension, oedema, neurogenic heterotopic ossification (NHO), pneumonia, urinary tract infection (UTI), urinary incontinence, faecal incontinence, constipation; International SCI QoL Basic Data Set; Spinal Cord Independence Measure III (SCIM-III) |
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January et al. 2014; USA Level 2 Longitudinal N=214 |
Population: N=214 (133 M, 81 F); mean age at injury (y) = 13.93±4.37 (range 0-18); Duration of injury (y) = 15.05±6.21 (range 5-34) Injury characteristics: Paraplegia (n=90), tetraplegia (n=124); complete (n=151), incomplete (n=60) Work & relationship status: Unemployed (n=70), employed (n=98), student (n=46); married (22.9%), not married (77.1%) Methodology: A survey was given over a period of 2 to 9 years (between 2000-2013) with an annual follow up to investigate the prevalence of depressive symptoms in adults who sustained a SCI before 19 years of age and to explore potential risk factors that may be associated with elevated symptoms. Outcome Measures: Craig Handicap Assessment and Reporting Technique (CHART), Patient Health Questionnaire-9 (PHQ-9), Functional Independence Measure (FIM) |
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Finnerup et al. 2016; Denmark & Sweden Level 2 Longitudinal N=81 |
Population: 81 people with SCI (88% M, 12% F); mean age at follow up (y) = 51.8±15.9 (range 21-80); mean TSI (y) = 3.5±0.6 SCI impairment: Complete (30%), incomplete (68%), paraplegia (42%), tetraplegia (56%), Methodology: Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and were given questionnaires at 3 months after injury (baseline), 6, 12 and 42 months following SCI to examine presence of pain and psychological function. Outcome Measures: Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index (MHI-5) and the 6-item Catastrophizing scale (CSQ-CAT) were used |
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Jorgensen et al. 2016; Sweden Level 5 Cross-sectional N=123 |
Population: 123 participants with SCI (71% M, 29% F), mean age (y)=63±9 (range 50-89), mean YPI=24±12 (range 10-56); Tetraplegia AIS A-C (n=22), paraplegia AIS A-C (n=41), all AIS D (n=60) Methodology: Data was collected from the participants’ medical records, and through structured interviews and assessments in their homes to describe secondary health conditions, activity limitations, and life satisfaction in older adults with long-term SCI and to investigate how sociodemographics, injury characteristics, and secondary health conditions are associated with their activity limitations and life satisfaction. Outcome Measures: Bowel and bladder function, nociceptive and neuropathic pain, spasticity, the Spinal Cord Independence Measure, third version, and the Satisfaction With Life Scale. |
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Murray et al. 2016; USA Level 5 Cross-sectional N=187 |
Population: 187 people with SCI (62% M); mean age (y)=34.3±7.4 (range 19-52); mean age at injury (y)=14.1±4.5 (range 0-19); mean TSI (y)= 20.2±8.5 (range 1-45); tetraplegia (56.1%), paraplegia (43.9%) Methodology: Participants who sustained an SCI before 19 years of age and received care at the Shriner’s Hospital for Children, but who were ≥19 years old during the study period completed interviews to determine medical and psychological correlates of pain in adults with pediatric-onset SCI. Outcome Measures: Beck Anxiety Inventory, Patient Health Questionnaire-9, pain intensity scale (11-point NRS) |
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Smith et al. 2016; USA Level 2 Longitudinal Ntotal=1594 |
Population: 1594 participants (64% F) that included people with SCI (n=414), MD (n=282), MS (n=509), and PPS (n=389); Mean age (y)=56.0±12.9 (range 20-94); mean disability duration (y)=15.3±10.5 Methodology: Survey questions were sent out to assess demographics and self-reported diagnosis of chronic comorbid medical conditions (CCMC) twice, 3.5 years (T1 and T2) apart, to study the incidence, prevalence, age of onset and predictors of five chronic conditions in a sample of adults with long-term physical disabilities (MS, MD, PSS, or SCI). Outcome Measures: Self-reported diagnosis of 5 CCMC’s: coronary heart disease, hypertension, arthritis, diabetes and cancer, and health behaviors (alcohol use, smoking, physical activity). |
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Yeh et al. 2016; Taiwan Level 2 Longitudinal NSCI=10,125 Ncontrol=10,125 |
Population: 10,125 people with SCI (50% F): mean age (y)=56.3±17.8 (range 20-90) Methodology: A total of 10,125 people with at least 2 ambulatory visits with a diagnosis of SCI in 2001 were enrolled in the SCI group. The non-SCI group comprised 10,125 propensity score-matched (age, gender etc) people without SCI. The median follow-up time was 30.4 months to investigate whether people with SCI are at an increased risk of developing Parkinson’s disease (PD) |
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Lin et al. 2015; Taiwan Level 2 Longitudinal NSCI=11 913 Ncontrol=59 565 |
Population: 11,913 persons with SCI (48.8% F): mean age (y)=56.0±17.9 (range 20-90) Methodology: The SCI group consisted of individuals who had received a diagnosis of SCI in ambulatory medical care between January 1, 2001 and December 31, 2001. For every SCI subject, there were 5 propensity score-matched non-SCI controls to determine whether patients with SCI are at a higher risk for developing multiple sclerosis (MS) after a median follow-up time of 30.6 months. |
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Saunders et al. 2015; USA Level 5 Cross-sectional N=1678 |
Population: 1678 people with SCI (74% M); mean age (y)=48.4±13.3, mean YPI=15.9±9.9; high tetraplegia (<10%), low tetraplegia (25.4%), paraplegia (33.6%), 31.2% ambulatory regardless of injury level Methodology: Mail-in surveys were distributed to perspective participants recruited from a large specialty rehab hospital to assess the lifetime prevalence of 7 chronic health conditions (CHCs) among a cohort of adults with traumatic SCI. Outcome Measures: CHCs measured using questions from Behavioral Risk Factor Surveillance System (BRFSS) for diabetes, heart attack, angina/coronary artery disease, stroke, hypertension, high blood cholesterol, or cancer |
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Chung et al. 2014; Taiwan Level 2 Longitudinal NSCI=47,916 Ncontrol= 191,664 |
Population: A total of 47,916 SCI patients (62.7% men, mean age of 50.0 y) and 191,664 controls were followed for 308,266 and 1,341,169 person-years, respectively. 51% were younger than 50 years old, 21.6% were between 50-65, and 27.4% were older than 65. Methodology: The entire hospitalized population in Taiwan for the 1998–2008 period was studied, with a follow-up period extending to the end of 2010. SCI patients were identified using the Taiwan National Health Insurance Research Database (NHIRD) to assess the risks of deep vein thrombosis (DVT), pulmonary thromboembolism (PE), and other comorbidites. Outcome Measures: Risk of DVT and PE, comorbidities: atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accident, congestive heart failure, lower leg fracture/surgery, cancer. |
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Hwang et al. 2014; USA Level 2 Longitudinal N=351 |
Population: 351 participants with SCI (226 M, 125 F); at initial interview: mean age (y) = 26.7; mean duration of injury (y) = 12.9; mean age at injury (y) = 13.8 (range 0-18) C1-4 ABC (14.8%), C5-8 ABC (35.9%), T1-S5 ABC (38.7%), AIS D (9.7%) Methodology: To determine longitudinal changes in the occurrence of medical complications in adults with pediatric-onset SCI, participants who sustained an SCI before 19 and who were ≥23 years during the study period were followed annually between 1996 and 2011 through interviews. Outcome Measures: A total of 1793 interviews were conducted. Generalized estimating equation (GEE) models were used to obtain the odds ratio (OR) of having a medical complication over time. |
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Molton et al. 2014; USA Level 5 Cross-sectional Ntotal=521 NSCI=239 |
Population: Younger aged (61 M, 87 F): 87 people with SCI and 61 people with MS; years since onset=10.6±6.6; Middle aged (120 M, 189 F): 127 people with SCI and 182 people with MS; years since onset=17.4±9.9; Older aged (31 M, 33 F): 25 people with SCI and 39 people with MS; years since onset=22.7±13.0 Methodology: Individuals with either MS or SCI experiencing chronic pain were recruited through disability specific registries at the University of Washington and given surveys to complete. Outcome Measures: Pain severity (11-point NRS), Patient Reported Outcomes Measurement Information System (PROMIS), Pain Interference Short Form (PRO-PI-SF), Patient Health Questionnaire-9 (PHQ-9), Primary Care Evaluation of Mental Disorders (PRIME-MD) |
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Molton et al. 2014; USA Level 5 evidence Cross-sectional Ntotal=1862 NSCI=492 |
Population: 340 people with MD (42.1% M), mean age (y)=53.2 (range 20-89); mean years since diagnosis=14.7±11.5 584 people with MS(17.5% M), mean age (y)=54.5 (range 21-84); mean years since diagnosis=15.3±10.1 446 people with PPS (24.7% M), mean age (y)=67.2 (range 41-94), mean years since diagnosis=16.1±10 492 with SCI (66.7% M), mean age (y)=50.0 (range 21-88), mean years since diagnosis=16.0±10.9; cervical (49.2%), thoracic (47.8%), lumbar (16.1%), sacral (1.4%) Methodology: Participants living with MS, SCI, MD, or PPS were recruited and completed an ongoing longitudinal survey to test a conceptual model of SHCs, age, and function in persons aging with long-term physical disabilities. |
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Molton et al. 2014; USA Level 5 Cross-sectional w/ AB Ntotal=910 |
Population: 910 total participants with disabilities; mean age (y)=53.3; mean time living with disability (y)=15.2 239 people with SCI. Methodology: Participants living with SCI, MS, PPS, or MD were mailed a survey asking them to describe rates of pain and pain interference. Outcome Measures: Patient Reported Outcomes Measurement Information System (PROMIS): pain severity, pain interference, other secondary symptoms (eg. Fatigue, physical function, mobility, depression, sleep) and health conditions (eg. Recent relapse, skin problems, UTI) |
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Ullrich et al. 2013; USA |
Population: 286 veterans with SCI (97% male): Age (yrs): mean 53; Duration of injury (yrs): mean 17; Type of SCI: 49% paraplegia, 38% low tetraplegia, 13% high tetraplegia; 46% complete. Methodology: 3 standardized annual psychological evaluations given to participants were reviewed. Administrative databases were used to collect SCI specialty care utilization data. Participants were categorized as having elevated pain, elevated depression, both elevated pain and depression, or neither elevated, using cut-off scores on the pain and depression scales. Outcome Measures: Center for Epidemiological Studies Depression Scale (CES-D), Numerical Rating Scale (NRS) for pain, medical comorbidities, SCI specialty care utilization. |
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Pershouse et al. 2012; Australia |
Population: 270 persons with traumatic SCI (81% male); mean (SD) age in yrs: 43.3(11.4), range 20-76; mean (SD) age at injury in yrs: 27.3(9.7). Methodology: Data were collected via telephone interviews and written questionnaires annually over 5 years, between 2004 and 2008, across 6 strata comprising participants grouped according to time since injury (<5y, 5–9y, 10–14y, 15–19y, 20–24y, ³25y). Outcome Measures: Secondary Conditions Surveillance Instrument (SCSI) |
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Saunders et al. 2012; USA |
Population: 801 adults with traumatic SCI; mean (SD) age in yrs at Time 1 of survey: 44.8(13.8); mean (SD) YPI in yrs at Time 2: 23(10.6). Methodology: There were 2 data collection time points: the first between 2002 and 2004 (Time 1) and second between 2007 and 2009 (Time 2). There were 1543 participants at Time 1 and of those, 993 participated at Time 2; Using information from participants who had valid depression scores at both time points (n=801), change in probable major depression (PMD) status was assessed between the two time points. Outcome Measures: Older Adult Health and Mood Questionnaire (OAHMQ). |
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Hitzig et al. 2010; Canada |
Population: 344 participants with SCI (293M 51F); 62 incomplete tetraplegia, 81 complete tetraplegia, 92 incomplete paraplegia, 109 complete paraplegia; age range 24-86 yrs; YPI 7-58. Treatment: AT Jousse Long-Term Follow-Up Questionnaire administered over the telephone during 1995-1997 (time 1) and 2003-2004 (time 2). Data collected on socio-demographics, mortality, impairment, health status, secondary health concerns and mobility. Outcome Measures: Chi square analyses, dependent samples t-test. |
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Charlifue et al. 1999; USA |
Population: 315 individuals with SCI, mean(SD) age 37.1(0.6) yrs, mean(SD) YPI 9.3(0.2). Methodology: Participants studied initially at their 5th, 10th, and 15th anniversaries post-injury and subsequently 5 yrs later at their 10th, 15th, and 20th anniversaries post-injury. Outcome Measures: Physical and psychosocial status. |
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Charlifue et al. 1999; USA |
Population: 315 individuals with SCI, mean(SD) age 37.1(0.6) yrs, mean(SD) YPI 9.3(0.2). Methodology: Participants studied initially at their 5th, 10th, and 15th anniversaries post-injury and subsequently 5 yrs later at their 10th, 15th, and 20th anniversaries post-injury. Outcome Measures: Physical and psychosocial status. |
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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.
Conclusion
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.