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Research on paralyzed patients brings new treatment options to VCU Health

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By Jackie Kruszewski
C. Kenneth and Dianne Wright Center for Clinical and Translational Research
(804) 828-6671
kruszewskij@vcu.edu

$7 million awarded for first-of-its-kind spinal cord injury research

Every year, 17,810 people in America are left paralyzed by motor vehicle crashes, falls, gunshot wounds and other traumas. One lapse in judgment or simply being in the wrong place at the wrong time can have life-long repercussions. 

No one knows that better than the doctors at VCU Health who meet and treat paralyzed people in their practices. And their experience has led them to reexamine existing treatments for the chronic pain and muscular atrophy that people without mobility in their legs experience.

Now, the Department of Defense (DoD) has awarded two VCU scientists grants totaling more than $7 million for their research. In collaboration with local, national and international partners, their research teams will study the effects of virtual reality on chronic pain and the use of exoskeletons, plus epidural stimulation, to improve the quality of life for paralyzed people.

Ashraf Gorgey, MPT, Ph.D., an associate professor in VCU School of Medicine’s department of physical medicine and rehabilitation, and Zina Trost, Ph.D., an associate professor in the same department, are the principal investigators of two research study teams that will enroll Virginia patients in trials.

“I'm excited and hopeful that the studies will improve the health and wellness of the participants,” Gorgey said. “This is just the first step, but we’re providing new hope for those with spinal injuries that didn’t exist before.”

Using virtual reality to treat pain – from the comfort of home

A common misconception about paralyzed people is that they don’t feel pain in immobilized parts of their body. In fact, around 50 percent of those with spinal cord injuries suffer from neuropathic pain that Zina Trost describes as often “burning, electrical and very uncomfortable.”

“The striking thing about this kind of pain is that almost nothing works for it,” she said. Even medication only offers some relief. And Trost says patients struggle with the significant side effects associated with some drug treatment.

Neuropathic pain has many similarities to phantom limb pain, where someone with an amputated arm, for example, feels pain in the hand that isn’t there. Visual illusion therapy, where a mirror trained on the remaining arm “shows” the missing hand, has proven effective in helping alleviate phantom limb pain.

Neuropathic pain in spinal cord injury is trickier, but the same concept appears to apply. And researchers have had success using mirrors and projections to simulate a patient’s experience of watching himself or herself walk.

“It's associated with positive brain reorganization,” Trost said. “The person knows it's not real, but the brain still responds.”

Now there’s virtual reality, and Trost believes the technology offers an interactive experience that might be even more successful – and portable. Participants in the study go home with a small headset that fits over their eyes, programmed with individualized games and therapies, complete with a self-designed, first-person walking avatar.  

“The goal is to have the person genuinely experience walking in the virtual environment”, Trost said.

Trost, who began her career as a health psychologist interested in chronic pain, says pilot testing also showed changes to participants’ brains in before-and-after imaging scans.

“We know that this pain is underpinned by brain processes, but still, no studies have examined brain mechanisms associated with treatment. We are not only looking for reorganization, but changes in levels of specific neuro-transmitters,” Trost said. “If we see those brain changes are responsible for changes in pain, then we may be able to target those changes in the brain independently, by other means, potentially preventing this whole condition, as opposed to treating it.”

The DoD awarded her team $3.7 million under its spinal cord injury research portfolio. The plan is to enroll 200 patients across three sites: VCU, the University of Alabama at Birmingham and the University of New South Wales in Australia. The government of Australia recently contributed $2.5 million to the project as well. 

“People are reacting amazingly to this,” said Trost of the study’s pilot testing. “Walking is a powerful experience, and the gaming component makes it fun. People don’t want to take it off when they’re done.”

And her study may provide insight and advancement for thousands of sufferers of neuropathic pain worldwide. “Studies have found that some people would rather have their pain go away than have their function return,” Trost said.

Taking exoskeletons to the next level

Pain is only one potential side effect of spinal cord injury and paralysis. People are also at high risk for a number of diseases, like diabetes, that stem from certain muscles’ lack of use. Cardiovascular health can suffer, as can bladder and bowel function.

Ashraf Gorgey has been studying spinal cord injury for 17 years and has long worked with exoskeletons — robotic suits that help people with spinal cord injuries walk. The suits have shown “really remarkable improvement” in quality of life for patients.

But that’s only half of Gorgey’s new project. A relatively new procedure called epidural stimulation, where doctors surgically implant a device into the spinal cord to supply electrical currents connecting nerve signals from the brain, has also shown promise. But the procedure can be invasive and expensive.

In an earlier study, Gorgey monitored the use of the exoskeleton on a patient who had had the epidural stimulation procedure and was surprised by the promising results after only 12 weeks of training.

“Imagine if you train someone like that for a full year,” said Gorgey. “We'll learn much more about how to activate the spinal cord, and even restore motion and become independent.”

That’s where Central Virginia VA Health Care System comes in. They’ve developed a less invasive epidural stimulation process – a two-hour, non-surgical procedure similar to the epidural injection given to women in childbirth.

The DoD awarded the innovative team of researchers $3.7 million to study the exoskeleton’s use in concert with the new version of epidural stimulation — the first study of its kind. The research could ultimately lead to a standard treatment for spinal cord injury that increases cardiovascular health, bladder and bowel function and even returns some motor control.

“This could be life-changing for veterans, as well as civilians, if it’s successful,” Gorgey said. “If you have seen people who have a spinal cord injury standing up and walking, even with the exoskeleton, it’s an emotional experience for everyone.”

Gorgey’s team plans to enroll 20 veterans in their study, which he doesn’t imagine will be difficult. Their pilot work, he says, has already piqued the interest of people around the world.

VCU leading in spinal cord injury research

Of dozens of applicants, both clinical trial awards for spinal cord injury from the DoD's Congressionally Directed Medical Research Programs went to VCU researchers this year. Trost began the application while working at the University of Alabama at Birmingham, before moving to VCU earlier this year.

Having VCU researchers on the front lines of spinal cord injury research means patients at VCU Health have access to top-tier clinicians and cutting-edge opportunities as the research progresses.

“This is all extremely innovative research,” said Ronald Seel, Ph.D., the executive director of VCU’s Center for Rehabilitation Science and Engineering, which works to integrate interdisciplinary rehabilitation expertise in service of patients. “And this research could easily be translated to civilian populations.”

The grants, announced in February, are for four years, with recruitment expected to begin in September. Some of the exoskeleton research will be based at the VA, where Gorgey is the director of research for spinal cord injury and disorders for the Central Virginia VA Health Care System.

“Ashraf and Zina are the type of researchers that we really strive to have here at VCU,” said Seel. “They’re very smart. They’re innovative. They’re very dedicated. And their focus is really on improving people's outcomes.”

Among other degrees, Gorgey holds a master’s degree in the Clinical and Translational Sciences program from VCU’s C. Kenneth and Dianne Wright Center for Clinical and Translational Research, which trains and supports VCU human health researchers with the help of a $21.5 million federal grant.

“VCU is where I learned how to design clinical trials, like what we're doing right now,” Gorgey said.

The grants coincide with the June opening of VCU Health’s Sheltering Arms Institute — an innovative, 114-bed inpatient rehabilitation facility outside of Richmond, where the investigators may recruit participants for their studies.