J Rehabil Med 2013 Epub ahead of print

ORIGINAL REPORT

Secondary health conditions in persons with spinal cord
injury: a longitudinal study from One to Five Years postdischarge
Jacinthe J. E. Adriaansen, MD1, Marcel W. M. Post, PhD1, Sonja de Groot, PhD2,3,
Floris W.A. van Asbeck, MD, PhD4, Janneke M. Stolwijk-Swüste, MD, PhD3, Marga Tepper,
MD5 and Eline Lindeman, MD†, PhD1
From the 1Rudolf Magnus Institute of Neuroscience and Center of Excellence for Rehabilitation Medicine, University
Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, 2Center for Human Movement Sciences, Universityof Groningen, University Medical Center Groningen, Groningen, 3Amsterdam Rehabilitation Research Center, Reade,
Amsterdam, 4Spinal Cord Injury Department De Hoogstraat Rehabilitation, Utrecht and 5University of Groningen,
University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands

Objective: To assess the occurrence of secondary health conditions and their potential risk factors in persons with spinal
cord injury from 1 to 5 years after discharge from initial
inpatient rehabilitation.
Design: Multicentre longitudinal study.
Subjects: A total of 139 wheelchair-dependent persons withspinal cord injury.
Methods: The occurrence of secondary health conditions andtheir potential risk factors were assessed in a clinical interview with a rehabilitation physician at 1 and 5 years after
discharge from inpatient rehabilitation and by a telephoneinterview 2 years after discharge. Self-report questionnaires
were used for the assessment of musculoskeletal and neuropathic pain.
Results: Neuropathic pain (83.7–92.1%), musculoskeletal
pain (62.3–87.1%) and urinary tract infection (56.5–58.9%)
were the most frequently reported secondary health conditions. The occurrence of several secondary health conditions
was higher among women and individuals with a complete
lesion, tetraplegia, and with a higher body mass index.
Conclusion: Secondary health conditions are common in thefirst years post-discharge following spinal cord injury, andtheir course seems to be relatively stable. These results emphasize the number of health issues that must be consideredduring post-injury care of persons with spinal cord injury
living in the community, and the importance of a wellcoordinated interdisciplinary approach from specialized rehabilitation centres.
Key words: spinal cord injury; secondary health conditions; risk
factors; rehabilitation; longitudinal.
J Rehabil Med 2013; 45: 00–00
Correspondence address: Marcel W. M. Post, De Hoogstraat
Rehabilitation, PO Box 85238, 3508 AE Utrecht, The Netherlands. E-mail address: m.post@dehoogstraat.nl
Accepted Apr 15, 2013; Epub ahead of print Oct 3, 2013

J Rehabil Med 45

Introduction
Persons with spinal cord injury (SCI) often face serious healthproblems, such as bladder and bowel disorders, pressure ulcers
and neuropathic pain. These secondary health conditions (SHCs)
have been defined as: physical or psychological health conditions
that are influenced directly or indirectly by the presence of adisability or underlying physical impairment (1). SHCs hamper
an active lifestyle and quality of life on top of the primary motorand sensory impairments due to the SCI (2). They are a frequentcause of mortality and rehospitalizations (3–6).
Few prospective studies have provided a longitudinal
perspective on the occurrence of SHCs in persons with SCI(7–9). Other studies have compared the occurrence of SHCs
between groups with different times since injury (TSI), but ina cross-sectional design (10–14).
One study is available in which persons with SCI participated in telephone interviews on SHCs at their first, third andfifth year post-injury (7). The most frequently reported SHCs
were problematic spasticity (34%, 31% and 28%, respectively)
and musculoskeletal pain (28%, 29% and 36%, respectively).
However, assessment of SHCs by self-report was a limitationof this study.
Some other studies collected their data through objective
assessments (8, 9, 11, 12). Two of these studies utilized the
National Spinal Cord Injuries Statistical Center (NSCISC)(8, 11). The NSCISC collects data through a combination ofannual medical history interviews and physical examinations.
The 2 studies reported on different SHCs. In the longitudinal
study (8), with a TSI of 5 years, the most frequently reported
SHCs were constipation (40.0%), bowel accidents (35.3%) andupper-extremity pain (34.1%). With an occurrence of 15.2%
at the first year, 17.8% at the second year, and 19.9% at the
fifth year post-injury, pressure ulcers were the most frequently
reported SHC in the retrospective study (11).

© 2013 The Authors. doi: 10.2340/16501977-1207
Journal Compilation © 2013 Foundation of Rehabilitation Information. ISSN 1650-1977

Secondary health conditions after SCI
Risk factors for SHCs in the first years post-injury, in particular SCI-related, have been investigated by previous studies.
Not surprisingly, persons with a complete lesion and tetraplegia
are most at risk for many SHCs (8–13, 15, 16). Higher age (9,11, 16), female gender (9, 12, 13), male gender (9, 11, 12),higher body mass index (BMI) (9), traumatic injury (9) andsmoking (9) are other identified risk factors.
Although differing in design and used methods these studies
emphasize the number of health issues that must be consideredduring the post-injury care.
The Dutch research programme on the restoration of mobility, “The Umbrella Project”, a prospective cohort study (17),provided the first objective information on the occurrence,course and risk factors of SHCs in the Netherlands, from thestart of inpatient rehabilitation until 1 year after discharge
from inpatient rehabilitation (9). During that follow-up period
most participants experienced neuropathic and musculoskeletal
pain, or spasticity. Increased age, higher BMI, traumatic lesion,tetraplegia and complete lesion were identified as risk factors
for SHCs. Knowledge on the course of SHCs during a longer
follow-up period is, however, needed to develop preventive
strategies and to improve treatment programmes for SHCs.
The present study assesses the occurrence of SHCs using datafrom The Umbrella Project at 1, 2 and 5 years after discharge
from inpatient rehabilitation. Research questions were:• What is the occurrence of SHCs (pressure ulcers, heterotopic
ossification, urinary tract infection (UTI), pulmonary infection, autonomic dysreflexia (AD), hypotension, oedema,problematic spasticity, neuropathic pain, musculoskeletal
pain and cardiovascular disorders) in persons with SCI 1, 2
and 5 years after discharge from inpatient rehabilitation?
• Are demographic (age, gender), lifestyle (smoking, bodymass index), or SCI-related (aetiology, level, completeness)variables risk factors for these SHCs?

Methods
Details on The Umbrella Project are provided elsewhere (17). In short:persons were recruited in all 8 rehabilitation centres with specialized
SCI units in the Netherlands between August 2000 and July 2003.
Inclusion criteria were: (i) recently acquired SCI; (ii) age between
18 and 65 years; (iii) grade A, B, C, or D on the American Spinal
Injury Association (ASIA) Impairment Scale (AIS); (iv) sufficientunderstanding of the Dutch language; and (v) expected to remain
wheelchair-dependent, at least for longer distances. This choice wasmade because The Umbrella Project was focused on restoration ofwheeled mobility, and the core physical tests were to be performed ina wheelchair. Exclusion criteria were: (i) a SCI caused by a progressive
disease (e.g. malignant tumour, multiple sclerosis); (ii) a progressive
disease (e.g. Parkinson's disease, progressive neuromuscular disorder);and (iii) psychiatric problems.
Approval of the research protocol was obtained from the Medical
Ethics Committee of the SRL/iRv Hoensbroeck and the Medical Ethics
Committee of the University Medical Center Utrecht. All participants
gave written informed consent prior to participation.
Procedure
Data from 3 measurement occasions were used for the present study: 1
year (T1), 2 years (T2) and 5 years (T3) after discharge from inpatient
rehabilitation.

1017

The measurements relevant for this study comprised a consultation
by a SCI rehabilitation physician, including a physical examination
at T1 and T3, a structured telephone interview by a trained research
assistant at T2, and a self-report questionnaire for the assessment ofneuropathic pain and lifestyle habits at all 3 measurement occasions.
A self-report questionnaire on musculoskeletal pain was only included
at T1 and T3. Assessment of the occurrence of SHCs was part of theconsultation at T1 and T3 and part of the telephone interview at T2.
Secondary health conditions
The occurrence of a SHC was assessed over the last 12 months andreported as 0 = no occurrence over the last 12 months, or 1 = currently
present or has occurred in the last 12 months. The SHCs assessed
this way were: pressure ulcers, problematic spasticity, UTIs, pulmonary infections, heterotopic ossification, oedema, hypotension, AD,musculoskeletal and neuropathic pain. Cardiovascular disorders weregrouped and included conditions such as myocardial infarction or
aortic valve stenosis.
When a participant indicated that he or she had a pressure ulcer in thepast 12 months, the rehabilitation physician asked further questions on
the location and the severity of the ulcer according to the classificationof the European Pressure Ulcer Advisory Panel (EPUAP): grade I, II,
III or IV (18). All pressure ulcers, irrespective of grade, were included.
The occurrence of problematic spasticity during certain activities
was assessed for: sleeping, the execution of a transfer, washing oneself and clothing, wheelchair propulsion, and other daily activities.
Answers were registered as follows: 0 = no discomfort caused byspasticity, 1 = some discomfort caused by spasticity, and 2 = muchdiscomfort caused by spasticity. Problematic spasticity was registeredwhen a participant scored much discomfort caused by spasticity forat least one activity.
UTI was operationalized as a symptomatic UTI (e.g. fever, malaise,incontinence, increased spasms of legs, abdomen or bladder, gritty
particles or mucus in the urine or cloudy urine, foul-smelling urine)
which was treated with antibiotics. Pulmonary infections were also
only included when they were treated with antibiotics.
Heterotopic ossification was defined as the presence of bone insoft tissue surrounding paralysed joints confirmed by radiologicalexamination.
Oedema was scored when the participant had received treatment(e.g. compression stockings, bandages, tubigrip, diuretic medication).
The occurrence of hypotension was checked by the assessment ofsymptoms (e.g. light-headedness or dizziness, fainting).
AD was defined as a sudden reaction of the autonomic nervous
system triggered by a stimulus below the level of the lesion (e.g.
bladder distension, UTI) which caused an increase in blood pressure
associated with symptoms such as: (i) below the level of the lesion:piloerection, pallor, cool extremities, profuse sweating; (ii) above thelevel of the lesion: severe headaches, nasal congestion, flushing of
the skin and bradycardia. When the occurrence of AD was checkeda description of AD with the most common associated symptoms, as
described above, was given.
Standardized questions on the nature of pain were completed when
the participant reported having pain. Musculoskeletal pain was defined
as nociceptive pain originating from bone, joint or muscle trauma or
overuse (19). Thirteen locations on the upper and lower limbs, backand neck were scored with a 5-point scale (ranging from 1: “not severe”
to 5: “very severe”). A sum score was made by adding up the scoresfor the 13 locations. Sum scores ranged from 1 to 65. The occurrenceof musculoskeletal pain was only registered at T1 and T3. Severe
musculoskeletal pain was defined as having scored severe pain or very
severe pain in at least one location.
Neuropathic pain was defined as at-level or below-level pain originating from syringomyelia, spinal cord ischaemia or trauma (19). The
presence (yes/no) and severity of 8 neuropathic pain characteristics(other pain than musculoskeletal pain, numbness, itching, tingling,
cold, warm, girdle zone pain and phantom feeling) were assessed using
a 5-point scale (ranging from 1: “not severe” to 5: “very severe”). A
J Rehabil Med 45

1018

J. J. E. Adriaansen et al.

sum score was made by adding up the scores of all 8 neuropathic paincharacteristics. Sum scores ranged from 1 to 40. Severe neuropathic
pain was defined as having scored at least one characteristic as severeor very severe.
Potential risk factors
We selected potential risk factors based on Haisma et al. (9): age, gender, smoking status (smoker vs non-smoker), BMI, aetiology (traumaticvs non-traumatic), level of the lesion (paraplegia vs tetraplegia) andcompleteness of the lesion (motor complete vs motor incomplete).
Tetraplegia was defined as a lesion at or above the first thoracic segment, and paraplegia as a lesion below the first thoracic segment. A
complete lesion was diagnosed in the absence of motor and sensory
function in the sacral segments, i.e. ASIA Impairment Scale grade A.
AIS grades B, C, and D were considered incomplete (20).The assessments of BMI, level and completeness of the lesion were all part of thephysical examination performed by the rehabilitation physician at T1
and T3. Since a physical examination was not possible at T2, the dataof level and completeness of the lesion were adopted from T1. At T2,height was also adopted from T1, and body weight was asked for by
the research assistant to determine the person’s BMI.
Statistics
Only persons who completed at least 2 measurement occasions were
included in the analyses. A non-response analysis was performed bycomparing data at the start of active rehabilitation between persons
who completed the measurement 5 years after discharge with persons
who did not, using χ2 and t-tests.
Descriptive statistics of participants demographic and SCI characteristics were calculated for each measurement. Random coefficient
analyses (MlwiN version 2.02) were used to estimate the occurrenceof the SHCs and the association with the potential risk factors.
Analysis of secondary health conditions. A logistic random coefficientmodel was made for the occurrence of each SHC. Time was included asa set of 2 dummy variables with T2 as reference. The occurrence of a
SHC at T2 was estimated by the intercept: 1/{1 + exp [ – (intercept)]}.
The occurrence of a SHC at the other 2 measurement occasions wasestimated as: 1/{1 + exp [ – (intercept + regression coefficient)]} (21).
Significance was set at a p-value less than 0.05.
The severity scores for neuropathic pain were estimated with a linear
regression model. Again, time was modelled as 2 dummy variables
and the score at T2 was estimated by the intercept. The sum scoresat the other measurements were calculated by adding the intercept to
the regression coefficient of the dummy variable.
Analysis of potential risk factors. All risk factors were simultaneously
added to the previous described models. With these multivariate models, the contribution of each risk factor was corrected for. Odds ratios(ORs) for the risk factors were calculated as: OR = exp[regression coefficient]. The corresponding 95% confidence intervals were calculated
as: exp[regression coefficient ± (standard error × 1.96)].

Results

Table I. Descriptive characteristics at the start of active rehabilitation of
the participants and non-participants 5 years after discharge
ParticipantsParticipants, n
139
Age, years, mean (SD)39 (14)
Gender, % male72
Body mass index, kg/m2,
mean (SD)22.8 (3.9)
Smoker, % smoker
24
Cause, % traumatic77
Level, % tetraplegia
36
Completeness, % complete 57

J Rehabil Med 4585
43 (14)
79

0.048
0.232

22.9 (3.7)
25
67
48
38

0.869
0.793
0.109
0.070
0.006

SD: standard deviation.

for several reasons: 27 persons died, 18 refused to collaborate,
5 moved, 11 could not be contacted, and the rest had otherreasons for dropping out of the study.
Table I gives the descriptive characteristics at the start ofactive rehabilitation of the participants and the non-participantsin the measurement occasion 5 years after discharge. No significant differences between both groups were seen, except thatthe non-participants were somewhat older than the participants,
and less often had a complete lesion.
Table II gives the descriptive characteristics of the participants at all measurement occasions. Approximately one-thirdof the participants had a lesion at or above the first thoracic
segment, and approximately half of the lesions were complete.
More than three-quarters of the lesions were of traumaticorigin.
Secondary health conditions
Fig. 1 shows the estimated occurrence of a SHC at each timepoint. The most frequently reported SHCs were neuropathic
pain (83.7–92.1%) and UTIs (56.5–58.9%). Musculoskeletal
pain was reported by 62.3% at T1 and 87.1% at T3.There wasa significant decrease in the occurrence of problematic spasticity and the occurrence of neuropathic pain between 1 and2 years after discharge.
The mean severity score for neuropathic pain at T1, T2 andT3 was, respectively, 7.1, 7.6 and 9.3 points. The differencesof 2.2 points between T1 and T3 and 1.7 points between T2
and T3 were significant.
Table II. Descriptive characteristics of the 139 participants who completed
at least 2 of the 3 measurements and who were included in the analyses
1 year after 2 years after 5 years after
discharge discharge
discharge

Participants
At the start of active rehabilitation, 224 persons with SCI were
included in the study. A total of 156 persons participated 1
year after discharge from the rehabilitation centre (the present
study’s first time of assessment), 99 persons 2 years and 146
persons 5 years after discharge. Because 2 rehabilitation centres
did not participate 2 years after discharge, a lower numberof participants appeared in this measurement. A total of 139
persons completed at least 2 of the 3 measurements and were
included in the analyses. Participants were lost to follow-up

Non-participants p-value

Participants, nAge, years, mean (SD)
Gender, % male
Body mass index, kg/m2,
mean (SD)
Smoker, % smoker
Cause, % traumatic
Level, % tetraplegia
Completeness, % complete
SD: standard deviation.

139
40 (14)72

98
41 (14)75

121
44 (13)73

24.4 (4.5)
35
77
33
53

24.4 (4.8)
32
81
31
54

25.6 (4.8)
24
78
34
58

Secondary health conditions after SCI
87.1
83.7
92.1
87.1

Neuropathic pain
Musculoskeletal pain

Secondary health conditions

*

62.3
58.9
58.3
56.5
44.4
39.8
41.7
29.1
40.6
41
33.6
36.1
33.5
31.2
23.4
36.3
34.7

Urinary tract infection
Severe neuropathic pain
Pressure ulcers
OedemaProblematic spasticity
Severe musculoskeletal pain

5 years after discharge*

2 years after discharge

22.3
22.6
15.9
15.2
15.5
11.9
9
5.2
12.5
10.1
7.7
9.4
10.1
8.6
8.1
3.5

Autonomic dysreflexia
Hypotension
Heterotopic ossification
Pulmonary infection
Cardiovascular disorders
01019

1 year after discharge

10

20

30

40

50

60

70

80

90

100

Percentage

Fig. 1. The estimated occurrence of the secondary health conditions at each time of assessment: random coefficient modelling. *Significant difference(p≤0.05) between the estimated occurrence of neuropathic pain and of problematic spasticity at 1 and 2 years after discharge from inpatient rehabilitation.
Table III. Odds ratios (and 95% confidence intervals (95% CI)) for the association between secondary health conditions (SHCs) and potential risk
factors: multivariate logistic random coefficient modelling. Regression coefficients (and 95% CI) for the association between the severity score ofneuropathic pain and potential risk factors: multivariate random coefficient modelling

Cardiovascular disorders
Pulmonary infection
Heterotopic ossification
Hypotension
Autonomic dysreflexia
OedemaPressure ulcers
Urinary tract infection
Problematic spasticity
Neuropathic pain
Musculoskeletal pain
Neuropathic pain
severity scorec
Musculoskeletal pain
severity scorecAge, years
OR (95% CI)

GenderaOR (95% CI)

Smokinga
OR (95% CI)

BMI, kg/m2
OR (95% CI)

CauseaOR (95% CI)

LevelaOR (95% CI)

Completenessa
OR (95% CI)

1.01(0.96–1.06)
1.03(0.99–1.07)
0.98(0.95–1.02)
0.99(0.95–1.03)
0.99(0.96–1.01)
1.03(1.01–1.06)
1.01(0.99–1.03)
1.00(0.98–1.02)
0.99(0.97–1.02)
1.04(1.00–1.07)
0.99(0.97–1.02)
0.06(0.00–0.11)–0.03(–0.12–0.06)

2.90(0.95–8.86)
2.73(1.09–6.81)
0.30(0.09–1.04)
2.78(1.16–6.66)
0.94(0.45–1.96)
2.14(1.19–3.85)
1.48(0.76–2.56)
1.58(0.91–2.73)
1.06(0.60–1.87)
1.59(0.60–4.20)
1.86(0.91–3.83)
1.65d(0.21–3.09)
2.67(0.33–5.01)

1.66(0.45–6.09)
0.96(0.33–2.86)
0.55(0.21–1.42)
1.04(0.41–2.60)
0.64(0.29–1.40)
0.70(0.381–1.28)
0.82(0.47–1.43)
0.83(0.49–1.40)
1.06(0.60–1.87)
0.86(0.37–2.00)
0.90(0.64–1.28)–1.28(–2.73–0.17)–0.838(–3.33–1.66)

1.17(1.04–1.32)
1.10(1.00–1.22)
0.94(0.86–1.04)
0.99(0.91–1.08)
1.09(1.02–1.16)
1.10(1.03–1.16)
1.03(0.97–1.09)
1.01(0.96–1.07)
1.00(0.94–1.06)
0.98(0.90–1.07)
1.11(1.03–1.20)
0.10(–0.05–0.25)
0.07(–0.18–0.32)

0.66(0.16–2.68)
0.63(0.18–2.22)
0.70(0.17–2.82)
1.24(0.34–4.54)
1.23(0.47–3.19)
1.35(0.66–2.77)
1.42(0.72–2.82)
1.06(0.55–2.01)
1.62(0.82–3.22)
3.60(0.76–17.10)
0.83(0.37–1.88)–1.39(–3.14–0.35)
2.51(–0.26–5.28)

2.29(0.57–9.25)
0.18b(0.06–0.52)
0.87(0.35–2.15)
0.09(0.03–0.23)
0.20(0.10–0.42)
0.49(0.27–0.90)
0.70(0.40;1.23)
0.69(0.41–1.19)
0.53(0.30–0.93)
0.34(0.13–0.89)
0.98(0.49–1.94)–0.89(–2.31–0.53)–1.12(–3.53–1.30)

0.70(0.22–2.29)
1.86(0.65–5.34)
1.56(0.62–3.88)
1.31(0.52–3.33)
3.09(1.43–6.67)
3.14(1.71–5.78)
3.34b(1.92–5.83)
2.84(1.70–4.75)
1.14(0.66–1.98)
1.22(0.54–2.74)
0.76(0.40–1.47)–0.35(–1.73–1.04)–2.28(–4.64–0.08)

Significant associations (p ≤ 0.05) are printed in bold.
Gender: men = 0, women = 1; Smoking: non-smoker = 0, smoker = 1; Cause: traumatic = 0; non-traumatic = 1; Level: tetraplegia = 0, paraplegia = 1;
Completeness: incomplete = 0, complete = 1.
b
As an example is given that persons with a complete lesion were 3.3 times more at risk of a pressure ulcer, than those with an incomplete lesion;
persons with a paraplegia were 5.6 times less at risk of a pulmonary infection, than those with a tetraplegia.
cRegression coefficients (and 95% CIs) are given.
d
As an example is given that women scored their degree of neuropathic pain 1.7 points higher than men.
a

J Rehabil Med 45

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J. J. E. Adriaansen et al.

Neuropathic pain was severe for 41.7% of the participants
at T1, 39.8% at T2 and 44.4% at T3.
The mean severity score for musculoskeletal pain at T1 andT3 was, respectively, 7.1 and 10.1 points. This was a significant
difference. Musculoskeletal pain was severe for 22.3% of theparticipants at T1 and 34.7% at T3.
Risk factors
Table III gives the ORs for the associations between the potential
risk factors and the occurrence of a SHC. The most frequently
observed significant risk factors were female gender, an increasein BMI, having a tetraplegia and having a complete lesion.
Persons with a complete lesion were at increased risk forpressure ulcers, UTIs, AD and oedema. Females had, compared with males, an increased risk for the occurrence of apulmonary infection, hypotension and oedema. Persons withparaplegia were significantly less susceptible for pulmonary
infections, AD, hypotension, oedema, problematic spasticity
and neuropathic pain compared with persons with tetraplegia.
A higher BMI was significantly associated with an increased
risk of pulmonary infection, AD, oedema, musculoskeletal
pain and cardiovascular disorders.
Table III also gives the regression coefficients for the association between potential risk factors and the severity scoreof neuropathic and musculoskeletal pain. An increase in age
was associated with an increase in severity score of neuropathic pain (0.6 points per 10 years of age). Females scoredtheir severity of neuropathic pain and musculoskeletal pain
respectively 1.7 and 2.7 points higher compared with males.
Discussion
Secondary health conditions
Our study shows that at 1, 2 and 5 years after discharge from
inpatient rehabilitation neuropathic pain and UTIs were mostoften reported by the participants. Musculoskeletal pain had
a high prevalence at 1 and 5 years after discharge. However,when we took only severe complaints of neuropathic and musculoskeletal pain into consideration the rates were considerably
lower. Furthermore, we found that the prevalence of SHCs was
relatively stable in this period.
The present study was a sequel to the study by Haisma et al.
(9), who researched the occurrence of the same SHCs during
inpatient rehabilitation until 1 year after discharge. As in ourstudy, neuropathic pain was the most frequently reported SHC,
with a stable occurrence of 89–91% across measurement occasions. We also noted some differences in the occurrence of
SHCs with regard to the results of Haisma et al. We observeda slight increase in the occurrence of AD, a decrease in theoccurrence of heterotopic ossification and a slight increase in
the occurrence of cardiovascular disorders.
Differences from other studies that assessed the occurrenceof several SHCs among persons with SCI in the first years postinjury might be attributed to the use of various study designs
and data collection methods; e.g. physical examinations (12),J Rehabil Med 45

in-person interviews (11, 12), self-report questionnaires (10,16) and telephone interviews (7, 11). Furthermore, none ofthese studies explored exactly the same SHCs as we did andthere were differences in the selection procedure of the study
population. We included relatively severely spinal cord injured
persons, since they all had to be dependent on a wheelchair, atleast for longer distances. Also, the period covered by our study(the previous 12 months) is likely to increase the prevalence of
SHCs compared with studies using a shorter time-frame (e.g. at
the time of medical examination, or in the previous 4 weeks).
Since neuropathic pain, musculoskeletal pain and UTIs werethe most frequently reported SHCs we will discuss these 3
SHCs separately.
Neuropathic pain
In a longitudinal cohort study (22) at-level neuropathic pain
and below-level neuropathic pain were present in, respectively, 41% and 34% of persons with traumatic SCI in thefirst 5 years post-injury. The latest review on the occurrence
and chronicity of neuropathic pain reported a prevalence of
40% (23). Our percentages are much higher (84–92%), whichmight be explained by not making a distinction between at- or
below-level neuropathic pain. We also included a wider rangeof characteristics in our definition of neuropathic pain. When
only severe neuropathic pain is addressed, our numbers of occurrence (40–44%) are more in accordance with the literature.
Furthermore, our results are consistent with the literature, inthat those with neuropathic pain early following their injury
are likely to continue to experience ongoing pain (22–24).
Musculoskeletal pain
In a study using a similar follow-up period (22), musculoskeletal pain was present in 40% of the participants at 6 months
following SCI (compared with 62.3% at our first follow-upyear) and in 59% of the participants 5 years after SCI (compared with 87.1% in our study). They also found that, at 5
years following SCI, 25% reported their musculoskeletal pain
as severe. We found a slightly higher percentage of 34.7%.
What corresponded was the increase in musculoskeletal pain
during the 5-year follow-up period, which can be explained by
the physiological age-related decline in the musculoskeletal
system and the chronic overuse of the upper extremities dueto their wheelchair-dependent life (25).
Urinary tract infections
In the present study we found an occurrence of UTIs at 1, 2
and 5 years following SCI of, respectively, 56.5%, 58.3% and58.9%. These results are similar to earlier findings of Levi etal. (12) and Noreau et al. (10), who noted an occurrence thatvaried between 55% and 77% (TSI 0–7 years).
Course of secondary health conditions
Only the changes in reported neuropathic pain and problematic
spasticity 2 years after discharge from inpatient rehabilitationcompared with 1 year after discharge were found to be signifi-

Secondary health conditions after SCI
cant. This might be explained by the rather short post-injury
period that was used for the follow-up measurements. Continuation of the follow-up is necessary to establish the long-termcourse of SHCs in this cohort.
Risk factors
We found that the occurrence of several SHCs was higher
among women and individuals with a complete lesion andparticularly those with tetraplegia and a higher BMI. For some
SHCs this was not surprising, since there is a pathophysiological explanation for it.
First, AD can occur only in spinal cord injured persons witha lesion at or above T6 (26, 27). Therefore, it is rational that
persons with paraplegia are less susceptible. It has also been
described as being less frequent and less severe in incomplete
lesions (26, 28). Secondly, persons with tetraplegia are more at
risk for pulmonary complications, such as pulmonary infection,
because these are associated with respiratory muscle paralysis,
which causes, for example, impaired cough, difficulty mobilizing secretions and microatelectasis (29). Thirdly, it is known
that the likelihood of experiencing (orthostatic) hypotension
is higher amongst persons with higher spinal cord lesions.
Sympathetic nervous system dysfunction below the level of
injury (due to loss of supraspinal control) and the loss of reflex
vasoconstriction are 2 major causes for hypotension following
SCI (30, 31). The extent to which this sympathetic control is
disrupted is directly related to the level of the lesion (30, 32).
The observed significant associations between female gender and pulmonary infections, hypotension, oedema and theseverity of musculoskeletal and neuropathic pain are difficult
to explain. As far as we know this also has not been describedin previous studies. Our observed significant association
between female gender and the severity of neuropathic pain
is in contradiction with the literature on pain in persons with
SCI. Cardenas et al. (33) for instance, reported no differences
between gender and pain severity scores in persons with SCI.
In addition, a retrospective study on neuropathic pain after
traumatic SCI found no correlations with gender (15).
We found no significant differences between traumatic andnon-traumatic SCI. This indicated that, adjusted for differences between age, gender, level and completeness of SCI,
the occurrence of SHCs did not differ between persons withtraumatic and persons with non-traumatic SCI.
Limitations
Our study was limited by the fact that only Dutch persons witha SCI between 18 and 65 years old who were wheelchair dependent (at least for longer distances) were included. This may
influence the degree to which the results can be generalized
to the whole population of persons with a SCI. Furthermore,
the period of observation is too short to make any statementon the course of different SHCs in the long-term.
It should also be taken into account that, at T2, the results
were based on a telephone interview by a trained research

1021

assistant. This is in contrast to the more objective manner ofdata collection by the consultation and physical examinationby the rehabilitation physician at T1 and T3.
Unfortunately, we could not report data on co-morbid
conditions or extra-spinal injuries, since these data were notsystematically registered.
Finally, we did not correct for medication use in the logistic
random coefficient models, since we had too much missing dataon medication use at T3. This is unfortunate, since medicationuse could have had an effect on the reported SHCs, in particularfor problematic spasticity and neuropathic pain.
Conclusion
These results emphasize the importance of a well-coordinatedinterdisciplinary approach during the follow-up care of persons
with SCI living in the community. Since this kind of approachis feasible only at specialized rehabilitation centres, persons
with SCI should be encouraged to contact these centres,
instead of their general practitioner, in case of SCI-related
health problems.
Follow-up care should consist of structured consultations
with a rehabilitation physician at set times. In addition tooffering adequate treatment in case of SHCs, follow-up careshould also be aimed at, for example, an early identificationof spinal cord injured persons at risk for certain SHCs andcontinued patient education on SHCs.
To be able to observe possible changing trajectory patternsof SHCs in persons ageing with SCI, studies such as theseneed to be conducted for more than 5 years. Future researchshould also be aimed at exploring which of these SHCs play arole in limiting participation, activity level and quality of life.
The new research project “Active LifestyLe Rehabilitation
Interventions in aging Spinal Cord injury” (ALLRISC) aims
at providing us with more knowledge on the health status
and functioning of persons ageing with SCI living in the
Netherlands and it will help us to formulate requirements
and guidelines for a lifespan-covering rehabilitation aftercare
system (34).

AcknowledgEments
This study was part of the Dutch research programme “Restoration ofmobility in SCI rehabilitation: The Umbrella Project” and is financially
supported by ZonMw Rehabilitation programme, grant no. 14350003
and 14350010.
The authors would like to thank the research assistants and physiatristsof the SCI units for collecting all the data, and the following participating
Dutch rehabilitation centres: Rehabilitation Center De Hoogstraat (Utrecht), Reade Center for Rehabilitation (Amsterdam); Rehabilitation Center
Het Roessingh (Enschede); Adelante Rehabilitation Center (Hoensbroek);
Sint Maartenskliniek (Nijmegen); University Medical Center Groningen,Center for Rehabilitation-location Beatrixoord (Haren); Rehabilitation
Center Heliomare (Wijk aan Zee) and Rijndam Rehabilitation Center(Rotterdam).
The authors declare no conflicts of interest.

J Rehabil Med 45

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J. J. E. Adriaansen et al.
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