ISCRR Improving Trauma Care Theme Spinal Cord Injury Projects Project Title: Improving Health After Spinal Injury: Bowel Management Research Project Leaders: Dr Brid Callaghan, Prof John Furness End Date: December 2016 Total ISCRR Funding: $1,060,000 Following injury to the spine, which severs descending nerve pathways, there is a loss of conscious control of the bowel. Therefore the bowel cannot be emptied voluntarily at a convenient time, which can lead to accidents and cause great inconvenience and embarrassment. In the longer term, impaction of bowel contents, with associated weakening of the bowel wall can require surgery to remove the bowel and the creation of an ileostomy, further compromising quality of life. This study involves clinical testing of colokinetic drugs with the aim to restore bowel control following SCI, thus significantly reducing attendant care requirements and reducing the eventual need for surgery. Treating failure of bowel emptying in people with SCI has the potential to greatly improve their quality of life and ability to participate in society. Project Title: Reduction of Secondary Complications of Spinal Cord Injury: Bladder Research Project Lead: A/Prof James Brock End Date: July 2016 Total ISCRR Funding: $533,473 The project focuses on an issue that is of significant importance to people living with Spinal Cord Injury (SCI) and aims to understand the mechanisms that contribute to the rapid disruption of the bladder lining (urothelium) following SCI with the objective of developing strategies to prevent its occurrence. The project will use urinary markers of urothelium breakdown identified in animal models to assess whether similar changes to the urothelium also occur immediately following SCI in humans. Importantly, the project will investigate the actions of drugs that are already used clinically for other purposes and potentially could be rapidly applied to patients with an SCI as a novel preventative treatment. The project has the potential to reduce the impact of bladder complications following SCI by building knowledge and contributing to the development of early identification and early preventative management approaches so that the individual can increase their participation in important social roles such as a family member and employee and to achieve maximal independence. 1
Project Title: Immediate Cooling and Emergency Decompression for the treatment of spinal cord injury Research Project Lead: Dr Peter Batchelor Organisation: The Florey Institute of Neuroscience and Mental Health End Date: December 2018 Total ISCRR Funding: $971,000 Traumatic injury to the spinal cord occurs at the time of impact and also from displaced vertebra compressing the spinal cord. Animal and preliminary human data demonstrate that urgent relief of compression greatly improves outcome. However, urgent decompression in humans is difficult to achieve because of logistical difficulties. Pre clinical data demonstrate that hypothermia can suspend the progressive damage caused to the spinal cord by compression, thereby allowing decompressive surgery to be performed in a clinically achievable time frame. A multicentre clinical trial of immediate cooling followed by emergency decompression (ICED) will be conducted to determine whether the combination of hypothermia and early decompression improves outcomes in patients with severe SCIs located in the neck. Patients will be cooled in the field by paramedics immediately following SCI and then rapidly transported to hospital to undergo surgical decompression. This project will aim to conduct the logistical and paramedic studies necessary before commencing a multicentre clinical trial. Project Title: Nerve transfers for restoration of upper limb function in tetraplegia Research Project Lead: Professor Mary Galea End Date: January 2019 Total ISCRR Funding: $426,498 The loss of hand function is one of the most devastating consequences of spinal cord injury (SCI) because of its severe impact on activities of daily living (ADL), and subsequent dependence on others. Nerve transfers for the reanimation of paralysed muscles are a well established surgical technique in brachial plexus and peripheral nerve injury and until very recently this technique has not been applied to the paralysis resulting from spinal cord injury. The Victorian Spinal Cord Service at Austin Health is the first in Australia to offer nerve transfers to patients with tetraplegia for upper limb reanimation and one of a handful worldwide. This unit is the first to combine procedures to restore elbow extension and grasp and release simultaneously using nerve transfers, functions which were unobtainable using standard tendon transfer techniques alone, and have the potential to greatly enhance independence and quality of life. At present there are no clear criteria for selection of appropriate patients for this procedure, and eligibility is determined on the basis of clinical judgment. This project will conduct a series of single case studies of patients who undergo nerve transfer surgery. In addition, detailed clinical and neurophysiological assessments pre and for up to 2 years post operatively, and histological investigation of donor and recipient nerves will be conducted. Together, these investigations will enable the development of appropriate criteria to determine eligibility of patients for nerve transfer surgery and to refine post operative training regimens. 2
Project Title: Assessment of the timing of decompressive surgery in spinal cord injury Research Project Lead: Dr Peter Batchelor Organisation: The Florey Institute of Neuroscience and Mental Health End date: July 2014 Total ISCRR Funding: $46,370 The pre clinical data on early decompression is compelling, demonstrating greatly improved outcomes following decompression of the traumatised spinal cord in the first hours following injury. Although performing decompressive surgery in humans within the first hours following injury would be ideal, transportation, stabilisation, investigation and organisation of surgery dictate delays of many hours. To date, the shortest average time to decompression in human trials is 12 14hrs. This project aims to (1) determine the average time to decompression in cases of SCI within Victoria over the last 3 years and (2) determine where substantial delays occur as patients move from the accident scene to surgery. This information, together with discussions with key personnel, will be used to develop methods and protocols for streamlining the movement of patients from the accident scene to surgery, with the eventual objective of enabling decompressive surgery to be performed as early as possible. This is essential for the conduct of the ICED clinical trial as well as improving outcomes more generally in SCI. Such a study has not previously been performed in any country and the data would therefore be of interest to the field generally. Project Title: Development of a clinical research database for spinal cord injury Research Project Lead: Dr David Berlowitz Organisation: Institute for Breathing and Sleep End Date May 2013 Total ISCRR Funding: $50,000 This project aimed to develop a local prototype of how nationally and internationally agreed spinal cord injury datasets could be collected, collated and analysed to facilitate research, quality improvement activities, and improved patient outcomes. The research team assembled a comprehensive, parsimonious dataset for the Victorian Spinal Cord Service (VSCS), which was thoroughly documented in a data dictionary. These data fields were mapped to clinical care within the unit, and staff of the VSCS have developed a protocol for how these data will be embedded into routine clinical care. This project drove a thorough review of current assessment and data collection practice in the VSCS, and as a result meaningful changes to the way in which some of the clinical data are collected have already been made. Further details of this completed project can be found on the ISCRR website. 3
Project Title: Assessing nutritional status in patients with spinal cord injury Research Project Lead: Prof Mary Galea End Date: November 2014 Total ISCRR Funding: $49,696 Acute spinal cord injury (SCI) can lead to malnutrition, with loss of lean body mass as a result of an initial hypermetabolic response to the stress of injury as well as an abrupt decrease in activity because of paralysis. This is associated with decreased immune function, delayed wound healing and early mortality. Assessment of nutritional needs in this population is difficult and challenging, with multiple factors affecting nutritional status and a lack of appropriate reference values. Dieticians use the Schofield equation to estimate the basal metabolic rate and the total caloric intake required to maintain body mass, however the equation has not been validated for people with spinal cord injury. This project will (1) validate the Schofield equation used to calculate energy requirements in people with spinal cord injury by using doubly labelled water and (2) validate the use of bioelectrical impedance analysis (BIA) to measure body composition in spinal cord injured patients by comparing results to dual x ray absorptiometry (DEXA), the current gold standard. The outcomes of this project will provide a sound basis for current practice in the estimation of nutritional requirements for people with spinal cord injury, and for the ongoing monitoring of the adequacy of dietary intake in this vulnerable population. Project Title: Management of Traumatic Spinal Cord Injuries in the Acute Setting Research Project Lead: Ian Mosley Organisation: National Trauma Research Institute, Monash University End Date: May 2015 Total ISCRR Funding: $50,000 Acute traumatic Spinal Cord Injury (SCI) is a particularly pernicious disorder. Most victims are young and the majority have severe paralysis. Much effort has been undertaken to ensure acute trauma patients including SCI patients are transferred rapidly to a Major Trauma Service and obtain critical lifesaving interventions. Acute traumatic SCI care is complex with around half of all SCI patients also experiencing concurrent injuries. Little is known about SCI care within the trauma system. Currently the Victorian Spinal Cord Service (VSCS) manages a third of SCI cases. This project will seek to map the flow of care for SCI patients in Victoria. The research team will identify care provided in the emergency / trauma, specialist in hospital and rehabilitation phases of care. This includes identifying, key decision points, clinical decision makers and factors associated with patient flow from trauma unit through to community care. The project will seek to broaden the focus of reporting to include hyper acute, acute, rehabilitation, and community outreach. This will improve our understanding of factors that influence the whole continuum of care. Subsequently, the investigators in conjunction with key clinical stakeholders will model data using Operations Research Simulation Modelling to inform developments in the process of care and improve patient outcomes. 4
Project Title: Remaking Masculinities After Spinal Cord Injury Research Project Lead: A/Prof Murray Fisher Organisation: University of Sydney End Date: April 2015 Total ISCRR Funding: $19,989 This life history project aims to examine how men following a SCI reconstruct their masculinity. SCI is a catastrophic life event, where individuals become functionally dependent, prone to depression and have a reduced quality of life. This study will identify the psychosocial needs of men as they transition to a post injury life, where their functional performance in areas of mobilization, urinary and bowel management, and sexuality has been significantly affected. Understanding this aspect of the SCI experience for men will help reduce physical and mental health complications. This study will seek to answer the following questions: How do men with SCI reconfigure masculinity following the injury event? How is the process of gender reconfiguration in men with SCI facilitated? What are the psychosocial needs of men with SCI during rehabilitation? This is important knowledge for the development of interventions that addresses the psychosocial needs of men with SCI throughout rehabilitation. Project Title: Rate, type and cost of complications experienced by spinal cord injury patients: Usage of linked data sources Research Project Lead: Prof Belinda Gabbe Organisation: Monash University End Date: November 2014 Total ISCRR Funding: $48,243 Spinal cord injured patients face complex and ongoing challenges in their care and recovery. Complications can involve single or multiple systems and include respiratory and genitourinary systems, as well as problems with pressure ulcers, pulmonary emboli and deep venous thrombosis. Despite the potential for complications, the rate and direct costs of complications experienced by spinal cord injured patients is largely unknown in Australia, and improved understanding of these complications is needed to improve the delivery and coordination of care to spinal cord injury patients. This project will use two linked datasets (hospital admissions and emergency department presentations, and trauma registry and TAC claims data) to significantly enhance our understanding of the incidence and costs of complications experienced by spinal cord injury patients in Victoria. In addition, the study will compare the Victorian experience with comparable linked data from Western Australia. The use of existing data provides an efficient approach to this problem and will be beneficial in informing future research directions in this field. 5
Project Title: Complications Audit of Urological Issues in Spinal Cord Injury Evaluation Study (CAUSES) Research Project Lead: Dr Andrew Nunn Organisation: Victorian Spinal Cord Service, Austin Health End Date: November 2014 Total ISCRR Funding: $40,000 This project will focus on a clinical audit of urological complications within VSCS, Austin Hospital with the findings expected to significantly enhance our understanding of urological practice in hospital settings and outcomes experienced by traumatic spinal cord injury patients in Victoria. The project will retrospectively analyse in more clinical detail existing practices and associated clinical data in relation to urological complications to establish patterns and current practice in the acute phase including types of catheter usage; incidence of urinary tract infection; incidence of MRO colonisation; upper and lower urinary tract complications, systemic symptoms, treatment and management strategies. The project will suggest Hospital costing models which may also provide more accurate cost groupings for consumables and antibiotics beyond bed stay which will be valuable information for the next phase of work. The project findings are expected to inform on how to best apply best practice and remeasure outcomes within the system and will be complementary to the outcomes obtained from the Rate, type and cost of complications experienced by spinal cord injury patients: Usage of linked data sources. Together these findings will provide the necessary information required for future research commitments and in particular the consecutive phases for the Secondary Complications of SCI program, the next phase of which is to develop an intervention focusing on treatment and management strategies that will aim to improve clinical practice at the Austin and within the community. The project may also allow for interstate comparisons and benchmarking leading to improved management of client outcomes for the TAC and spinal cord community. 6