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The authors look forward and discuss future directions in spinal cord injury (SCI) from a perspective of biomedical, psychosocial and technologic research. This discussion is based both on recent developments from various fields of knowledge and, more specifically, on SCI Model Systems' research contributions to medical rehabilitation. Biomedical research, as described here, includes (1) the process of moving from the "bench to bedside" and harnessing knowledge from basic science to produce new clinical treatment options for SCI during the life span; (2) the rapid proliferation of clinical trials aimed at neurologic recovery; (3) the growth of new technologies to restore and improve function; and (4) the challenges of developing relevant outcome measures to evaluate efficacy and effectiveness of interventions. Recent progress in psychosocial research has contributed significantly to understanding of the many factors associated with disability during the life course, the importance of quality of life issues, and the value of activity, participation, and the environment in promoting successful rehabilitation outcomes following SCI. Technology and bioengineering advances are discussed in relation to access to high-quality technology; restoration and replacement of movement; and technology to enhance rehabilitation outcomes., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine age-period-duration patterns of the prevalence of pressure ulcers in community-residing people with spinal cord injury (SCI)., Design: Multicenter cohort study., Setting: Nine Model Spinal Cord Injury Systems throughout the United States., Participants: People with SCI (N=3361) injured between 1986 and 1995 and followed up thereafter on a yearly basis through 2002., Interventions: Not applicable., Main Outcome Measure: Physician-confirmed pressure ulcers of stage II or greater at the follow-up visits., Results: The multivariable generalized estimating equations model showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993: odds ratio=1.4; 95% confidence interval, 1.2-1.6) not explained by aging, years since injury, or demographic and clinical factors. The risk of pressure ulcers appeared to be steady during the first 10 years and increased 15 years postinjury. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and other medical conditions. Injury cause and level had no significant effect., Conclusions: These results highlight the need for research into factors that contribute to the increasing pressure ulcer prevalence.

Objective: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI)., Design: Case series., Settings: Model Spinal Cord Injury Systems (MSCIS) throughout the United States., Participants: People (N=14,433) admitted to an MSCIS within 30 days of injury., Interventions: Not applicable., Main Outcome Measures: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI., Results: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI., Conclusions: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.

Objective: To examine the association of health, community integration, and economic status with subsequent mortality and life expectancy among persons with spinal cord injury., Design: Cohort study., Setting: Model Spinal Cord Injury Systems (MSCIS) hospitals., Participants: A total of 5947 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and who were still alive and received an annual evaluation from November 1995 through March 2002., Interventions: Not applicable., Main Outcome Measure: Mortality was determined by routine follow-up supplemented by information from the Social Security Death Index. A logistic regression model based on the full set of predictor variables was developed to estimate the chance of dying in any given year., Results: After adjusting for demographic characteristics and injury severity, health status indicators, measures of community integration, and economic status indicators all had relatively small but statistically significant effects (20%-70% increases) on the likelihood of dying during the next year. Inclusion of these factors may result in higher life expectancy estimates under highly favorable conditions., Conclusions: Whereas previous reports of the MSCIS data have identified the life expectancies associated with a particular set of demographic (eg, age, gender) and injury-related characteristics (level and completeness of injury; ventilator dependence), the current analysis suggests that consideration of health, economic, and psychosocial factors may make computations of life expectancy more accurate.

Objective: To evaluate epidemiologic trends in new spinal cord injuries (SCIs) in the United States over 3 decades., Design: Consecutive case series., Setting: Model Spinal Cord Injury Systems (MSCIS) facilities., Participants: Persons (N=30,532) admitted to MSCIS facilities within 365 days of injury between 1973 and 2003, and enrolled in the National Spinal Cord Injury Database., Interventions: Not applicable., Main Outcome Measures: Data were collected at MSCIS admission and rehabilitation discharge. Variables included age, gender, race and ethnic group, year of injury, and level and extent of injury. Specific etiologies were grouped as motor vehicle collisions (MVCs), violence, falls, sports, and other. Demographic and injury severity trends were analyzed by year of injury groupings according to decades (1973-1979, 1980-1989, 1990-1999, 2000-2003.) Chi-square tests assessed statistical significance. One-way analysis of variance compared mean ages., Results: The male/female ratio remained fairly stable at 4:1, but the percentage of women increased slightly over time, especially from MVC etiologies ( P <.001). Over time, the mean age at injury increased significantly ( P <.001); it was 37.7+/-17.5 years in 2000-2003. The majority of cases were white (66.1%). Tetraplegia (54.1%) and complete injuries (55.6%) occurred more than paraplegia and incomplete injuries, respectively. MVCs (45.6%) remained the most common etiology; falls (19.6%) held the second position over violence (17.8%), except for the 1990-1999 period when the positions were reversed. Significantly increasing percentages of new injuries were seen for SCI due to automobile, motorcycle, bicycle, and all-terrain vehicle crashes, blunt object attacks, snow skiing, and medical and surgical mishaps., Conclusions: Many previously seen SCI demographic trends continued into the 2000 decade.

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.

Objective: To determine the predictive value of serum levels of creatine phosphokinase (CPK) and alkaline phosphatase (ALP) in identifying patients with spinal cord injury (SCI) who are at risk to develop heterotopic ossification (HO) at the hips., Design: Prospective cohort study., Setting: Tertiary-care level I trauma center., Participants: Consecutive sample of 18 adults with acute traumatic SCI. Patients were excluded if they had medical or surgical conditions that are known to cause elevated enzyme levels., Interventions: Not applicable., Main Outcome Measures: Conventional hip radiographs were taken approximately 3 weeks after injury and again from between 3 to 6 months after injury. Serum ALP and CPK were measured approximately 3 weeks after SCI. Patients were later separated into 2 groups: group 1 was comprised of those who developed HO and group 2 was comprised of those who did not., Results: The initial radiographs showed no evidence of HO in either group. The radiographs taken at 3 to 6 months showed HO in 7 of 18 patients. The levels of CPK at the initial evaluation were significantly higher (R=.947, P<.0024) in group 1 than in group 2 and correlated with the severity of HO. There was no correlation between serum ALP levels and subsequent development of HO between the 2 groups (P=.07)., Conclusion: Elevated serum levels of CPK have value in predicting the HO.

Objective: To examine upper-extremity motor recovery of subjects with tetraplegia with both complete and incomplete injuries, to predict which patients and at what time they would recover a motor level., Design: Prospective, multicenter clinical study of upper-extremity motor recovery in subjects with acute traumatic spinal cord injury., Setting: Three regional spinal cord injury centers., Subjects: One hundred sixty-seven individuals with acute traumatic tetraplegia (144 males [86%], and 23 females [14%]) between the ages of 15 and 75 years (mean age, 35.5 yrs)., Methods: Subjects were examined and classified using sequential manual muscle tests performed on admission, 72 hours, 1, 2, and 3 weeks, and 1, 2, 3, 6, 12, 18, and 24 months postinjury. C5 biceps, C6 extensor carpi radialis, C7 triceps, and C8 flexor digitorum profundus were evaluated using a 0-5 scale. Analyses of the right motor levels used a series of logistic regression models, and for multiple measurements on each subject, models were estimated using generalized estimating equations., Results: The analysis for recovery of the biceps for the C4 group showed 70% of complete compared with 90% of incomplete injuries recovered (p < .001); of the extensor carpi radialis in the C5 group, 75% complete and 90% incomplete recovered (p < .002); and of the triceps in the C6 group, 85% of complete and 90% of incomplete injuries recovered (p < .16)., Conclusion: Predicting future potential for upper-extremity motor recovery and for independence in self-care in groups of patients at a specific motor level is possible within the first week of injury.

Objective: To analyze the incidence, risk factors, and trends of long-term secondary medical complications in individuals with traumatic spinal cord injury., Design: Data were reviewed from the National SCI Statistical Center on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and 1998., Setting: Multicenter Regional SCI Model Systems., Main Outcome Measures: Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi., Results: Pressure ulcers were the most frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5), and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common method of bladder management among patients with paraplegia but became less common at later postinjury visits., Conclusions: Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury, tetraplegia, older age, concomitant illness, and violent injury.

Objective: Little attention has been given to women's reproductive health issues in the disabled population. This study documents the unique reproductive health conditions, complications, and behaviors in women with spinal cord injury (SCI)., Subjects: A total of 472 women at least 18 years of age who were at least 1 year post-SCI. Their average age at injury was 32 years., Design: An extensive questionnaire regarding gynecologic, sexual, obstetric, and menopausal health issues was developed and piloted. The questionnaire was then administered by a trained woman health care clinician to women who agreed to participate in the study., Setting: Private outpatient clinics at 10 regional model SCI systems of care., Results: Women reported similar gynecologic problems in both preinjury and postinjury time periods. Exceptions were urinary tract infections and vaginal yeast infections. Sexually transmitted infections appear to be less common after injury, but the difference was not statistically significant. The number of hysterectomies was similar both before and after injury, but reasons differed greatly. Women with SCI were less likely to have routine mammograms. They reported similar preventive practices such as performing self-breast examinations and obtaining Papanicolaou smears. Almost 14% of women with SCI became pregnant after injury (101 pregnancies). Complications from pregnancy, labor, and delivery were reported to be more frequent in their postinjury than in their preinjury obstetric experiences. They tended to have babies of lower birth weight and with more complications at time of delivery. Of the sample, 87% reported having sexual intercourse before injury, with only 67% having intercourse after injury. Years postinjury and level of injury were predictive of intercourse; extent of injury was not. Experience of orgasms and methods of contraception varied among the two groups. There were significant complaints of dysreflexia and bladder incontinence with sexual function. Menopause after injury was reported by 14.6% of the women. Postinjury menopausal symptoms were of low frequency, but more than those reported by women who had undergone menopause before injury. Only 19% of women who had menopause after SCI were placed on hormone replacement therapy. Almost one third of the women who had menopause after injury reported new bone fractures., Conclusion: This study illustrates the unique reproductive health concerns of women with SCI. Many pregnancy, labor, and delivery experiences in these women are different. Sexual activity and function have several disability-related consequences and the effects of menopause are still unknown, but may be more problematic than for able-bodied women.

From 1985 to 1990 five Model Regional Spinal Cord Injury (SCI) Care Systems participated in a collaborative effort to prospectively document the occurrence of adult respiratory distress syndrome (ARDS), aspiration, atelectasis, bronchitis, bronchospasm, lung abscess, pleural effusion, pneumonia, pneumo/hemothorax, pulmonary edema, pulmonary thromboembolism, tracheitis, upper respiratory infection, and ventilatory failure in patients admitted within 48 hours of SCI with a level of C1-T12 and Frankel Grade A, B, or C. The mean, standard deviation and range was calculated for the time of onset and duration of each complication. Of the 261 patients who entered the study, 175 (67%) experience 544 respiratory complications with atelectasis being the most common (36.4%) followed by pneumonia (31.4%) and ventilatory failure (22.6%). These complications occurred on the average of 17.7 days, 24.5 days and 4.5 days postinjury and lasted 12.8 days, 15.5 days, and 35.9 days, respectively. Twenty-two percent, 47%, and 31% had injury levels at C1-4, C5-8, T1-12, respectively with the majority being Frankel Grade A (78%). Eighty-four percent of C1-4, 60% of the C5-8, and 65% of the T1-12 had respiratory complications. Statistical analysis revealed complications to be significantly greater (p < .05) and of longer duration (p < .05) for the C1-4 group. Ventilatory failure and aspiration were the earliest to occur (at 4.5 days) for all SCI patients. Surprisingly, however, complications overall occurred significantly sooner (p < .05) in the T1-12 group. In conclusion, patients who sustain SCI have a high incidence of respiratory complications; however, some occur earlier and more frequently depending on the level of injury.

One hundred eight women and 434 men admitted with spinal cord injuries between 1973 and 1987 were observed prospectively to determine the effects of age, sex, neurological classification, and method of bladder management method on renal function and urological complications. The primary method of bladder management for women throughout the study period was indwelling urethral catheterization as compared to condom drainage for their male counterparts. Renal function was determined by effective renal plasma flow and urological complications were determined by clinical symptoms and/or objective findings on intravenous pyelography (IVP). Analysis reveals that as in the general population advancing age and being female were significantly associated with lower ERPF (p < .05). Only in men were neurological classification (quadriplegia) and bladder management (ileoconduit) associated with significant decreases in ERPF (p < .05). Furthermore, women and men showed no significant differences in urological complication rates. From the data it can be concluded that there is no particular method of bladder management for women that necessarily leads to impaired renal function.

Loss of normal bladder function results in increased risk of developing urinary tract infection. Recurrent bacteriuria continues to be a problem in most spinal cord injured persons regardless of the bladder emptying method used. Lower urinary tract complications have decreased with intermittent catheterization, but the effect of increased intravesical pressure and presence of bacteriuria on renal function are still undetermined. Current methods of neurogenic bladder management are often based on professional or institutional presuppositions rather than scientific data. Although there are many unanswered questions about the role of urinary tract infection in spinal cord injury patients, treatment should be based on scientific knowledge, even though the knowledge base is still limited. Preservation of renal function is the ultimate goal of any method of neurogenic bladder management. Although a person with spinal cord injury is described, the material covered is applicable to other neurogenic bladder disturbances.