420 Spinal Cord Injury
report that women with complete SCI experience orgasm in
response to genital and nongenital stimulation. Changes in
heart rate, blood pressure, and arousal were monitored in 16
women with complete SCI and 5 able-bodied women. De-
spite having complete SCIs, the women retained the ability to
achieve orgasm and registered physiologic and subjective
changes similar to those of the able-bodied women.
Post-SCI amenorrhea is a common occurrence (Charlifue
et al., 1992, Comarr, 1966) and can last an average of “ve
months. With the resumption of the ovulatory menstrual
cycle, a woman•s ability to conceive also returns. However,
Charlifue et al. found that the greater the level of impairment,
the likelihood of having children decreased. This “nding may
possibly be due to women•s recognition of the dif“culty as-
sociated with caring for a child.
Medical problems associated with pregnancy in women
with SCI include urinary tract infection (UTI) secondary to
incomplete emptying of the bladder, spasticity, decubiti,
increased risk of respiratory distress, and autonomic dysre-
”exia, which is the most life-threatening complication. Auto-
nomic dysre”exia and preeclampsia must be distinguished to
provide appropriate treatment. Complications associated
with the loss of sensation include an absence of awareness of
labor. However, women with SCI can be taught to recognize
sympathetic nervous system symptoms as indicators of labor.
There do not appear to be increased risks of preterm or rapid
labor, nor of mode of delivery in this population (Baker &
Cardenas, 1996).
Aging and Physiologic Changes
The history of spinal cord injury survival in this country pro-
vides a good illustration of the process of aging with SCI. In
the 1940s, the only survivors of spinal cord trauma were in-
dividuals with low- to mid-level paraplegia. Survival was the
primary medical goal, and subsequent lifetime institutional-
ization was the norm. The discovery and widespread use of
antibiotic agents such as streptomycin and tetracycline to
augment the ef“cacy of penicillin increased the survival rate
of individuals with high-level paraplegia in the 1950s. At this
time, rehabilitation goals for these persons were modi“ed to
include deinstitutionalization and return home with supervi-
sion. In the 1960s, the odds of survival increased for individ-
uals who incurred low-level tetraplegia. The active social
movement of the time sought rehabilitation goals of commu-
nity reintegration and increased independence. In the 1970s,
standards of care for emergency medical services were estab-
lished. Regulation respiratory procedures greatly increased
survival for individuals with mid- and high-level tetraplegia.
In addition to the improved technology, activism and the cre-
ation of independent living centers with home-based support
services resulted in the creation of •super paras,Ž who man-
aged to supercede functional goals and expectations. High-
energy expenditure, increased risk of injury, and mechanical
overuse were some of the long-term consequences of this
overachieving lifestyle. The past two decades have seen an
increase in incomplete SCIs along with the recognition of
aging-related issues. As survivors approach 40 years post-
SCI, age-related complications such as orthopedic problems,
neurologic complications, infections, obesity, and psychoso-
cial dif“culties are being recognized and addressed
(Hohmann, 1982; Trieschmann, 1987).
A disturbing trend reported by the NSCIDRC is an increase
in persons 61 years of age and older who are incurring SCIs.
Many of these individuals have preexisting medical condi-
tions that place them at higher risk for falls. Early data from
this population reveal that these individuals are more likely to
suffer cervical injuries that result in tetraplegia, have a greater
likelihood of experiencing secondary complications during
their acute and rehabilitation hospitalizations, and have an in-
creased probability of requiring skilled nursing home place-
ment following rehabilitation. Finally, this older cohort of
persons with SCI is evidencing a greater number of rehospi-
talizations post-SCI compared to younger persons with SCI.
The process of aging affects the body systems of a person
with SCI in much the same way as it will someone without an
SCI. However, the difference lies in the way the aging-related
physiologic changes affect functional ability for a person with
SCI. For example, with time, the skin and subcutaneous tissue
becomes thinner and less elastic. For individuals with SCI,
this change increases susceptibility to tearing and/or bruising
during transfers. The slowed healing process associated with
aging-related immune functioning increases the likelihood of
opportunistic infections and the potential development of de-
cubitus ulcers (i.e., pressure sores). Endocrinological adjust-
ments may lead to an increase in serum cholesterol levels and
decreased glucose tolerance. Endocrine-associated complica-
tions include coronary artery disease, poor circulation, slow
healing wounds, amputation, and blindness. Decreased range
of motion and ”exibility and increased incidence of contrac-
tures differentially affect the musculoskeletal system and,
thus, the mobility of the individual with SCI. Osteoporosis,
osteoarthritis, and the concomitant stiffening of joint and con-
nective tissues increase risk of injury from mechanical stress.
Fractures from spasticity and falls also increase with age.MortalityCurrent data indicate that 26% of all SCI deaths are attribut-
able to heart disease and pulmonary emboli. Lifestyle factors
including lack of aerobic exercise, smoking, diet high in sat-
urated fats, high blood pressure, obesity, and stress are all