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Hopeful movement: progress in spinal cord injury treatment

Advances in the understanding of nerve regeneration are leading to quality-of-life improvements but are also raising new issues for these patients' primary care physicians.

By Susan J. Landers, AMNews staff. June 2/9, 2003.

Nowadays when people think of spinal cord injuries, they think of actor Christopher Reeve, who was paralyzed in a fall from a horse eight years ago.

But there's also the woman who was injured in a car crash, the young shooting victim, the rangy teen who dove into the shallow end of the pool, or the man who fell from a ladder while cleaning his gutters.

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More than 200,000 people in the United States have spinal cord injuries and another 11,000 are injured each year, according to estimates made by the National Spinal Cord Injury Statistical Center at the University of Alabama in Birmingham.

As trauma care advances, more and more of these patients are surviving their injuries. After they are discharged from rehabilitation hospitals, they likely will continue medical treatment with their primary care physicians.

The good news is that thanks to a burst of recent research activity, there is more to offer them.

"Over the course of the last 10 years, the knowledge and understanding about spinal cord injury has exploded, leading us not only to a better understanding of the pathology, but also to potential treatments and interventions for recovery," says Steven Kirshblum, MD, director of the spinal cord injury and ventilator program at Kessler Institute for Rehabilitation in West Orange, N.J. Dr. Kirshblum is one of Reeve's physicians.

With these advances come new challenges, for both physicians and patients. Because these patients are living longer, fuller lives, that gives rise to a second level of treatment concerns.

For example, shoulder pain may become a problem for those who have spent years propelling themselves in wheelchairs, and skin care, always a worry for people with limited sensation, may become even more important because aging skin is more fragile.

A factor driving the research is the realization that, because spinal cord injuries generally happen to relatively young individuals, the long-term cost is catastrophic. Someone injured at 16 is likely to live to be 70, and when the medical expenses of caring for this person over a lifetime are factored in with their lost productivity, it is among the most costly injuries for society to cover, notes Naomi Kleitman, PhD, program director at the National Institute of Neurological Disorders and Stroke, Bethesda, Md. Thus, findings that result in even small gains in recovered function can make a huge difference in injured individuals' lives, sometimes the difference between being able to feed themselves or requiring an attendant.

Christopher Reeve can be thanked in part for the furious pace of some of these gains. He's a very visible and determined figure, and improvements he has made since his accident are reason for hope for many others with similar injuries. Reeve and his wife have also established the Christopher Reeve Paralysis Foundation, through which they advocate and raise funds for spinal cord research.

Never say never

Reeve's progress also has forced the rethinking of a common perception that all post-injury gains occur within the first two years of the injury. Reeve began regaining sensation and movement five years post-injury.

Though he still cannot walk and he has not regained bowel or bladder function, his recovery defies previous expectations. It was predicted that Reeve would never be able to feel or move below head level. Yet he has regained the ability to move some joints voluntarily and others against resistance. He can sense touch over much of his body, and his overall health has improved.

Another spark behind the research boom occurred with the discovery in the late 1980s that nerves could regenerate. "Neuroscientists are quite excited about this area, because it is rewriting the textbooks," says W. Dalton Dietrich, PhD, scientific director of the Miami Project to Cure Paralysis at the University of Miami School of Medicine in Florida.

"We used to teach students that the adult nervous system cannot be repaired. But that is probably not true," he says. "There are various ways we can wake up neurons and get them to grow again."

Among the methods under investigation is the injection of various "helper cells" to encourage nerve regrowth at the injury site. Schwann cells grown from peripheral nerves have been under investigation for use in spinal cord injuries, as have olfactory ensheathing cells that are found in the nerves to the nose.

While these techniques are sparking interest and excitement, probably the most visible regeneration attempts involve repetitive motion. Many specialists believe that getting people up and moving is a good way to wake up dormant nerves. To that end, patients are exercising on treadmills, stationary bikes and in pools.

Reeve's participation in the activity-based therapy program developed at Washington University School of Medicine in Saint Louis is thought to account for much of his progress. But one patient's progress, albeit a prominent patient, does not provide conclusive evidence. Additional trials are under way.

Treadmill-assisted walking has been tried for some years with spinal cord patients. It is based on the theory that the spinal cord retains control of such rhythmic locomotion patterns as walking or running even if it is no longer in direct communication with the brain. Repetitions of walking are believed to reactivate this control so the injured patient can relearn the stepping mechanism and walk.

Hit the treadmill

A robotic walking machine called a Lokomat was developed several years ago in Europe and is now in clinical trials at rehabilitation centers in this country. The device operates the legs of a person strapped into the machine while the person's upper body is suspended in a harness over a treadmill. One clinical trial using the Lokomat recently began with funding from the U.S. Army Medical Research Activity.

Another study, this one funded by the National Institute of Child Health and Human Development, has enrolled 150 individuals with spinal cord injuries and will gauge the effect of assisted treadmill walking on their ability to walk unaided.

Rather than using a Lokomat or other robotic device, these patients are aided by physical therapists, says Bruce Dobkin, MD, professor of neurology at the University of California, Los Angeles, and the trial's principal investigator. Patients will be suspended by a harness over a treadmill and will have their legs guided by physical therapists. The therapists will coordinate their actions to mirror the normal range and pace of walking.

John McDonald, MD, PhD, a Washington University neurologist, is also trying to help patients regain movement through an activity-based recovery program.

Dr. McDonald applied many of the same techniques he used when working with stroke patients to his work with spinal-cord-injured patients. "Everything from the developmental neurosciences has taught us that patterned neural activity is important for most aspects of development, including new cell birth, cell survival and myelinization," he says. So it wasn't a huge leap of faith to apply the same principles to spinal cord injuries. "Sending people with spinal cord injuries home and basically saying don't bother doing anything, your legs are extra weight, made no sense."

The program developed at WUSM aims at improving cardiovascular health, bone density and muscle mass as well as helping injured individuals recover movement and sensation.

Added benefits

The centerpiece of Dr. McDonald's program is the recumbent stationary bike that patients pedal with the aid of electrodes attached to their leg muscles. Even though the brain is not directing the muscles, workouts on the bike apparently improve cardiovascular and skin health, increase muscle mass and build bone strength.

Most people can use the functional electrical stimulation bike for one hour three times a week in their homes. Being able to exercise at home is a big plus. "In the end, time becomes the biggest limitation. If you are asking people with a disability to have a life, have a family, have a job and then go down to the gym three times a week, it's too hard," Dr. McDonald says.

About 100 individuals, including Reeve, have enrolled in the program. A study of 20 of those patients is due to be completed this summer, and if the study demonstrates that there are physical benefits to the program, investigators hope that insurance companies might be persuaded to pay for it.

Individuals' physical improvements could help keep down costly hospitalizations. "More than 30% of people with spinal cord injuries have to be readmitted to a hospital every single year for major medical complications such as bone fractures or skin breakdowns, each one costing $70,000 or more," Dr. McDonald adds.

Reeve's overall health improvements have kept him out of hospitals for the past few years and enabled him to take vacations abroad with his family and undertake jobs that he is confident he will be able to complete -- major quality-of-life improvements.

Although a program of physical activity seems to be the way to go, it is not always stressed by physicians, even physicians in rehab facilities.

"Given the increased amount of pressure to get people out of the hospital, they often don't spend much time attempting to walk unless their injury is less severe," Dr. Dobkin says. The time allotted is consumed by learning how to use a wheelchair and skin, bladder and bowel concerns.

A study at the University of Michigan in Ann Arbor found that the majority of spinal-cord-injured patients wanted to exercise but feared that fitness centers would not be able to work with them on an appropriate program.

"Improvements in medical care and rehabilitation are giving spinal-cord-injured patients a longer post-accident life expectancy and better quality of life," says David Gater, MD, PhD, who heads the University of Michigan's Model Spinal Cord Injury Care System.

"Now we need to focus more and more on the outsize risk of heart disease, diabetes and other disorders that spinal-cord-injured patients face because of a combination of lifestyle factors and the secondary physical effects of spinal cord injury," he says.

Primary care physicians can do a lot when working with rehab specialists to set up an appropriate exercise program for a patient by prescribing physical or aqua therapy, Dr. McDonald says. "There is enough evidence now that it's a shame not to try."

Diet and exercise have both been neglected in people with spinal cord injury. Fast-food diets and lack of exercise are taking a toll. "There is a discussion in the field that there may be an accelerated aging process in this group of people," Dr. Dietrich says.

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Copyright 2003 American Medical Association. All rights reserved.

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