David S. Tulsky, PhD, co-director, Spinal Cord Injury Research, Kessler Medical Rehabilitation Research and Education Corporation; associate professor, Department of Physical Medicine and Rehabilitation (pm&R), UMDNJ-New Jersey Medical School (NJMS); Steven Kirshblum, MD, medical director, Spinal Cord Injury Program, Kessler Institute for Rehabilitation; associate professor pm&r, njms

Improving outcomes for spinal cord injuries by David S. Tulsky & Steven Kirshblum

There are approximately 11,000 new traumatic spinal cord injuries (SCI) that occur in the U.S. each year. As one of only 16 Model Spinal Cord Injury Systems (MSCIS) in the country, the primary purpose of the Northern New Jersey Spinal Cord Injury System (NNJSCIS) is to generate new knowledge to improve outcomes for persons with SCI through the development of improved interventions and expanded service delivery options. It is a collaborative effort between Kessler Medical Rehabilitation Research and Education Corporation (KMRREC), the University of Medicine and Dentistry of New Jersey (UMDNJ), UMDNJ-University Hospital (UH) and the Kessler Institute for Rehabilitation (KIR). I am the principal investigator of the NNJSCIS and Steven Kirshblum, MD, is the co-PI. The NNJSCIS has a well-established interdisciplinary system of rehabilitation care designed to meet the needs of individuals with SCI, including: emergency medical
services; acute care; psychological, social and vocational services; state-of-the-art rehabilitation; peer support and independent living services; community and job placement; and long-term health maintenance.

The MSCIS program began as a research and demonstration project in 1970 and, today, is overseen by the National Institute on Disability and Rehabilitation Research (NIDRR) within the Department of Education. The Northern New Jersey Spinal Cord Injury System has been a part of the Model System program since 1990, working to improve outcomes for individuals with SCI through the development of improved interventions and expanded service delivery options. NNJSCIS was the first system of its kind to receive accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF) for general rehabilitation, as well as specialized accreditation for an SCI program, in the state of New Jersey. The NNJSCIS provides a comprehensive continuum of state-of-the-art care for persons with spinal cord injury and their significant others from the time of injury through long-term follow-up in the community. Approximately 100 persons with traumatic spinal cord injury are admitted each year to our system of care.

Model systems centers are encouraged to conduct state-of-the-art research in spinal cord injury medicine. The spinal cord injury research program at the KMRREC, in affiliation with KIR and UMDNJ, is designed to restore lost function to individuals with spinal cord injuries, minimize secondary complications associated with SCI, and help individuals reintegrate into the community.

Restoring Lost Function

ProCord (Activated Macrophages)
P.I.: Steven Kirshblum, MD; funded by Proneuron
The ProCord study (Proneuron) is an international, multi-center, Phase II clinical trial investigating the regenerative effects of injecting activated macrophages into the damaged spinal cord of individuals with acute neurologically complete SCI within 14 days of injury. The study is a collaborative effort between the KIR, UMDNJ-New Jersey Medical School and KMRREC, and is directed by Dr. Steven Kirshblum in association with UH. Key personnel include Robert Heary, MD (Department of Neurosurgery), Karen Kepler, DO, PhD (Department of Physical Medicine and Rehabilitation), and David Livingston, MD (The New Jersey Trauma Center at UH). It is one of only six sites in the world that are currently participating in this clinical trial. For additional information about this study see page 11.

HP-184 Study
P.I.: Steven Kirshblum, MD; funded by Aventis Pharmaceuticals
This is a Phase II clinical trial using a medication called HP-184 to study its effect on muscle score improvement and changes in ambulation in subjects with chronic spinal cord injury. HP-184 is a combination of a potassium (K+) and sodium (Na+) channel blocker that, in animal models, appeared to improve locomotion. A previous Phase I trial in 48 human subjects with a chronic neurologically incomplete SCI showed an improvement in motor scores (i.e., increased strength after using the medication). This current trial is an international, multi-center study, with 240 subjects already enrolled. The recruitment phase is complete and data analysis will begin shortly.

Eliminating Medical Complications and Preventing Loss of Function

Pharmacological Management of Dyslipidemia
P.I.: Trevor Dyson-Hudson, MD; funded by National Institute on Disability and Rehabilitation Research
Early cardiovascular disease has emerged as a significant cause of illness and a leading cause of death for persons with SCI. Investigators have found abnormally depressed levels of high-density lipoprotein cholesterol (HDL-C) and elevated levels of low-density lipoprotein cholesterol (LDL-C) in persons with SCI, which researchers believe is one of the primary causes of early onset cardiovascular disease in this population. KMRREC has joined investigators from the Miami Project to Cure Paralysis and the Rancho Los Amigos National Rehabilitation Center (Downey, CA) to examine the ability of Niaspan to improve the lipid profiles and reverse the effects of cardiovascular disease in individuals with tetraplegia.

Acupuncture for Shoulder Pain
P.I.: Trevor Dyson-Hudson, MD; funded by New Jersey Commission on Spinal Cord Research
Shoulder pain is another common medical complication associated with SCI and can lead to substantial disability in this population. Due to lower limb paralysis, individuals with SCI must rely extensively on their upper limbs for mobility and other activities of daily living, which puts them at significant risk for overuse injuries and shoulder pain. Common treatments for shoulder pain include rest, non-steroidal anti-inflammatory drugs, corticosteroid injections, physical therapy modalities and surgery. Unfortunately, the evidence supporting the efficacy of many of these treatments is limited and some are associated with side-effects. KMRREC researchers recently completed a study investigating the effectiveness of acupuncture for shoulder pain in persons with SCI. This study found acupuncture to be effective, decreasing pain by 64% on average.

Community Reintegration
Development of a Web-Based Consumer Index of Accessibility for Restaurants
P.I.: David Tulsky, PhD; funded by the National Institute on Disability and Rehabilitation Research and the Northern New Jersey SCI System
Much of the research conducted in the SCI lab is aimed at eliminating environmental barriers and increasing accessibility of public places. The goal of one such study is to provide individuals with SCI information about the wheelchair accessibility of local restaurants. Initially, the research team held focus groups with consumers to identify the specific issues related to wheelchair accessibility in restaurants and other public places. From these comments and feedback, we developed a restaurant accessibility index, which was subsequently reviewed by focus group participants, as well as professionals working at KMRREC, all of whom are familiar with accessibility issues.

Participants in the study helped to identify potential restaurants and were subsequently instructed to each visit three of them, rate their level of accessibility and submit their ratings on line. Additional funding from NIDRR will allow members of the study team to visit the restaurants and obtain objective measures of the establishment, using an ADA checklist.

Restoring Driving Functioning Following Spinal Cord Injury: A Virtual Reality Approach
P.I.: David Tulsky, PhD; funded by the New Jersey Commission on Spinal Cord Research
This study uses an innovative virtual reality (VR) technology to retrain drivers following SCI. The research team, including Drs. Maria Schultheis and Lisa Simone, developed an accessible VR driving simulator, with an adapted steering wheel and hand controls. A software program has been developed to allow individuals the opportunity to “experience” driving within ecologically valid driving environments (e.g. residential, commercial, highway and school zones). The virtual reality simulator offers a safe and secure alternative for individuals to experience driving with adaptive equipment before participating in a traditional driver retraining program, which typically focuses on actual behind the wheel experiences. Individuals have the opportunity to relearn how to control an automobile using the VR simulator and build confidence in their ability to drive again following their SCI.

David S. Tulsky, PhD, an associate professor in the Department of Physical Medicine and Rehabilitation (PM&R) at UMDNJ-New Jersey Medical School, heads the Spinal Cord Injury Research Laboratory at Kessler Medical Rehabilitation Research and Education Corporation and serves as the director of the Northern New Jersey Spinal Cord Injury System (NNJSCIS). Dr. Tulsky earned a doctorate from the University of Illinois at Chicago in clinical psychology with a subspecialty in research methods and measurement. His current interests include the measurement of quality of life, intelligence and memory testing, and the prevention of secondary conditions after experiencing a spinal cord injury. Steven Kirshblum, MD, graduated from the University of Health Sciences/Chicago Medical School and completed training in PM&R at Mt. Sinai Medical Center. He has been the director of the Spinal Cord Injury Program and Ventilator Dependent Program at Kessler Institute for Rehabilitation since 1994. Dr. Kirshblum is also an associate professor in the Department of Physical Medicine and Rehabilitation at NJMS.