More Than Paralysis: The Secondary Complications of Spinal Cord Injury

Trevor Dyson-Hudson, MD, director, Center for Spinal Cord Injury Research, and co-director, Spinal Cord Injury Model System Center, Kessler Foundation

Trevor Dyson-Hudson, MD

Spinal cord injury can be devasting to those who go through it. But perhaps even more debilitating than the paralysis and loss of function can be the many effects that go unseen.

These secondary medical complications can include pain and other challenges. In fact, Trevor Dyson-Hudson, MD, director, Center for Spinal Cord Injury Research, and co-director, Spinal Cord Injury Model System Center, Kessler Foundation, told NeurologyLive that sometimes, despite not being able to feel certain limbs, patients with spinal cord injury have expressed that, if given the choice, they’d prefer to lose this secondary complication over regaining use of their limbs.

Dyson-Hudson, who has experienced a spinal cord injury and is wheelchair-bound himself, spoke to the work that he and colleagues are doing to help alleviate some of these secondary complications for patients, as well as the benefits that model systems within spinal cord injury can offer these individuals. He explained that the research, though in its early stages, also includes combination work with magnetic resonance imaging (MRI) work to explore if there are brain changes occurring during these complications, as well as how to address upper limb pain which occurs for patients who are wheelchair-bound.

NeurologyLive: Could you share your personal experience with spinal cord injury?

Trevor Dyson-Hudson, MD: I was injured approximately 27 years ago—it's hard to believe that it's been that long—when I was a medical student. At the time, I was just starting my fourth year and I had this injury. I had worked with people with spinal cord injury through my rehabilitation rotation but having the injury itself was an exposure that you can't describe. It exposed me to a whole new world. After this injury, you're thrown into this world where you have no idea. You feel isolated. You feel alone.

I did my rehabilitation at Mount Sinai in New York City, and at that hospital, then, one of my doctors introduced me to the spinal cord injury model system and for me that suddenly gave me this comfort that I wasn't alone. That there actually were these rehabilitation and medical professionals who were dedicated to caring for people with spinal cord injury. That there was a team and resources there to help me through the injury, and that was a great comfort.

As far as the injury itself, it certainly gives me a unique perspective when we talk about some of the medical complications. I certainly live them or run the risk of many of them, whether it be things like pressure injuries—we hear them called pressure sores—or others. I know the impact that those can have on a person's life. I know what it's like to be non-compliant, to have to try to follow through some of the therapies that we're supposed to do, and the challenges that you face on these medications. In terms of just the changes within my own body that happened, whether we talk about the autonomic nervous system or autonomic dysfunction—it's like their nervous system goes haywire. People, a lot of times, know about the sensory aspect of spinal cord injury and the motor aspect. I can't feel, I can't walk, I can't move my arms. But they don't realize that with that is your autonomic nervous system too, which affects your bowels, your bladder, your blood pressure. People with spinal cord injury are dealing with low blood pressure, high blood pressure, periodic high blood pressure in response to pain their body may feel, and that's often difficult for people to understand because it's “You can't feel, how do you feel pain?” and it's like, “I may not feel pain, but my body feels pain.” For a listener who's a neurologist, they understand completely what I'm talking about in the sense that the autonomic nervous system is what controls your cardiovascular system and so you have you know these blood pressure changes. With pain what can happen is you your body feels it and there's a fight or flight response which causes your blood pressure to go up. Then there are all the consequences of that.

One of the other things as a person with spinal cord injury that I appreciate looking back was all the other resources that being part of a model system center, or a center that specializes in the care of people with spinal cord injury, offers. Whether it be the right wheelchair because that wheelchair just gives me the mobility that I need without dealing with some of the challenges that having an improper wheelchair would provide, or otherwise. It made connections for me in terms of returning back to school, so it helped with my future employment. While rehabilitation and the physical therapy aspect of it and the occupational therapy aspect of it is so important, one of the most valuable things I got from my rehabilitation was the connections that I made in terms of getting back on with my life. So even though I have a spinal cord injury, I'm still going on with my life. I still can go back to work, I can still have a family, I can still have children. So even though I had a spinal cord injury, I had paralysis, I couldn't feel—I had all these challenges—I still could live as normal a life as possible.

What research is Kessler Foundation conducting regarding spinal cord injury?

In terms of the secondary medical complications and the areas of research that we're looking at—I mentioned pain. For many people, pain can be even more significant than the paralysis that goes along with the injury, which is strange to say. There's even research that suggests that if people were given the choice, they'd rather get rid of the pain than be able to walk again—which is a pretty profound statement. But if you think about it, pain is relentless, it's constantly there. The neuropathic pain which people can often relate to it, that burning tingling pain that you get when you fall asleep on your arm or something, imagine that throughout your body. It can be very confusing for people with spinal cord injury because they can't feel, yet they feel like their toes are burning. It's equivalent to the term phantom limb pain.

Jeanna Zanca, PhD, is doing research in the areas of nonpharmacological treatment such as mind-body therapies—what can we give the individual, what can we teach or train the individual to do, that can help them address the pain? One of the things she's been looking at is some mind-based therapies, cognitive behavioral therapy, meditation—I'm doing a very basic overview of this—but she's looking at ways that the individual can try to address them.

Many of our studies are very early stage, so we haven't had a chance to truly understand or see their effectiveness. We're trying to combine some of that research with the MRI Center, looking at the changes that happen in the brain to see whether we can actually do real-time MRI while having somebody do some sort of mind-body therapy. So while they're trying to decrease the pain through whatever technique they use, to see if there actually are changes in the brain that are happening, or to see through some sort of feedback, they might actually be able to control it while looking at a visual image and seeing activity in their brain and seeing changes. They could use that as a biofeedback method. We're taking advantage of all the resources that we have here.

What research are you currently involved in with patients with spinal cord injury?

One of my personal areas of interest is upper limb pain and overuse injuries, so people with spinal cord injury who use manual wheelchairs and are pushing them throughout the day non-stop. Over time, they can develop overuse injuries. They're also reaching environments that are designed for able-bodied people, so that can cause overuse, also transferring their body weight, all these activities over time can develop shoulder pain. That can it be a very debilitating condition in itself because if you think about it, you have somebody who's totally reliant on their upper limbs and now they're losing that function. It's equivalent to having an injury of a higher neurological level, so you take these incredibly independent people and now they're becoming more debilitated, and because of that, they become very depressed. Surgery is not necessarily a good option for them because after surgery you're supposed to rest your upper limbs, but for somebody who's relying on their upper limb, it's very difficult to do and it puts an incredible strain on their loved ones if they're providing assistance. There's a lot of negative consequences because of that decreased function.

We're looking at non-operative treatments for the management of shoulder pain. In the past, we have done some studies with acupuncture—I found that to be effective. We have started to look at some of the regenerative treatments such as platelet-rich plasma. More recently, we've looked at what's termed autologous micro-fragmented adipose tissue, in which we harvest fat from people (which people usually have plenty to give and it's their own fat, so people can't donate. I know a lot of people want to donate.). We take their fat and we process it and we break it down and the idea is to isolate the tissues, remove some of the waste products, and then inject that fat into the shoulder, into areas of damaged tendons, and the idea is it provides cushioning and is supposed to, theoretically, provide this scaffolding. Within the fat itself may be growth factors that encourage healing, and so that's something we've started more recently in the past 2 years.

We've actually had excellent results with that. We've had some people respond, some people don't—no treatment is 100%, but the majority of people we've seen really good success. Some people have responded fantastically. These are people who have tried other treatments, so they are what we call “treatment failures,” and for those individuals, they've been told they should get shoulder surgery, they don't want to do shoulder surgery, and so they're trying this to see if this will help, and we're seeing fantastic results. It boils down to how people feel and how they function, and they feel great and they function great. We see improvements in their range of motion and other things like that, such as shoulder pain.

I've done collaborative studies with mobility and rehabilitation engineering, as well. Gail Forrest, PhD, and I have done some collaborative research looking at some different types of medications, seeing if we can use them to supplement or augment some of the training activities that we're doing. We tried to address neurological complications, respiratory complications, cardiovascular complications, and some of the more common causes either of death and/or disability in this population.

Transcript edited for clarity.