As the consortium begins its fifth year, Kusiak said, investigators will attempt to replicate Lu’s results in non-human primates at the National Primate Research Center at University of California-Davis: transplanting and integrating human neuroprogenitor cells, stimulating axonal growth with rehabilitation, and measuring their longevity. Researchers are also planning delayed transplants in some primate subjects, to make the research more clinically relevant to the veteran population. “We do have some pilot data on one animal,” said Kusiak, “and it’s very promising. This is brand-new territory. If we do get this to work in a more chronic model, this opens up the possibility of regeneration for people who have had spinal cord injuries for a year or so. We may be able to perform transplants that could help them.”

 

SCI’s Collateral Damage

The spinal cord is the brain’s neural pathway to virtually every part of the human body – the skin, muscles, internal organs, and glands – and damage to it involves severe complications, including limb paralysis, respiratory difficulties, blood clots in the veins and the lungs, impaired temperature and blood pressure regulation, loss of bladder and/or bowel control, hormonal imbalances, and repeated infections of the pulmonary, renal, and urinary systems.

These consequences make spinal cord injury a chronic condition; SCI appears to accelerate the aging process, increasing risks for cardiovascular, musculoskeletal, metabolic, and other conditions often associated with the older population. For example, SCI can result in the loss of 60 percent or more of the bone and muscle tissue in the legs. Drugs aimed at reversing these losses, such as bisphosphonates, involve short- and long-term adverse effects, but bone and muscle loss are a significant concern for both clinicians and researchers, who remain optimistic about the prospect of a “cure” for spinal damage: Musculoskeletal integrity is important not only to improve strength and balance and prevent fractures associated with falls, but also to preserve one’s physical integrity for future cell-based or orthotic therapies.

VA investigators at Stanford University and the Palo Alto VAMC are developing a new approach to restoring muscle density that includes the engineering of vascularized muscle tissue for transplant in rodent models. Because there are different types of muscle tissues, but a limited number of muscle stem cells available to replenish lost muscle, muscle tissue engineering is difficult – but the studies so far suggest that muscle can be engineered with the desired properties.

To an outsider, it may be difficult to fathom that Clinical Video Telehealth technology, in terms of its impact of VA health care for spinal cord injury patients, may have implications as significant as those of the VA’s cutting-edge stem cell and tissue engineering researchers.

Researchers and clinician investigators throughout the VA’s SCI/D care network conduct research devoted to improving the quality of life for people with spinal cord injury. An important research hub is the Center of Excellence on the Medical Consequences of Spinal Cord Injury, administered by VA’s Rehabilitation Research & Development Service at the Bronx VAMC in New York. Center of Excellence investigators seek to improve outcomes for SCI/D patients with complications related to the cardiovascular/autonomic, endocrine, gastrointestinal, pulmonary, genitourinary, musculoskeletal, and thermoregulatory systems; researchers in neurorehabilitation and physical activity work to restore lost neural function and movement, and help veterans with SCI engage in appropriate physical exercise.

The Bronx’s physical activity/quality of life research group, led by Dr. Ann Spungen, last spring conducted evaluations of a robotic exoskeleton-assisted walking technology developed by an Israeli scientist who was paralyzed in 1997. The ReWalk exoskeleton is a motorized orthotic device that is strapped on to the body and allows some individuals to walk with a more natural-looking gait with less energy consumption. Walking with long leg braces takes a lot of energy, and the ReWalk has the potential to reduce that energy consumption, and to help people with a spinal cord injury walk short distances. The device might enable patients to do everyday things around the house and possibly even get out and walk around in a store, for example.

One of the study’s participants, Theresa Hannigan, a paralyzed Army sergeant from Long Island, walked a mile in the ReWalk last fall, during a fundraiser for Hope for Warriors, a nonprofit that provides assistance to combat-wounded service members. Based on clinical studies, including the reporting from Spungen’s group, the U.S. Food and Drug Administration (FDA) cleared the device for use at home and in the community on June 26, 2014.

 

The SCI-QUERI: Improving Health Care Delivery to SCI Patients

VA’s Quality Enhancement Research Initiative (QUERI), launched in 1998, is a research program aimed squarely at the health care setting, with the goal of enhancing the quality and outcomes of VA health care through the application of evidence-based research to clinical practice. There are currently 10 QUERI programs, including one dedicated to SCI care.

Dr. Charlesnika Evans, co-director of the SCI-QUERI at the Edward Hines Jr. VAMC in the Chicagoland area, said program investigators have identified four primary areas of focus for research and clinical practice:

• Pressure ulcer prevention and management. Standards of care typically prevent pressure ulcers – or “bedsores,” injuries to the skin resulting from prolonged pressure over a bony prominence – from forming among VHA inpatients with SCI, so QUERI investigators, said Evans, are focused on the prevention and treatment of “community-acquired” pressure ulcers – those acquired outside the health care setting.

Among the QUERI projects underway in this area is evaluating implementation of an assessment tool, developed through VA funding, to monitor pressure ulcer healing: the SCI Pressure Ulcer Management Tool (SCI-PUMT). QUERI investigators are finding variations, Evans said, in the way the PUMT is implemented, and its resulting data documented. “What they eventually want to be able to do,” said Evans, “is to provide some best practices for using this data, for other facilities that want to use it effectively.”

• Infection prevention and management. SCI-QUERI researchers collaborated with VA SCI clinicians in improving influenza and pneumococcal vaccination rates among veterans with SCI/D. Between 2000 and 2010, veterans with SCI/D increased their influenza vaccination rates from 28 percent to 79 percent; their pneumococcal pneumonia vaccination rates rose from 40 to 94 percent.

QUERI researchers have identified a need to target health care workers for influenza vaccination. “This is actually an effort we are working on not only with the VA SCI/D services,” said Evans, “but also the VA Office of Public Health, which has a very strong interest in it. One of their goals is to improve health care worker influenza vaccinations across the VA, and so we’ve been working with them to implement a program to improve influenza vaccination rates among providers caring for spinal cord-injured veterans. This is really something we’re hoping could be used for the larger VA if shown to be successful.”

• Optimizing function. This is an emerging area of study within the SCI-QUERI, one currently being evaluated by researchers who plan to measure the implementation of and effectiveness of environmental control units – devices that allow patients to perform a number of simple tasks, such as changing the thermostat, signaling for assistance, or using the Internet.

• Implementation of virtual health care and consultation. The use of Clinical Video Telehealth (CVT), secure messaging, and other virtual health technologies to connect providers with patients – and with each other – is a relatively new area of study for the SCI-QUERI. Because much of the VA’s SCI/D expertise is located at 24 regional centers, the use of CVT allows for the transfer of this expertise to patients in their homes or at local facilities. “The work we’re doing,” said Evans, “is focused on understanding the facilitators and challenges VA facilities confront in being able to provide this type of telehealth care. Eventually we hope to understand how veterans perceive the care and use of this technology, as well.”

To an outsider, it may be difficult to fathom that CVT technology, in terms of its impact of VA health care for SCI patients, may have implications as significant as those of the VA’s cutting-edge stem cell and tissue engineering researchers. Both point to a new era in the care and management of spinal cord injury: one in which many spinal injuries and their complications may be repaired or virtually erased, and others can be cared for and managed, anywhere in the world, with the expertise of some of the best SCI care specialists working today.

This article first appeared in the Year in Veterans Affairs & Military Medicine 2014-2015 Edition.