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Sunday, 9 November 2014

UWA's Sarah Dunlop has spent 20 years researching spinal cord injury in the hope of helping the wheelchair-bound to recover at least some of the movement they lost after a devastating accident. Many of the victims are young men whose lives changed in an instant, and Western Australia - with its love of cars, sport and the great outdoors - has twice as many cases as any other State.

"People tend to think of paralysis solely in terms of ‘nothing' as a result of loss of movement, but it's much more complex," says Professor Sarah Dunlop who is researching neurotrauma leading to paralysis.

"We were born to move and loss of movement plus forced inactivity sets in train serious health complications.They range from cardiovascular disease to urinary tract infections, pain, depression and pressure areas where tissues starved of oxygen lead to necrosis and infection. That's how Christopher Reeve - who did so much to raise awareness of spinal injuries - eventually died."

Spinal cord injuries cost Australia $2 billion a year and the human cost is incalculable. Every year in Australia and New Zealand around 350 new cases are added to those whose lives have been tragically changed in an instant, generally by motor vehicle accidents, but also through surfing, diving, horse and dune riding and skylarking. "It's almost one a day," says Professor Dunlop, "There are about 11,000 people living with spinal cord injury in Australia. Adding another dimension is the tyranny of distance - because accidents can happen far from hospitals."

The UWA Professor in the School of Animal Biology is currently involved in leading the WA arm of a clinical trial exploring the use of moderate hypothermia in spinal injury cases. Immediate Cooling & Emergency Decompression (ICED) involves bringing the patient's body temperature down to 34 degrees, ideally en route to hospital. This is achieved by administering an intravenous icy saltwater solution that reduces swelling and slows metabolic activity in the damaged spinal cord.

"In cases of spinal injury, some tissue will be lost immediately, but a substantial amount may remain and you need to get in early with moderate hypothermia to prevent the spread of damage that makes the injury worse. Dropping body temperature to 3 degrees below normal buys time to get the patient into hospital for emergency decompression to relieve pressure on the spinal cord. Cooling is a relatively simple thing that paramedics can perform on the way to the emergency department. The idea is to ‘stop the rot' and preserve as much tissue as possible to give patients the best possible chance for rehabilitation.

"A great example of the importance of emergency decompression is a young lady, Katie Ferguson, whom I met recently and who had a spinal cord injury while on holiday in Bolivia. She was in a bus en route to a major hospital with someone else on her tour who had been taken ill. The bus hit a speed bump, throwing Katie out of her seat. She immediately realised the seriousness of her injury and the bus driver called ahead. Katie was very lucky to be greeted at the hospital by a neurosurgeon who knew he had to operate within four hours, otherwise she would not walk again. Katie is now back in Australia undergoing rehabilitation and making great progress.

"In WA and elsewhere in Australia, it is often not possible to undertake complex surgery within four hours and that is why we need hypothermia to buy time. Indeed, four hours is the gold standard for treating ischaemic stroke, where, just like spinal cord injury, tissue continues to be lost after the initial infarct. So, if we treat stroke within that time frame, why not think the same way for spinal cord injury?"

Professor Dunlop says that a century ago, the survivor of a traumatic spinal cord injury would be lucky to survive. Today, life expectancy can be close to that of the able-bodied, and she believes it's vital to encourage those who have lost the use of limbs to participate in exercise regimes and social life.

In another area of research she is pursuing, she has seen first-hand the positive effects of intensive exercise regimes and while gains tend to be small, they are incremental. To advance this research, the UWA scientist was instrumental with a colleague in Victoria, Professor Mary Galea, in establishing SCIPA (Spinal Cord Injury Physical Activity), a bi-national, multi-centre series of randomised controlled trials focusing on ongoing exercise to optimise health and wellbeing.

"SCIPA focuses on people with severe injuries where, if any function can be regained, it will give the patient more independence," she explains.

"It's about getting people who've been flat on their backs upright in a harness and on a treadmill with therapists moving their legs. If there is enough circuitry below the level of the injury that still works, it can make a difference - some stepping movements can start to happen.

The SCIPA trials also include exercising at acute stages after injury using bed cycles with electrodes on the legs to keep the ‘engine' ticking and prevent loss of bone and muscle mass so that the patient is better prepared for rehabilitation."

She says teamwork is a vital component in an area of research such as this and funding from the National Health and Medical Research Council, the Victorian Government and the WA State Government's Neurotrauma Research Program (NRP), a local initiative funded by the Road Safety Council's Road Trauma Trust Account, has made a huge difference.

"Funding like this enables people to collaborate - often in ways which haven't happened before - and to try new approaches. For instance, my NRP funding of $400,000 enabled us to leverage a further $8 million in funding from other sources," she says. "Importantly, we've forged links between basic scientists such as myself and clinicians - and that it so important..." says the researcher.

"It's about first preserving as much tissue as you can and then driving neurological recovery in the circuitry that remains intact, as well as using exercise to reduce the impact of those secondary complications that come with a loss of movement.

"Once discharged people with spinal cord injuries experience many barriers to doing exercises, so SCIPA is also training trainers in gyms to make exercise safe and increase participation."

Working in the Shenton Park gym with a young man who clearly relished the exercise sessions spurs her commitment to this research.

"The first time we got him upright on that treadmill he was elated. Of course it's expensive: a team of therapists, one on each leg, one behind, one operating the hoist. He's upright, three times a week for 12 weeks. We've watched his skin colour change, we've seen him smile for the first time in a long while and he's lost six kilos just from doing exercise."

The NRP is the longest standing program administered by the UWA-affiliated Harry Perkins Institute of Medical Research. In addition to clinical research, the NRP also supports laboratory-based studies in brain and spinal cord injury.

The enormous human cost of spinal cord injury underscores the need for research with potential to deliver better outcomes for patients. Thanks to the generous funding provided by the WA State Government, the NRP has been able to support Professor Dunlop's work, which is one impressive example of how neurotrauma research is being translated from the laboratory to clinical trials and out into the community to improve lives.

The NRP warmly welcomes private donations and sponsorship, which will ensure continuity and expansion of the program in years to come.

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