Current Projects Projects for Consideration Research Strategy Applications for Medical Research
Current Projects
Central Nervous System (CNS) reorganisation after spinal cord injury: its
relationship to pain and response to mental imagery
Below level pain (phantom pain) in the Spinal Cord Injured
(SCI) is common, often severe and difficult to treat with conventional medicines.
The causes of this pain are complex, with experiments showing changes in
electrical activity in all areas of the brain, related to the loss of normal
sensation and movement. The relationship between below level pain and changes
in brain activity has not been established in humans with spinal cord injury.
The development of specialised brain scans known as functional Magnetic
Resonance Imaging (fMRI) allows us to investigate this relationship in a
non-invasive, non-radiation manner. Using fMRI, it has been shown in previous
research that people with phantom pain can be helped by teaching them to
“move” and “feel” their phantom limb, and that this
pain reduction is linked to a normalisation of brain activity. In a more
recent pilot study (funded by INPIRE) it was found that changes in brain
activity were more extensive in people with spinal cord injury (SCI) and
below level pain compared to those with SCI and no pain and healthy controls.
It was also found that, when participants with below level pain were taught
to practice regular imagined movement and sensation in the paralysed, painful
areas, it was possible for this imagination to relieve the pain and reduce
the abnormal patterns of activity. In effect, using the brain’s own
powers to heal itself. The pilot study has helped to refine the technique,
show that fMRI can measure brain changes in the spinally injured and take
note of the comments of those who participated.
This application intends to expand on these promising results by studying
a larger group of participants (a total of 20 in each of the 3 groups [SCI
with pain, SCI without pain and healthy controls] including those from the
pilot). All participants will be scanned at the outset of the study, and
brain activation in response to tasks such as blowing a kiss, moving the
fingers, imagining movement of the toes will be measured. The two SCI groups
will then undergo the therapy, which will consist of 6 x one hour sessions
with the therapist plus a CD for home practice. The group with pain will
learn a simple relaxation technique plus imagining normal movement and sensation
in the paralysed or painful limbs. At the end of therapy the SCI participants
will be re-scanned. A careful record will be kept of pain scores throughout
the study. At six months all participants will be interviewed and asked
to keep a final diary so the long term effect of the intervention can be
measured.
It is hoped that this study will benefit the wider SCI community in two
ways. First, if the clinical therapy is successful, a CD of the therapy
would be available for general distribution, plus training for health care
professionals involved in the care of people with SCI. Secondly, the information
from the brain scans will help researchers and clinicians to learn more
about the effect of SCI on the function of the brain, and the mechanisms
behind this most distressing pain condition. Moreover, the brain imaging
results, showing the extent of activation in the motor cortex of the brain
may be useful to those seeking to improve mobility after spinal injury.
What are the views of people with Spinal Cord Injury (SCI),
healthcare professionals and researchers about the current and future use
of FES?
For nearly half a century Functional Electrical Stimulation
(FES) has been used in the treatment and management of physical problems
encountered by people with SCI. Applications have encompassed bladder and
bowel control, pain, movement, tissue viability and musculoskeletal and
cardio-respiratory function. Although there appears to be a growing body
of research developing and evaluating these techniques, it is generally
found they have only been used by a small fraction of the SCI community.
While techniques have evolved to be more effective and technically sophisticated,
they have often undergone phases of great popularity followed by periods
of rejection. Popularity has often been associated with highly active research
groups and faded with loss of funding of research or a failure to achieve
technology or clinical transfer. In order to address issues related to problems
with transferability and application to clinical practice, it is important
to ensure that future developments in FES are patient-led and fulfil the
needs of people with spinal cord injury. Developments encompass research,
technology development, clinical and service provision and commercialisation.
Unless each of these is driven by the needs of the SCI community then the
money and time invested may be wasted. It could be argued, that to continue
without this knowledge is an unethical use of public funds and the time
and energy of people with SCI.
Although the first stage of the programme of research has provided an important
insight into some of the key issues regarding the current and future use
of FES, this qualitative approach involved in-depth methods that gather
the views of a relatively small group of people. Therefore, the second stage
of this research is to use the themes identified in the qualitative study
to develop a series of questionnaires that will explore the extent to which
the wider SCI community hold these views. This will involve carrying out
an international study with a much large sample of people.
Projects for Consideration
The Potential Therapeutic Benefit Of Cortical Repetitive Transcranial Magnetic Stimulation on Pelvic Sphincter “Guarding Reflex” Function To Promote Continence In Incomplete Spinal Cord Injury: A Pilot Study
Bladder and bowel problems continue to be the most troublesome
aspects of everyday life for people with paraplegia. Indeed, recent surveys
have shown that above all the many other medical conditions in spinal cord
injury, the need to continue targeting recovery of bladder, bowel and sexual
functions are uppermost in patients’ own desires; this is despite
the considerable progress achieved to manage them over the past 60 years.
There are a number of treatments to alleviate the bothersome symptoms of
urinary and faecal incontinence including drugs, medical devices and surgery,
but none are completely satisfactory. Furthermore, the so-called “cure”
by nerve regeneration and repair, if it is possible, is now looking likely
to require many more years of development . So it is timely to consider
some alternative therapies that might be achievable in the shorter-term.
One such new therapy could involve tapping into the “plasticity”
of surviving nervous pathways in the spinal cord following an injury; pathways
that normally control voluntary contractions of the bladder and bowel sphincters
that help to maintain continence and achieve voiding.
Recently, our team, at the London Spinal Cord Injuries Centre at Stanmore,
together with Imperial College and University College London, has been investigating
the integrity and function of any elements of the spinal pathways controlling
bladder and bowel sphincters that have survived in people with incomplete
spinal cord injuries. When compared to people without an injury we have
found, not unexpectedly, that voluntary sphincter contractions are weak,
variable and poorly sustained. Interestingly, when we stimulate these residual
spinal pathways with a single non-invasive magnetic stimulation pulse to
the correct part of the brain we can momentarily enhance reflexes that contract
the sphincters, but only to a much lower level as compared with people without
a spinal injury. In neither group of people do we observe this enhancing
effect lasting longer than a few seconds at most. Clearly such brief interaction
does not impact significantly on the plasticity of the brain or spinal cord
and provides no lasting functional benefits.
However, studies of limb muscles have shown that by giving bursts of repetitive
magnetic transcranial stimulation (known as rTMS) to the brain, the voluntary
pathways to muscles can be significantly facilitated and the effects made
to persist for up to many hours or even days. We suggest that the potential
for extending these persistent effects to bladder and bowel sphincters may
well be the basis of a therapy, for example as an adjunct to proven rehabilitation
techniques, to improve continence in spinal cord injury. In a small preliminary
study on healthy volunteers we have already demonstrated the utility of
rTMS for enhancing sphincter reflex function. This application is now for
funding a pilot study to investigate, in a randomized scientifically controlled
way, whether similar effects can be demonstrated in persons with an incomplete
spinal cord injury. If we are successful in this endeavour then we would
go on to develop a more comprehensive study to investigate the impact of
such important effects on improving continence and voiding in spinal cord
injury.
Effect of functional electrical stimulation-assisted rowing on cardiorespiratory function in persons with spinal cord injury
People with spinal cord injury (SCI) are at an increased risk of the diseases of inactivity (cardiovascular disease, diabetes, osteoporosis and obesity) compared with their able bodied counterparts. In addition, some of the physiological consequences of SCI (e.g. impaired bladder, bowel and sexual function) result in a reduced quality of life. Improvements in cardiorespiratory fitness are related to a reduced incidence of the diseases of inactivity and an enhanced quality of life in people with SCI. To improve cardiorespiratory fitness an appropriate exercise training programme is required. Such a programme needs to place the cardiorespiratory system under sufficient stress to stimulate adaptation. Neither upper body exercise nor functional electrical stimulation (FES)-assisted cycling appear to provide sufficient physiologic stress to bring about significant improvements in cardiorespiratory fitness.
Hybrid functional electrical stimulation (FES)-assisted exercise systems, which recruit the paralysed lower limbs simultaneous with the voluntary action of the arms, significantly increase the cardiorespiratory demand of exercise. FES-rowing has been shown to elicit a greater acute cardiorespiratory response than any other type of exercise in people with SCI. It is possible, therefore, that people with SCI may derive significant cardiorespiratory benefits from a programme of FES-rowing training.
Studies that have investigated the cardiorespiratory benefits of FES rowing have focused on gross measures of aerobic capacity. Although important, these studies have not examined the effect of FES-rowing upon the physiological systems that underpin changes in cardiorespiratory fitness. Cardiac, vascular and respiratory structure and function may all change in response to a structured programme of FES-rowing. Therefore, the purpose of the present study is to determine how the physiologic systems underpinning cardiorespiratory fitness and quality of life adapt in response to a programme of FES-rowing. Such information may ultimately provide a basis for using FES-rowing training as an additional therapeutic measure in people with SCI.
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) and has partnership status with the National Institute for Health Research (NIHR)..
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 27th April 2010
