20 Years of Discovery and Innovation at the National Center for Medical Rehabilitation Research (NCMRR)

This Spotlight continues to focus on the NCMRR as the Center commemorates its 20th anniversary.

The need for the Center and its research programs was clear in 1991, when it was established, and has only grown in the last two decades. For instance, the Centers for Disease Control and Prevention estimates that approximately:

• One in five Americans—about 53 million people—has a disability of some kind; 
• 33 million Americans have a disability that makes it difficult for them to carry out daily activities; some have challenges with everyday activities such as attending school or going to work and may need help with their daily care.
• 2.2 million people in the United States depend on a wheelchair for day-to-day tasks and mobility; and
• 6.5 million people use a cane, a walker, or crutches to assist with their mobility. 

A previous Spotlight explained the Center's establishment and early years; here we highlight the NCMRR's wide-ranging research programs and resulting advances in the field of medical rehabilitation. To learn more, select a link below:

• Research Programs
  • Behavioral Sciences and Rehabilitative Technology (BSRT) Program
  • Biological Sciences and Career Development (BSCD) Program
  • Pediatric Critical Care and Rehabilitation (PCCR) Program
  • Spinal Cord and Musculoskeletal Disorders and Assistive Devices (SMAD) Program
  • Traumatic Brain Injury (TBI) and Stroke Rehabilitation (TSR) Program
• Research Progress
• A Conversation with the NCMRR Director
• A Bright Future for the NCMRR

Research Programs

Much of the Center's initial activities aimed to further build medical rehabilitation as an innovative scientific field and to expand infrastructure for rehabilitation research. Later, the NCMRR expanded its activities to support basic and patient-oriented research within seven priority areas. With these areas defined and a Research Plan (PDF - 222 KB) in place, the NCMRR began building its own infrastructure by creating several distinct but interrelated research programs to address a broad portfolio of research on rehabilitation of physical disabilities across the lifespan. Although each program has its own specific focus area(s), many of the NCMRR's projects are multidisciplinary and cross multiple programs.

Behavioral Sciences and Rehabilitative Technology (BSRT) Program

The BSRT Program includes two broad rehabilitation research areas—behavioral research and rehabilitative technology research. The behavioral portion of the Program's portfolio is meant to address not only the unique behavioral and social challenges faced by those with disabilities, but also the direct effects, such as the cognitive symptoms related to stroke, of chronic and disabling conditions and the effects of behavioral and social influences on treatment outcomes. Some research topics within this area include, but are not limited to, studies of: how those with disabilities and their families shape social encounters to create desired outcomes; the effects of family-centered therapy versus individual-centered therapy; alternative methods for reducing pain among those going through rehabilitation; and understanding the behavioral and social risk factors associated with the onset and course of illness and health. 

The rehabilitative technology aspect of the Program's portfolio focuses on applied research. Projects within this Program area aim to enhance human-environment interactions by improving or restoring a person's ability to function in his or her environment. Such activities include not only cutting-edge innovations, but also approaches that can standardize measurement and outcomes reporting, which is critical for comparing interventions. Some research topics in this area include, but are not limited to, studies of: robotics for use in rehabilitation therapy; development of instrument systems to measure symptoms and rehabilitation progress; body-computer interface technologies; and improvements to wheelchairs. For more information on the BSRT Program, please visit the BSRT Program Web site.

Biological Sciences and Career Development (BSCD) Program

The BSCD Programsupports basic research on substrate responses to injury and on strategies to promote regeneration, recovery, plasticity, adaptation, and recovery. This type of research could include studies of: activity-mediated processes, such as treadmill training and constrained-use therapy for movement problems from stroke and other conditions; muscle and bone function, such as contractures and sarcopenia that result from chronic disuse of muscles; secondary conditions, such as pain, depression, and cardiovascular dysfunction; and genomic influences, meaning that slight differences in genetic code could influence response to injury and interventions.

Training and career development have been a top priority since the inception of NCMRR. The BSCD Program supports individual fellowships and national career development networks for rehabilitation clinicians. To further support rehabilitation researchers and attract researchers from allied fields, the Program hosts workshops to review NIH funding opportunities, peer review, grantsmanship, and networking. In addition, the Program works with other NIH Institutes to sponsor the Medical Rehabilitation Research Infrastructure Network to improve research capacity and information transfer. For more information on the BSCD Program, visit the BSCD Program Web site.

Pediatric Critical Care and Rehabilitation (PCCR) Program

The PCCR Program focuses on research topics related to longer term issues faced by children and young adults with disabling, complex, and special health care needs. Most of these patients have many years of life and development ahead of them and have either survived life-threatening critical illness or injury, or were born with disabling conditions. Program research addresses (but is not limited to): examining issues faced by children who have survived trauma or injury of diverse causes (including birth trauma); understanding critical illness or injury treatment and recovery; mapping the course of critical illness or disease, such as septic shock or organ failure, and patients' recovery from these conditions. The Program's research also addresses developmental and genetic disorders and chronic conditions that cause disabilities, such as cerebral palsy, a leading cause of disability in children.

A primary activity of the PCCR Program is support for the Collaborative Pediatric Critical Care Research Network (CPCCRN), a network of translational and clinical centers dedicated to advancing PCCR medicine by conducting clinical trials and other meaningful studies in pediatric and young adult populations. The Program also supports research on pediatric-appropriate instruments, technologies, methods/approaches, and other issues related to the care of children with special health care needs. Some examples of these types of efforts include the use of less-invasive respiratory support, technologically advanced monitoring of vital functions, and the translation of adult critical care science into meaningful strategies for infants and children. For more information on the PCCR Program, visit the PCCR Program Web site.

Spinal Cord and Musculoskeletal Disorders and Assistive Devices (SMAD) Program

The SMAD Programportfolio addresses multiple research areas, including spinal cord injury (SCI), musculoskeletal disorders, and the development, testing, and evaluation of assistive devices. Within the context of SCI, the Program supports translational and clinical research studies focused on rehabilitation of conditions associated with chronic complete and incomplete SCI across the lifespan. Some topics include: enhancing spinal cord circuitry; enabling beneficial plasticity; restoring movement; and understanding important SCI secondary conditions, such as pain, pressure ulcers, chronic bladder and bowel dysfunction, and symptoms related to autonomic dysreflexia (a life-threatening spike in blood pressure common in SCI patients). Research for SCI also includes musculoskeletal conditions, such as bone loss and muscle atrophy, and therapeutic interventions, such as exercise, to address symptoms and improve overall fitness and health. Other research addresses impairments in upper and lower limb function and motor control, gait, human motion, posture, and physical fitness and health. This research is important not only for those with musculoskeletal disabilities (with or without paralysis), but also for those with cerebral palsy, multiple sclerosis, spinal bifida, Parkinson's disease, stroke, low back pain, some joint disorders or conditions that result from arthritis and injury, and other conditions.

The SMAD Program also supports research related to assistive devices designed to restore or enhance a person's ability to function in his/her environment. Some examples include: improved seating and wheelchair technologies; tools and modeling approaches to understand, prevent, or detect specific conditions related to physical disabilities; new or improved devices or systems designed to enable accessibility or fitness for persons with physical disabilities; orthoses (orthopedic devices that support, align, prevent, or correct deformities or improve function); mobility monitors; and communication aids. The SMAD Program also has a focus on brain-computer or brain-machine interface technologies that may be clinically designed to improve brain control over functions, such as limb movement, or to control the use of assistive devices to improve function and quality of life. This portion of the SMAD Program portfolio complements the rehabilitative technology portion of the BSRT Program by also supporting the development, application, and evaluation of innovative technologies to improve function and capability. For more information on the SMAD Program, visit the SMAD Program Web site.

TBI and Stroke Rehabilitation (TSR) Program

The TSR Program supports research on two leading causes of acute and chronic disability in the United States. Many people are familiar with TBI from motor and bicycle accidents, falls, and sports injuries; but research now shows that even a concussion, which was once thought of as a minor injury, can have major effects on brain and body function. Although researchers understand significantly more about TBI and its mechanisms that they did when the NCMRR was established, much work remains to improve the outcomes of those affected by TBI. Ongoing studies include: refining clinical guidelines for the treatment of TBI immediately following the injury, and at different time periods after the injury; exploring the capabilities of cognitive therapy for improving outcomes after TBI; measuring impact experiences to determine levels of damage and the best way to detect damage; and understanding the link between TBI and secondary conditions, such as depression. Another project that is in its last year of funding is the NICHD TBI Clinical Trials Network, which relied on multiple centers using the same research protocols and interventions to enroll enough TBI patients to collect rich data and provide answers more quickly than individual centers could alone.

Stroke occurs when a blood clot or a break in a blood vessel interrupts blood flow to the brain; this lack of blood flow causes damage that can affect cognitive and motor abilities. Some of the projects within the TSR Program complement those supported by the SMAD Program, especially those that address issues related to recovering movement and mobility following stroke. Other ongoing areas of research within the stroke portion of the Program include studies of combinations of pharmacological, surgical, and physical therapies to improve stroke outcomes; the effect of compensatory training for unimpaired extremities; and measuring caregiver burden at different times post stroke. For more information on the TSR Program, please visit the TSR Program Web site.

Research Progress

The list below highlights some of the innovative projects and research advances supported by the NCMRR. This list is not meant to be comprehensive, but aims to help explain the breadth of the Center's research portfolio.

• NCMRR grantees, with support from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) and the Department of Veterans' Affairs, developed technology that detects brain signals and uses them to control assisted devices. This investigational system—called BrainGate2 —aims to help people with SCI, stroke, muscular dystrophy, amyotrophic lateral sclerosis, limb loss, or other conditions to restore their mobility and independence. By turning brain signals into useful commands for external devices, such as a standard computer desktop or other communication device, a powered wheelchair, or a prosthetic or robotic limb, the system components can turn thought into action. Recently reported findings related to BrainGate2 indicate that the interface provides repeatable, accurate, point-and-click control of a computer interface to an individual 1,000 days after implantation of this sensor.
• In studies of a surgical technique in which targeted muscles produce signals on the surface of the skin that can be measured and can be used to control prosthetic arms, Center grantees reported successful results. The item appeared in the Journal of the American Medical Association and followup studies are now underway.
• The Center supports a project at the University of California, Irvine, that focuses on robotics for rehabilitation therapy. This project, cofunded by NIBIB, included the development and testing of two robotic exoskeletons—Pneumatic Wilmington Exoskeleton (Pneu-WREX) and Biomimetic Orthosis for Neurorehabilitation of the Elbow and Shoulder (BONES)—for rehabilitation of upper extremities. A summary of the results of clinical testing of these exoskeletons will soon be published at http://biorobotics.eng.uci.edu/ ; videos of these devises in action are available at http://biorobotics.eng.uci.edu/videos .
• Many rehabilitation projects aim to improve motor function outcomes of stroke patients. Some NCMRR grantees sought to identify key biological substrates needed for improvements in mobility as a way to predict and maximize treatment outcomes. They found that the degree of injury to specific motor tracts predicts gains from treatment in stroke patients. Knowing the degree of injury could help therapists to select more targeted and effective treatments for these patients.
• While much research on Alzheimer disease focuses on memory, Center grantees are examining a lesser known aspect of the condition: its physical impacts. One recent study found that decreases in bone mineral density—a common feature of Alzheimer's—is actually related to the neurodegeneration that occurs in the brains of those with the disease. The finding suggests that some usual means of increasing bone density could be ineffective in certain Alzheimer patients.
• Physical pain—especially chronic pain in the lower back and the neck—is known to be associated with depression, which can make treatments less effective. A group of NCMRR grantees aimed to determine whether pain in other body regions led to the same likelihood of depression and poor treatment outcomes. They found that pain in other body regions was related to greater depressive symptoms and to poorer treatment outcomes, which suggests that patients should be screened for depression regardless of where in the body the pain occurs.
• In early 2011, the NIH provided 30 million dollars of funding over a five-year period to fund the Medical Rehabilitation Research Infrastructure Network. This network of centers provides researchers with access to new technologies, resources, and infrastructure to support rehabilitation research and advance the field. 
• Results from a recent Center-funded study, published in Pediatrics, found that after prolonged use of pain medications or opioids, critically ill children developed a tolerance to the medicine as well as an increased insensitivity to pain. The patients also experienced withdrawal symptoms after the medication was stopped.  The study further explored strategies for prevention of pain medicine tolerance based on the mechanisms of opioid tolerance and withdrawal.
• Another recent NCMRR-funded study surveyed parents following a child's death in the pediatric intensive care unit to understand the incidence and risk factors for "complicated grief" and responses to professional bereavement support. The study found that parents with high levels of complicated grief had symptoms, such as a sense of disbelief about the death, six months after the death. Prolonged periods of complicated grief are associated with poor mental and physical health and reduced quality of life. Better understanding of a parent's grief as well as risk factors, such as demographics and caregiving style, could enable those who are most vulnerable to get professional grief counseling.
• One recent Center grantee evaluated the varying functional status of children during hospitalization, including their motor or major cognitive deficits. The goal of the study was to develop a quantitative, rapid, reliable scale of functional status for children that is conceptually similar to activities of daily living. The research aimed to compare the scale's performance against a validated, more-extensive measure of adaptive behavior to support its use as a standard measure. The study showed that the functional status scale or FSS was, in fact, well suited for large studies.  
• Researchers supported by the NCMRR and the NIBIB are studying the Robotic Upper Extremity Repetitive Therapy (RUPERT) device, a portable robotic device that helps stroke patients retrain their muscles to perform basic tasks, such as picking up a cup. As the patient's abilities improve, the robot's computer adjusts the assistance given to the used by stroke patients to help retrain their muscles. The device offers multiple degrees of arm movement for the shoulder, elbow, and wrist. Studies showed that RUPERT offered a low-cost, safe, and easy-to-use robotic-device to assist patients and therapists in systematic therapy at home or in the clinic.
• A Center-supported study of brain-body interface recently reported results of restored movement through a "virtual" arm in people with long-standing tetraplegia (total or partial paralysis of all four limbs). Using a combination of functional electrical stimulation (FES), the coordinated electrical activation of multiple muscles, and intracortical signaling, a tetraplegic individual  was able to control a virtual, two-joint, dynamic arm in real time. The study showed the feasibility of combining these technologies to provide a high-performance, natural system for restoring arm and hand function in individuals with extensive paralysis.
• In collaboration with the NICHD Pregnancy and Perinatology Branch, the NCMRR and hosted a two-day workshop, Pregnancy in Women with Physical Disabilities to explore the unique challenges and the common features of women with physical disabilities who are or who plan to become pregnant and to develop a research agenda for further study of this topic. An Executive Summary from the workshop was recently published in Obstetrics & Gynecology.
• Several NCMRR-supported research studies and clinical trials have demonstrated progress in developing new therapeutic treatments, such as electrical stimulation. Some of these studies are testing new exercise training protocols designed to address specific conditions, such as bone loss after SCI,  muscle atrophy after SCI, instability and gait deficiencies, and low fitness and weakness, while other approaches aim to provide effective treatment alternatives for rehabilitation of the injured knee.
• The NCMRR has supported the development and testing of the High-Impact Telemetry (HIT) System, a device that continuously measures, records, and evaluates head impacts during wear. The system is being used in football helmets and headgear for other sports in which head impacts are likely. In addition to providing a rich set of data related to all impacts, including measures of acceleration, angle, G-force, etc., the HIT System can also alert sideline staff to any impacts that could have caused damage or that have a potentially injurious profile. Riddell®, a leading manufacturer of football helmets, is collaborating with the NCMRR grantee to make the technology available to football players at all levels. An article related to the HIT System recently appeared in Medicine and Science in Sports and Exercise.
• Center grantees are also actively involved in the Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, which examines the theory that hand restraint forces the patient to use the affected hand or arm thereby them regain its use. The EXCITE trial showed strong evidence that constraint-induced movement therapy (CIMT) can help stroke patients regain lost arm function. In the trial, stroke patients who had lost the use of their arm were given a unique two-week rehabilitation regimen that involved training the weakened hand and arm through repetitive exercises, while restricting the use of the unaffected hand and arm with a boxing glove-like mitt.
• Because many patients in the intensive care unit (ICU) may be unable to communicate their needs through speech, NCMRR grantees are studying methods of augmentative and alternative communication (AAC) for these patients. One study examined both high- and low-technology communication devices with voice output in patients of varying motor and cognitive abilities. The study showed positive results and has the potential to improve symptom communication and ease suffering to those in the ICU with speech limitations. The National Institute of Nursing Research is supporting a followup study of these results.
• Although many survivors of TBI experience depression, it was unclear whether TBI was really associated with depression, and the likelihood of poorer treatment and quality-of-life outcomes that are common with depression. NCMRR-supported researchers evaluated patients who were hospitalized for a TBI and found that more than one-half of the patients reported depression, compared to less than 10 percent in the general population. Depression was also associated with poorer health-related quality of life, lower cognitive functioning, aggression, anxiety, higher rate of suicide attempts, and increased health care costs. 

A Conversation with the NCMRR Director

In the previous Spotlight, Michael Weinrich, M.D., Director of the NCMRR, shared some of his thoughts about the Center's establishment and early years. In this continued conversation with Dr. Weinrich, he addresses NCMRR-supported research innovations.

Question: What do you view as the top five NCMRR-supported rehabilitation innovations over the last 20 years?
Dr. Weinrich: It is difficult to single out individual projects as there has been so much progress along so many different lines. I'd prefer to highlight areas of research and use individual projects as illustrative examples: 

1. Clinical Trials. Rehabilitation requires a firm evidence base, along with the rest of medical practice.  The gold standard of evidence is the randomized clinical trial (RCT). The NCMRR has supported a range of clinical research, including observational studies, pilot trials, planning grants, and of course, RCTs. All of these are essential components of a research program to produce the evidence that will lead to improved clinical practice. Major RCTs supported by the NCMRR include EXCITE (described above); Spinal Cord Injury Locomotor Trial (SCILT), a trial of body-weight supported treadmill training for partial SCI; Locomotor Experience Applied Post-Stroke (LEAPS) study, a trial of treadmill training to improve ambulation after stroke (in collaboration with National Institute of Neurological Diseases and Stroke); and CRISIS, a medication trial for severe infections in children. The NCMRR encourages investigators to use adaptive designs and include of genetic markers to increase the power of clinical trials when appropriate.
2. Improved Wheelchair Design. Wheelchairs remain an important assistive device for a wide spectrum of individuals with disabilities. The NCMRR has supported research to improve the functionality of wheelchairs. These investigations have resulted in commercially available, practical enhancements to wheelchairs, including two-speed gearing for moving up and down inclines or grades, omni-directional wheels to improve maneuverability, and enhanced controllers for safe navigation of powered chairs. Improved wheelchair biomechanics can reduce the incidence of overuse injuries and pain among wheelchair users. The NCMRR has supported both basic and applied research in this area.
3. Improved Prosthetic Design. The NCMRR has supported research on a range of problems in prosthetics. These investigations have resulted in the development of new and improved designs for: prosthetic ankle and knee joints; improved socket designs, including the development of variable geometry sockets; and new methods of controlling prostheses, including advanced myoelectrical control strategies that allow individuals with nearly complete loss of an arm to control an artificial arm naturally and with great precision. Ongoing research includes further development of strategies to facilitate neural control of prostheses and incorporation of sensory feedback into control systems.
4. Health Services Research. Effective rehabilitation requires that services be accessible and available to the individuals who need them. The NCMRR has supported research to evaluate and develop systems of care for individuals with disabilities. These efforts span a wide variety of areas including: testing different social interventions for children with cerebral palsy; determining availability and outcomes of care for amputees; developing a classification method for Medicare rehabilitation admissions to inpatient rehabilitation hospitals; surveying the incidence and treatment of depression after TBI; developing and testing of a strategy to decrease the incidence of complicated grief in parents after the loss of a child; and investigations into the roles of psychosocial approaches to promoting healthy behaviors and community and environmental supports in enhancing function and participation in daily activities.
5. Basic Research. The fundamental substrates underlying recovery from illness and injury are plasticity and adaptation. Plasticity, that is, change in the body's structure and physiology in reaction to injury, occurs in virtually all tissues of the body, from the central nervous system to bone. Adaptation includes the conscious and unconscious changes in strategies that individuals use to accomplish tasks in new ways to surmount their disabilities. The NCMRR has supported and continues to support research into both of these processes. Learning how to augment and improve the body's natural mechanisms of plasticity is central to developing more effective rehabilitation interventions. The Center has also supported research on the role of genetic factors in modulating recovery, and in developing novel combinations of therapeutics to improve outcomes. Understanding how individuals adapt to disabilities helps investigators design more effective assistive devices and community supports.

Question: What do you anticipate will be the most promising scientific opportunities down the road for the Center?
Dr. Weinrich: Promising scientific opportunities are best identified by the individuals working in the field. Some obvious opportunities exist for more effective community translation of rehabilitation interventions using modern telecommunications. Recent advances in robotics, battery and motor design, and signal processing may allow for the development of user-friendly powered assistive devices that will improve functional abilities for individuals in the community. The potential of stem cells and regenerative medicine is vast. We do not yet know how to accomplish effective repair of damage to the nervous system. 

Finally, an understanding of function at the cellular and subcellular level can yield astonishing advances. For example, a currently funded NIH project on macular degeneration and retinitis pigmentosa (the most common causes of acquired blindness in the United States) is developing a way to make the retinal ganglion cells that survive light sensitive. This research may be the beginning of an entirely new approach to vision rehabilitation for these individuals. 

In addition, the NCMRR is involved in the NICHD-wide Vision process. Many Vision themes, such as Plasticity and Diagnostics and Therapeutics, are integral to the Center's mission and research. The Institute's decisions related to the Vision process will undoubtedly influence future research plans at the NCMRR. 

A Bright Future for the NCMRR

During the last 20 years, the NCMRR has not only solidified medical rehabilitation as a scientifically robust and innovative field, but has also helped to advance understanding and management of various physical disabilities and conditions throughout the lifespan. The NCMRR remains a leader in supporting new discoveries, new technologies, and new approaches that improve the lives of those with physical disabilities and disabling conditions. By continuing to expand its research portfolio and the cadre of rehabilitation researchers and clinicians, the Center's future is both exciting and bright.

For more information, select one of the links below:

• National Center for Medical Rehabilitation Research (NCMRR)
  • Center Research Programs
    • BSRT Program
    • BSCD Program
      • Medical Rehabilitation Research Infrastructure Network
    • PCCR Program
      • Collaborative Pediatric Critical Care Research Network
    • SMAD Program
    • TSR Program
  • NCMRR Supported Research Projects for 2011
  • NCMRR Reports and Publications
  • Previous NICHD Spotlights Related to NCMRR:
    • NCMRR Celebrates Its 20th Anniversary
    • The Hidden Damage of TBI
  • NICHD News Releases on NCMRR-related Topics
  • National Advisory Board on Medical Rehabilitation Research (NABMRR)

Originally posted: June 13, 2011

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