Pain stalking at the Spine Research Institute

Millions of people suffer from back pain. Many of them lose time at work. Some will lose their livelihoods altogether. They try to push through it. They throw money at the problem with over-the-counter patches, pads, pills and creams. Many will be prescribed opioid painkillers, and some will become dependent on them. Bodies will become so attuned to pain that they will feel it even after the source has been resolved. One of the world’s most debilitating health issues, back pain remains a vexing problem for physicians. William Marras of the university’s Spine Research Institute is determined to change that. Through the convergence and community that can happen only at Ohio State, Marras has created an environment where researchers and practitioners from divergent fields of study apply their collective knowledge to solve what seems like an intractable problem.

article by Ross Bishoff, originally appeared in spring 2021 issue of Ohio State Alumni Magazine

Picture yourself standing in a large open space, surrounded by white walls adorned with giant projector screens and distinctive cameras that are staring into your very bones. On your back is a futuristic vest-style contraption loaded with computer sensors. Reflective markers that resemble tiny lightbulbs have been taped to your elbows, knees and ankles.

At the instruction of a researcher, you raise and lower your arms, bend at the waist, then side to side, and the dozens of cameras fire infrared lights that track precisely how every bone in your body is moving. You’re the person projected on the screens, and researchers capture images they’ll later use to create a computer model of your spine and how it moves.

Welcome to the motion capture lab at Ohio State’s Spine Research Institute (SRI). One of the largest of its kind, it is a critical tool its designer — William Marras, founder and executive director of SRI — and his team are using to unravel the mysteries of the human spine. 

This lab is a hive of groundbreaking research where, on a typical day in a more typical year, surgeons, physicians, industry leaders and even military personnel work with the lab’s bioengineers to create tools to help us move better and to cure the devastating ailment that is chronic lower back pain.

This revolutionary facility takes up the entire fifth floor of Baker Systems Engineering Building. And Marras, the visionary who developed this revolutionary lab? Well, his roots sprouted from a basketball court.

Decades ago, Marras, sidelined by a back injury, couldn’t understand why doctors didn’t have answers.

It was baffling. But not unique.

Even now, the spine is an enigma, and lower back pain is a pernicious condition that evades solutions, even as it afflicts more than 1.3 billion people worldwide. In a typical day, 17 million Americans live with it. Over the course of a lifetime, 8 in 10 of us will experience it.

The effects ripple far beyond the acute pain felt in our bodies. In the United States alone, workers are sidelined by lower back pain to the tune of 100,000 work days each year. It is among the top reasons opioids are prescribed.

“It’s just a tremendous problem — the most disabling condition known to mankind,” says Marras, a bioengineer and ergonomist by training. “It’s intriguing and challenging. It’s a puzzle I’ve spent my professional career trying to piece together.”

But he is not alone. Far from it.

A complex problem demands complex approaches. The Spine Research Institute exists through a close partnership between Ohio State’s College of Engineering and College of Medicine, bringing together engineers, surgeons, rehabilitation specialists, mathematic modelers and doctors.

Among those physicians is Tristan Weaver ’10 MD, director of Ohio State’s Spine Care Center. An anesthesiologist and interventional pain specialist, he experienced chronic lower back pain in his 20s. He was treated for sciatica, a common condition in which a pinched nerve causes pain that radiates from the lower back down through a leg.

“There’s a lot of fear with having that intensity of pain and with that fear comes anxiety,” Weaver says. “You’re wondering if you’re going to make it through a day at work. You’re wondering if this is how you’ll feel the rest of your life. That’s life-changing.”

‘A tremendously complex mechanism’
Consider the mechanical marvel that is the spine: 24 discs, 26 vertebrae, 220 muscles and 364 joints, stacked on top of each other, each performing a different job. When one component is faulty, that failure might register as pain. But which component is to blame?

Imaging tools including X-rays, MRIs and CT scans might reveal something that can be treated. But studies show those diagnostic methods uncover a definitive cause only about 15% of the time, Marras says.

In the other 85% of cases? Physicians turn to the best practices available, a series of intensifying trial-and-error treatments. A patient may be told to rest, alter diet and activity, do physical therapy exercises, take medication injections and, if those don’t work, have surgery, which is effective only half of the time. If pain becomes chronic, doctors may prescribe opioid painkillers for relief.

“The spine is a tremendously complicated system mechanically, as well as all the things that influence it, like your mind and your body,” Marras says. “The vast majority of the time, people don’t know what the problem is, and if you don’t know what the problem is, it’s hard to treat.”

Treating the problem quickly is imperative. Studies have shown that when pain lasts about 12 weeks, it moves from acute to chronic. Chronic pain is complex and hard to relieve because it is the result of enduring signals in the nervous system that can stay active for months and even years. This means that, even if the root cause of the pain is gone, a person’s brain believes it’s still there, so the sensation of pain remains.

“With chronic pain, the first thing is you get plasticity and chronic changes within the brain and spinal cord that aren’t necessarily fixable by just a needle or a surgery,” Weaver says. “To be able to reverse any of that, we have to treat all the different aspects of a person to see meaningful improvement.”

That’s why Marras’ approach to healing diverts from the norm by looking at the whole person, not just the physical body.

“There are biomechanical elements, biochemical elements, psychological elements, sociological elements, anxiety, depression and all of these things are rolled up into this thing we call a person,” Marras says. “That’s why everyone’s back pain is different.”

That’s also why Marras studies causal pathways, or everything that could lead to musculoskeletal pain or injuries. Using a model that accounts for biological, psychological and sociological factors, he strives to understand everything that feeds into a person’s individual pain. One interesting example: A study led by Marras in the early 2000s found that introverts are more likely than extroverts to experience back pain because they internalize stress and clench their muscles in response to it.

“I remember having my mind blown by that, and this guy at Ohio State was able to test and research it,” says Eric Weston ’16 MS, a doctoral candidate who joined Marras’ lab in 2015. “That’s why I came to Ohio State. I was drawn to how he was putting the whole puzzle together.”

It boils down to curiosity, a trait Marras takes everywhere.

Hoops, karate and Silicon Valley
A lifelong athlete who earned a full-ride scholarship to play basketball at Wright State University, Marras was no stranger to sports injuries, especially to his ankles. However, a serious back injury in college benched him for months. Subsequent visits to doctors in search of the cause lodged in his budding engineer’s mind.

“I was impressed at how little they knew about what was going on with my back,” Marras says. “When I got into graduate school, one of my missions was to see if I could marry engineering with knowledge of the human body.”

One thing that made no sense to Marras was why doctors and tools such as X-rays and scans investigated injuries while a patient was sitting or standing. Pain is typically triggered by mobility — not immobility. “I thought that was ridiculous,” he says. “For my dissertation, I had this idea of how to analyze the dynamic biomechanics of the elbow. My advisor said, ‘Wow, that’s a great idea, but if you apply that to the spine, you’ll do a lot of good and you’ll have something to do for the rest of your life.’”

Marras has done exactly that: A signature of his work is analyzing what happens when bodies are in motion. And while his innate curiosity has taken him down other paths in his personal life, they often circle back to his interest in the biomechanics of the body.

Around the time he joined Ohio State as an assistant professor in 1982, he became interested in karate. Years later, he earned a black belt. Karate gave him remarkable insight into the biomechanics of movement, as in which muscles contract when you throw a punch.

“If you look at our technology, it’s based around measuring how people move and monitoring how people move,” he says. “Physicians have told me, ‘I can tell when somebody’s not moving right. I just can’t quantify it.’ What we’re trying to do is quantify that.

“You need a curious mind and [to] follow that curiosity, be creative and think differently than other people. All this comes together and evolves. It’s serendipity, but it’s planned serendipity.”

In his own lab, Marras meticulously created an environment where serendipitous ideas flow. With its open environment, collaborative work spaces and wall-to-wall tech, creativity bubbles up organically.

SRI’s office design was inspired by a visit to Silicon Valley, where Marras was consulting with other researchers. There, he discovered creative environments conducive to free thinking. He even took classes on how to construct those spaces.

“I started thinking about how good ideas come about. I opened my mind and tried not to be constrained by what I’ve seen in the Midwest forever,” Marras says. “All I can really do is create an environment where people can be creative and productive. I got rid of the barriers and tried to design the environment.”

Weston’s experiences in the lab bear that out. “It’s a collaborative, fast-paced environment, and you get a lot of access to different perspectives for your research,” Weston says “That’s important.”

'You can't do this in a silo'
Ohio State is uniquely suited to Marras’ research.

He credits university leadership for helping him build his ideal lab and open doors across campus, including to the College of Medicine.

“Anybody you need with an expertise is here,” he says. “I’ve got a medical center within a five-minute walk from my lab. I have surgeons, physicians, sociologists, statisticians, all kinds of engineering you could ever imagine.

“That’s critical. This isn’t something you can do on your own. When you embrace diversity, you get a melting pot of creativity.”

Working hand-in-hand with stakeholders to his research has paid off. For much of his time here, Marras has collaborated with Ohio State colleagues and a variety of industries, from manufacturing to hospitality, to design ergonomic solutions to prevent back problems and work loss — benefiting both business and personnel. His research with Honda alone reduced injury rates among vehicle door assembly line workers by over 90%. 

“I want to make the most impact I can as a researcher, and our lab work is immediately impactful,” Weston says. “A lot of research is basic science. This is applied science. I love that.”

Several years ago, Marras and his team began to pivot to treatment, envisioning and beginning to build next-generation quantitative tools — based on analysis of metrics and measurements taken in SRI’s tech-rich motion capture lab — that would lead to personalized back care. Ohio State researchers are in learning and testing phases with this technology, but it is expected to accelerate now that it has backing from federal agencies. The ultimate goal is commercialization, which would make these tools more accessible and widely used.

First, Marras is attached to a National Institutes of Health initiative called HEAL (Helping to End Long-Term Addiction), which seeks to prevent and treat opioid misuse. Because chronic pain is a leading reason people use opioid medications, Marras’ work on developing computerized tools for personalized back pain treatment is part of this initiative. Last year, this work received an additional boost with a rare “breakthrough” designation by the U.S. Food and Drug Administration. This means the FDA will help fast-track the technology to market once it is ready.

The goal of the project is to build a digital platform that houses a database of patient phenotypes, or profiles based on characteristics related to spines, injuries and symptoms. Another piece of the project involves the development of wearable sensors that analyze individuals’ spines as they move, discovering pain points and mobility problems through computer modeling.

By gathering in one place massive amounts of data about back injuries and how they affect the spine, Marras’ team would give clinicians the ability to decipher precisely what is happening to someone experiencing lower back pain and more accurately treat the person. If the appropriate treatment is indeed surgery, the technology should help surgeons improve on the current 50% success rate, Marras says.

SRI’s neurosurgery clinical director, Dr. Ehud Mendel, who also leads the Spine Oncology Program at Ohio State’s Comprehensive Cancer Center, says he will be able to use the technology SRI is developing to create computerized models of a person’s spine based on a CT scan or MRI. Those models can help surgeons identify the correct procedure and even test it out virtually.

“Once we can create the model, we can create all kinds of variations to see what happens,” Mendel says. “We can simulate the surgery to see what happens with those constructs. It helps facilitate my work when it comes to trying to provide optimal care for the patients and minimizing complications.

“(Marras’) understanding of the biomechanics of the spine is so critical to what we’re doing, it’s almost like working with another surgeon. He’s an engineer with the mind of a surgeon.”

In personalized treatments, the quantitative tools Marras and his team develop bring invaluable peace of mind to those living with chronic lower back pain.

“When we’ve shown this technology to people in our studies, one of the things that surprised us is everyone said, ‘This validates what I’m feeling,’” Marras says. “They may have been suffering for months if not years, but a lot of people start to doubt themselves. This shows them it’s not just in their minds.

“It’s gratifying to hear things like that, but it doesn't mean we’re done. We’re on the right track but we need to keep pushing in this direction.”