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Dr. Young- stroke question

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  • Dr. Young- stroke question

    Dr. Young-
    After reading a recent Newsweek article on strokes, a theme continued in which I am puzzled. Why is recovery much more optimistic with brain injuries due to stroke? I mean you have some neurologists admitting in the press that recovery can take place years after the initial insult, but with a spinal cord injury no one would dare make this bold claim with such confidence. I am not referring specifically to recovery of paralysis as opposed to a brain infarction or bleed, but overall more degree of optimism?

    sherman brayton
    sherman brayton

  • #2

    Almost everybody recovers substantially from their first stroke or hemorrhage. This is because brains have an amazing capability to recover despite severe damage. I think that scientists are optimistic about brain injuries because they hope to harness the brain's plasticity to do so. To tell you the truth, I am just as optimistic (if not more) about the possibility for recovery and cure for spinal cord injury. The spinal cord is even more "plastic" than the brain. I believe that the first restorative therapies will come for spinal cord injury. At the present, much of stroke research is still focussed on prevention.

    I have done research in both fields, stroke and spinal cord injury. It is much more difficult in stroke. The outcome measures in stroke studies (both animals and humans) are poorly defined. Animal stroke models are not as well developed as spinal cord injury models. Although there have been numerous clinical stroke trials (the stroke research budget is many times that of spinal cord injury), there have been few treatments of any kind that have been shown to work, with the spectacular exception of anticoagulation (TPA, aspirin). Many of the most important therapies now holding promise for restoring function have come from spinal cord injury research.

    I have long wondered by physicians are so pessimistic about spinal cord injury to their patients. A majority of people with spinal cord injury recover walking after their spinal cord injury... even if we were to exclude all the cases of whiplash, stingers, burners, and other causes of transient paralysis. One reason why physicians are so pessimistic may be the disconnect between those who take care of people with spinal cord injury during acute hospitalization and during rehabilitation. The average neurosurgeon or orthopedic surgeon, and certainly emergency room doctors, seldom see their patients again beyond the first month after injury, unless there are complications. Recovery takes a long time in spinal cord injury. In many cases, it takes a year or more. So, the doctors who see you during your initial hospital stay don't know that people recover from spinal cord injury. All they know and see are families crying and people being paralyzed.

    Rehabilitation doctors, on the other hand, have been trained since the 1950's to help people make the most of what they have, rather than to try to restore function. Although this attitude has been changing in the younger doctors, many of the older physiatrists continue to be pessimistic about recovery, particularly in Europe. I remember one venerable physiatrist in Germany telling me what it was like in the 1960's. He told me that they could measure how long people surved cervical spinal cord injury from the level of their injury... C1 survived 1 day, C2 survived 2 days, C3 3 days, etc. They spent all their time dealing with urinary tract infections, neuropathic pain, decubiti, spasticity, and support. How could they think of recovery? So, they didn't.


    [This message was edited by Wise Young on 03-03-04 at 07:40 AM.]


    • #3
      Originally posted by Wise Young:

      Almost everybody recovers substantially from their first stroke or hemorrhage. This is because brains have an amazing capability to recover despite severe damage.

      Stroke Statistics

      Stroke killed 163,538 people in 2001. It's the third largest cause of death, ranking behind "diseases of the heart" and all forms of cancer. Stroke is a leading cause of serious, long-term disability in the United States.
      About 4,800,000 stroke survivors are alive today.

      About 700,000 people suffer a new or recurrent stroke each year. About 500,000 of these are first attacks and 200,000 are recurrent attacks.


      I have to disagree with you Dr. Young: though the potential of recovery of the brain is substantially greater than the spinal cord, the fact remains that one third of all stroke victims are left with severe disability, another one third with moderate disability and only one third recovers with only minor or no disability.

      This translates to between 1 1/2 to 2 million people in the US living with severe disabilities including paralysis due to stroke.

      "Together we stand, divided we fall..."

      [This message was edited by Faye on 03-03-04 at 10:26 AM.]

      [This message was edited by Faye on 03-03-04 at 10:27 AM.]


      • #4
        Faye, I think perhaps you misunderstand me. When I say that almost everybody who gets their first stroke tend to recover substantially doesn't mean that everybody recovers completely. Don't you agree with me that "most people get substantial recovery" when a third of people who get strokes recover almost completely, that a third recover with only moderate disability, and that only a third are left with severe disability? The brain cannot achieve miracles, however. Of course, with sufficient damage, people will have residual deficits after a stroke. I have, however, seen people recover remarkable function with as much as half of their brains severely damaged from stroke. Also, the most severe disabilities occur in people who have had multiple strokes.

        I want to emphasize again that our experience with spinal cord injury is based largely on people who have severe spinal cord injury. People who have recovered don't often come to this site. It is useful to take a look at the data of spinal cord injury recovery. The national model systems database has a database of nearly 30,000 patients with spinal cord injury, collected since the late 1970's. This database suggests that only about 5% of patients who are admitted with an ASIA A classification get back ASIA C. However, in the past 10 years, I believe that the statistics have changed. For example, the NASCIS clinical trials in the 1990's suggest that about 67% of people admitted to hospital in the United States have incomplete spinal cord injury. Given good emergency care, methylprednisolone, rapid decompression, and aggressive rehabilitation, most people with initially incomplete spinal cord injuries have a good chance of recovering walking. Also, I think that more people who are initially "complete" are becoming "incomplete". I estimate that 17% of people admitted to hospital with ASIA A diagnosis and treated with methylprednisolone will progress to ASIA C over several years. Of course ASIA C is not enough and there are still more millions of people who need the cure.

        We should not paint the doom and gloom picture too darkly. Most journalists are starting every news story by saying that nobody recovers from strokes and spinal cord injuries. This widespread misperception is even spread by doctors. Over 50% of people on this site have recovered more than their doctors predicted. We should not mislead people with new injuries into thinking that they have no chance of recovery and therefore discourage them from trying or aggressive efforts to rehabilitate people.


        [This message was edited by Wise Young on 03-03-04 at 11:41 AM.]


        • #5
          Thank you for explaining your previous post, Dr. Young.

          The following statement you made is absolutely amazing:
          For example, in my experience, of the 34% of patients admitted to hospital with ASIA A diagnosis, 17% will progress to ASIA C. Unfortunately, there is no hard statistics to document this recent shift in recovery. For example, the national model systems database still bases most of its analyses on the entire database of patients collected since the late 1970's. This database suggests that only about 5% of patients who are admitted with an ASIA A classification get back ASIA C.
          "Together we stand, divided we fall..."


          • #6
            faye, sorry, I had posted very quickly and was in the process of editing my previous message when you posted. You are too fast for me. Yes, I agree, recovery from spinal cord injury is better than most people think. It means that medical care and rehabilitation is getting better. This is the way it should be. We still need the cure. Wise.


            • #7
              I am amazed by the number of people I have talked to over the years who recovered from Spinal Cord Injury. It actually has been quite surprising to me. I just met a woman this winter in Florida who had what appeared to be a complete c-5 injury at first and walked out of the Hospital. I met a guy in Nashville tn at a health club a few years back, same thing. I never remember hearing so many stories like this 23 years ago when I was injured.
              "Life is about how you
              respond to not only the
              challenges you're dealt but
              the challenges you seek...If
              you have no goals, no
              mountains to climb, your
              soul dies".~Liz Fordred


              • #8
                is the degree of recovery different because nerve cells of the brain have a shorter distance to travel to the spinal cord, whereas damaged spinal nerve cells have to migrate all the way up and down. are spinal nerve cells motivated or smart enough to make that journey?

                sherman brayton
                sherman brayton