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Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972–2014
Accepted Manuscript Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972-2014 Yuying Chen, MD, PhD, Yin He, MA, Michael J. DeVivo, DrPH PII:
S0003-9993(16)30068-5
DOI:
10.1016/j.apmr.2016.03.017
Reference:
YAPMR 56515
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 8 November 2015 Revised Date:
4 March 2016
Accepted Date: 5 March 2016
Please cite this article as: Chen Y, He Y, DeVivo MJ, Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972-2014, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.03.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Running head: Spinal Cord Injury Demographic Trends Title: Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the
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United States, 1972-2014 Authors: Yuying Chen, MD, PhD; Yin He, MA; Michael J DeVivo, DrPH
Institution and affiliation: Department of Physical Medicine and Rehabilitation, University of
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Alabama at Birmingham, Birmingham, Alabama
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Acknowledgement: This work was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0011). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy
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of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. Conflicts of Interest: None of the authors has declared any conflicts of interest with this publication.
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Corresponding Author: Yuying Chen, MD, PhD; Spain Rehabilitation Center Room 515, 1717
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Sixth Avenue South, Birmingham, AL 35249-7330; Phone: 205-934-3329; Fax: 205-934-2709; Email: [email protected] Reprints: Reprints are not available from the authors.
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Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries
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in the United States, 1972-2014 Please note this manuscript is directed to an Archives’ special issue that features Spinal Cord
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Injury Model Systems research
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ABSTRACT
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Objective: Document trends in demographic and injury profile of new spinal cord injury (SCI)
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over time.
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Design: Cross-sectional analysis of longitudinal data by injury years (1972–1979, 1980–1989,
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1990–1999, 2000–2009, and 2010-2014)
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Setting: 28 SCI Model Systems centers throughout the United States
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Participants: 30,881 persons with traumatic SCI enrolled in the National SCI Database
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Interventions: Not applicable.
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Main Outcome Measures: Age, sex, race, education level, employment, marital status, etiology,
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and severity of injury
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Results: Age at injury has increased from 28.7 years in the 1970s to 42.2 years during 2010-
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2014. This aging phenomenon was noted for both sexes, all races, and all etiologies except acts
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of violence. The percentage of racial minorities expanded continuously over the last 5 decades.
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Virtually among all age groups, the average education levels and percentage of single/never
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married status has increased, which is similar to the trends noted in the general population.
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Although vehicular crashes continue to be the leading cause of SCI overall, the percentage has
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declined from 47.0% in the 1970s to 38.1% during 2010-2014. Injuries due to falls have
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increased over time particularly among those aged 46 years and older. Progressive increases in
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the percentages of high cervical and motor incomplete injuries were noted for various age, sex,
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race, and etiology groups.
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Conclusions: Study findings call for geriatrics expertise and intercultural competency of clinical
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team in the acute and rehabilitation care for SCI. This study also highlights the need for a multi-
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dimensional risk assessment and multi-factorial intervention, especially to reduce falls and SCI
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in older adults.
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Key Words: Spinal cord injuries; Epidemiology; Trends
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LIST OF ABBREVIATIONS
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AIS
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NSCID National Spinal Cord Injury Database
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SCI
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SCIMS Spinal Cord Injury Model Systems
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spinal cord injury
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American Spinal Injury Association Impairment Scale
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United States
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INTRODUCTION Profound physical, psychological, and economic consequences, as well as the lack of a cure, underscore the importance of primary prevention of spinal cord injury (SCI).1-3
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Understanding the current trends in the demographic and injury profile of new SCI is the key for
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the development of effective prevention strategies targeted to persons at greatest risk for
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injury. By providing detailed information about SCI trends, future health care needs could also
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be assessed.
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The SCI Model Systems (SCIMS) Program and its National SCI Database (NSCID) have
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existed since 1970.4 Information contained in the NSCID has been the major source for
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documenting trends in the demographic and injury profile of traumatic SCI in the US.5-10 As
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demonstrated in recent analyses of NSCID data up to 2008, significant trends toward older age
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at the time of injury and increasing proportions of injuries occurring in racial minority
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populations, injuries caused by falls, and high cervical injuries were observed.5;6 A slight trend
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toward an increasing proportion of women with new SCI was also documented. Considering the pace of previously observed changes in the face of SCI, the fast
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changing compositions of the US population, and the need to base prevention and clinical
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management on the most recent information, it is critical to update the epidemiology of SCI at
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regular intervals. The purpose of this study was to document the demographic and injury
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profile of new SCI cases and assess whether previously noted trends were continued to 2014.
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Given a large sample size, we were able to examine the trends in detail by cross-tabulating
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several demographic and injury factors.
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METHODS
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Participants The NSCID contains baseline and follow-up information on persons with traumatic SCI
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who received initial hospital care from one of the 28 SCIMS Centers since the early 1970s; it
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historically captures data from approximately 13% of new SCIs in the US.11 To be qualified for
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the NSCID, individuals must: 1) have sustained a SCI due to a traumatic event; 2) reside in the
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geographic catchment area of the SCIMS center at injury; 3) be admitted to the SCIMS center
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within one year of injury; 4) be discharged from the SCIMS center as either neurologically
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normal, having completed rehabilitation, or deceased; and 5) provide informed consent. As of
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March 2015, there were 30,881 persons injured between 1972 and 2014 enrolled in the NSCID.
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Detail about the NSCID structure, SCIMS centers, and follow-up data collection appears in an
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article elsewhere in this issue of Archives of Physical Medicine and Rehabilitation.12
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Variables and measures
All variables for this study were obtained by trained personnel during initial hospital
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care from medical records and by personal interview. Institutional Review Board approval was
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obtained at the National SCI Statistical Center as well as locally at each SCIMS center.
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The NSCID documents 37 causes of injury,13 which we grouped into 6 categories for
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analysis: vehicular crashes; falls; acts of violence; sports; medical/surgical complications,
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defined as impairment of spinal cord function resulting from adverse effects of medical,
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surgical, or diagnostic procedures and treatments for non-spinal cord conditions; and all other,
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including pedestrian injury, hit by flying/falling object, etc.
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Neurological data were obtained within 7 days of discharge in accordance with the version of the International Standards for Neurological Classification of SCI that was in use at
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the time of examinations.14 Prior to August 1993, completeness of injury was assessed using
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Frankel’s classification scale.15 The major difference between Frankel scale and the American
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Spinal Injury Association Impairment Scale (AIS) is that some injuries are classified incomplete
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by Frankel scale but complete by the AIS. Ventilator-dependency was defined as any use of any
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type of mechanical ventilation for sustaining respiration, including phrenic nerve stimulator.
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Employment status was classified as: 1) employed for pay, full or part time, including
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military; 2) unemployed; 3) student, including on-the-job training, sheltered workshop, and
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those aged 0 to 5 years; 4) homemaker; 5) retired; and 6) other, including volunteer,
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disability/medical leave, etc. Additional information about variables can be found in the NSCID
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Data Dictionary (https://www.nscisc.uab.edu/nscisc-database.aspx).
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Statistical Analysis
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To evaluate trends, all cases were grouped by decade of injury (1972–1979, 1980–1989, 1990–1999, 2000–2009, and 2010-2014). Mean age at injury was determined for each time
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period and compared by one-way analysis of variance. For categorical variables such as sex,
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race, education, and severity of injury, frequencies and percentages were presented for each
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decade, based on the entire sample without any age restriction; differences across decades
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were assessed for statistical significance by the chi-square test. To examine the potential bias of
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changing designation of SCIMS centers on the trends over time, we repeated the above analysis
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for each of the 6 centers that have been funded for 35 or longer years, located in Alabama,
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Pennsylvania, Illinois, Texas, Colorado, and Washington. All analyses were conducted using SAS
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v9.3 (SAS Institute Inc, Cary, NC).
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RESULTS
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Demographic profile
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Average age at injury increased from 28.7 years in the 1970s to 42.2 years during 20102014 (Table 1). The trend toward increasing age at injury was noted for both sexes and all races,
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with the greatest increase in White females, followed by White males, Hispanic females, Black
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females, Hispanic males, and Black males (Table 2). The gradual increase in age at injury was
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observed within all etiology groups except acts of violence.
The percentage of new SCI cases who were members of a racial minority expanded
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continuously over the last 5 decades (Table 1). The percentage of Blacks peaked in the 1990s,
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then dropped by 3.5% during 2000-2009, and stayed 22% since 2010. The percentage of Black
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males of age 46 years and older, however, progressively declined since 1980s (Figure 1). While
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Hispanic males followed a similar trend as Black males among those aged 16-30 years, an
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increase in percentage of Hispanic males over the last 5 decades occurred in the older age
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groups.
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Average education levels of newly injured persons increased (Table 1); this trend was
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noted in all age groups from age 16 years and older. With increasing age at injury, we observed
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an increase in the percentages of people who were retired, married, divorced or widowed,
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while the percentage of people who were single/never married has decreased (Table 1).
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However, within each age group, the percentage of single/never married increased over the
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last 5 decades among the age 16-30, 31-45, and 46-60 groups (Figure 2).
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Injury profile
Although vehicular crashes continue to be the leading cause of SCI, the percentage
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declined from 47.0% in the 1970s to 38.1% during 2010-2014 (Table 3). Injuries due to falls
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increased particularly among those aged 46 and older (Figure 3). Injuries due to acts of violence
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peaked in the 1990s (24.8%) but have since declined (13.5% currently). However, acts of
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violence account for 27% of all SCIs occurring among the age 16-30 group and rank first among
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Black males (42.9%).
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Sports-related SCIs declined slightly from 14.4% during the 1970s to 8.9% since 2010 (Table 3). Among those aged 46-60 years, however, the percentage of SCI as a result of sports
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increased from 2.2% in the 1970s to 7.2% recently. This trend is consistent with the observation
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of increasing age for sports-related SCI over the last 4 decades, from 21.1 years to 34.3 years
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(Table 2).
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The percentage of high cervical injuries increased over the last 5 decades, while the
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percentage of low cervical injuries decreased and that of T1-S3 injuries remained relatively
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constant (Table 3). The motor incomplete injuries (AIS C, D, or E) increased from 36.4% to
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53.2%, while neurologically complete injuries (AIS A) decreased from 53.8% to 33.7%.
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When combining level and completeness of injury, we observed an increase of the C1-
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C4 AIS A, B, and C injuries since 1970s for all etiologies (Figure 4) and among the age groups 16-
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30, 31-45, and 46-60 years. Concurrently, the percentage of C5-C8 AIS A, B, and C decreased
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over the last 5 decades for all etiologies and age groups. The AIS D and E injuries gradually
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increased since 1970s among those of age 46 years and older (38.4% in the 1970s and 55.3% in
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the 2010s) and among all etiologies except violence (Figure 5).
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The percentage of persons discharged ventilator dependent doubled from 2.2% in the 1970s, 4.6% in the 1990s, and 4.3% in the 2000s before declining to 3.1% in the 2010s. The
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decrease in ventilator use between 1990s and 2010s was particularly notable among those of
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age 46 years or older (7.6% and 2.7%, respectively) and injuries as a result of falls (5.5% and
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2.2%, respectively).
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Subgroup analysis
Similar demographic and injury trends were noted in each of the SCIMS centers that have been continuously funded, although the level of changes over the last 5 decades varied
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slightly from one center to another.
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DISCUSSION
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Analysis of the demographic and injury profile of traumatic SCI enrolled in the NSCID over the last 5 decades reveals new findings, including progressive increases in motor
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incomplete injuries, age-specific single/never married status, and education level. Previously
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reported trends, including increasing age at injury and proportions of racial minority, fall
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etiology, and higher cervical injurie across decades, were continued to 2014 among various age,
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sex, race, and etiology groups. Below we review these trends in reference to the changes in the
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general US population, age-sex-specific SCI incidence, and designation of SCIMS centers over
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the last decades. The implications for SCI prevention and future health care needs for SCI are
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also discussed.
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Age
Aging of the US population (Table 4) largely contributes to the increasing age at the time of SCI over the last 5 decades. Had the SCI incidence rate across all age groups remained
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constant, the growth in the elderly SCI population would have perfectly paralleled the general
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population, but this is not the case. The aging of new SCI cases is more dramatic than that of
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the general US population. The percentage of the new SCI cases of age ≥ 65 years has increased
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from 3.1% in the 1970s to 13.2% in 2010-2014, and the corresponding figure for the general
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population is 9.8% and 13.1%, respectively. The average age at injury in 2010-2014 was 42.2
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years, which is about 5 years older than the median age of the US population in 2010 (37.2).
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This aging phenomenon in the SCI population can be explained by a recent finding of a higher
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SCI incidence rate in the elderly (age ≥ 65 years) than their younger peers (age 18-64 years, 87.7
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vs 49.9 new cases per million in 2009)16 and a trend toward an increasing incidence rate in the
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elderly over the last 10 years.17 Based on a Nationwide Inpatient Sample database, Jain et al.
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(2015)17 found the incidence rates among the younger male population declined (for example,
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from 144 cases per million in 1993 to 87 cases per million in 2012 for age 16 to 24 years),
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whereas the incidence rate in men aged 65 to 74 years increased from 84 cases per million in
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1993 to 131 cases per million in 2012.
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Sex Although males and females in the US population have been aging at about the same
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pace (increase by 8.1 and 8.9 years, respectively between 1970 and 2010; Table 4), we observe
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a larger increase in average age at SCI in females than males, regardless of race (Table 2). This
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finding reflects an increase of injuries among older adults as well as a smaller difference in SCI
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risk between males and females among the elderly than that in teenagers and young adults. For
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example, the male to female incidence ratio was 1.5 for those aged 75-84 years, but 3.2 for
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those aged 16-24 years in 2012.17 The incidence rate of SCI, however, is higher for males than
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females regardless of ages. As a result, the recent increase in the number of older women with
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SCI did not change the percentage of females in the SCI population dramatically (18.2% in 1970s
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and 20.2% in 2010s).
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Race
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The changing racial composition of the SCI population is not as dramatic as what has been observed in the general US population over the last 5 decades. This is likely due to a
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combination of factors including the geographic representation of the SCIMS centers, racial
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difference in the incidence rates of SCI that Blacks overall have a higher incidence rate than
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Whites,18-21 and changes in the injury etiology pattern over time.5;6;8;9;17 For example, the high
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percentage of Blacks and Hispanics in the 1990s may reflect the epidemic of violence-onset SCI
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(Table 1), as this epidemic mostly affected Blacks and Hispanics.13 Changing racial composition
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is also possible due to trends in age-sex-race-specific incidence rates over time, which needs
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further investigation. Native American, Asian, and other races made up about 3% of SCI cases in
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the database. A small fluctuation in percentage was observed over time, but the numbers were
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too small to make a precise estimate and projection. The small number of Asian and other races
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is partly due to the facts that non-English or non-Spanish speaking people are excluded from
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NSCID because of consenting requirements.
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Given the continued growth of minorities, especially Hispanics, in the US population,
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increasing SCI patients of minority background should be expected by health care providers.
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Therefore, staff diversification and cultural competency training are needed to avoid racial bias
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in health care and health.22
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Other sociodemographic characteristics
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Our observations of trends in education, employment, and marital status of new SCI cases are generally consistent with the US general population and largely explained by the
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aging of the SCI population. We hope that this increased education level over time would lead
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to improved post-injury employment, which deserves further study.23 It is also unknown
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whether the lower marriage rate would adversely affect the marriage rate and overall quality of
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life after SCI, as the marriage rate is lower in the SCI population than in the general population;
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marriage is associated with favorable psychosocial outcomes.24-27
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Injury etiology
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Changes in etiology of injury are relevant to the development of prevention programs.
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For example, diving-related SCI was the focus of research as a potentially preventable injury in
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the context of primary prevention programs.28 These programs appear to have contributed to
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the success in reducing the incidence of diving-related SCI. With fall-induced SCI on the rise
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further prevention efforts are needed to reduce falls particularly among the elderly and those
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occurring at home as a result of slipping, tripping, stumbling, and falling on the same level and
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from stairs, steps, beds, chairs, and toilets, as suggested by previous studies.29;30
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Severity of injury
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These trends are likely due to a combination of advances in medical and surgical
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management,31 improved acute survival of high cervical injuries,32 as well as changes in
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demographics, etiology, and referral pattern of SCIMS centers. For example, older persons are
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most likely injured in falls on the same level that result in tetraplegia and AIS D injuries.29
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Gunshot-related SCIs are on the decline in the past decades, and these typically result in
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complete paraplegia. Use of methylprednisolone and other medications as well as surgical
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intervention in the early management of SCI is not documented in the NSCID and, therefore, its
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contribution to the decrease in neurologically complete injuries cannot be evaluated. Advances
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in rehabilitation therapy might also contribute to the favorable trends.
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Strengths and limitations
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The NSCID has several well-documented strengths and limitations that must be
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considered when evaluating the results of this study. Strengths include the long history, large
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sample size, geographic and patient diversity, standardization of data collection methods and
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measures, excellent case identification procedures, prospective data collection using both
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physical examination and personal interview, and comprehensiveness of the information in the
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database. Due to constraints by the design of the SCIMS program and NSCID, however, the
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generalizability of the present study findings are limited; these constraints include a hospital-
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based sample of the NSCID participants, strict eligibility criteria, and change in the number and
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designation of SCIMS centers as well as information contained in the database. For example,
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our finding of average age at injury in 2011-2014 (42.2 years) is about 8 years younger than
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what was reported in a study of a US representative inpatient sample of acute traumatic SCI in
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2012 (50.5 years).17 Although Jain et al.’s study is subject to potential counting of readmissions
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after SCI and exclusion of children younger than 16 year that could have overestimated the
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average age at injury, the NSCID over-represents violent etiology that occurs primarily in teens
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and young adult males because of the urban location of many of the SCIMS centers. The NSCID
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eligibility criteria call for neurological deficits and completed rehabilitation with some
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exceptions, which excludes older patients with fall etiologies and with minimal neurological
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deficits who never received rehabilitation. A recent study that compared the NSCID with the
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Inpatient Rehabilitation Facilities Patient Assessment Instrument database concluded that the
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NSCID is largely representative of the national population of patients receiving inpatient
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rehabilitation for new onset of traumatic SCI during 2001-2010.33
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Because the NSCID is not population-based, data can only be presented as percentages,
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which do not necessarily imply corresponding changes in incidence. For example, the recent
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decline in the percentage of new SCI cases caused by vehicular crashes could be due to the
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decrease in the underlying incidence. The percentage of vehicular-related SCI would also drop if
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the underlying incidence rate rises but at a slower rate than that of other causes. However,
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provided that the statistics are interpreted with some understanding of how the data have
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been collected and analyzed, the trends reported here are relevant to service providers, policy
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makers, and researchers.
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Conclusions
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Demographic and injury trends in new SCIs call for greater involvement of experts in gerontology and geriatrics and intercultural competency of clinical teams during acute and
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rehabilitation care for SCI. Educational materials that portray SCI cases as men in their teens
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and early 20 years of age need to be updated. Prevention efforts should incorporate multi-
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dimensional risk assessments, especially to reduce falls and associated SCI in older adults.
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(22) Williams DR, Wyatt R. Racial Bias in Health Care and Health: Challenges and Opportunities. JAMA 2015;314:555-556.
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(23) Frieden L, Winnegar AJ. Opportunities for research to improve employment for people with spinal cord injuries. Spinal Cord 2012;50:379-381.
343 344
(24) Cao Y, Krause JS, Saunders LL, Clark JM. Impact of Marital Status on 20-Year Subjective Wellbeing Trajectories. Top Spinal Cord Inj Rehabil 2015;21:208-217.
345 346
(25) Chen Y, Anderson CJ, Vogel LC, Chlan KM, Betz RR, McDonald CM. Change in life satisfaction of adults with pediatric-onset spinal cord injury. Arch Phys Med Rehabil 2008;89:2285-2292.
347 348 349
(26) Kalpakjian CZ, Houlihan B, Meade MA et al. Marital status, marital transitions, well-being, and spinal cord injury: an examination of the effects of sex and time. Arch Phys Med Rehabil 2011;92:433-440.
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(27) Kreuter M. Spinal cord injury and partner relationships. Spinal Cord 2000;38:2-6.
351 352
(28) DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord 1997;35:509-515.
353 354
(29) Chen Y, Tang Y, Allen V, DeVivo MJ. Fall-induced spinal cord injury: External causes and implications for prevention. J Spinal Cord Med 2015.
355 356
(30) Chen Y, Tang Y, Allen V, DeVivo MJ. Aging and Spinal Cord Injury: External Causes of Injury and Implications for Prevention. Top Spinal Cord Inj Rehabil 2015;21:218-226.
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(31) van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013;30:1781-1794.
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(32) Strauss DJ, DeVivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil 2006;87:1079-1085.
362 363 364 365 366
(33) Cuthbert J, Charlifue S, Chen D et al. Generalizability of spinal cord injury model systems data 2001-2010 [abstract]Cuthbert J, Charlifue S, Chen D et al. Journal of Spinal Cord Medicine 2014;37:438-439
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357 358 359
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EP
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M AN U
SC
367
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368
FIGURE LEGENDS
369
Figure 1.
370
Note: Percentages of White male and female for each decade were not shown, which add up
371
to 100% along with those of Blacks and Hispanics.
372
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Percentages of Blacks and Hispanics by decades: age and sex differences.
Figure 2.
Percentages of Single/Never married by decades and age groups.
374
Note: Percentages of other marital status (married, divorced, separated, widowed, and others)
375
for each decade were not shown, which add up to 100% along with single/never married for
376
each age group.
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SC
373
377
Figure 3.
379
Note: Percentages of other etiologies (vehicular, violence, sports, medical/surgical
380
complications, and others) for each decade was not shown, which add up to 100% along with
381
falls for each age group.
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382
Percentages of SCI as a result of falls by decades and age groups
TE D
378
Figure 4.
384
Note: Percentages of other level and completeness of injury for each decade was not shown,
385
which add up to 100% along with the C1-C4 AIS A, B, and C injuries for each etiology.
386
Percentages of C1-C4 AIS A, B, and C injuries by decades and etiologies of injury
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383
387
Figure 5.
Percentages of AIS D and E injuries by decades and etiologies of injury
388
Note: Percentages of other level and completeness of injury for each decade was not shown,
389
which add up to 100% along with AIS D and E injuries for each etiology
18
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Table 1: Demographic profile of people with new SCI over the last 5 decades Injury Year Intervals 1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Total
Sample Size*
4,562
8,791
6,918
7,050
3,560
30,881
13
19
20
28.7
31.3
35.1
0-15
6.4
3.8
16-30
62.0
58.1
31-45
17.9
46-60
9.0
61-75
4.0
75+
0.7
No. SCIMS Age at injury, mean (y)
39.1
42.2
34.8
1.3
1.0
3.1
45.6
38.6
34.4
48.7
27.8
25.0
20.7
23.1
9.9
13.6
21.9
25.2
15.1
5.0
7.5
10.0
14.9
7.7
1.6
2.4
3.2
3.8
2.2
4.8
7.3
9.5
13.2
7.1
18.2
17.5
19.6
21.5
20.2
19.3
76.9
68.3
57.1
62.4
64.0
65.3
EP
Female (%)
28
3.0
M AN U
3.1
18
21.6
TE D
Age ≥ 65 (%)
21
SC
Age group at injury (%)
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Characteristic
14.2
20.8
27.8
24.3
22.0
22.3
5.9
8.1
12.1
10.6
10.6
9.5
Native American
1.9
1.1
0.4
0.4
0.6
0.8
Asian/Pacific Islander
0.9
1.3
2.0
1.9
1.8
1.6
Other
0.1
0.3
0.6
0.5
1.1
0.5
8th grade or less
15.8
11.1
9.5
5.2
3.2
9.2
9th - 11th grade
27.6
28.5
27.9
20.0
14.8
24.7
Race (%) White Black
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Hispanic
Education level at injury (%)
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49.0
50.4
50.4
55.6
51.5
51.5
Associate degree
0.5
1.3
2.7
4.4
8.1
3.0
Bachelor
5.2
5.9
6.2
9.6
13.7
7.6
Masters/Doctorate
1.8
2.0
2.2
4.1
7.2
3.1
Other
0.1
0.6
1.0
Employed
60.6
59.4
53.6
Unemployed
10.4
15.2
21.3
Student
23.4
17.9
13.8
2.9
Retired
2.6
Other
0.1
Marital Status at injury (%)
0.8
59.4
57.9
58.1
15.1
16.3
16.0
11.8
10.5
15.6
1.9
1.4
1.0
1.9
4.7
7.8
9.8
12.2
7.1
0.7
1.7
2.5
2.1
1.4
54.1
53.3
47.7
45.8
51.8
31.8
30.4
30.4
36.7
36.5
32.8
7.9
8.8
9.9
10.2
11.1
9.5
4.8
4.1
3.5
2.2
2.0
3.4
EP
Married
1.5
2.5
2.9
2.8
3.0
2.6
0.0
0.2
0.0
0.3
1.7
0.3
Divorced Separated Widowed
54.0
1.4
2.2
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Never Married (Single)
M AN U
Homemaker
1.1
SC
Employment at injury (%)
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High School graduate
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Other, unclassified
NOTE. All comparisons across injury years are statistically significant, P value for the analysis of variance and chi-square ≤ 0.0001. *Sample size varies by characteristics because of unknown and missing responses that ranged from 0% for age and sex to 6% for education.
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Table 2: Distributions of the average age at injury by sex, race, and etiology over the last 5 decades Injury Year Intervals Characteristic
N
1972-1979
1980-1989
1990-1999
15,798
28.1
30.5
36.7
White Female
4,168
29.2
33.1
38.7
Black Male
5,763
31.7
33.4
32.6
Black Female
1,058
28.6
35.6
Hispanic Male
2,478
26.7
27.3
432
25.8
13,088
27.5
Falls
6,785
37.0
Violence
5,338
27.6
Sports
3,161
Medical/Surgical
2000-2009
2010-2014
Total
Hispanic Female
42.2
47.0
37.5
35.7
36.9
34.0
SC
34.8
39.0
40.6
36.9
28.5
34.1
36.9
30.4
33.1
33.8
39.2
32.8
29.5
34.1
36.3
38.1
32.6
41.5
46.3
50.8
53.0
46.4
27.8
26.4
27.6
28.6
27.4
21.1
23.7
27.5
30.8
34.3
26.2
1,632
32.4
33.8
37.3
40.2
42.8
36.1
846
42.2
46.4
54.3
54.6
57.7
52.8
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Other
44.0
29.5
Etiology of Injury Vehicular
40.5
38.0
M AN U
White Male
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Sex-race
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Note: Values are mean age (y).
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Table 3: Injury profile of people with new SCI over the last 5 decades Injury Year Intervals 1972-1979 1980-1989 1990-1999 2000-2009
Sample Size*
4,562
8,791
6,918
Vehicular
47.0
43.9
38.3
Falls
16.5
18.6
21.8
Violence
13.3
17.2
24.8
Sports
14.4
12.5
7.3
1.2
Other
7.7
Level of Injury (%) 14.5
C5-C8
39.5
43.9
38.1
42.4
25.5
31.0
22.0
14.5
13.5
17.3
8.4
8.9
10.2
3.0
3.7
4.7
2.7
6.0
4.8
4.1
3.8
5.3
17.8
20.8
25.2
32.8
21.2
35.8
28.9
30.7
26.2
32.7
35.6
35.2
38.2
33.5
32.0
35.2
10.4
11.1
12.1
10.6
9.1
10.9
EP
T1-T12
30,881
1.9
TE D
C1-C4
3,560
7,050
M AN U
Medical/Surgical
Total
SC
Etiology of Injury (%)
2010-2014
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Characteristic
53.8
46.5
48.6
41.8
33.7
45.6
9.8
10.7
10.4
12.4
13.2
11.1
8.2
10.2
15.1
14.2
16.2
12.5
27.2
32.0
25.5
31.0
36.6
30.1
1.0
0.6
0.5
0.5
0.4
0.6
Ventilator dependent
2.2
2.9
4.6
4.3
3.1
3.5
C1-C4 AIS/Frankel ABC
8.2
9.2
11.0
13.3
14.9
11.0
L1-S3 AIS/Frankel grade (%) A
C D E
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B
Neurological category (%)
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C5-C8 AIS/Frankel ABC
27.2
22.3
18.1
16.4
13.9
20.0
T1-S3 AIS/Frankel ABC
34.1
32.8
40.2
33.8
30.7
34.6
AIS/Frankel DE
28.3
32.8
26.2
32.3
37.4
31.0
0.0001.
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NOTE. All comparisons across injury years are statistically significant, P value for the chi-square ≤
*Sample size for each injury decade varies by characteristics because of unknown and missing responses
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that ranged from 0.7% for etiology to 6.0% for level of injury.
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1970
1980
1990
2000
2010
205,052,174
226,862,400
249,622,814
281,421,906
308,745,538
28.3
30.0
32.8
35.3
37.2
0-14
28.3
22.6
21.7
21.4
19.8
15-29
24.5
27.4
23.3
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Table 4: Statistical information of the US population by decades
20.8
20.9
30-44
16.9
19.1
23.6
23.4
19.8
45-59
16.3
15.2
14.2
18.2
21.0
60-74
10.3
Population size Age, median
11.3
11.4
10.3
12.4
4.4
5.3
5.9
6.1
11.3
12.5
12.4
13.1
28.8
31.6
34.0
35.8
31.3
34.0
36.5
38.5
31.0
34.8
38.1
41.3
24.0
28.0
30.3
32.1
22.0
25.3
25.8
27.5
48.8
48.6
48.7
49.1
49.2
83.5
79.6
75.6
69.1
63.7
11.5
11.7
12.1
12.2
6.4
9.0
12.5
16.3
0.7
0.7
0.7
3.7
Age ≥ 65 (%)
9.8
Age, median 27.7
Age, median White Black
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Hispanic
29.6
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Female
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Male
M AN U
75+
SC
Age category (%)
Sex (%) Male
Race/Ethnicity (%) White Black Hispanic
Native American
4.4
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Asian/ Pacific Islander
2.8
3.7
4.8
Other
0.1
1.8
2.3
7.5
6.2
Education level (Population 25 years and over) (%)
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8th or less 9th to 12th grade
12.1
8.7
28.6
29.0
21.0
20.6
6.3
7.5
15.5
17.6
8.9
10.3
22.2
27.1
32.2
61.9
54.4
48.8
2.2
2.2
7.6
6.6
6.0
8.3
9.7
10.8
63.4
63.9
59.7
57.0
Unemployed
3.7
6.9
In armed forces
0.5
0.6
36.1
35.6
High school graduate
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Some college, no degree Associate's degree
Graduate or professional degree
M AN U
Bachelor’s degress
Marital Status (Population 15 years and over) (%) Never married Now married, except separated
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Separated Widowed Divorced
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Employment Status (Population 16 years and over) (%) In civilian labor force
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Employed
Not in labor force
NOTE. Data sources: US Bureau of the Census (www.census.gov), including American FactFinder (http://factfinder.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t); Statistical Abstract of the United States 1970s-2010s (www.census.gov/library/publications/time-series/statistical_abstracts.html); and "Historical Census Statistics on Population Totals By Race, 1790 to 1990, and By Hispanic Origin, 1970 to 1990, For Large Cities and Other Urban Places In The United States (https://www.census.gov/population/www/documentation/twps0076/twps0076.pdf).
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Figure 1. Percentages of Blacks and Hispanics by decades: age and sex differences
Age 16-30
30
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25
Black Male
15
Hispanic Male
SC
Percentage (%)
20
5
0
1972-1979
1980-1989
Hispanic Female
M AN U
10
Black Female
1990-1999
2000-2009
2010-2014
Year of Injury
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30
Age 31-45
25
EP
15
Black Male Hispanic Male Black Female
AC C
Percentage (%)
20
10
Hispanic Female
5
0
1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Year of Injury
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30
Age 46-60
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25
Percentage %
20
Black Male
15
Hispanic Male Black Female
10
SC
Hispanic Female
0 1972-1979
1980-1989
M AN U
5
1990-1999
2000-2009
2010-2014
Year of Injury
30
Age 61-75
TE D
25
15
AC C
10
Black Male Hispanic Male
EP
Percentage %
20
Black Female Hispanic Female
5
0
1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Year of Injury
2
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Figure 2. Percentage of Single/Never married by decades and age groups 100 90
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70 60
Age 16 - 30
50
Age 31 - 45
40
Age 46 - 60
SC
Never Married (Single) %
80
30
10 0 1972-1979
1980-1989
M AN U
20
1990-1999
AC C
EP
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Year of Injury
2000-2009
2010-2014
Age 60+
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Figure 3. Percentage of SCI as a result of falls by decades and age groups 70
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60
Fall %
50 40
Age 16 - 30 Age 31 - 45
30
SC
Age 46 - 60
10 0 1972-1979
1980-1989
M AN U
20
1990-1999
AC C
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Year of Injury
2000-2009
2010-2014
Age 60+
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Figure 4. Percentage of C1-C4 AIS A, B, and C injuries by decades and etiologies of injury 25
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Vehicular Accidents
15
Falls
Violence
10
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C1-C4 AIS ABC %
20
0 1972-1979
1980-1989
M AN U
5
1990-1999
AC C
EP
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Year of Injury
2000-2009
2010-2014
Sports
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Figure 5. Percentage of AIS D and E injuries by decades and etiologies of injury 60
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50
Vehicular Accidents Falls
30
Violence
SC
AIS DE %
40
20
0 1972-1979
1980-1989
M AN U
10
Sports
1990-1999
2000-2009
2010-2014
Year of Injury
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.
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S0003-9993(16)30068-5
DOI:
10.1016/j.apmr.2016.03.017
Reference:
YAPMR 56515
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 8 November 2015 Revised Date:
4 March 2016
Accepted Date: 5 March 2016
Please cite this article as: Chen Y, He Y, DeVivo MJ, Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972-2014, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.03.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Running head: Spinal Cord Injury Demographic Trends Title: Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the
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United States, 1972-2014 Authors: Yuying Chen, MD, PhD; Yin He, MA; Michael J DeVivo, DrPH
Institution and affiliation: Department of Physical Medicine and Rehabilitation, University of
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Alabama at Birmingham, Birmingham, Alabama
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Acknowledgement: This work was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0011). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy
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of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. Conflicts of Interest: None of the authors has declared any conflicts of interest with this publication.
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Corresponding Author: Yuying Chen, MD, PhD; Spain Rehabilitation Center Room 515, 1717
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Sixth Avenue South, Birmingham, AL 35249-7330; Phone: 205-934-3329; Fax: 205-934-2709; Email: [email protected] Reprints: Reprints are not available from the authors.
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Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries
2
in the United States, 1972-2014 Please note this manuscript is directed to an Archives’ special issue that features Spinal Cord
4
Injury Model Systems research
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3
5
ABSTRACT
7
Objective: Document trends in demographic and injury profile of new spinal cord injury (SCI)
8
over time.
9
Design: Cross-sectional analysis of longitudinal data by injury years (1972–1979, 1980–1989,
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6
1990–1999, 2000–2009, and 2010-2014)
11
Setting: 28 SCI Model Systems centers throughout the United States
12
Participants: 30,881 persons with traumatic SCI enrolled in the National SCI Database
13
Interventions: Not applicable.
14
Main Outcome Measures: Age, sex, race, education level, employment, marital status, etiology,
15
and severity of injury
16
Results: Age at injury has increased from 28.7 years in the 1970s to 42.2 years during 2010-
17
2014. This aging phenomenon was noted for both sexes, all races, and all etiologies except acts
18
of violence. The percentage of racial minorities expanded continuously over the last 5 decades.
19
Virtually among all age groups, the average education levels and percentage of single/never
20
married status has increased, which is similar to the trends noted in the general population.
21
Although vehicular crashes continue to be the leading cause of SCI overall, the percentage has
22
declined from 47.0% in the 1970s to 38.1% during 2010-2014. Injuries due to falls have
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increased over time particularly among those aged 46 years and older. Progressive increases in
24
the percentages of high cervical and motor incomplete injuries were noted for various age, sex,
25
race, and etiology groups.
26
Conclusions: Study findings call for geriatrics expertise and intercultural competency of clinical
27
team in the acute and rehabilitation care for SCI. This study also highlights the need for a multi-
28
dimensional risk assessment and multi-factorial intervention, especially to reduce falls and SCI
29
in older adults.
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31
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Key Words: Spinal cord injuries; Epidemiology; Trends
32 33
LIST OF ABBREVIATIONS
34
AIS
35
NSCID National Spinal Cord Injury Database
36
SCI
37
SCIMS Spinal Cord Injury Model Systems
38
US
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spinal cord injury
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American Spinal Injury Association Impairment Scale
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United States
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39 40
INTRODUCTION Profound physical, psychological, and economic consequences, as well as the lack of a cure, underscore the importance of primary prevention of spinal cord injury (SCI).1-3
42
Understanding the current trends in the demographic and injury profile of new SCI is the key for
43
the development of effective prevention strategies targeted to persons at greatest risk for
44
injury. By providing detailed information about SCI trends, future health care needs could also
45
be assessed.
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The SCI Model Systems (SCIMS) Program and its National SCI Database (NSCID) have
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46
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41
existed since 1970.4 Information contained in the NSCID has been the major source for
48
documenting trends in the demographic and injury profile of traumatic SCI in the US.5-10 As
49
demonstrated in recent analyses of NSCID data up to 2008, significant trends toward older age
50
at the time of injury and increasing proportions of injuries occurring in racial minority
51
populations, injuries caused by falls, and high cervical injuries were observed.5;6 A slight trend
52
toward an increasing proportion of women with new SCI was also documented. Considering the pace of previously observed changes in the face of SCI, the fast
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53
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47
changing compositions of the US population, and the need to base prevention and clinical
55
management on the most recent information, it is critical to update the epidemiology of SCI at
56
regular intervals. The purpose of this study was to document the demographic and injury
57
profile of new SCI cases and assess whether previously noted trends were continued to 2014.
58
Given a large sample size, we were able to examine the trends in detail by cross-tabulating
59
several demographic and injury factors.
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61
METHODS
62
Participants The NSCID contains baseline and follow-up information on persons with traumatic SCI
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63
who received initial hospital care from one of the 28 SCIMS Centers since the early 1970s; it
65
historically captures data from approximately 13% of new SCIs in the US.11 To be qualified for
66
the NSCID, individuals must: 1) have sustained a SCI due to a traumatic event; 2) reside in the
67
geographic catchment area of the SCIMS center at injury; 3) be admitted to the SCIMS center
68
within one year of injury; 4) be discharged from the SCIMS center as either neurologically
69
normal, having completed rehabilitation, or deceased; and 5) provide informed consent. As of
70
March 2015, there were 30,881 persons injured between 1972 and 2014 enrolled in the NSCID.
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Detail about the NSCID structure, SCIMS centers, and follow-up data collection appears in an
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article elsewhere in this issue of Archives of Physical Medicine and Rehabilitation.12
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Variables and measures
All variables for this study were obtained by trained personnel during initial hospital
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care from medical records and by personal interview. Institutional Review Board approval was
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obtained at the National SCI Statistical Center as well as locally at each SCIMS center.
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The NSCID documents 37 causes of injury,13 which we grouped into 6 categories for
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analysis: vehicular crashes; falls; acts of violence; sports; medical/surgical complications,
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defined as impairment of spinal cord function resulting from adverse effects of medical,
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surgical, or diagnostic procedures and treatments for non-spinal cord conditions; and all other,
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including pedestrian injury, hit by flying/falling object, etc.
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Neurological data were obtained within 7 days of discharge in accordance with the version of the International Standards for Neurological Classification of SCI that was in use at
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the time of examinations.14 Prior to August 1993, completeness of injury was assessed using
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Frankel’s classification scale.15 The major difference between Frankel scale and the American
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Spinal Injury Association Impairment Scale (AIS) is that some injuries are classified incomplete
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by Frankel scale but complete by the AIS. Ventilator-dependency was defined as any use of any
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type of mechanical ventilation for sustaining respiration, including phrenic nerve stimulator.
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Employment status was classified as: 1) employed for pay, full or part time, including
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military; 2) unemployed; 3) student, including on-the-job training, sheltered workshop, and
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those aged 0 to 5 years; 4) homemaker; 5) retired; and 6) other, including volunteer,
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disability/medical leave, etc. Additional information about variables can be found in the NSCID
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Data Dictionary (https://www.nscisc.uab.edu/nscisc-database.aspx).
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Statistical Analysis
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To evaluate trends, all cases were grouped by decade of injury (1972–1979, 1980–1989, 1990–1999, 2000–2009, and 2010-2014). Mean age at injury was determined for each time
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period and compared by one-way analysis of variance. For categorical variables such as sex,
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race, education, and severity of injury, frequencies and percentages were presented for each
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decade, based on the entire sample without any age restriction; differences across decades
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were assessed for statistical significance by the chi-square test. To examine the potential bias of
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changing designation of SCIMS centers on the trends over time, we repeated the above analysis
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for each of the 6 centers that have been funded for 35 or longer years, located in Alabama,
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Pennsylvania, Illinois, Texas, Colorado, and Washington. All analyses were conducted using SAS
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v9.3 (SAS Institute Inc, Cary, NC).
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RESULTS
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Demographic profile
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Average age at injury increased from 28.7 years in the 1970s to 42.2 years during 20102014 (Table 1). The trend toward increasing age at injury was noted for both sexes and all races,
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with the greatest increase in White females, followed by White males, Hispanic females, Black
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females, Hispanic males, and Black males (Table 2). The gradual increase in age at injury was
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observed within all etiology groups except acts of violence.
The percentage of new SCI cases who were members of a racial minority expanded
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continuously over the last 5 decades (Table 1). The percentage of Blacks peaked in the 1990s,
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then dropped by 3.5% during 2000-2009, and stayed 22% since 2010. The percentage of Black
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males of age 46 years and older, however, progressively declined since 1980s (Figure 1). While
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Hispanic males followed a similar trend as Black males among those aged 16-30 years, an
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increase in percentage of Hispanic males over the last 5 decades occurred in the older age
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groups.
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Average education levels of newly injured persons increased (Table 1); this trend was
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noted in all age groups from age 16 years and older. With increasing age at injury, we observed
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an increase in the percentages of people who were retired, married, divorced or widowed,
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while the percentage of people who were single/never married has decreased (Table 1).
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However, within each age group, the percentage of single/never married increased over the
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last 5 decades among the age 16-30, 31-45, and 46-60 groups (Figure 2).
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Injury profile
Although vehicular crashes continue to be the leading cause of SCI, the percentage
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declined from 47.0% in the 1970s to 38.1% during 2010-2014 (Table 3). Injuries due to falls
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increased particularly among those aged 46 and older (Figure 3). Injuries due to acts of violence
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peaked in the 1990s (24.8%) but have since declined (13.5% currently). However, acts of
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violence account for 27% of all SCIs occurring among the age 16-30 group and rank first among
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Black males (42.9%).
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Sports-related SCIs declined slightly from 14.4% during the 1970s to 8.9% since 2010 (Table 3). Among those aged 46-60 years, however, the percentage of SCI as a result of sports
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increased from 2.2% in the 1970s to 7.2% recently. This trend is consistent with the observation
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of increasing age for sports-related SCI over the last 4 decades, from 21.1 years to 34.3 years
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(Table 2).
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The percentage of high cervical injuries increased over the last 5 decades, while the
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percentage of low cervical injuries decreased and that of T1-S3 injuries remained relatively
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constant (Table 3). The motor incomplete injuries (AIS C, D, or E) increased from 36.4% to
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53.2%, while neurologically complete injuries (AIS A) decreased from 53.8% to 33.7%.
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When combining level and completeness of injury, we observed an increase of the C1-
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C4 AIS A, B, and C injuries since 1970s for all etiologies (Figure 4) and among the age groups 16-
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30, 31-45, and 46-60 years. Concurrently, the percentage of C5-C8 AIS A, B, and C decreased
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over the last 5 decades for all etiologies and age groups. The AIS D and E injuries gradually
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increased since 1970s among those of age 46 years and older (38.4% in the 1970s and 55.3% in
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the 2010s) and among all etiologies except violence (Figure 5).
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The percentage of persons discharged ventilator dependent doubled from 2.2% in the 1970s, 4.6% in the 1990s, and 4.3% in the 2000s before declining to 3.1% in the 2010s. The
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decrease in ventilator use between 1990s and 2010s was particularly notable among those of
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age 46 years or older (7.6% and 2.7%, respectively) and injuries as a result of falls (5.5% and
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2.2%, respectively).
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156 157 158
Subgroup analysis
Similar demographic and injury trends were noted in each of the SCIMS centers that have been continuously funded, although the level of changes over the last 5 decades varied
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slightly from one center to another.
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DISCUSSION
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Analysis of the demographic and injury profile of traumatic SCI enrolled in the NSCID over the last 5 decades reveals new findings, including progressive increases in motor
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incomplete injuries, age-specific single/never married status, and education level. Previously
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reported trends, including increasing age at injury and proportions of racial minority, fall
167
etiology, and higher cervical injurie across decades, were continued to 2014 among various age,
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sex, race, and etiology groups. Below we review these trends in reference to the changes in the
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general US population, age-sex-specific SCI incidence, and designation of SCIMS centers over
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the last decades. The implications for SCI prevention and future health care needs for SCI are
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also discussed.
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Age
Aging of the US population (Table 4) largely contributes to the increasing age at the time of SCI over the last 5 decades. Had the SCI incidence rate across all age groups remained
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constant, the growth in the elderly SCI population would have perfectly paralleled the general
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population, but this is not the case. The aging of new SCI cases is more dramatic than that of
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the general US population. The percentage of the new SCI cases of age ≥ 65 years has increased
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from 3.1% in the 1970s to 13.2% in 2010-2014, and the corresponding figure for the general
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population is 9.8% and 13.1%, respectively. The average age at injury in 2010-2014 was 42.2
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years, which is about 5 years older than the median age of the US population in 2010 (37.2).
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This aging phenomenon in the SCI population can be explained by a recent finding of a higher
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SCI incidence rate in the elderly (age ≥ 65 years) than their younger peers (age 18-64 years, 87.7
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vs 49.9 new cases per million in 2009)16 and a trend toward an increasing incidence rate in the
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elderly over the last 10 years.17 Based on a Nationwide Inpatient Sample database, Jain et al.
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(2015)17 found the incidence rates among the younger male population declined (for example,
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from 144 cases per million in 1993 to 87 cases per million in 2012 for age 16 to 24 years),
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whereas the incidence rate in men aged 65 to 74 years increased from 84 cases per million in
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1993 to 131 cases per million in 2012.
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191
Sex Although males and females in the US population have been aging at about the same
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pace (increase by 8.1 and 8.9 years, respectively between 1970 and 2010; Table 4), we observe
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a larger increase in average age at SCI in females than males, regardless of race (Table 2). This
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finding reflects an increase of injuries among older adults as well as a smaller difference in SCI
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risk between males and females among the elderly than that in teenagers and young adults. For
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example, the male to female incidence ratio was 1.5 for those aged 75-84 years, but 3.2 for
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those aged 16-24 years in 2012.17 The incidence rate of SCI, however, is higher for males than
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females regardless of ages. As a result, the recent increase in the number of older women with
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SCI did not change the percentage of females in the SCI population dramatically (18.2% in 1970s
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and 20.2% in 2010s).
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203 204
Race
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The changing racial composition of the SCI population is not as dramatic as what has been observed in the general US population over the last 5 decades. This is likely due to a
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combination of factors including the geographic representation of the SCIMS centers, racial
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difference in the incidence rates of SCI that Blacks overall have a higher incidence rate than
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Whites,18-21 and changes in the injury etiology pattern over time.5;6;8;9;17 For example, the high
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percentage of Blacks and Hispanics in the 1990s may reflect the epidemic of violence-onset SCI
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(Table 1), as this epidemic mostly affected Blacks and Hispanics.13 Changing racial composition
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is also possible due to trends in age-sex-race-specific incidence rates over time, which needs
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further investigation. Native American, Asian, and other races made up about 3% of SCI cases in
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the database. A small fluctuation in percentage was observed over time, but the numbers were
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too small to make a precise estimate and projection. The small number of Asian and other races
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is partly due to the facts that non-English or non-Spanish speaking people are excluded from
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NSCID because of consenting requirements.
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Given the continued growth of minorities, especially Hispanics, in the US population,
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increasing SCI patients of minority background should be expected by health care providers.
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Therefore, staff diversification and cultural competency training are needed to avoid racial bias
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in health care and health.22
221 222 223
Other sociodemographic characteristics
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Our observations of trends in education, employment, and marital status of new SCI cases are generally consistent with the US general population and largely explained by the
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aging of the SCI population. We hope that this increased education level over time would lead
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to improved post-injury employment, which deserves further study.23 It is also unknown
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whether the lower marriage rate would adversely affect the marriage rate and overall quality of
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life after SCI, as the marriage rate is lower in the SCI population than in the general population;
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marriage is associated with favorable psychosocial outcomes.24-27
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Injury etiology
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Changes in etiology of injury are relevant to the development of prevention programs.
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For example, diving-related SCI was the focus of research as a potentially preventable injury in
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the context of primary prevention programs.28 These programs appear to have contributed to
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the success in reducing the incidence of diving-related SCI. With fall-induced SCI on the rise
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further prevention efforts are needed to reduce falls particularly among the elderly and those
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occurring at home as a result of slipping, tripping, stumbling, and falling on the same level and
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from stairs, steps, beds, chairs, and toilets, as suggested by previous studies.29;30
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Severity of injury
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These trends are likely due to a combination of advances in medical and surgical
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management,31 improved acute survival of high cervical injuries,32 as well as changes in
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demographics, etiology, and referral pattern of SCIMS centers. For example, older persons are
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most likely injured in falls on the same level that result in tetraplegia and AIS D injuries.29
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Gunshot-related SCIs are on the decline in the past decades, and these typically result in
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complete paraplegia. Use of methylprednisolone and other medications as well as surgical
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intervention in the early management of SCI is not documented in the NSCID and, therefore, its
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contribution to the decrease in neurologically complete injuries cannot be evaluated. Advances
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in rehabilitation therapy might also contribute to the favorable trends.
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Strengths and limitations
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The NSCID has several well-documented strengths and limitations that must be
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considered when evaluating the results of this study. Strengths include the long history, large
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sample size, geographic and patient diversity, standardization of data collection methods and
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measures, excellent case identification procedures, prospective data collection using both
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physical examination and personal interview, and comprehensiveness of the information in the
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database. Due to constraints by the design of the SCIMS program and NSCID, however, the
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generalizability of the present study findings are limited; these constraints include a hospital-
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based sample of the NSCID participants, strict eligibility criteria, and change in the number and
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designation of SCIMS centers as well as information contained in the database. For example,
262
our finding of average age at injury in 2011-2014 (42.2 years) is about 8 years younger than
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what was reported in a study of a US representative inpatient sample of acute traumatic SCI in
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2012 (50.5 years).17 Although Jain et al.’s study is subject to potential counting of readmissions
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after SCI and exclusion of children younger than 16 year that could have overestimated the
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average age at injury, the NSCID over-represents violent etiology that occurs primarily in teens
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and young adult males because of the urban location of many of the SCIMS centers. The NSCID
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eligibility criteria call for neurological deficits and completed rehabilitation with some
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exceptions, which excludes older patients with fall etiologies and with minimal neurological
270
deficits who never received rehabilitation. A recent study that compared the NSCID with the
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Inpatient Rehabilitation Facilities Patient Assessment Instrument database concluded that the
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NSCID is largely representative of the national population of patients receiving inpatient
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rehabilitation for new onset of traumatic SCI during 2001-2010.33
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Because the NSCID is not population-based, data can only be presented as percentages,
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which do not necessarily imply corresponding changes in incidence. For example, the recent
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decline in the percentage of new SCI cases caused by vehicular crashes could be due to the
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decrease in the underlying incidence. The percentage of vehicular-related SCI would also drop if
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the underlying incidence rate rises but at a slower rate than that of other causes. However,
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provided that the statistics are interpreted with some understanding of how the data have
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been collected and analyzed, the trends reported here are relevant to service providers, policy
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makers, and researchers.
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Conclusions
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Demographic and injury trends in new SCIs call for greater involvement of experts in gerontology and geriatrics and intercultural competency of clinical teams during acute and
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rehabilitation care for SCI. Educational materials that portray SCI cases as men in their teens
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and early 20 years of age need to be updated. Prevention efforts should incorporate multi-
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dimensional risk assessments, especially to reduce falls and associated SCI in older adults.
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(2) Kirshblum S, Campagnolo DI, Nash MS, Heary RF, Gorman PH. Spinal Cord Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.
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(5) DeVivo MJ. Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord 2012;50:365-372.
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(6) DeVivo MJ, Chen Y. Trends in new injuries, prevalent cases, and aging with spinal cord injury. Arch Phys Med Rehabil 2011;92:332-338.
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(8) Jackson AB, Dijkers M, DeVivo MJ, Poczatek RB. A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years. Arch Phys Med Rehabil 2004;85:1740-1748.
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(9) Nobunaga AI, Go BK, Karunas RB. Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems. Arch Phys Med Rehabil 1999;80:1372-1382.
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(12) Chen Y, DeVivo MJ, Richards JS, SanAugustin TB. Spinal Cord Injury Model Systems: Program and National Database 1970-2015. Archives of Physical Medicine and Rehabilitation 2016.
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(13) Chen Y, Tang Y, Vogel LC, DeVivo MJ. Causes of spinal cord injury. Topics in Spinal Cord Injury Rehabilitation 2013;19:1-8.
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(14) Kirshblum SC, Burns SP, Biering-Sorensen F et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 2011;34:535-546.
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(15) Frankel HL, Hancock DO, Hyslop G et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969;7:179-192.
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(16) Selvarajah S, Hammond ER, Haider AH et al. The burden of acute traumatic spinal cord injury among adults in the united states: an update. J Neurotrauma 2014;31:228-238.
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(17) Jain NB, Ayers GD, Peterson EN et al. Traumatic spinal cord injury in the United States, 19932012. JAMA 2015;313:2236-2243.
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(18) Acton PA, Farley T, Freni LW, Ilegbodu VA, Sniezek JE, Wohlleb JC. Traumatic spinal cord injury in Arkansas, 1980 to 1989. Archives of Physical Medicine & Rehabilitation 1993;74:1035-1040.
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(19) Burke DA, Linden RD, Zhang YP, Maiste AC, Shields CB. Incidence rates and populations at risk for spinal cord injury: A regional study. Spinal Cord 2001;39:274-278.
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(20) Price C, Makintubee S, Herndon W, Istre GR. Epidemiology of traumatic spinal cord injury and acute hospitalization and rehabilitation charges for spinal cord injuries in Oklahoma, 1988-1990. American Journal of Epidemiology 1994;139:37-47.
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(21) Surkin J, Gilbert BJ, Harkey HL, III, Sniezek J, Currier M. Spinal cord injury in Mississippi. Findings and evaluation, 1992-1994. Spine (Phila Pa 1976 ) 2000;25:716-721.
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(22) Williams DR, Wyatt R. Racial Bias in Health Care and Health: Challenges and Opportunities. JAMA 2015;314:555-556.
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(23) Frieden L, Winnegar AJ. Opportunities for research to improve employment for people with spinal cord injuries. Spinal Cord 2012;50:379-381.
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(24) Cao Y, Krause JS, Saunders LL, Clark JM. Impact of Marital Status on 20-Year Subjective Wellbeing Trajectories. Top Spinal Cord Inj Rehabil 2015;21:208-217.
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(25) Chen Y, Anderson CJ, Vogel LC, Chlan KM, Betz RR, McDonald CM. Change in life satisfaction of adults with pediatric-onset spinal cord injury. Arch Phys Med Rehabil 2008;89:2285-2292.
347 348 349
(26) Kalpakjian CZ, Houlihan B, Meade MA et al. Marital status, marital transitions, well-being, and spinal cord injury: an examination of the effects of sex and time. Arch Phys Med Rehabil 2011;92:433-440.
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(27) Kreuter M. Spinal cord injury and partner relationships. Spinal Cord 2000;38:2-6.
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(28) DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord 1997;35:509-515.
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(29) Chen Y, Tang Y, Allen V, DeVivo MJ. Fall-induced spinal cord injury: External causes and implications for prevention. J Spinal Cord Med 2015.
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(30) Chen Y, Tang Y, Allen V, DeVivo MJ. Aging and Spinal Cord Injury: External Causes of Injury and Implications for Prevention. Top Spinal Cord Inj Rehabil 2015;21:218-226.
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(31) van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013;30:1781-1794.
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(32) Strauss DJ, DeVivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil 2006;87:1079-1085.
362 363 364 365 366
(33) Cuthbert J, Charlifue S, Chen D et al. Generalizability of spinal cord injury model systems data 2001-2010 [abstract]Cuthbert J, Charlifue S, Chen D et al. Journal of Spinal Cord Medicine 2014;37:438-439
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FIGURE LEGENDS
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Figure 1.
370
Note: Percentages of White male and female for each decade were not shown, which add up
371
to 100% along with those of Blacks and Hispanics.
372
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Percentages of Blacks and Hispanics by decades: age and sex differences.
Figure 2.
Percentages of Single/Never married by decades and age groups.
374
Note: Percentages of other marital status (married, divorced, separated, widowed, and others)
375
for each decade were not shown, which add up to 100% along with single/never married for
376
each age group.
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Figure 3.
379
Note: Percentages of other etiologies (vehicular, violence, sports, medical/surgical
380
complications, and others) for each decade was not shown, which add up to 100% along with
381
falls for each age group.
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Percentages of SCI as a result of falls by decades and age groups
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Figure 4.
384
Note: Percentages of other level and completeness of injury for each decade was not shown,
385
which add up to 100% along with the C1-C4 AIS A, B, and C injuries for each etiology.
386
Percentages of C1-C4 AIS A, B, and C injuries by decades and etiologies of injury
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Figure 5.
Percentages of AIS D and E injuries by decades and etiologies of injury
388
Note: Percentages of other level and completeness of injury for each decade was not shown,
389
which add up to 100% along with AIS D and E injuries for each etiology
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Table 1: Demographic profile of people with new SCI over the last 5 decades Injury Year Intervals 1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Total
Sample Size*
4,562
8,791
6,918
7,050
3,560
30,881
13
19
20
28.7
31.3
35.1
0-15
6.4
3.8
16-30
62.0
58.1
31-45
17.9
46-60
9.0
61-75
4.0
75+
0.7
No. SCIMS Age at injury, mean (y)
39.1
42.2
34.8
1.3
1.0
3.1
45.6
38.6
34.4
48.7
27.8
25.0
20.7
23.1
9.9
13.6
21.9
25.2
15.1
5.0
7.5
10.0
14.9
7.7
1.6
2.4
3.2
3.8
2.2
4.8
7.3
9.5
13.2
7.1
18.2
17.5
19.6
21.5
20.2
19.3
76.9
68.3
57.1
62.4
64.0
65.3
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Female (%)
28
3.0
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18
21.6
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Age ≥ 65 (%)
21
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Age group at injury (%)
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Characteristic
14.2
20.8
27.8
24.3
22.0
22.3
5.9
8.1
12.1
10.6
10.6
9.5
Native American
1.9
1.1
0.4
0.4
0.6
0.8
Asian/Pacific Islander
0.9
1.3
2.0
1.9
1.8
1.6
Other
0.1
0.3
0.6
0.5
1.1
0.5
8th grade or less
15.8
11.1
9.5
5.2
3.2
9.2
9th - 11th grade
27.6
28.5
27.9
20.0
14.8
24.7
Race (%) White Black
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Education level at injury (%)
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49.0
50.4
50.4
55.6
51.5
51.5
Associate degree
0.5
1.3
2.7
4.4
8.1
3.0
Bachelor
5.2
5.9
6.2
9.6
13.7
7.6
Masters/Doctorate
1.8
2.0
2.2
4.1
7.2
3.1
Other
0.1
0.6
1.0
Employed
60.6
59.4
53.6
Unemployed
10.4
15.2
21.3
Student
23.4
17.9
13.8
2.9
Retired
2.6
Other
0.1
Marital Status at injury (%)
0.8
59.4
57.9
58.1
15.1
16.3
16.0
11.8
10.5
15.6
1.9
1.4
1.0
1.9
4.7
7.8
9.8
12.2
7.1
0.7
1.7
2.5
2.1
1.4
54.1
53.3
47.7
45.8
51.8
31.8
30.4
30.4
36.7
36.5
32.8
7.9
8.8
9.9
10.2
11.1
9.5
4.8
4.1
3.5
2.2
2.0
3.4
EP
Married
1.5
2.5
2.9
2.8
3.0
2.6
0.0
0.2
0.0
0.3
1.7
0.3
Divorced Separated Widowed
54.0
1.4
2.2
TE D
Never Married (Single)
M AN U
Homemaker
1.1
SC
Employment at injury (%)
RI PT
High School graduate
AC C
Other, unclassified
NOTE. All comparisons across injury years are statistically significant, P value for the analysis of variance and chi-square ≤ 0.0001. *Sample size varies by characteristics because of unknown and missing responses that ranged from 0% for age and sex to 6% for education.
2
ACCEPTED MANUSCRIPT
Table 2: Distributions of the average age at injury by sex, race, and etiology over the last 5 decades Injury Year Intervals Characteristic
N
1972-1979
1980-1989
1990-1999
15,798
28.1
30.5
36.7
White Female
4,168
29.2
33.1
38.7
Black Male
5,763
31.7
33.4
32.6
Black Female
1,058
28.6
35.6
Hispanic Male
2,478
26.7
27.3
432
25.8
13,088
27.5
Falls
6,785
37.0
Violence
5,338
27.6
Sports
3,161
Medical/Surgical
2000-2009
2010-2014
Total
Hispanic Female
42.2
47.0
37.5
35.7
36.9
34.0
SC
34.8
39.0
40.6
36.9
28.5
34.1
36.9
30.4
33.1
33.8
39.2
32.8
29.5
34.1
36.3
38.1
32.6
41.5
46.3
50.8
53.0
46.4
27.8
26.4
27.6
28.6
27.4
21.1
23.7
27.5
30.8
34.3
26.2
1,632
32.4
33.8
37.3
40.2
42.8
36.1
846
42.2
46.4
54.3
54.6
57.7
52.8
TE D
EP
Other
44.0
29.5
Etiology of Injury Vehicular
40.5
38.0
M AN U
White Male
RI PT
Sex-race
AC C
Note: Values are mean age (y).
ACCEPTED MANUSCRIPT
Table 3: Injury profile of people with new SCI over the last 5 decades Injury Year Intervals 1972-1979 1980-1989 1990-1999 2000-2009
Sample Size*
4,562
8,791
6,918
Vehicular
47.0
43.9
38.3
Falls
16.5
18.6
21.8
Violence
13.3
17.2
24.8
Sports
14.4
12.5
7.3
1.2
Other
7.7
Level of Injury (%) 14.5
C5-C8
39.5
43.9
38.1
42.4
25.5
31.0
22.0
14.5
13.5
17.3
8.4
8.9
10.2
3.0
3.7
4.7
2.7
6.0
4.8
4.1
3.8
5.3
17.8
20.8
25.2
32.8
21.2
35.8
28.9
30.7
26.2
32.7
35.6
35.2
38.2
33.5
32.0
35.2
10.4
11.1
12.1
10.6
9.1
10.9
EP
T1-T12
30,881
1.9
TE D
C1-C4
3,560
7,050
M AN U
Medical/Surgical
Total
SC
Etiology of Injury (%)
2010-2014
RI PT
Characteristic
53.8
46.5
48.6
41.8
33.7
45.6
9.8
10.7
10.4
12.4
13.2
11.1
8.2
10.2
15.1
14.2
16.2
12.5
27.2
32.0
25.5
31.0
36.6
30.1
1.0
0.6
0.5
0.5
0.4
0.6
Ventilator dependent
2.2
2.9
4.6
4.3
3.1
3.5
C1-C4 AIS/Frankel ABC
8.2
9.2
11.0
13.3
14.9
11.0
L1-S3 AIS/Frankel grade (%) A
C D E
AC C
B
Neurological category (%)
1
ACCEPTED MANUSCRIPT
C5-C8 AIS/Frankel ABC
27.2
22.3
18.1
16.4
13.9
20.0
T1-S3 AIS/Frankel ABC
34.1
32.8
40.2
33.8
30.7
34.6
AIS/Frankel DE
28.3
32.8
26.2
32.3
37.4
31.0
0.0001.
RI PT
NOTE. All comparisons across injury years are statistically significant, P value for the chi-square ≤
*Sample size for each injury decade varies by characteristics because of unknown and missing responses
AC C
EP
TE D
M AN U
SC
that ranged from 0.7% for etiology to 6.0% for level of injury.
2
ACCEPTED MANUSCRIPT
1970
1980
1990
2000
2010
205,052,174
226,862,400
249,622,814
281,421,906
308,745,538
28.3
30.0
32.8
35.3
37.2
0-14
28.3
22.6
21.7
21.4
19.8
15-29
24.5
27.4
23.3
RI PT
Table 4: Statistical information of the US population by decades
20.8
20.9
30-44
16.9
19.1
23.6
23.4
19.8
45-59
16.3
15.2
14.2
18.2
21.0
60-74
10.3
Population size Age, median
11.3
11.4
10.3
12.4
4.4
5.3
5.9
6.1
11.3
12.5
12.4
13.1
28.8
31.6
34.0
35.8
31.3
34.0
36.5
38.5
31.0
34.8
38.1
41.3
24.0
28.0
30.3
32.1
22.0
25.3
25.8
27.5
48.8
48.6
48.7
49.1
49.2
83.5
79.6
75.6
69.1
63.7
11.5
11.7
12.1
12.2
6.4
9.0
12.5
16.3
0.7
0.7
0.7
3.7
Age ≥ 65 (%)
9.8
Age, median 27.7
Age, median White Black
AC C
Hispanic
29.6
EP
Female
TE D
Male
M AN U
75+
SC
Age category (%)
Sex (%) Male
Race/Ethnicity (%) White Black Hispanic
Native American
4.4
ACCEPTED MANUSCRIPT
Asian/ Pacific Islander
2.8
3.7
4.8
Other
0.1
1.8
2.3
7.5
6.2
Education level (Population 25 years and over) (%)
RI PT
8th or less 9th to 12th grade
12.1
8.7
28.6
29.0
21.0
20.6
6.3
7.5
15.5
17.6
8.9
10.3
22.2
27.1
32.2
61.9
54.4
48.8
2.2
2.2
7.6
6.6
6.0
8.3
9.7
10.8
63.4
63.9
59.7
57.0
Unemployed
3.7
6.9
In armed forces
0.5
0.6
36.1
35.6
High school graduate
SC
Some college, no degree Associate's degree
Graduate or professional degree
M AN U
Bachelor’s degress
Marital Status (Population 15 years and over) (%) Never married Now married, except separated
TE D
Separated Widowed Divorced
EP
Employment Status (Population 16 years and over) (%) In civilian labor force
AC C
Employed
Not in labor force
NOTE. Data sources: US Bureau of the Census (www.census.gov), including American FactFinder (http://factfinder.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t); Statistical Abstract of the United States 1970s-2010s (www.census.gov/library/publications/time-series/statistical_abstracts.html); and "Historical Census Statistics on Population Totals By Race, 1790 to 1990, and By Hispanic Origin, 1970 to 1990, For Large Cities and Other Urban Places In The United States (https://www.census.gov/population/www/documentation/twps0076/twps0076.pdf).
ACCEPTED MANUSCRIPT
Figure 1. Percentages of Blacks and Hispanics by decades: age and sex differences
Age 16-30
30
RI PT
25
Black Male
15
Hispanic Male
SC
Percentage (%)
20
5
0
1972-1979
1980-1989
Hispanic Female
M AN U
10
Black Female
1990-1999
2000-2009
2010-2014
Year of Injury
TE D
30
Age 31-45
25
EP
15
Black Male Hispanic Male Black Female
AC C
Percentage (%)
20
10
Hispanic Female
5
0
1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Year of Injury
1
ACCEPTED MANUSCRIPT
30
Age 46-60
RI PT
25
Percentage %
20
Black Male
15
Hispanic Male Black Female
10
SC
Hispanic Female
0 1972-1979
1980-1989
M AN U
5
1990-1999
2000-2009
2010-2014
Year of Injury
30
Age 61-75
TE D
25
15
AC C
10
Black Male Hispanic Male
EP
Percentage %
20
Black Female Hispanic Female
5
0
1972-1979
1980-1989
1990-1999
2000-2009
2010-2014
Year of Injury
2
ACCEPTED MANUSCRIPT
Figure 2. Percentage of Single/Never married by decades and age groups 100 90
RI PT
70 60
Age 16 - 30
50
Age 31 - 45
40
Age 46 - 60
SC
Never Married (Single) %
80
30
10 0 1972-1979
1980-1989
M AN U
20
1990-1999
AC C
EP
TE D
Year of Injury
2000-2009
2010-2014
Age 60+
ACCEPTED MANUSCRIPT
Figure 3. Percentage of SCI as a result of falls by decades and age groups 70
RI PT
60
Fall %
50 40
Age 16 - 30 Age 31 - 45
30
SC
Age 46 - 60
10 0 1972-1979
1980-1989
M AN U
20
1990-1999
AC C
EP
TE D
Year of Injury
2000-2009
2010-2014
Age 60+
ACCEPTED MANUSCRIPT
Figure 4. Percentage of C1-C4 AIS A, B, and C injuries by decades and etiologies of injury 25
RI PT
Vehicular Accidents
15
Falls
Violence
10
SC
C1-C4 AIS ABC %
20
0 1972-1979
1980-1989
M AN U
5
1990-1999
AC C
EP
TE D
Year of Injury
2000-2009
2010-2014
Sports
ACCEPTED MANUSCRIPT
Figure 5. Percentage of AIS D and E injuries by decades and etiologies of injury 60
RI PT
50
Vehicular Accidents Falls
30
Violence
SC
AIS DE %
40
20
0 1972-1979
1980-1989
M AN U
10
Sports
1990-1999
2000-2009
2010-2014
Year of Injury
AC C
EP
TE D
.
1