Current Projects
A systematic exploration of users’ perspectives of Neuromuscular Electrical Stimulation (NMES)
There appears to be a marked reluctance of the SCI to volunteer to take part in clinical trials or indeed to come forward to have an a clinically approved implanted bladder stimulator which would, in most cases, have overwhelming medical and social advantages.
As a result the Trustees have approved a proposal to survey the SCI, their carers, clinicians and researchers to establish the cause for this reluctance. The Survey will consist of two phases and last three years. The first phase will be qualitative survey of 9 focus groups, the results of which will lead to a questionnaire that will go out in the second phase
It is anticipated that results will have a profound affect on the future of NMES clinical use and research within the SCI community. Most importantly it will ensure that provision of treatment, services and clinical research in this area is based on the views and needs of those who it affects – people with spinal cord injury.
A randomised trial of rectal stimulants for neurogenic bowel management after spinal cord injury
Neurogenic bowel dysfunction is a major problem to spinal cord injured (SCI)
individuals . It has a significant impact on quality of life and contributes
to long term morbidity.
Rectal stimulation is used by many SCI individuals with reflex bowel function
and is used specifically to trigger bowel evacuation at a chosen time. Pharmacological
rectal stimulants have a direct effect on the speed and efficiency of evacuation,
which in turn have a significant effect on the quality of life of SCI individuals.
However, there is little evidence regarding efficacy and side effects. It
is not known which stimulants might reduce the requirement for interventions
such as ano-rectal stimulation and manual evacuation of stool. A multi-centre
randomized trial is proposed to address these issues.
The short-term efficacy of Sacral Nerve Stimulation (SNS) in patients with neurological constipation
Introduction: Patients with spinal disease often suffer from constipation. Routine treatments are usually ineffective leading to a reduced quality of life. SNS offers a minimally invasive and safe alternative in such situations but there have been no studies on its efficacy yet.
Hypothesis: Patients suffering from refractory neuro-constipation will benefit from SNS.
Methods: 30 patients with refractory neuro-constipation recruited to twelve week within-group study. The study will include data collection during three phases of study using diary cards, self-administered questionnaires, transit times and laser doppler flowcytometry. As the study is uncontrolled and unblinded, transit time and laser doppler flowcytometry will provide important physiological evidence about the efficacy.
Conclusion: This study will provide valuable information regarding the role of SNS in these patients and its application in clinical practice. As a proof of concept study it will award impetus for future research projects involving the use of SNS in neurological constipation.
Optimising power output during electrically stimulated cycling in people with a spinal cord injury.
Electrically stimulated cycling (ESC) enables people with a spinal cord injury to participate in recreational and competitive exercise and gain the associated health-related and psychological benefits. We have been studying the effects of ESC training over a one year period and the results have revealed a number of issues that need to be addressed if the benefits of ESC are to be optimised. While the subjects became much stronger, the power output achieved was less than expected from the muscle strength and sufficient only to allow cycling indoors on a smooth, flat surface. Although muscle fatigability improved, the subjects showed a marked loss of power output after only a few minutes of cycling. There are a number of possible causes for these findings and we propose a series of linked experiments to explore ways in which power output during ESC can be improved and maintained in order to optimise cycling ability.
Central nervous system reorganisation after spinal cord injury: its relationship to pain and response to mental imagery. See link
People with spinal cord injury commonly suffer from pain below
the level of injury. This pain is severe and resistant to standard pain-killing
drugs. It is believed that this pain occurs because of changes in activation
in the brain, which are known to occur following damage to the spinal cord.
These changes are more extensive in people who have pain below the level of
spinal cord injury, and we think this is because there is a loss of balance
between information going from the brain to the body, and a lack of information
from the paralysed areas of the body back to the brain. Scientists are able
to measure brain activation using functional Magnetic Resonance Imaging (fMRI),
which is a non-invasive, non-radiation technique using a strong magnetic field
to allow measurement of how the brain responds to stimuli.
Previous research at the Pain Research Institute with people with phantom
pain after limb amputation has shown that learning to imagine movement and
sensation in the missing limb helps to relieve the pain and normalize the
altered brain activity. Brain imaging has shown that imagining the performance
of a task, such as moving the toes, will activate the same areas of the brain
that would be activated if the toes were actually moved. This study has been
designed to investigate the value of mental imagery as a way of helping people
with spinal injury to “move” their paralysed limbs to relieve
their pain. It is planned to carry out brain imaging in people with spinal
injury (with and without pain below the level of spinal cord damage), compared
with healthy volunteers, using functional Magnetic Resonance Imaging (fMRI).
Following the first scanning sessions, the participants will be taught a simple
meditation technique which will include imagining movement and sensation in
the paralysed limbs, in an attempt to restore the balance of information going
to and from the brain. Brain scans will then be repeated and compared with
the first set of scans.
It is believed this technique will relieve below-level pain because it targets
the cause of the pain – i.e. the altered brain activity. The method
is simple and easy to learn. If successful, it would be a simple task to produce
a CD of the therapy, which would be available to the wider Spinal Cord Injury
community. Those who do not have pain below the level of injury might benefit
from learning the meditation as a means of relaxation. Finally, it is also
possible that training specific areas of the brain to respond to imagined
movement and sensation might be of value in the preliminary stages of interventions
to improve mobility.
Improving the efficiency of electrically stimulated cycling
Functional electrically stimulated (FES) cycling offers people with a spinal cord injury (SCI) the benefits of exercise combined with participation in recreational and functional activities. However we have shown that even with prolonged and intense training the power output (PO) remains too low for functional cycling out of doors. Current work indicates that the primary problem is not the muscles themselves but inefficiency in converting metabolic energy into power at the crankshaft. We will investigate how to increase the efficiency, and therefore the PO of FES cycling. One of the major muscle groups stimulated appears also to act to reduce net PO and efficiency. We aim to determine ways in which its activation can be minimised. Secondly, we aim to establish a stimulation pattern that allows SCI people to cycle at a higher cadence, since the current stimulation pattern produces cycling at a cadence well below the optimal for PO.
Projects for Review
A pilot study of a contextual cognitive-behavioural therapy based pain management programme for patients with spinal cord injury; an analysis of outcome in comparison to a waiting phase
This project was not recommended to the Board by the Scientific Committee.
Central nervous system reorganisation after spinal cord injury: its relationship to pain and response to mental imagery
The Applicant was asked to resubmit in time for the next round having taken into account the Scientific Committee's concerns.
Development of an implanted Functional Electrical Stimulation (FES) system to improve grip function in C6 tetraplegia. (TETRAGRIP)
The Applicant was asked to submit an application for the first phase.
Research Strategy
INTRODUCTION
1. INSPIRE is a UK national medical research charity, the object of which
is to promote research into and the development of electronic, mechanical
and medical aids to assist the mobility and enablement of those suffering
from spinal cord paralysis and its associated effects and to communicate the
useful results of such research. It is also a member of the Association of
Medical Research Charities (AMRC).
2. Our organisation includes both a Scientific Committee which includes SCI
as well as specialist clinicians, and a User Committee whose membership is
entirely comprised of SCI. This research strategy has evolved as a result
of their ongoing work.
RESEARCH PRIORITIES
3. INSPIRE's research priorities are based upon improving the quality of life
of the SCI. It should be noted that, in general, spinal cord injury is not
a degenerative condition and once the SCI have adjusted to their new situation,
the individuals get on with their lives. They are not ill, but they may need
help. The end result of our research should therefore offer or lead to a significant
improvement to the existing quality of their lives. If it does not the researcher
should be prepared to explain to both the Review panels and the Board of Trustees
why INSPIRE should provide funding support.
4. INSPIRE's members recently agreed the following list of priorities. As
with this strategic document they are subject to change.
a. Bladder function
b. Bowel function
c. Pain management
d. Pressure sores
e. Enablement for Tetraplegics
f. Mobility for paraplegics
g. Sexual function
TYPES OF RESEARCH
5. Because one of the main effects of a spinal cord injury is a breakdown
in the body’s nerve communication system, there has been major research
into the provision of an alternative by the use of electrical stimulation.
. However, as the following examples show, INSPIRE has also provided grants
towards:
a. A virtual reality project designed to help the SCI managed their chronic
phantom pain.
b. A wheelchair cushion and backrest project designed to improve pushing efficiency
and even-out seating pressures.
c. The use of Botulin toxin to reduce the occurrence of spasticity in upper
limb tetraplegia.
6. INSPIRE will not close its mind to other types of research providing the
end result fits in with INSPIRE's objective and ultimately benefits the SCI.
7. Educational grants are no longer given unless the student's supervisor
assures both the User and Scientific Committees that the work involved will
not only benefit the student but also the SCI. In addition, the student should
continue to work with the SCI for at least a further five years. Failure to
do this could necessitate the forfeiture of the grant.
FUNDING OF APPLICATIONS
8. INSPIRE is not a large charity in monetary terms and whilst the Trustees
might wish to be the sole funder, in many cases this is simply not possible.
Pump priming of the early stages is often the best we can offer. Applicants
are therefore urged, when working out their costings, to consider submitting
their proposals to another funder for the balance of the costs. It would be
helpful to inform the Trustees if this were the case as it may make an award
more likely. Based on experience, INSPIRE has successfully funded pilot studies
and the evidence gained has helped the respective Applicants to gain much
larger awards from other grant making bodies.
9. Costings should therefore cover essential rather than desirable costs.
INSPIRE will not make an award for institute running costs.
REVIEW OF APPLICATIONS
10. All applications seeking an INSPIRE grant are subject to review by first
the User Committee and then the Scientific Committee. It would be unusual
for a project rejected by the Users to go on to the Scientific Committee but,
in any event, the final decision rests with the Board of Trustees.
11. The Committees generally meet in July and December each year and the Board
of Trustees soon after.
NOTIFICATION
12. The Executive Director undertakes to notify all applicants of the progress
of their proposal.
Applications for Medical Research
If you would like to apply for funding support for a project which is designed to help and improve the quality of life the spinal cord injured, then write to the Executive Director of INSPIRE at the address below or send an email and ask for an application form.
The INSPIRE Foundation
Spinal Treatment Centre
Salisbury District Hospital
SALISBURY
SP2 8BJ.
The Chairman of the Committee will write to all applicants informing them of the Committee's opinions and recommendations. If successful, the Executive Director will confirm result after the succeeding Trustees Meeting. Trustees tend to meet in March and August each year.
Closing Dates
The closing date for the next round is 23rd October 2008
