Spinal cord injuries (SCIs) impair the brain's ability to send messages to the rest of the body. These injuries can result in paralysis, loss of feeling, chronic pain, and other serious medical problems below the site of injury. SCIs are estimated to affect as many as 337,000 Americans, with about 12,500 new injuries occurring each year. About 80 percent of people with new injuries are males.
Nearly half of all injuries occur in people between the ages of 16 and 30, so many patients live with the effects of these injuries for decades. VA provides care to more than 27,000 Veterans with SCIs and related disorders (SCI/D) each year, making the department the largest health care system in the world providing lifelong spinal cord care.
VA integrates vocational, psychological, and social services and addresses the changing needs of Veterans with SCI/Ds throughout their lives.
SCI services are delivered through a "hub and spoke" system of care, extending from 25 regional SCI centers that offer primary and specialty care by multidisciplinary teams to more than 130 SCI primary care teams or support clinics at local VA medical centers. Locations and telephone numbers for each of VA's SCI centers can be found here.
VA is also one of 23 members of the Consortium for Spinal Cord Medicine, an organization founded by Paralyzed Veterans of America (PVA) to make care for persons with SCI/D more evidence-based. The consortium makes recommendations to health care providers based on current research findings that expert methodologists have graded for their scientific strength and validity.
VA research on SCI focuses on returning motor and sensory function to Veterans with these injuries. Researchers focus on areas including neural engineering, which uses neuroscience and engineering methods to design solutions to problems associated with neurological limitations and dysfunction; wheelchair and other adaptive technology; treatment of the medical complications of SCI, and new rehabilitation methods and outcomes.
VA researchers are also working in the field of regenerative medicine, learning how to restore tissue and organ function, including spinal cord function, lost as a result of aging, injury, or disease. They are using a variety of tools to change the ways wounds heal in humans to enable damaged organs and tissues to repair and regenerate themselves.
VA has played a major role in supporting the development of BrainGate. The system, spearheaded by researchers at the Providence, Rhode Island, VA Medical Center and Brown University, relies on microelectrodes implanted in the brain to pick up neural signals.
The electrodes are placed in a part of the brain that controls voluntary movement. They send signals to an external decoder that translates them into commands for electronic or robotic devices.
A 2011 study found that the system continued to control a computer cursor accurately through brain activity more than 1,000 days after it was initially implanted. In 2012, in a widely publicized study, the team showed that people with tetraplegia (paralysis that results in the partial or total loss of use of all of a patient's limbs and torso) could use the system to control a robotic arm to reach and grasp for items, including coffee from a bottle.
In 2015, the BrainGate team reported that the system could allow point-and-click communication by someone with incomplete locked-in syndrome, which can be caused by a spinal cord injury. In locked-in syndrome, patients are fully conscious but unable to move any muscles except for those that control eye movement. They can see, hear, smell, taste, and even feel, but may be unable to speak or vocalize at all. Those with incomplete locked-in syndrome can make small movements of the head, fingers, and toes.
Another 2015 BrainGate study found that volunteers using the system were able to acquire "targets" on a computer screen, such as letters on a keyboard, more than twice as quickly as in previous studies, thanks to advances in the system.
Among other project, the BrainGate team is now studying whether the system can be effective as a means of natural, intuitive control of prosthetic limbs, or as a way to help patients move their own paralyzed limbs. The latter work is being carried out in partnership with the Cleveland FES Center.
VA's Center on the Medical Consequences of Spinal Cord Injury is located at the James J. Peters VA Medical Center in the Bronx, New York. The center's mission is to improve Veterans' quality of life and increase their longevity by preventing and intervening in the secondary medical consequences that result from having a spinal cord injury. These consequences can include bone and muscle loss, metabolic and cardiovascular changes.
Researchers at the center continue to study an Israeli technology that allows paraplegics to stand, walk, and climb stairs, called ReWalk. ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with SCI to stand upright, walk, and turn. On their first day using the device, most people can stand and take a few steps, although it takes practice and training to use it properly.
Participants in past studies have lost fat tissue, their bowel function has improved, and their diabetes symptoms have been reduced. The center is now conducting further studies on ReWalk's impact on mobility, bowel function, and cardio-metabolic health.
The researchers' work has provided critical data for the U.S. Food and Drug Administration, leading toward the agency's 2014 approval of ReWalk for sale in the United States. In 2015, VA announced it would provide the device to eligible Veterans who could benefit from it.
Also in 2014, Drs. William A. Bauman and Ann M. Spungen of the center were awarded Samuel J. Hyman Service to America medals in the category of Science and Environment for their contributions in the understanding and treatment of medical consequences following SCI. The Service to America medals are presented annually by the Partnership for Public Service to honor excellence in the federal civil service.
10-year clinical trial—In 2015, researchers at VA's Cleveland FES Center and Case Western Reserve University completed a 10-year clinical trial to test a surgically implanted electrical stimulation system in people with SCI. During the surgery, electrodes are implanted in muscles of the trunk and legs, and leads are connected to a stimulator.
By stimulating muscles, the system activates muscles to allow for standing, better balance, and exercise. Patients are given functional training and rehabilitation using the stimulation system, and are prescribed a course of exercise. Lab tests focus on strength, balance, and patients' abilities with or without the system.
Long-term neuroprostheses usage—In 2012, FES Center researchers published a study in which they tested 15 people with spinal cord injuries who had received such an implant, called a neuroprosthesis, to help them stand and exercise. The 15 patients were tested once they learned to use the device, and again a year later.
The researchers found that the patients had incorporated the neuroprostheses into their lives; that the system worked as well for patients after a year as it had when they first received it; and that the neuroprosthesis was safe and reliable to use.
Established in 1991, the FES Center is a consortium with three institutional partners: the Cleveland VA Medical Center, Case Western Reserve University, and MetroHealth Medical Center. The center focuses on the application of electrical currents to either generate or suppress activity in the nervous system. This technique is known as functional electrical stimulation. FES can produce and control the movement of otherwise paralyzed limbs for standing and hand grasp, activate bodily functions such as bladder control or respiration, create touch perception, dampen pain or spasm, and spur natural recovery.
VA's Advanced Platform Technology Center, also in Cleveland, focuses on the practical medical needs of Veterans disabled by problems related to the sensory or motor systems, cognitive deficits, or limb loss. Work here focuses on prosthetics and orthotics, wireless health monitoring and maintenance, interfaces to connect the nervous system with internal or external devices, and emerging technologies to enable people to exert greater control over their nervous and organ systems.
One of the most intriguing questions SCI researchers are pursuing is how to repair damage to the spinal cord, and how function might be restored. In 2010, VA and several academic partners established a consortium, now named the Gordon Mansfield Spinal Cord Injury Translational Collaborative Consortium, to pursue high-risk, high-return ideas that might otherwise be unlikely candidates for funding.
Mansfield, who sustained a spinal cord injury in Vietnam, was deputy secretary of Veterans Affairs from January 2004 through January 2009.
The consortium hopes to advance the field of "regenerative rehabilitation"—the restoration of tissue and organ function lost as a result of aging, injury, or disease.
Scientists in the consortium have already generated promising early findings highlighting cell transplantation as a potential way to repair the nervous system. They have demonstrated in animal models that cell transplants can survive and integrate with a chronically injured spinal cord, and form connections with host tissue.
The consortium recently partnered with the Craig H. Neilsen Foundation to examine the long-term safety and efficacy of cell therapy. A VA researcher will conduct studies on what happens to animals for up to one year after cell transplantations to determine the safety of the procedure and how it may be used for future clinical trials in humans.
Chronic neuropathic pain (pain resulting from injury to the nervous system) and spasticity (tight or stiff muscles and an inability to control those muscles) occur in as many as 60 percent of those with spinal cord injury.
The VA Rehabilitation Research and Development Center for the Restoration of Nervous System Function is dedicated to making molecular and cell-based discoveries to alleviate pain and restore nervous system function in Veterans whose nerves have been damaged by injuries or illnesses such as SCI, multiple sclerosis, and diabetes.
Studies at the center focus on the role of sodium channels in mediating chronic neuropathic pain in various diseases. Sodium channels are proteins that conduct sodium ions through a cell's plasma membrane. By transmitting impulses quickly throughout cells and cell networks, they enable the coordination of higher processes ranging from movement to cognition.
Mutations in sodium channels can lead to chronic pain or the lack of pain sensation. VA researchers are looking at the role of sodium channels in glial scar formation following SCI, and at the possibility of using precision-medicine techniques to help individual patients deal with their pain.
Glial scars—Glial scars are structures that develop at places where the central nervous system has been injured. Just like scarring in other organs and tissues, glial scars are the body's way to protect and begin the healing process in the nervous system.
Dendritic spine dysgenesis—Researchers at the center, which is based at the VA Connecticut Healthcare System and the Yale School of Medicine, have also demonstrated that aberrant connections (dendritic spine dysgenesis) in motor neurons following SCI are a cause of spasticity and neuropathic pain. The finding may lead to new ways to treat these problems.
Neuronal hyperexcitability—Other work at the center has identified and characterized new mutations in sodium channels that produce neuronal hyperexcitability (excessive activity) and severe pain in people with rare genetic diseases or common peripheral nerve diseases.
Polymorphism—Still other work has identified and characterized a new gene variation, or polymorphism, that increases a person's risk for neuropathic pain. Treating people with a sodium channel blocker (lamotrigine) provided some relief to two pairs of twin sisters in a family who had the same kind of unusual pain after exercising. This led the researchers to conclude that their sodium channel mutation was directly related to the twins' pain. The implication is that individualizing care based on genetic testing could help lead to effective treatment strategies. The researchers are pursuing other precision-medicine approaches to pain, as well.
Employment can be a major challenge for Veterans with SCIs. The average rate of any paid employment for people with SCIs is
One of VA's most important responsibilities is to help disabled Veterans prepare for, find, and keep suitable jobs. VA provides a comprehensive rehabilitation evaluation to determine a Veteran's abilities, skills and interests for employment.
The department also offers vocational counseling and rehabilitation planning for employment services; job training and job seeking skills; help finding and keeping a job; and post-secondary school training. Individual placement and support (IPS) is an evidence-based form of supported employment, which has been used for years in Veterans with serious mental illnesses.
Initial work by VA researchers at the VA North Texas Health Care System examined the value of IPS for Veterans with SCI. The program uses a team approach that includes vocational rehabilitation specialists working alongside clinical care providers.
The study found that Veterans in the IPS group were more than twice as likely to obtain competitive employment, compared with Veterans who received only standard vocational support, such as state services or other VA services. They also found that Veterans who received IPS had at least a tenfold greater chance of finding competitive employment, compared with usual-care participants at VA sites that did not offer IPS.
To follow up on these findings, researchers conducted a larger multisite trial of the effectiveness of IPS for spinal-cord-injured patients. More than 1,000 Veterans with SCI participated in baseline interviews, with 279 enrolled in IPS, who were then followed for 24 months. Although all data collection is completed, final results are not yet available. The researchers will look at employment and quality-of-life outcomes and try to zero in on the precise factors that yield the best results.
In 1980, a U.S. Army soldier stationed in Germany injured his spinal cord in a bicycle accident. During his recovery, the soldier was given a bulky and heavy wheelchair to use, which greatly limited his mobility—especially when he tried to take part in competitive wheelchair athletics.
The soldier, Rory Cooper, immediately realized there was a great deal of room for improvement in wheelchair design, and dedicated the remainder of his life to making those improvements.
Cooper, who later received his Ph.D. in electrical and computer engineering, is now the director of the VA Center in Wheelchairs and Associated Rehabilitation Engineering. The center, which Cooper founded in 1994, is part of the Human Research Engineering Laboratories (HERL), and is operated jointly by the VA Pittsburgh Healthcare System and the University of Pittsburgh.
HERL's mission is to continually improve the mobility and function of people with disabilities through advancing engineering and clinical research in medical rehabilitation. HERL occupies more than 15,000 square feet and features state-of-the-art research instruments and machines for prototype fabrication.
Among the organization's many projects is the development of an electronic powered wheelchair, called the Personal Mobility and Manipulation Appliance. This is a powered wheelchair fitted with robotic arms to help wheelchair users with limited hand function manipulate their environment and objects within it. The arms can also function autonomously or be controlled remotely by an assistant.
Another HERL project, the SmartWheel, examines manual wheelchair use by analyzing each push on the handrim. It measures push forces, frequency, length, smoothness, and speed, and creates automated reports that allow therapists to optimize wheelchair set-up and push style to reduce repetitive stress.
Adapting VA MOVE! For Veterans with SCI—Nearly 66 percent of VA's patients with SCI/D are either overweight or obese. In 2011, a team led by researchers at VA's Puget Sound Health Care System adopted materials on weight management and physical activity on the VA MOVE! program's website to make them helpful to Veterans with spinal cord injuries. They also developed new materials on their own.
The researchers modified 22 existing pamphlets by including wheelchair fitness activities and photographs, providing safety tips for wheelchair users, and offering other ideas to help SCI patients perform physical activity safely. They also developed five new pamphlets. The MOVE! program uses these pamphlets to improve coordinators' ability to work with those who use a wheelchair for mobility.
Trainer phone calls for weight loss—In a study published in 2013, VA researchers from the Jesse Brown VA Medical Center in Chicago and the University of Alabama at Birmingham found that regular 30-minute targeted phone calls from a trainer can result in significant weight loss for disabled persons.
More than 100 participants, including patients with SCI, were assigned to one of three groups. One group received a physical-activity toolkit along with regular calls from coaches who used a Web-based coaching tool. A second group received the toolkit, calls, and nutritional advice. The third group, a control group, received the physical activity toolkit only after the study was completed, and received no phone coaching.
For four months, those receiving calls were contacted weekly to develop a plan, monitor their progress, and troubleshoot any barriers. The calls dropped to every other week after that. At seven months, the calls came only monthly.
The researchers found that, after nine months, those receiving the toolkit and regular calls had lost, on average, nearly five pounds. Those who received nutritional advice lost an additional pound. Participants in the control group actually gained an average of five to six pounds.
Activity and participation after spinal cord injury: State-of-the-art report. Ullrich PM, Spungen AM, Atkinson D, Bombardier CH, Chen Y, Erosa NA, Groer S, Ottomanelli L, Tulsky DS. This report summarizes the recommendations for researchers on the topic of measuring activity and participation among persons with SCI formulated by the Spinal Cord Injury workgroup at the State-of-the-Art Conference on Outcome Measures in Rehabilitation held in January 2010. J Rehabil Res Dev. 2012;49(1):155-74.
Longitudinal performance of a surgically implanted neuroprosthesis for lower-extremity exercise, standing, and transfers after spinal cord injury. Triolo RJ, Bailey SN, Miller ME, Rohde LM, Anderson JS, Davis JA Jr, Abbass JJ, DiPonio LA, Forrest GP, Gater DR JR, Yang LJ. After a year of home use of a neuroprosthetic device, 15 patients incorporated the device into their lives, and the device was shown to be safe and reliable. Arch Phys Med Rehabil. 2012 May:93(5):896-904.
Technology, trends, and the future for people with spinal cord injury. Cooper RA. In the future, we will see more teams of scientists, engineers, and clinicians that include people with and without SCI working together to conduct pioneering research, to create transformational technology, and to establish model clinical programs. J Spinal Cord Med. Jul 2013;36(4):257
Vertical ground reaction force-based analysis of powered exoskeleton-assisted walking in persons with motor-complete paraplegia. Fineberg DB, Asselin P, Harel NY, Agranova-Breyter I, Kornfeld SD, Bauman WA, Spungen AM. Powered exoskeleton-assisted walking in persons with motor-complete SCI generated vertical ground reaction force similar in magnitude and pattern to that of able-bodied walking. This suggests the potential for powered exoskeleton-assisted walking to provide a mechanism for mechanical loading to the lower extremities. J Spinal Cord Med. 2013 Jul;36(4):313-21
Telehealth weight management intervention for adults with physical disabilities: A randomized controlled trial. Rimmer JH, Wang E, Pellegrini CA, Lullo C, Gerber BS. A low-cost telephone intervention supported with a Web-based remote coaching tool (POWERS) can be an effective strategy for assisting overweight adults with physical disabilities in maintaining or reducing their body weight. Am J Phys Med Rehabil. 2013 Dec;92(12):1084-94.
Identification and treatment of sleep-disordered breathing in chronic spinal cord injury. Sankari A, Martin JL, Bascom AT, Mitchell MN, Badr MS. Disordered breathing during sleep is common and severe among SCI/D patients. Spinal Cord. 2015 Feb;53(2):145-9.
Dendritic spine dysgenesis contributes to hyperreflexia after spinal cord injury. Bandaru SP, Liu S, Waxman SG, Tan AM. This study demonstrates that changes in spine distribution and density are correlated with reflex dysfunction following SCI. J Neurophysiol. 2015 Mar 1;113(5):1598-615.
Neural point-and-click communication by a person with incomplete locked-in syndrome. Bacher D, Jarosiewicz B, Masse NY, Stavisky SD, Simeral JD, Newell K, Oakley EM, Cash SS, Friehs G, Hochberg LR. This study demonstrates the first use of an intracortical brain-computer interface for neural point-and-click communication by an individual with incomplete locked-in syndrome. Neurorehabil Neural Repair. 2015 Jn;29(5):462-71.
Does upper extremity training influence body composition after spinal cord injury? Fisher JA, McNelis MA, Gorgey AS, Dolbow DR, Goetz LL. The available evidence does not support the theory that circuit resistance training can lead to positive adaptations in body composition after a SCI. Aging Dis. 2015 Aug 1;6(4):271-81.
Dendritic spine dysgenesis in neuropathic pain. Tan AM, Waxman SG. The study of dendritic spine abnormality may provide a new perspective for investigating pain, and the identification of specific molecular players that regulate spine morphology may guide the development of more effective and long-lasting therapies. Neurosci Lett. 2015 Aug 5;601:54-60.
Friedli L, Rosenzweig ES, Barraud Q, Schubert M, Dominici N, Awai L, Nielson JL, Musienko P, Nout-Lomas Y, Zhong H, Zdunowski S, Roy RR, Strand SC, van den Brand R, Havton LA, Beattie MS, Bresnahan JC, BÃ©zard E, Bloch J, Edgerton VR, Ferguson AR, Curt A, Tuszynski MH, Courtine G. This study uncovered pronounced interspecies differences in the nature and extent of spinal cord repair mechanisms, likely resulting from fundamental differences in the anatomical and functional characteristics of the motor systems in primates versus rodents. Sci Transl Med. 2015 Aug 26;7(302):302.
Virtual typing by people with tetraplegia using a self-calibrating intracortical brain-computer interface. Jarosiewicz B, Sarma AA, Bacher D, Masse NY, Simeral JD, Sorice B, Oakley EM, Blabe C, Pandarinath C, Gilia V, Cash SS, Eskandar EN, Friehs B, Henderson JM, Shenoy KV, Donoghue JP, Hochberg LR. This study demonstrates that changes in neural activity can be corrected with software changes. Science Translational Medicine. 2015 Nov 11;7(313):313.
Vocational rehabilitation in spinal cord injury: What vocational service activities are associated with employment program outcome? Ottomanelli L, Barnett SD, Goetz LL, Toscano R. This study identifies the components of a successful vocational program on employment. Top Spinal Cord Inj Rehabil. 2015 Winter;21(1):31-9