SpinalCure speaks to Dr Camila Quel de Oliveira, the lead researcher on a study testing the feasibility of robotics-assisted game-based arm and hand rehabilitation for people with spinal cord injury (SCI). This study is funded by SpinalCure, due to its potential to greatly improve rehabilitation outcomes and to help improve outcomes when combined with other interventions such as neurostimulation.
Research participants are currently being sought: to enquire please email [email protected]
How did you become interested in research relating to spinal cord injuries?
I’m a physiotherapist and I graduated in Brazil. I decided to specialize in people with neurological conditions. As part of my training, I spent a lot of time working with people with SCI. I was always very interested in SCI because one injury is not like the other. It’s a very complex condition, and so, very interesting to rehabilitate.
As part of my training, I did a research component looking at the use of stem cells to treat SCIs —that was when I started to study the spinal cord in more depth. The research in animals back then (in 2006) seemed quite promising, unfortunately, the research around stem cells didn’t progress as fast as we were hoping.
Through further readings, I found that there were new treatments starting to arise to improve someone’s movement after a SCI and came across activity-based therapies. This novel treatment strategy, developed in the U.S, used exercises to stimulate the paralysed areas and promote recovery. This was a very new concept back in the early 2000s.
I decided I’d like to do my PhD in this area. I came to Australia to do it as I was lucky to receive a Scholarship from Spinal Cord injuries Australia (SCIA) in association with SpinalCure.
Can you tell me a bit about your work on the NeuroMoves program?
The overall aim of my PhD was to investigate the benefits of activity-based therapy delivered in a community setting.
At the time, the type of intervention delivered at NeuroMoves was new to Australia. It was already being used the US with some success, and some Australians were travelling to the US or Europe to receive this type of therapy. However, the research supporting the effects of those programs was weak and understandably there was a lot of resistance to using it from rehabilitation professionals here in Australia.
So SCIA and SpinalCure wanted to investigate further the potential effects of the activity-based therapy program delivered at NeuroMoves (then known as Walk On) for people with SCI.
My research helped to identify that gains in mobility, independence and balance were possible after participating in NeuroMoves, and the timeframe in which those changes occurred more frequently. It also showed that participants were very satisfied with the program.
After I finished my PhD in 2018, I started working at University of Technology Sydney, where they had recently acquired the robotic equipment that I am using in my current project. I saw that as a good opportunity to continue my research in rehabilitation strategies for people with SCI.
And how did you become interested in robotics for rehabilitation?
Exercise to bring about recovery of paralysed or partially-paralysed areas requires hands-on, high-dosage, intense exercise—this is necessary, but not always feasible. Some protocols recommend two to five hours a day, four to five days per week.
In research, we often have an ideal setting to deliver high-dosage therapies. This may not be the reality in hospitals or the community, so it’s way harder to achieve those goals outside research settings.
Robotics brings the possibility of doing high-dosage exercises with lots of repetitions with less work from the therapist. So, it might maximise therapy time as well as recovery.
Why did you decide to focus on hand and arm function for your study?
A survey conducted in America by Dr Kim Anderson with more than 300 people found that the number one priority of people with tetraplegia (also known as quadriplegia) is to recover or improve their hand function.
Improving hand function has the potential to increase independence and help people return to pre-injury activities. It can also help people participate more in their community and ultimately, lead to greater quality of life.
The gaming component gives the user real-time feedback, and can make training more enjoyable, facilitating high-repetition exercise. When you’re playing a game, you don’t realize how much you’re moving. You’re more focused on the challenge of game and not so focused on what your body is doing.
What is the research process needed to bring something like robotics into practice in the Australian community?
First, we need to check if an intervention is safe and feasible. The safety of using robotics in people with neurological conditions has already been shown by previous studies.
The feasibility includes understanding users’ needs and perspectives. Before using new rehabilitation technologies, it is important to understand if it works, but it is just as important to find out what people expect, if they would be keen to have it and their opinions about it. Because, even if a treatment works, if people don’t want to do it, it’s not worth putting into clinical practice.
This is what my study is investigating. People are doing 10 sessions and then we get their perspectives and reported changes (or no changes) after using game-based robotic devices.
The robotic devices are very expensive to buy, so it is important to check if participants would use this type of rehabilitation and their impressions about it.
The second stage would be to compare this robotic intervention with conventional treatments for hands and arms after SCI and see if game-based robotics can achieve greater, lesser or the same results.
If we find that game-based robotics can achieve greater or similar results to conventional treatments, then we could recommend it to be used in clinical settings. Another important stage is to assess the costs versus the-benefits.
So, there’s a lot to understand before we can make evidence-based recommendations on the use of game-based robotics for people with SCI.
And where are you with the study to date?
Unfortunately, with COVID, the University put a hold on most face-to-face research until almost the end of last year.
So, we restarted recruitment in February 2021. It then was on hold again because of the recent COVID outbreak in NSW. It’s going way slower than I expected. But we don’t want to put anyone at risk. So far, two out of the 20 people that we want to recruit have completed the protocol.
We’re now recruiting more participants. To get involved they can contact Esminio Rivera at [email protected]
Are there any other areas, drugs or technologies that you think are really promising in changing lives for people with spinal cord injury?
In the early 2000s, stem cells were looking very promising as a strategy to promote recovery after SCI, however this type of intervention is still being refined and is not largely available outside research settings. So, I believe the best next thing that we have is neurostimulation.
Studies with neurostimulation of the spinal cord have shown improvement in walking, standing, hand function, bowel, bladder and temperature control.
It’s very pleasing to see neurostimulation protocols being investigated in Australia with the support of SpinalCure.
Although the results of the previous neurostimulation studies are promising, they are quite small in numbers of participants. Hence, we still require studies on a larger scale, which is the aim of the studies that will be conducted in Australia.
It’s good to see that this technology is going to become available in Australia, even if at a research level, so people can have access to it. Neurostimulation seems to have great potential to change the outcomes of people living with SCI.
The studies published so far, mostly from America show that you need a combination of neurostimulation and exercise. So, maybe robotics could help with the exercise aspect of that, as it can provide high dosage training.
Obviously for people with an SCI, the progress in research can seem slow.
Yes, research assessing the safety and effects of new interventions requires a rigorous systematic process that is very time consuming. And I understand that it can get quite frustrating for the community waiting for the results.
There are a lot of steps to make to be sure that research-based recommendations are safe, valid, true and accurate.
You’ve done a lot of work now with people with spinal cord injuries. Is there anything you’ve learned that really surprised you?
A lesson that I’ve learned from people with SCI is never make assumptions, never box someone just based on their level or severity of injury. People are not the same and do not respond equally to treatments (that’s why research is so important).
Two people with very similar injuries can have different levels of independence and it’s not necessarily the person that has more severe injury who is the one that is going to have a lesser quality of life.
As therapists and researchers, we always must keep our minds open, we never know how far someone can improve. People often have much more potential than we might think.
Read more about Dr Quel de Oliveiria’s robotics and rehabilitation research funded by SpinalCure.
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