RD Research and Development



Overview of Research and Development Activities

State of the Science on Spinal Cory Injury

Research Projects: Effect of Local Cooling | Effects of Weight Shifting | Handrim Technology

Development Projects: Inflammation Modeling | Low Shear, Cool Cushion | Propulsion Training Tools


Overview of Research and Development Activities

Overview of Research and Development Activitiesur Center contains three development and three research projects, plus a Clinical Core. The 'R' projects are primarily research, while the 'D' projects focus on development. Each project has multiple aims and, in some circumstances, an R may contain elements of development and vice versa. As a general rule, all of our R&D projects have implementation and/or commercialization as their ultimate goal. The fundamental difference between our R&D projects is that the research projects generally begin with evaluation of technology that has already been developed, whereas development projects aim to create technology and then evaluate it.

In choosing the projects for inclusion in this RERC we considered 1) the importance of the problem; 2) the potential of achieving outcomes likely to improve rehabilitation, treatment, employment, and reintegration into society of and for persons with SCI; 3) the expertise available to the proposed center; 4) the fit of the project with the mission of the RERC program; and 5) the innovativeness of the underlying technologies and approaches.

We choose to focus our R&D on technologies and approaches addressing pressure ulcer, urinary tract infection, and musculoskeletal injury prevention. Pressure ulcers exact a devastating loss of function, increase the risk of death, and increase healthcare costs. An analysis of the Collaborative SCI Survival Study database maintained by the National Spinal Cord Injury Statistics Center (NSCISC) on the primary cause of death for 3,574 individuals treated at a Model System within one year of injury showed that "the third leading cause of death was infective and parasitic diseases" that where "virtually always cases of septicemia (93.5%) and were usually associated with decubitus ulcers (pressure ulcers), urinary tract or respiratory infections" (National Spinal Cord Injury Statistical Center 2006). The two highest leading causes of death were diseases of the respiratory system (21.9%) and heart disease (12.4%). Infective and parasitic diseases were determined to be the cause of death in 9.4 % of the cases. The most common complications post injury for persons in the Model Systems database are pneumonia (34.0%) followed by pressure ulcers (33.6%). For persons with SCI at least one year post injury, pressure ulcers is far and away the most frequent complication, with incidence rates of 14.9% in the first year post-injury and steadily increasing thereafter to 26.7% 30 years post-injury (National Spinal Cord Injury Statistical Center 2006). The leading cause of rehospitalization of persons with SCI was "diseases of the genitourinary system, including urinary tract infections." The second leading cause was skin diseases including pressure ulcers (Cardenas, Hoffman et al. 2004).

Persons with SCI rely extensively on their upper limbs for mobility and activities of daily living. The long-term reliance on the upper limbs for performing daily activities has led to an increase in the prevalence of musculoskeletal injuries and reports of pain (Silfverskiold and Waters 1991; Sie, Waters et al. 1992; Pentland and Twomey 1994; Curtis, Roach et al. 1995). Recognizing the significance of upper limb pain/injury and their negative impact on quality of life, the Consortium for Spinal Cord Medicine with PVA's (Paralyzed Veterans of America) support recently published the monograph, Preservation of Upper Extremity Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals which provides concise ergonomic and equipment recommendations based on review of published evidence-based research (Consortium for Spinal Cord Medicine 2005). Upper Extremity pain among manual wheelchair users has been well documented with prevalence estimates between 30 and 73% (Gellman, Sie et al. 1988; Pentland and Twomey 1991; Curtis, Drysdale et al. 1999; Ballinger, Rintala et al. 2000). Lundqvist et al. (Lundqvist, Siosteen et al. 1991) found that pain was the only factor correlated with lower quality of life scores. Gerhart et al. (Gerhart, Bergstrom et al. 1993) found that upper limb pain was a major reason for functional decline in individuals with SCI who required more physical assistance since their injury. Many attribute the high prevalence of arm pain to "overuse syndrome" resulting from the repetitive loading that occurs during wheelchair propulsion (Nichols, Norman et al. 1979; Bayley, Cochran et al. 1987; Subbarao, Klopfstein et al. 1994). Multiple studies have found that the prevalence of shoulder pain increases with the duration of use (Nichols, Norman et al. 1979; Gellman, Chandler et al. 1988; Gellman, Sie et al. 1988; Sie, Waters et al. 1992; Pentland and Twomey 1994).

Carpal tunnel syndrome (CTS) is a common diagnosis among MWUs with prevalence between 49% and 67% (Aljure, Eltorai et al. 1985; Gellman, Chandler et al. 1988; Tun and Upton 1988; Sie, Waters et al. 1992; Burnham and Steadward 1994). These studies have shown both historical or physical examination evidence and electrodiagnostic findings of CTS. These studies also found the incidence of CTS increased with increased duration of wheelchair use.

In light of the foregoing information, we determined that the RERC on SCI should aim to prevent pressure ulcers, prevent upper extremity injury and its associated pain, and improve bladder function. With consideration given to the origin and mission of the RERC program as defined in the Rehabilitation Act of 1973 (as amended) and the specific priority statement for this RERC on SCI (the RERC must research, develop and evaluate innovative technologies and approaches that will improve the treatment, rehabilitation, employment, and reintegration into society of persons with spinal cord injury) we were able to further focus our R&D portfolio. The result of our deliberations is depicted in Figure 1 where our six R&D projects are shown grouped according to their respective focus area (pressure ulcer and musculoskeletal injury prevention) with their interactions (i.e. utilization of outputs) between the Clinical Core and the inflammation modeling development project. The Clinical Core provides IRB and recruitment services for all projects. The inflammation modeling project, D1, draws information from the clinical core to develop agent based models (ABM) for pressure ulcers and urinary tract infections. Likewise, D1 draws data from the Clinical Core and R3, the project investigating the effects of handrim technology on upper extremity injury, to create an ABM for musculoskeletal injury. Emerging from the modeling project, D1, is an ABM for pressure ulcer development that will be used for evaluation in the cushion development project, D2. The scheduling and duration of projects is depicted in Figure 2.

RERC SCI R&D Activities chart
Figure 1 - Flow chart showing the focus areas and interrelationships between the R&D projects


5 year chart

Aljure, J., I. Eltorai, et al. (1985). "Carpal tunnel syndrome in paraplegic patients." PARAPLEGIA 23: 182-186.

Ballinger, D. A., D. H. Rintala, et al. (2000). "The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: a multifaceted longitudinal study." Arch.Phys.Med.Rehabil. 81(12): 1575-1581.

Bayley, J. C., T. P. Cochran, et al. (1987). "The weight-bearing shoulder. The impingement syndrome in paraplegics." J Bone Joint Surg [Am] 69: 676-678.

Burnham, R. S. and R. D. Steadward (1994). "Upper extremity peripheral nerve entrapments among wheelchair athletes: Prevalence, location, and risk factors." Arch Phys Med Rehabil 75: 519-524.

Cardenas, D. D., J. M. Hoffman, et al. (2004). "Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis." Arch Phys Med Rehabil 85(11): 1757-63.

Consortium for Spinal Cord Medicine (2001). Acute Management of Autonomic Dysreflexia: Individuals with Spinal Cord Injury Presenting to Health-Care Facilities.

Curtis, K. A., G. A. Drysdale, et al. (1999). "Shoulder Pain in Wheelchair Users With Tetraplegia and Paraplegia." Arch.Phys.Med.Rehabil. 80: 453-457.

Gellman, H., D. R. Chandler, et al. (1988). "Carpal tunnel syndrome in paraplegic patients." J Bone Joint Surg [Am] 70: 517-519.

Gellman, H., I. Sie, et al. (1988). "Late complications of the weight-bearing upper extremity in the paraplegic patient." Clinical Orthopaedics & Related Research 233(August): 132-135.

Gerhart, K. A., E. Bergstrom, et al. (1993). "Long-term spinal cord injury: functional changes over time." Arch Phys Med Rehabil 74(10): 1030-1034.

Lundqvist, C., A. Siosteen, et al. (1991). "Spinal cord injuries. Clinical, functional, and emotional status." Spine 16(1): 78-83.

National Spinal Cord Injury Statistical Center (2006). Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL, University of Alabama.

Nichols, P. J., P. A. Norman, et al. (1979). "Wheelchair user's shoulder? Shoulder pain in patients with spinal cord lesions." Scand J Rehabil Med 11: 29-32.

Pentland, W. E. and L. T. Twomey (1994). "Upper limb function in persons with long term paraplegia and implications for independence: Part I." Paraplegia 32(4): 211-8.

Sie, I. H., R. L. Waters, et al. (1992). "Upper extremity pain in the postrehabilitation spinal cord injured patient." Arch Phys Med Rehabil 73(1): 44-8.

Silfverskiold, J. and R. Waters (1991). "Shoulder Pain and Functional Disability in Spinal Cord Injury Patients. SECTION II." Clinical Orthopaedics & Related Research 272: 141-145.

Subbarao, J. V., J. Klopfstein, et al. (1994). "Prevalence and impact of wrist and shoulder pain in patients with spinal cord injury." J Spinal Cord Med 18(1): 9-13.

Tun, C. G. and J. Upton (1988). "The paraplegic hand: Electrodiagnostic studies and clinical findings." J Hand Surg [Am] 13: 716-719.

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This work is funded by the National Institute on Disability and Rehabilitation Research (NIDRR),
Rehabilitation Engineering Research Center (RERC) on Spinal Cord Injury, Grant #H133E070024
The ideas and opinions expressed herein are those of the authors and not necessarily reflective of the NIDRR.

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Last Updated: 11.28.2011 | 14:40

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