Annie Palermo (PT, DPT, PhD) completed her clinical (2015) and academic doctorates (2020) in Physical Therapy at the University of Miami and the Miami Project to Cure Paralysis. She has clinical experience in acute care and has research experience in the field of Spinal Cord Injury including work in respiratory function, seated balance, blood pressure control, and physio-based interventions after or in conjunction with cell-based and neuromodulatory therapies. Annie is currently involved with trials assessing the impact of abdominal functional electrical stimulation on blood pressure, respiration, and bowel function post-SCI. She plans to further investigate the effect of inspiratory muscle training and abdominal functional electrical stimulation on these factors and seated balance.
Bowel complications, resulting from impaired bowel function, are common for people living with a spinal cord injury (SCI). As a result, people with a SCI have high rates of bowel related illness, even compared with those with other neurological disorders. This includes high rates of abdominal pain, constipation, faecal incontinence and bloating. These problems lower the quality of life of people with a SCI and place a financial burden on the health system. A treatment that improves bowel function for people with a SCI should reduce illness, improve quality of life and lead to a large cost saving for health care providers.
Bowel problems have traditionally been managed with manual and pharmacological interventions, such as digital rectal stimulation, enemas, and suppositories. These solutions are usually only partially effective, highlighting the need for improved interventions. The abdominal muscles are one of the major muscle groups used during defecation. Training the abdominal muscles should improve bowel function by increasing abdominal pressure. During our previous Abdominal FES research with people with a SCI, we observed that Abdominal FES appeared to lead to more consistent and effective bowel motion. However, this evidence remains anecdotal. As such, we are going to undertake a large randomised controlled trial to investigate the effectiveness of Abdominal FES to improve the bowel function of people with a SCI. This study will make use of a novel measurement system (SmartPill, Medtronic) that can be swallowed to measure whole gut and colonic transit time. We will also assess whether Abdominal FES can change constipation-related quality of life and the use of laxatives and manual procedures, as well as the frequency of defecation and the time taken. A positive outcome from this study is likely to lead to the rapid clinical translation of this technology for people living with a SCI.
Spinal cord injury (SCI) results in the loss of function to not only voluntary motor control, but also to the regulatory systems that control bodily processes. Orthostatic (postural) hypotension (OH) is a common clinical feature in SCI patients, affecting up to 73% of patients with cervical spine and upper thoracic spine injuries during mobilisation and postural changes. This often results in symptoms of dizziness, light-headedness, fatigue and confusion, in turn limiting individual participation in physical rehabilitation and restricting progress towards regaining function and independence.
Therapeutic interventions are centred around ameliorating symptoms of OH; however, options for patients remain limited. Non-pharmacological treatments have had little success at treating hypotension in the long-term, while pharmacological interventions are used only when necessary as they may contribute to hypertension and even worsen episodes of autonomic dysreflexia, a life-threatening condition.
Functional Electrical Stimulation (FES) is one of the only interventions that has been shown to display some benefit in improving OH. Recently, stimulation of the lower limbs has been shown to acutely increase blood pressure in patients with SCI. Our recent projects have involved the use of FES applied over the abdominal muscles, termed abdominal FES, for SCI patients at risk of respiratory complications with promising results. As this same population is at risk of orthostatic hypotension, this study aims to determine whether abdominal stimulation can also be used to help this condition.
Based on our previous research, we believe that abdominal FES will increase blood pressure acutely during an orthostatic challenge in individuals with acute spinal cord injury, allowing for a longer time spent in a standing position. This will facilitate more effective rehabilitation, therefore improving quality of life and decreasing associated medical complications.
While tetraplegia is often characterized by paralysis of all four limbs, paralysis also affects the major respiratory muscles, namely the diaphragm and abdominal and intercostal muscles. This reduces respiratory function, with associated respiratory complications, such as pneumonia and atelectasis. Such complications are a leading cause of illness and death for the tetraplegic population. Up to 68% of patients with tetraplegia have a respiratory complication in the first 6 weeks (i.e. the acute stage) of injury. A reduction in respiratory complications in acute tetraplegia would decrease illness and death, reduce rehabilitation time, improve quality of life, and result in a large cost saving for global health systems.
Surface electrical stimulation of the abdominal muscles, termed Abdominal Functional Electrical Stimulation (FES), can contract the abdominal muscles, even when paralysed. We have shown that the repeated application of Abdominal FES improves the respiratory function of people with tetraplegia. However, while respiratory function is a predictor of respiratory complications in tetraplegia, evidence that Abdominal FES reduces respiratory complications is only anecdotal. We will undertake the first prospective, multi-centre, randomised placebo controlled trial, to determine whether Abdominal FES reduces respiratory complications in acute tetraplegia.
Definitive evidence of the effectiveness of Abdominal FES to reduce respiratory complications in tetraplegia will drive the rapid worldwide translation of this low cost and easily applied technology for this vulnerable patient group. This will decrease illness and death, reduce rehabilitation time, improve quality of life, and result in a large cost saving for global health systems.
This international collaboration brings together leading research and medical teams from: Neuroscience Research Australia, the Prince of Wales Hospital, and the Royal North Shore Hospital in Australia; The Indian Spinal Cord Injury Centre; Chang Mai University Hospital in Thailand and The Queen Elizabeth National Spinal Injuries Unit and the University of Glasgow in Scotland.
While tetraplegia is commonly associated with paralysis of all four limbs, paralysis also affects the major respiratory muscles, namely the diaphragm, abdominal and intercostal muscles. The reduction in respiratory function results in approximately 40% of tetraplegic patients requiring mechanical ventilation in the acute stage (first six weeks) of injury to support respiration. The use of mechanical ventilation increases lifelong morbidity and mortality, delays rehabilitation, results in longer hospital stays and costs the health care provider an additional $2,000 per patient per day.
Surface electrical stimulation of the abdominal muscles, termed Abdominal Functional Electrical Stimulation (FES), can contract the abdominal muscles, even when paralysed. We have shown that surface FES of the abdominal muscles, termed Abdominal FES, improves respiratory function in tetraplegia, and respiratory function is a known predictor of mechanical ventilation time. Dr McCaughey’s pilot work also shows that eight weeks of abdominal FES is a feasible method to reduce mechanical ventilation time in acute tetraplegia.
Despite these positive results, a lack of data from randomised control trials, and lack of a standard Abdominal FES protocol, has prevented this technology from being adopted as a standard clinical treatment.
This project will provide the first information on the effectiveness and cost-effectiveness of Abdominal FES to reduce mechanical ventilation duration in tetraplegia. In addition, it will provide detailed information about respiratory function and its impact on quality of life in tetraplegia.
This is an international collaboration brings together leading research and medical teams from: Neuroscience Research Australia, the Prince of Wales Hospital, Royal North Shore Hospital, Austin Health and Fiona Stanley Hospital in Australia; The Indian Spinal Cord Injury Centre and the Christian Medical College, Vellore, in India; The Queen Elizabeth National Spinal Injuries Unit and the University of Glasgow in Scotland; Middlemore Hospital in Auckland, New Zealand, and the University of Alberta and McMaster University in Canada.
To (1) compare energy expenditure during seated rest, standing, and prolonged bionic ambulation or bipedal ambulation in participants with spinal cord injury (SCI) and noninjured controls, respectively, and (2) test effects on postbionic ambulation glycemia in SCI. Work intensity during prolonged bionic ambulation for this bionic exoskeleton is below a threshold for cardiorespiratory conditioning but above seated rest and passive standing. Bionic ambulation metabolism is consistent with low RPE and unchanged fuel partitioning from seated rest. Bionic ambulation did not promote beneficial effects on glycemia in well-conditioned, euglycemic participants. These findings may differ in less fit individuals with SCI or those with impaired glucose tolerance. Observed trends favoring this benefit suggest they are worthy of testing.