Royal Society Conference: Trauma recovery: new science and technology for mental and physical health

Part of the Royal Society conference series Breakthrough science and technologies: Transforming our future

Read the full report here.

On 4 March 2020, the Royal Society held an international conference in partnership with the Invictus Games Foundation to explore recent innovations in the field of trauma science and recovery. This is an area of vital concern in which new technologies and treatments have the real potential to improve the lives of those affected by trauma in the very near future. The meeting brought together leading experts from industry, academia, the military, healthcare and the wider scientific community, as well as those who have experienced trauma.

The programme was shaped by Professor Russell Foster CBE FRS (University of Oxford), Professor Jackie Hunter CBE (BenevolentAI) and Sir Simon Wessely FMedSci (King’s College London). The day focused on two broad themes: our increased understanding of the human biology of mental and physical health following trauma, and the application of innovative new technologies and interactions with industry to help individuals adapt to life-changing injuries. At a private reception following the conference, speakers gave interactive demonstrations – from virtual reality environments used to treat mental health disorders to best-in-class prosthetics – to guests including Prince Harry, Duke of Sussex and patron of the Invictus Games Foundation.

Speakers explored a range of developments, from the results of large-scale cohort studies to robotics for rehabilitation and direct neural control of prosthetics. Key topics included:

• The effects of trauma on mental and physical health
• Technology to rehabilitate and recovery from mental and physical trauma
• Critical areas of scientific focus to drive forward innovations

Key themes

• Technological and healthcare developments for trauma recovery within the military bring significant benefit to the wider civilian population.
• Recent neural science advances are leading to greater control of prosthetics and freedom for amputees.
• Virtual Reality Exposure Therapy is an incredibly powerful tool in the treatment of mental health disorders. Greater investment in VR by technology companies has led to accelerated innovation in this space.
• Traumatic Brain Injury and Post-Traumatic Stress Disorder share symptoms and are often misdiagnosed. Greater investment and research are needed to diagnose and treat the conditions correctly and efficiently.
• Sleep is an overlooked and critical factor in the recovery of mental health disorders caused by trauma. New treatments and initiatives can help individuals with visual impairments and patients on acute trauma wards to regulate their sleep and regain emotional and physiological health.
• While there is great momentum and funding to develop new treatments during times of conflict, there is a need to maintain this in times of peace so that we are better placed to help veterans in the future.

Summary of talks

The ADVANCE Study (ArmeD SerVices TrAuma RehabilitatioN OutComE) is the first prospective study to investigate the long-term physical and psychosocial outcomes of battlefield casualties related to recent armed conflict. In the opening keynote, Dr Christopher Boos, Poole Hospital NHS Foundation Trust, described the initial findings. While preliminary, the results demonstrate the link between combat-related traumatic injury and increased risk of cardiovascular disease, with the markers of risk being highest in those with more than one amputation. In a second keynote, Afghanistan veteran Dave Henson MBE offered his personal perspective of recovering from war: while rehabilitating following a bilateral amputation, he found solace in running using his prosthetic legs, and competed in international competitions including the inaugural Invictus Games and the Rio Paralympics in 2016. He argued that, just as warfare has been optimised, so should recovery. Dave applied the principles of war to his rehabilitation – from selection and maintenance of the aim, to concentration of force and long-term sustainability.

New treatments for sleep and mental health disorders

Professor Russell Foster explained how traumatic injury to the eyes can profoundly affect sleep and disrupt circadian rhythm, influencing a person’s emotional, cognitive and physiological health as they become ‘out of sync’ with normal routines and socially isolated. Yet there is hope: his work has shown that in addition to the rods and cones that provide us with our sense of vision, there is a third group of light sensitive cells in the eye called photosensitive retinal ganglion cells (pRGCs) which regulate our circadian rhythms and set the body clock to the outside world. This understanding is providing two treatment options: (i) Eye damage that renders an individual visually bind, due to the loss of rods and cones, may preserve the pRGCs. In such cases, appropriate light treatments can be used to restore a sense of time; (ii) Based upon an understanding of how the pRGCs regulate the circadian system, drugs are being developed that can “fool” the body clock that it has seen light. In individuals who have lost their eyes, these new drugs will be used to restore sleep/wake timing.

Sleep is critical for normal brain function including mood, memory and metabolism. This makes sleep a key tool for recovery after a physical or mental health problem – one that can be exploited. Dr Kirstie Anderson, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, emphasised that it is especially important to protect sleep in hospital wards where patients are particularly vulnerable to mental health problems, such as the acute trauma ward. The SleepWell pilot study which uses Cognitive Behavioural Therapy for insomnia (CBTi) had a major impact upon insomnia, including a 23% decrease in use of hypnotics and a decrease in mental health states such as deliberate self-harm.

Major General (Rtd) Nick Caplin, Blind Veterans UK, expanded on the devastating physical and mental effects of sight loss. Blind Veterans UK researches factors to maintain and improve quality of health and social inclusion, while accelerating innovation. Three key areas of focus of their research are sleep, traumatic brain injury (TBI), and the development of autonomous vehicles for disabled individuals, 98% of blind veterans want to drive again and regain their independence, and this is acting as a major initiative for new autonomous vehicles. In the area of sleep, 80% of veterans report poor sleep and shortened sleep (average ~5.7 hours) along with significant poor health and a 41% risk of mental health disorders. New treatment options to improve sleep are being developed for the veterans. It was stressed that this knowledge and new treatment options will not only benefit blind veterans today and tomorrow but inform health and wellbeing in the broader blind population.

Virtual Reality (VR) can help to deliver effective psychological interventions fast. Mental health disorders are very common, but far too few people receive the best treatments. Professor Daniel Freeman, University of Oxford, posited that delivering automated treatments in VR can help provide the best possible evidence-based psychological treatments to large numbers of individuals – all within a safe virtual environment. Professor Barbara Rothbaum, Emory Healthcare Veterans Program, discussed VR Exposure Therapy (VRE) for PTSD. VRE combines Prolonged Exposure Therapy, a kind of Cognitive Behaviour Therapy (CBT) in which patients recount their experience aloud, with a VR environment mimicking their description. VRE was found to be more effective than Prolonged Exposure Therapy alone. Two novel recommendations were also introduced. The efficacy of VRE can be increased by combining it with cognitive enhancers, such as the antibiotic D-Cycloserine or MDMA. Furthermore, providing Exposure Therapy within hours of trauma exposure could halve the rate of PTSD.

Recovery from physical injuries

TBI arises as a result of a physical injury to the brain and dramatically affects the lives of the patient and the people around them, as well as the economy. Professor Melinda Fitzgerald, Curtin University and the Perron Institute for Neurological and Translational Science in Western Australia, emphasised the real clinical need in this area: patient outcomes have not improved in the last decade. The Australian Mission for TBI presents a unified approach across Australia and has received 50 million AUD of federal funding over 10 years. It aims to identify predictors of poor outcome and recovery following TBI then develop feasible interventions to improve lives.

Physical rehabilitation following neurological damage can be challenging when patients are weakened and motivation runs dry. Dr Anders Sørensen, University of Southern Denmark, introduced RoboTrainer, a simple, low cost training robot that allows trauma victims to complete rehabilitative training in clinics or even in their own homes. By using the RoboTrainer, patients with neurological damage, but who were considered not to be suitable for further rehabilitation, experienced very significant functional improvements. In addition to this, recent research has shown potential for neural recovery in both animals and people with Spinal Cord Injury (SCI). Professor Jane Burridge presented work by the University of Southampton that combines Functional Electrical Stimulation (FES) with a cycling ergometer. This stimulates leg muscles on alternate revolutions only, meaning that patients drive the pedals voluntarily on alternate pushes, motivated to see their bike go faster on a screen. Using voluntary effort opposed to FES alone helps to achieve greater neuroplasticity – the ability of a brain to form and reorganise synaptic connections, especially when learning or following injury.

Indeed, there is now scope to turn direct neural interface therapies – using electronic devices that interact with the nervous system – into a clinical reality. Neural interfaces transfer data from software to biology. However, they must also interpret the information coming back from the nervous system in a bi-directional connection to understand the device’s clinical effect. This has, so far, been clinically elusive. Dr Oliver Armitage presented pioneering work by BIOS that uses AI to continually decode and encode neural information on small-scale devices. This is bringing neural recording and stimulation to the clinic, with applications in prosthetic control and SCI amongst other therapies.

Ottobock is a leader in human mobility, from prosthetics to orthotics and exoskeletons. Dr Andreas Goppelt, Ottobock, presented advanced devices that use artificial intelligence in their controls. For the first time, this allows patients to intuitively move their artificial limbs and lead a more active and independent lifestyle. The expectation is that very many amputees will be able to maintain high levels of activity through to old age, something that seemed to be out of reach of most. Professor Anthony Bull, Imperial College London, presented research into biomechanics that seeks to understand why amputation is associated with an increased likelihood of osteoarthritis and what can be done to mitigate against damage. Solutions include countering the high metabolic cost of walking with a prosthetic using powered prostheses, and tackling increased loading and higher incidence of osteoarthritis via activity limits that signal when bone needs time to repair.

Closing the conference, a panel discussion led by Sir Simon Wessely comprised experts from across the military, healthcare and academia: Air Commodore Rich Withnall QHS, UK Defence Medical Services; Professor Barbara Rothbaum, Emory Healthcare Veterans Program; Wing Commander Marcus Stow, JHubMed; Professor Jane Burridge, University of Southampton; Alexandra Crick, Salisbury NHS Trust. Questions probed into whether existing technology is being used as well as it could, where scientists should focus efforts, and how to increase the pace of innovation within large organisations such as universities and the NHS. Recurring themes were that:

• Innovation occurs rapidly during war, with effective international collaboration, but innovation stops when the war stops – to the loss of servicemen’s lives at the start of the next conflict.
• Innovating at pace requires agility that large organisations struggle with, partly due to the difficulty in predicting where innovation will lie to forecast budget needs. For public services it is hard to take the risk that a substantial investment may be a dead end: one solution is to establish an organisation as a corporate entity attached to the NHS, a hospital or university to supply flexible funding.
• The UK is good at getting to proof of principal but there is a shortcoming when it comes to exploitation. Organisations such as JHubMed help to achieve scale at pace.

This optimistic conference demonstrated examples of where the impact of trauma has been mitigated and blunted. However, while there have been successes, what has been learned in recent conflicts must not be forgotten: instead it must be taken forward and developed, maintaining the imperative and momentum to innovate in times of peace. Sectors must work in tandem to consider what can be achieved in the short and medium term – periods of years not decades – how to drive these achievements forward, and how to prioritise based on the experiences of those who have suffered traumatic injury in order to drive forward change for the better. When combined, science, engineering, motivation, courage and hope have the power to genuinely transform lives.

For a full list of speakers and information about the event, please visit the Royal Society’s website.

“While injury and trauma are facts of life, trauma need not be a life sentence. I’m convinced that the impossible is genuinely being transformed tangibly into the possible, and individuals who have suffered mental and physical injury can achieve the almost limitless potential of the human spirit. The Royal Society is committed to promoting science for the benefit of for humanity, and in collaboration with the Invictus Games Foundation has genuinely achieved this today.” - Professor Russell Foster CBE FRS, University of Oxford

“From an industry perspective, we are living in very exciting times in terms of the frontiers of what technology can do today, with truly practical applications not only in the research environment, but products that can be brought to the market.” – Dr Andreas Goppelt, Ottobock