Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2016;97:1610-9

ORIGINAL RESEARCH

Changing Demographics and Injury Profile of New

Traumatic Spinal Cord Injuries in the United States,
1972e2014
Yuying Chen, MD, PhD, Yin He, MA, Michael J. DeVivo, DrPH
From the Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL.

Abstract
Objective: To document trends in the demographic and injury profile of new spinal cord injury (SCI) over time.
Design: Cross-sectional analysis of longitudinal data by injury years (1972e1979, 1980e1989, 1990e1999, 2000e2009, 2010e2014).
Setting: Twenty-eight Spinal Cord Injury Model Systems centers throughout the United States.
Participants: Persons with traumatic SCI (NZ30,881) enrolled in the National Spinal Cord Injury Database.
Interventions: Not applicable.
Main Outcome Measures: Age, sex, race, education level, employment, marital status, etiology, and severity of injury.
Results: Age at injury has increased from 28.7 years in the 1970s to 42.2 years during 2010 to 2014. This aging phenomenon was noted for both
sexes, all races, and all etiologies except acts of violence. The percentage of racial minorities expanded continuously over the last 5 decades.
Virtually among all age groups, the average education levels and percentage of single/never married status have increased, which is similar to the
trends noted in the general population. Although vehicular crashes continue to be the leading cause of SCI overall, the percentage has declined from
47.0% in the 1970s to 38.1% during 2010 to 2014. Injuries caused by falls have increased over time, particularly among those aged
46 years.
Progressive increases in the percentages of high cervical and motor incomplete injuries were noted for various age, sex, race, and etiology groups.
Conclusions: Study findings call for geriatrics expertise and intercultural competency of the clinical team in the acute and rehabilitation care for
SCI. This study also highlights the need for a multidimensional risk assessment and multifactorial intervention, especially to reduce falls and SCI
in older adults.
Archives of Physical Medicine and Rehabilitation 2016;97:1610-9
ª 2016 by the American Congress of Rehabilitation Medicine

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 Understanding the
current trends in the demographic and injury profile of new SCI is
the key for the development of effective prevention strategies
targeted to persons at greatest risk for injury. By providing
detailed information about SCI trends, future health care needs
could also be assessed.
The Spinal Cord Injury Model Systems (SCIMS) program and
its National Spinal Cord Injury Database (NSCID) have existed
Supported by the National Institute on Disability, Independent Living, and Rehabilitation
Research (NIDILRR) (grant no. 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 of NIDILRR, ACL, HHS, and you should not
assume endorsement by the Federal Government.
Disclosures: none.
since 1970.4 Information contained in the NSCID has been the
major source for documenting trends in the demographic and
injury profile of traumatic SCI in the United States.5-10 As
demonstrated in recent analyses of NSCID data up to 2008, sig-
nificant trends toward older age at the time of injury and
increasing proportions of injuries occurring in racial minority
populations, injuries caused by falls, and high cervical injuries
were observed.5,6 A slight trend toward an increasing proportion
of women with new SCI was also documented.
Because of the pace of previously observed changes in the face
of SCI, the fast-changing compositions of the U.S. population, and
the need to base prevention and clinical management on the most
recent information, it is critical to update the epidemiology of SCI
at regular intervals. The purpose of this study was to document the
demographic and injury profile of new SCI cases and assess
whether previously noted trends were continued to 2014. Given a

0003-9993/16/$36 - see front matter ª 2016 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2016.03.017
Spinal cord injury demographic trends
large sample size, we were able to examine the trends in detail by
cross-tabulating several demographic and injury factors.
Methods
Participants
The NSCID contains baseline and follow-up information on per-
sons with traumatic SCI who received initial hospital care from 1
of the 28 SCIMS centers since the early 1970s; it historically
captures data from approximately 13% of new SCIs in the United
States.11 To be qualified for the NSCID, individuals must (1) have
sustained an SCI due to a traumatic event; (2) reside in the
geographic catchment area of the SCIMS center at injury; (3) be
admitted to the SCIMS center within 1 year of injury; (4) be
discharged from the SCIMS center as either neurologically
normal, having completed rehabilitation, or deceased; and (5)
provide informed consent. As of March 2015, there were 30,881
persons injured between 1972 and 2014 enrolled in the NSCID.
Details about the NSCID structure, SCIMS centers, and follow-up
data collection appear in an article12 elsewhere in this issue of
Archives of Physical Medicine and Rehabilitation.
Variables and measures
All variables for this study were obtained by trained personnel
during initial hospital care from medical records and by personal
interview. Institutional review board approval was obtained at the
National Spinal Cord Injury Statistical Center as well as locally at
each SCIMS center.
The NSCID documents 37 causes of injury,13 which we
grouped into 6 categories for analysis: (1) vehicular crashes; (2)
falls; (3) acts of violence; (4) sports; (5) medical/surgical com-
plications, defined as impairment of spinal cord function resulting
from adverse effects of medical, surgical, or diagnostic procedures
and treatments for nonespinal cord conditions; and (6) all other,
including pedestrian injury, hit by flying/falling object, etc.
Neurologic 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 the time of
examinations.14 Before August 1993, completeness of injury was
assessed using Frankel’s classification scale.15 The major difference
between the Frankel scale and the American Spinal Injury Association
Impairment Scale (AIS) is that some injuries are classified incomplete
by the Frankel scale but complete by the AIS. Ventilator dependency
was defined as any use of any type of mechanical ventilation for
sustaining respiration, including phrenic nerve stimulation.
Employment status was classified as (1) employed for pay, full
or part time, including military; (2) unemployed; (3) student,
including on-the-job training, sheltered workshop, and those aged
0 to 5 years; (4) homemaker; (5) retired; and (6) other, including
volunteer, disability/medical leave, etc. Additional information
about variables can be found in the NSCID Data Dictionary
(https://www.nscisc.uab.edu/nscisc-database.aspx).
List of abbreviations:
AIS American Spinal Injury Association Impairment Scale
NSCID National Spinal Cord Injury Database
SCI spinal cord injury
SCIMS Spinal Cord Injury Model Systems
www.archives-pmr.org
1611
Statistical analysis
To evaluate trends, all cases were grouped by decade of injury
(1972e1979, 1980e1989, 1990e1999, 2000e2009, 2010e2014).
Mean age at injury was determined for each period and compared
by 1-way analysis of variance. For categorical variables such as
sex, race, education, and severity of injury, frequencies and
percentages were presented for each decade, based on the entire
sample without any age restriction; differences across decades
were assessed for statistical significance by the chi-square test. To
examine the potential bias of changing designation of SCIMS
centers on the trends over time, we repeated the above analysis for
each of the 6 centers that have been funded for
35 years, located
in Alabama, Pennsylvania, Illinois, Texas, Colorado, and Wash-
ington. All analyses were conducted using SAS v9.3.a
Results
Demographic profile
The average age at injury increased from 28.7 years in the 1970s
to 42.2 years during 2010 to 2014 (table 1). The trend toward
increasing age at injury was noted for both sexes and all races,
with the greatest increase in white females, followed by white
males, Hispanic females, black females, Hispanic males, and
black males (table 2). The gradual increase in age at injury was
observed within all etiology groups except acts of violence.
The percentage of new SCI cases who were members of a
racial minority expanded continuously over the last 5 decades (see
table 1). The percentage of blacks peaked in the 1990s, then
dropped by 3.5% during 2000 to 2009, and stayed at 22% since
2010. The percentage of black males aged
46 years, however,
progressively declined since the 1980s (fig 1). While Hispanic
males followed a similar trend as black males among those aged
16 to 30 years, an increase in the percentage of Hispanic males
over the last 5 decades occurred in the older age groups.
Average education levels of newly injured persons increased
(see table 1); this trend was noted in all age groups from 16 years
and older. With increasing age at injury, we observed an increase
in the percentages of people who were retired, married, divorced,
or widowed, while the percentage of people who were single/never
married has decreased (see table 1). However, within each age
group, the percentage of single/never married increased over the
last 5 decades among the age groups of 16 to 30, 31 to 45, and 46
to 60 years (fig 2).
Injury profile
Although vehicular crashes continue to be the leading cause of
SCI, the percentage declined from 47.0% in the 1970s to 38.1%
during 2010 to 2014 (table 3). Injuries resulting from falls
increased particularly among those aged
46 years (fig 3).
Injuries resulting from acts of violence peaked in the 1990s
(24.8%) but have since declined (13.5% currently). However, acts
of violence account for 27% of all SCIs occurring among the 16-
to 30-year age group and rank first among black males (42.9%).
Sports-related SCIs declined slightly from 14.4% during the
1970s to 8.9% since 2010 (see table 3). Among those aged 46 to
60 years, however, the percentage of SCI as a result of sports
increased from 2.2% in the 1970s to 7.2% recently. This trend is
consistent with the observation of increasing age for sports-related
1612 Y. Chen et al

Table 1 Demographic profile of people with new SCI over the last 5 decades
Injury Year Intervals
Characteristics 1972e1979 1980e1989 1990e1999 2000e2009 2010e2014 Total
Sample size* (n) 4562 8791 6918 7050 3560 30,881
No. of SCIMS 13 19 20 21 18 28
Mean age at injury (y) 28.7 31.3 35.1 39.1 42.2 34.8
Age group at injury
0e15 6.4 3.8 3.0 1.3 1.0 3.1
16e30 62.0 58.1 45.6 38.6 34.4 48.7
31e45 17.9 21.6 27.8 25.0 20.7 23.1
46e60 9.0 9.9 13.6 21.9 25.2 15.1
61e75 4.0 5.0 7.5 10.0 14.9 7.7
75þ 0.7 1.6 2.4 3.2 3.8 2.2
Age
65 3.1 4.8 7.3 9.5 13.2 7.1
Female 18.2 17.5 19.6 21.5 20.2 19.3
Race
White 76.9 68.3 57.1 62.4 64.0 65.3
Black 14.2 20.8 27.8 24.3 22.0 22.3
Hispanic 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
Education level at injury
8th grade 15.8 11.1 9.5 5.2 3.2 9.2
9th to 11th grade 27.6 28.5 27.9 20.0 14.8 24.7
High school graduate 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
Master’s/doctorate 1.8 2.0 2.2 4.1 7.2 3.1
Other 0.1 0.6 1.0 1.1 1.4 0.8
Employment at injury
Employed 60.6 59.4 53.6 59.4 57.9 58.1
Unemployed 10.4 15.2 21.3 15.1 16.3 16.0
Student 23.4 17.9 13.8 11.8 10.5 15.6
Homemaker 2.9 2.2 1.9 1.4 1.0 1.9
Retired 2.6 4.7 7.8 9.8 12.2 7.1
Other 0.1 0.7 1.7 2.5 2.1 1.4
Marital status at injury
Never married (single) 54.0 54.1 53.3 47.7 45.8 51.8
Married 31.8 30.4 30.4 36.7 36.5 32.8
Divorced 7.9 8.8 9.9 10.2 11.1 9.5
Separated 4.8 4.1 3.5 2.2 2.0 3.4
Widowed 1.5 2.5 2.9 2.8 3.0 2.6
Other, unclassified 0.0 0.2 0.0 0.3 1.7 0.3
NOTE. Values are percentages or as otherwise indicated. All comparisons across injury years are statistically significant; P value for the analysis of
variance and chi-square .0001.
* Sample size varies by characteristics because of unknown and missing responses that ranged from 0% for age and sex to 6% for education.

SCI over the last 4 decades, from 21.1 years to 34.3 years
(see table 2).
The percentage of high cervical injuries increased over the last
5 decades, while the percentage of low cervical injuries decreased
and that of T1 to S3 injuries remained relatively constant (see
table 3). The motor incomplete injuries (AIS C, D, or E) increased
from 36.4% to 53.2%, while neurologically complete injuries
(AIS A) decreased from 53.8% to 33.7%.
When combining level and completeness of injury, we
observed an increase of the C1-4 AIS A, B, and C injuries since
1970s for all etiologies (fig 4) and among the age groups of 16 to
30, 31 to 45, and 46 to 60 years. Concurrently, the percentage of
C5-8 AIS A, B, and C injuries decreased over the last 5 decades
for all etiologies and age groups. The AIS D and E injuries
gradually increased since the 1970s among those aged
46 years
(38.4% in the 1970s and 55.3% in the 2010s) and among all eti-
ologies except violence (fig 5).
The percentage of persons discharged ventilator dependent
doubled from 2.2% in the 1970s to 4.6% in the 1990s and 4.3% in
the 2000s, before declining to 3.1% in the 2010s. The decrease in
ventilator use between the 1990s and 2010s was particularly
notable among those aged
46 years (7.6% and 2.7%,

www.archives-pmr.org
Spinal cord injury demographic trends 1613

Table 2 Distributions of average age at injury by sex, race, and etiology over the last 5 decades
Injury Year Intervals
Characteristics N 1972e1979 1980e1989 1990e1999 2000e2009 2010e2014 Total
Sex-race
White male 15,798 28.1 30.5 36.7 40.5 44.0 34.8
White female 4,168 29.2 33.1 38.7 42.2 47.0 37.5
Black male 5,763 31.7 33.4 32.6 35.7 36.9 34.0
Black female 1,058 28.6 35.6 38.0 39.0 40.6 36.9
Hispanic male 2,478 26.7 27.3 28.5 34.1 36.9 30.4
Hispanic female 432 25.8 29.5 33.1 33.8 39.2 32.8
Etiology of injury
Vehicular 13,088 27.5 29.5 34.1 36.3 38.1 32.6
Falls 6,785 37.0 41.5 46.3 50.8 53.0 46.4
Violence 5,338 27.6 27.8 26.4 27.6 28.6 27.4
Sports 3,161 21.1 23.7 27.5 30.8 34.3 26.2
Medical/surgical 1,632 32.4 33.8 37.3 40.2 42.8 36.1
Other 846 42.2 46.4 54.3 54.6 57.7 52.8
NOTE. Values are mean age (y) or as otherwise indicated.

respectively) and those whose injuries were caused by falls (5.5%
and 2.2%, respectively).
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 slightly from one
center to another.
Discussion
Analysis of the demographic and injury profile of traumatic SCI
enrolled in the NSCID over the last 5 decades reveals new find-
ings, including progressive increases in motor incomplete injuries,
age-specific single/never married status, and education level.
Previously reported trends, including increasing age at injury and
proportions of racial minorities, fall etiology, and higher cervical
injuries across decades, were continued to 2014 among various

Fig 1 Percentages of blacks and Hispanics by decades: age and sex differences. Note: Percentages of white males and females for each decade
were not shown, which add up to 100% along with those of blacks and Hispanics.

www.archives-pmr.org
1614 Y. Chen et al

Fig 2 Percentages of single/never married by decades and age groups. Note: Percentages of other marital status (married, divorced, separated,
widowed, and others) for each decade were not shown, which add up to 100% along with single/never married for each age group.

Table 3 Injury profile of people with new SCI over the last 5 decades
Injury Year Intervals
Characteristics 1972e1979 1980e1989 1990e1999 2000e2009 2010e2014 Total
Sample size* (n) 4562 8791 6918 7050 3560 30,881
Etiology of injury
Vehicular 47.0 43.9 38.3 43.9 38.1 42.4
Falls 16.5 18.6 21.8 25.5 31.0 22.0
Violence 13.3 17.2 24.8 14.5 13.5 17.3
Sports 14.4 12.5 7.3 8.4 8.9 10.2
Medical/surgical 1.2 1.9 3.0 3.7 4.7 2.7
Other 7.7 6.0 4.8 4.1 3.8 5.3
Level of injury
C1-4 14.5 17.8 20.8 25.2 32.8 21.2
C5-8 39.5 35.8 28.9 30.7 26.2 32.7
T1-12 35.6 35.2 38.2 33.5 32.0 35.2
L1-S3 10.4 11.1 12.1 10.6 9.1 10.9
AIS/Frankel grade
A 53.8 46.5 48.6 41.8 33.7 45.6
B 9.8 10.7 10.4 12.4 13.2 11.1
C 8.2 10.2 15.1 14.2 16.2 12.5
D 27.2 32.0 25.5 31.0 36.6 30.1
E 1.0 0.6 0.5 0.5 0.4 0.6
Neurologic category
Ventilator dependent 2.2 2.9 4.6 4.3 3.1 3.5
C1-4 AIS/Frankel ABC 8.2 9.2 11.0 13.3 14.9 11.0
C5-8 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
NOTE. Values are percentages or as otherwise indicated. All comparisons across injury years are statistically significant; P value for the chi-square
.0001.
* Sample size for each injury decade varies by characteristics because of unknown and missing responses that ranged from 0.7% for etiology to 6.0%
for level of injury.

www.archives-pmr.org
Spinal cord injury demographic trends 1615

70

60

50

40
Age 16 - 30
Fall %

Age 31 - 45
30
Age 46 - 60
Age 60+
20

10

0
1972-1979 1980-1989 1990-1999 2000-2009 2010-2014
Year of Injury

Fig 3 Percentages of SCI as a result of falls by decades and age groups. Note: Percentages of other etiologies (vehicular, violence, sports,
medical/surgical complications, and others) for each decade were not shown, which add up to 100% along with falls for each age group.

age, sex, race, and etiology groups. Below we review these trends
in reference to the changes in the general U.S. population, age-
and sex-specific SCI incidence, and designation of SCIMS centers
over the last decades. The implications for SCI prevention and
future health care needs for SCI are also discussed.
Age
Aging of the U.S. 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 constant, the
growth in the elderly SCI population would have perfectly
paralleled the general population, but this is not the case. The aging
of new SCI cases is more dramatic than that of the general U.S.
population. The percentage of the new SCI cases of age
65 years
has increased from 3.1% in the 1970s to 13.2% in 2010 to 2014,
and the corresponding figure for the general population is 9.8% and
13.1%, respectively. The average age at injury in 2010 to 2014 was
42.2 years, which is about 5 years older than the median age of the
U.S. population in 2010 (37.2y). This aging phenomenon in the
SCI population can be explained by a recent finding of a higher SCI
incidence rate in the elderly (age
65y) than their younger peers
(age 18e64y; 87.7 vs 49.9 new cases per million in 2009)16 and a
trend toward an increasing incidence rate in the elderly over the last

25

20
C1-C4 AIS ABC %

Vehicular
15 Accidents
Falls

10 Violence

Sports

0
1972-1979 1980-1989 1990-1999 2000-2009 2010-2014
Year of Injury

Fig 4 Percentages of C1-4 AIS A, B, and C injuries by decades and etiologies of injury. Note: Percentages of other level and completeness of
injury for each decade were not shown, which add up to 100% along with the C1-4 AIS A, B, and C injuries for each etiology.

www.archives-pmr.org
1616
60
50
40
AIS DE %
30
20
10
0
1972-1979 1980-1989 1990-1999
Year of Injury
Fig 5 Percentages of AIS D and E injuries by decades and etiologies of injury. Note: Percentages of other level and completeness of injury for
each decade were not shown, which add up to 100% along with AIS D and E injuries for each etiology.
10 years.17 Based on a Nationwide Inpatient Sample database, Jain
et al17 found the incidence rates among the younger male popu-
lation declined (eg, from 144 cases per million in 1993 to 87 cases
per million in 2012 for ages 16e24y), whereas the incidence rate in
men aged 65 to 74 years increased from 84 cases per million in
1993 to 131 cases per million in 2012.
Sex
Although males and females in the U.S. population have been
aging at about the same pace (increase by 8.1 and 8.9y, respec-
tively, between 1970 and 2010; see table 4), we observe a larger
increase in average age at SCI in females than males, regardless of
race (see table 2). This finding reflects an increase of injuries
among older adults as well as a smaller difference in SCI risk
between men and women among the elderly than that in teenagers
and young adults. For example, the male-to-female incidence ratio
was 1.5 for those aged 75 to 84 years, but 3.2 for those aged 16 to
24 years in 2012.17 The incidence rate of SCI, however, is higher
for males than females regardless of ages. As a result, the recent
increase in the number of older women with SCI did not change
the percentage of females in the SCI population dramatically
(18.2% in 1970s and 20.2% in 2010s).
Race
The changing racial composition of the SCI population is not as
dramatic as what has been observed in the general U.S. population
over the last 5 decades. This is likely due to a combination of
factors including the geographic representation of the SCIMS
centers; the racial difference in the incidence rates of SCI, with
blacks overall having a higher incidence rate than whites18-21; and
changes in the injury etiology pattern over time.5,6,8,9,17 For
example, the high percentage of blacks and Hispanics in the 1990s
may reflect the epidemic of violence-onset SCI (see table 1), as this
epidemic mostly affected blacks and Hispanics.13 Changing racial
composition is also possible because of trends in age-, sex- and
Y. Chen et al
Vehicular
Accidents
Falls
Violence
Sports
2000-2009 2010-2014
race-specific incidence rates over time, which need further inves-
tigation. Native American, Asian, and other races made up about
3% of SCI cases in the database. A small fluctuation in percentage
was observed over time, but the numbers were too small to make a
precise estimate and projection. The small number of Asian and
other races is partly due to the exclusion of non-Englishe or non-
Spanishespeaking people from the NSCID because of consenting
requirements.
Given the continued growth of minorities, especially His-
panics, in the U.S. population, increasing SCI patients of minority
background should be expected by health care providers. There-
fore, staff diversification and cultural competency training are
needed to avoid racial bias in health care and health.22
Other sociodemographic characteristics
Our observations of trends in education, employment, and marital
status of new SCI cases are generally consistent with the U.S.
general population and largely explained by the aging of the SCI
population. We hope that this increased education level over time
would lead to improved postinjury employment, which deserves
further study.23 It is also unknown whether the lower marriage rate
would adversely affect the marriage rate and overall quality of life
after SCI, as the marriage rate is lower in the SCI population than
in the general population; marriage is associated with favorable
psychosocial outcomes.24-27
Injury etiology
Changes in etiology of injury are relevant to the development of
prevention programs. For example, diving-related SCI was the focus
of research as a potentially preventable injury in the context of
primary prevention programs.28 These programs appear to have
contributed to the success in reducing the incidence of diving-
related SCI. With fall-induced SCI on the rise, further prevention
efforts are needed to reduce falls particularly among the elderly, and
those occurring at home as a result of slipping, tripping, stumbling,
www.archives-pmr.org
Spinal cord injury demographic trends 1617

Table 4 Statistical information of the U.S. population by decades

Characteristics 1970 1980 1990 2000 2010
Population size (n) 205,052,174 226,862,400 249,622,814 281,421,906 308,745,538
Median age (y) 28.3 30.0 32.8 35.3 37.2
Age category
0e14 28.3 22.6 21.7 21.4 19.8
15e29 24.5 27.4 23.3 20.8 20.9
30e44 16.9 19.1 23.6 23.4 19.8
45e59 16.3 15.2 14.2 18.2 21.0
60e74 10.3 11.3 11.4 10.3 12.4
75þ 3.7 4.4 5.3 5.9 6.1
Age
65 9.8 11.3 12.5 12.4 13.1
Median age (y)
Male 27.7 28.8 31.6 34.0 35.8
Female 29.6 31.3 34.0 36.5 38.5
White NA 31.0 34.8 38.1 41.3
Black NA 24.0 28.0 30.3 32.1
Hispanic NA 22.0 25.3 25.8 27.5
Sex
Male 48.8 48.6 48.7 49.1 49.2
Race/ethnicity
White 83.5 79.6 75.6 69.1 63.7
Black NA 11.5 11.7 12.1 12.2
Hispanic 4.4 6.4 9.0 12.5 16.3
Native American NA NA 0.7 0.7 0.7
Asian/Pacific Islander NA NA 2.8 3.7 4.8
Other NA NA 0.1 1.8 2.3
Education level (population aged
25y)
8th grade NA NA NA 7.5 6.2
9th to 12th grade NA NA NA 12.1 8.7
High school graduate NA NA NA 28.6 29.0
Some college, no degree NA NA NA 21.0 20.6
Associate’s degree NA NA NA 6.3 7.5
Bachelor’s degree NA NA NA 15.5 17.6
Graduate or professional degree NA NA NA 8.9 10.3
Marital status (population aged
15y)
Never married NA NA 22.2 27.1 32.2
Now married, except separated NA NA 61.9 54.4 48.8
Separated NA NA NA 2.2 2.2
Widowed NA NA 7.6 6.6 6.0
Divorced NA NA 8.3 9.7 10.8
Employment status (population aged
16y)
In civilian labor force NA NA NA 63.4 63.9
Employed NA NA NA 59.7 57.0
Unemployed NA NA NA 3.7 6.9
In armed forces NA NA NA 0.5 0.6
Not in labor force NA NA NA 36.1 35.6
NOTE. Values are percentages or as otherwise indicated. Data sources: U.S. Bureau of the Census (www.census.gov), including American FactFinder
(http://factfinder.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refreshZt); 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).
Abbreviation: NA, not available.

and falling on the same level and from stairs, steps, beds, chairs, and
toilets, as suggested by previous studies.29,30
Severity of injury
These trends are likely due to a combination of advances in
medical and surgical management,31 improved acute survival of
high cervical injuries,32 as well as changes in demographics,
etiology, and referral pattern of SCIMS centers. For example,
older persons are most likely injured in falls on the same level that
result in tetraplegia and AIS D injuries.29 Gunshot-related SCIs
are on the decline in the past decades, and these typically result in
complete paraplegia. Use of methylprednisolone and other medi-
cations as well as surgical intervention in the early management of

www.archives-pmr.org
1618
SCI is not documented in the NSCID and, therefore, its contri-
bution to the decrease in neurologically complete injuries cannot
be evaluated. Advances in rehabilitation therapy might also
contribute to the favorable trends.
Study limitations
The NSCID has several well-documented strengths and limitations
that must be considered when evaluating the results of this study.
Strengths include the long history, large sample size, geographic
and patient diversity, standardization of data collection methods
and measures, excellent case identification procedures, prospec-
tive data collection using both physical examination and personal
interview, and comprehensiveness of the information in
the database.
Because of constraints by the design of the SCIMS program
and NSCID, however, the generalizability of the present study
findings is limited; these constraints include a hospital-based
sample of the NSCID participants, strict eligibility criteria, and
change in the number and designation of SCIMS centers as well
as information contained in the database. For example, our
finding of average age at injury in 2011 to 2014 (42.2y) is about
8 years younger than what was reported in a study17 of a U.S.
representative inpatient sample of acute traumatic SCI in 2012
(50.5y). Although Jain’s study17 is subject to potential counting
of readmissions after SCI and exclusion of children younger
than 16 years that could have overestimated the average age at
injury, the NSCID overrepresents violent etiology that occurs
primarily in teens and young men because of the urban location
of many of the SCIMS centers. The NSCID eligibility criteria
call for neurologic deficits and completed rehabilitation with
some exceptions, which excludes older patients with fall etiol-
ogies and with minimal neurologic deficits who never received
rehabilitation. A recent study33 that compared the NSCID with
the Inpatient Rehabilitation FacilitiesePatient Assessment
Instrument database concluded that the NSCID is largely
representative of the national population of patients receiving
inpatient rehabilitation for new-onset traumatic SCI during
2001 to 2010.
Because the NSCID is not population-based, data can only be
presented as percentages, which do not necessarily imply corre-
sponding changes in incidence. For example, the recent decline in
the percentage of new SCI cases caused by vehicular crashes
could be due to the decrease in the underlying incidence. The
percentage of vehicular-related SCI would also drop if the
underlying incidence rate rises but at a slower rate than that of
other causes. However, provided that the statistics are interpreted
with some understanding of how the data have been collected and
analyzed, the trends reported here are relevant to service
providers, policymakers, and researchers.
Conclusions
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
rehabilitation care for SCI. Educational materials that portray
SCI cases as men in their teens and early 20s need to be
updated. Prevention efforts should incorporate multidimen-
sional risk assessments, especially to reduce falls and associated
SCI in older adults.
Y. Chen et al
Supplier
a. SAS v9.3; SAS Institute Inc.
Keywords
Epidemiology; Rehabilitation; Spinal cord injuries; Trends
Corresponding author
Yuying Chen, MD, PhD, Spain Rehabilitation Center, Room 515,
1717 Sixth Ave South, Birmingham, AL 35249-7330. E-mail
address: yuyingchen@uabmc.edu.
References
1. Cao Y, Chen Y, DeVivo MJ. Lifetime direct cost after spinal cord
injury. Top Spinal Cord Inj Rehabil 2011;16:10-6.
2. Kirshblum S, Campagnolo DI, Nash MS, Heary RF, Gorman PH. Spinal
cord medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2011.
3. Tator CH, Hashimoto R, Raich A, et al. Translational potential of
preclinical trials of neuroprotection through pharmacotherapy for
spinal cord injury. J Neurosurg Spine 2012;17:157-229.
4. Chen Y, Deutsch A, DeVivo MJ, et al. Current research outcomes from
the Spinal Cord Injury Model Systems. Arch Phys Med Rehabil 2011;
92:329-31.
5. DeVivo MJ. Epidemiology of traumatic spinal cord injury: trends and
future implications. Spinal Cord 2012;50:365-72.
6. DeVivo MJ, Chen Y. Trends in new injuries, prevalent cases, and aging
with spinal cord injury. Arch Phys Med Rehabil 2011;92:332-8.
7. Go BK, DeVivo MJ, Richards JS. The epidemiology of spinal cord
injury. In: Stover SL, DeLisa JA, Whiteneck GC, editors. Spinal cord
injury: clinical outcomes from the model systems. Gaithersburg:
Aspen; 1995. p 21-55.
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;85:1740-8.
9. Nobunaga AI, Go BK, Karunas RB. Recent demographic and injury
trends in people served by the Model Spinal Cord Injury Care Sys-
tems. Arch Phys Med Rehabil 1999;80:1372-82.
10. National Spinal Cord Injury Statistical Center. Spinal cord injury facts
and figures at a glance. Available at: https://www.nscisc.uab.edu/.
Accessed February 24, 2015.
11. DeVivo MJ, Jackson AB, Dijkers MP, Becker BE. Current research
outcomes from the Model Spinal Cord Injury Care Systems. Arch
Phys Med Rehabil 1999;80:1363-4.
12. Chen Y, DeVivo MJ, Richards JS, SanAugustin TB. Spinal Cord
Injury Model Systems: review of program and national database from
1970 to 2015. Arch Phys Med Rehabil 2016;97:1797-804.
13. Chen Y, Tang Y, Vogel LC, DeVivo MJ. Causes of spinal cord injury.
Top Spinal Cord Inj Rehabil 2013;19:1-8.
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;34:535-46.
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;7:179-92.
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;31:228-38.
17. Jain NB, Ayers GD, Peterson EN, et al. Traumatic spinal cord injury in
the United States, 1993-2012. JAMA 2015;313:2236-43.
www.archives-pmr.org
Spinal cord injury demographic trends
18. Acton PA, Farley T, Freni LW, Ilegbodu VA, Sniezek JE, Wohlleb JC.
Traumatic spinal cord injury in Arkansas, 1980 to 1989. Arch Phys
Med Rehabil 1993;74:1035-40.
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;39:274-8.
20. Price C, Makintubee S, Herndon W, Istre GR. Epidemiology of
traumatic spinal cord injury and acute hospitalization and rehabilita-
tion charges for spinal cord injuries in Oklahoma, 1988-1990. Am J
Epidemiol 1994;139:37-47.
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;25:716-21.
22. Williams DR, Wyatt R. Racial bias in health care and health: chal-
lenges and opportunities. JAMA 2015;314:555-6.
23. Frieden L, Winnegar AJ. Opportunities for research to improve employ-
ment for people with spinal cord injuries. Spinal Cord 2012;50:379-81.
24. Cao Y, Krause JS, Saunders LL, Clark JM. Impact of marital status on
20-year subjective well-being trajectories. Top Spinal Cord Inj Rehabil
2015;21:208-17.
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;89:2285-92.
www.archives-pmr.org
1619
26. Kalpakjian CZ, Houlihan B, Meade MA, et al. Marital status,
marital transitions, well-being, and spinal cord injury: an exami-
nation of the effects of sex and time. Arch Phys Med Rehabil 2011;
92:433-40.
27. Kreuter M. Spinal cord injury and partner relationships. Spinal Cord
2000;38:2-6.
28. DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in
swimming pools. Spinal Cord 1997;35:509-15.
29. Chen Y, Tang Y, Allen V, DeVivo MJ. Fall-induced spinal cord injury:
external causes and implications for prevention. J Spinal Cord Med
2016;39:24-31.
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;21:218-26.
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;30:1781-94.
32. Strauss DJ, DeVivo MJ, Paculdo DR, Shavelle RM. Trends in life
expectancy after spinal cord injury. Arch Phys Med Rehabil 2006;87:
1079-85.
33. Cuthbert J, Charlifue S, Chen D, et al. Generalizability of Spinal Cord
Injury Model Systems data 2001-2010 [abstract]. J Spinal Cord Med
2014;37:438-9.