Secondary Complications Following Spinal Cord Injury 421known contributors to heart disease. Additionally, though not
yet proven, it is believed that moderate exercise in persons
with SCI may yield positive cardiovascular bene“ts that may
ameliorate cardiovascular disease associated with aging.
Following SCI, muscle “bers change from slow aerobic to
fast anaerobic. This change affects contraction and relaxation
speed. Concomitantly, there is a reduction in endurance and
an increase in fatigue that may, in turn, contribute to seden-
tariness. It is believed that ischemic heart disease will con-
tribute to morbidity/mortality with increasing age of persons
with SCI. Although electrocardiogram tests are not currently
a routine part of physical exams for individuals with SCI, it is
suggested that education and training regarding known risk
factors and preventive measures be provided to reduce car-
diovascular disease in this population.
SECONDARY COMPLICATIONS FOLLOWING
SPINAL CORD INJURY
Other conditions that occur among persons who have SCI can
stem from the physical and neurological impairments sec-
ondary to the cord injury, but may also be mediated by be-
havioral and social pathways. Among these complications
are pain, pressure sores, contractures and spasticity, urinary
tract infections, and psychological disorders of depression
and anxiety. Other complications that merit attention but
require more medical interventions can be reviewed else-
where (e.g., deep vein thrombosis, heterotropic ossi“cation;
Cardenas, Burns, & Chan, 2000).
Pain
The incidence and prevalence estimates of pain following
SCI vary considerably for several reasons including (a) the
use of different measures of pain with samples from
acute and community settings, and (b) the absence of opera-
tional de“nitions of pain following SCI. As a result,
prevalence estimates of pain range from 18% to 91%
(Anson & Shepard, 1996; Johnson, Gerhart, McCray,
Menconi, & Whiteneck, 1998; Siddall, Taylor, McClelland,
Rutklowki, & Cousins, 1999). Pain after SCI has been con-
ceptualized into four different categories: musculoskeletal,
visceral, neuropathic, and other (Siddall, Taylor, & Cousins,
1997). Research indicates that neuropathic pain is probably
the most frequently reported pain condition and is more
likely to be severe and resistant to treatment (Levi, Hultling,
& Seiger, 1995; Siddall et al., 1999; Yezierski, 1996). Neuro-
pathic pain is often described as •burning, stabbing, shooting,
or electrical,Ž and it may occur at the level of lesion or below
(Siddall et al., 1997). The mechanisms of pain below the site
of lesion are not well understood, but research suggests
that there are psychophysiological indicators of such pain.
Research using single photon emission computed tomogra-
phy (Ness et al., 1998) has recorded observed changes in
cerebral ”ow, and these changes corresponded with the indi-
vidual•s pain reports.Pressure SoresPressure sores result from restriction of blood ”ow to the
skin, depletion of oxygen, and gradual erosion of tissue. Im-
mobilization, paralysis, and loss of neuronal innervation and
sensory input following SCI interact to set the stage for this
sequence of events to which persons are at risk for the re-
mainder of their lives. Skin is susceptible to persistent appli-
cations of even moderate pressure with a direct relationship
between tissue damage, intensity, and duration of pressure
(Yarkony, 1994). Atrophy, repeated trauma, scarring and/or
secondary bacterial infection, shearing force, reduced tran-
scutaneous oxygen tension, and friction are also major
etiologic factors (Mawson et al., 1993; Yarkony, 1994).
Metabolic and local factors thought to contribute to pressure
ulcers include increased moisture, hypoalbuminemia, vita-
min C de“ciency, anemia, lean body build, muscle atrophy,
older age, fever, and poor personal hygiene (Mawson et al.,
1993; Yarkony, 1994). Sites most prone to development of
pressure ulcers are bony prominences such as sacrum, is-
chium, heels, ankles, and trochanter. Untreated or improperly
treated pressure ulcers that do not heal place persons at risk
for potentially life-threatening complications.
Pressure ulcers are one of the most common, costly, and
debilitating secondary complications in persons with SCI.
Persons who develop severe pressure sores often require ex-
pensive and intensive medical intervention for repair, reha-
bilitation, and management of the skin ulcer (over $17,000
per person, excluding physician fees; Johnson, Brooks, &
Whiteneck, 1996). Unquanti“ed indirect costs include frus-
tration; inconvenience; interference with rehabilitation, edu-
cation, and vocational activities; and separation from the
family unit with its impact on psychological and social de-
velopment and successful reintegration into the community
(Yarkony, 1994).
About 50% to 80% of persons with SCI will develop a
pressure ulcer at some time in their lives (Mawson et al.,
1993; Yarkony, 1994). Incidence ranges from 22% to 59%
during acute care/rehabilitation and from 20% to 30% during
one to “ve years postinjury (Stover, Whiteneck, et al., 1995;
Yarkony, 1994). Pressure sores are considered preventable
complications, as individuals who develop these sores are
often noncompliant with recommended self-care regimens,