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New York Times article: Exercising Toward Repair of the Spinal Cord

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    New York Times article: Exercising Toward Repair of the Spinal Cord

    The newspaper itself has a great picture of John McDonald sitting in front of the rat impactor.

    http://www.nytimes.com/2002/09/22/national/22NEUR.html
    Exercising Toward Repair of the Spinal Cord
    By SANDRA BLAKESLEE


    When Christopher Reeve went on national television last week to announce that he could wiggle his fingers and hips, the news seemed startling. Paralyzed from the neck down after a horseback riding accident in 1995, Mr. Reeve had been told repeatedly that he would never be able to move any part of his body below his shoulders.

    But scientists who study the brain say Mr. Reeve's recovery is part of a quiet revolution in how intense physical exercise can help restore the brain and spinal cord after serious injury.

    At academic research centers in the United States, Europe and Japan, paralyzed patients are hanging from harnesses, walking on treadmills and tying down limbs to force the use of paralyzed arms and legs. Some are being fit into robots designed to help move their bodies. Using such techniques, an estimated 500 paraplegics who had limited sensations in their lower bodies are now able to walk for short distances, unassisted or using walkers, scientists say.

    The limits of what physical exercise can do for paralyzed patients is not known. While each person and each injury is unique, and some people recover spontaneously, an estimated 200,000 Americans are living with spinal cord injuries that have not improved, according to the National Spinal Cord Injury Statistical Center at the University of Alabama at Birmingham. Which therapy or combination of therapies will work for each person ó including the use of experimental drugs and stem cells ó is also not known.

    However, the ordinary repetitive motions used in most rehabilitation centers, like squeezing a ball, are almost certainly not enough to revive badly injured adult brains and spinal cords, scientists say. Indeed, patients are usually told that after one year, two at the most, they will never make further progress in their abilities to move or feel sensation.

    Mr. Reeve, the actor and director, was totally paralyzed for five years after his accident but stuck to an exercise regime because, he says, it kept his muscles strong and his mood elevated. Then one morning two years ago, he found that he could lift his left index finger on his own.

    Thinking back on that day, he said: "My first reaction was to curb my enthusiasm. But inside, my hope and belief was that if my finger could suddenly move on command, I had to explore every other part of my body to see what was possible."

    While still dependent on a wheelchair and respirator, Mr. Reeve, who will turn 50 on Wednesday, has recovered the ability to move all fingers on both hands, move each of his joints while floating in water and from a supine position push hard against a therapist's chest with each of his legs. This does not mean he can walk ó for one thing, he cannot support his upper body ó but he has regained enough muscle strength to carry out a pushing motion.

    "Chris Reeve has called into question every assumption about the capacity of the human brain and spinal cord to recover after catastrophic injury," said Dr. Michael Merzenich, a pioneer in neuroplasticity research at the University of California San Francisco School of Medicine. "He has shown that intense exercise is not only good for the healthy nervous system, it can bring body and brain back from the oblivion of paralysis."

    But the activity has to be specially designed to engage a mature nervous system, Dr. Merzenich said. The experience needs to be relevant and to have many components. It has to be broken down into very small steps and then pounded into the patient's body. Such therapy may have to go on for years before it will have an effect, he said. Because these therapies are still largely experimental, Medicare and most insurance companies will not cover their costs, which tend to be much higher than costs for conventional physical therapy. The weeks or months of rehabilitation typically paid for by insurance companies are rarely enough, scientists say.

    These new ideas about adult plasticity have been slow to catch on because people are discouraged by what they see around them, said Dr. Bruce Dobkin, a rehabilitation expert at the University of California in Los Angeles. The fact is that most stroke and spinal cord patients reach a plateau after several months, he said. They are told to go home and live with their permanent disability.

    The idea that the adult nervous system is set in stone began to change more than 20 years ago, said Dr. John W. McDonald, an assistant professor of neurology at the Washington University School of Medicine in St. Louis who is also Mr. Reeve's doctor. The synapses that help carry signals inside the brain turn over or renew themselves ó a person gets entirely new ones ó several times in adulthood, Dr. McDonald said. This means the adult brain is capable not only of learning but of repairing itself if challenged with the right kind of activity.

    The brains of infants and children build all their complex circuitry in response to activity, Dr. McDonald said. This natural plasticity slows way down in adulthood but does not turn off. One way to drive plasticity in the adult brain is to break what has to be learned into smaller steps.

    Adult Japanese speakers can easily be taught to hear and pronounce L's and R's ó sounds that they cannot usually distinguish ó if the sounds are stretched out by a computer. The activity also must matter to the individual, Dr. Merzenich said. If it is boring and mindless, the brain's plasticity mechanisms will not kick in. When a person focuses and pays attention, brain molecules turn on the reward circuitry that promotes plasticity.

    These strategies for enhancing adult brain plasticity apply to damaged brains as well as to healthy ones. At research centers, including one at the University of Alabama in Birmingham, some stroke patients are making unexpected progress when their good arms are tied down and they are forced to use their bad arms for everyday tasks. The activity literally rewires damaged areas of their brains.

    In spinal cord rehabilitation, patients in Los Angeles, Miami and Zurich are suspended in harnesses while their feet are put through walking movements on treadmills. Doctors at the University of California are building robots to help paralyzed patients practice walking.

    Many spinal cord injuries leave some ascending and descending nerve tracts alive but stunned, Dr. McDonald said. Without activity, these fibers atrophy and the person ends up in a wheelchair. But when muscles are stimulated with electrodes and exercise, the nerve tracts sometimes partly revive.

    Mr. Reeve is challenging the accepted limits of all such therapies based on exercise and plasticity. First, his injuries are more severe. Most patients who get on treadmills or tie down limbs have some spared movement and can breathe on their own. Second, he refuses to give up.

    In a recent telephone interview, Mr. Reeve recalled his efforts to reawaken his body. After the accident he used electrical current to maintain his muscle mass and increase circulation. He lay on a table that tilted him vertically to increase bone density and enhance circulation. He hung in a harness over a treadmill. In 1999 he began an intense exercise program on a recumbent bicycle in which his muscles were electrically stimulated to move the pedals an hour at a time.

    After a year on the bike, he could move a finger. "That's when I decided to exercise even more intensely," he said. "What I think happened, by exercising over such a long period of time, is that perhaps dormant pathways have been reawakened."

    Mr. Reeve said brain scans show that 70 percent of his body is now actively represented in his brain, meaning sensory information is flowing into his cortex from the periphery. A study confirming this is to be published in the Journal of Neuroscience. Some motor functions also appear to be coming back. By artificially raising levels of carbon dioxide in his blood via his respirator, he is forcing nerves in his brain stem to reflexively move muscles in his diaphragm ó thus retraining his body to breathe on its own. The high level of carbon dioxide tells the brain it is suffocating and triggers the breathing reflex.

    It may take many years of intense exercise to produce these effects, Mr. Reeve said. To people who must use wheelchairs, he gave this advice: "Do not give up. Go back to exercise. Even if not much happens right away, you've got to believe. Nothing is impossible."

    #2
    Listed on front of NY Times

    I was in NY/NJ and picked up a copy of the Times today. The CR article was mentioned on the Front page and the article was Section A page 36 which for the Times is a great placement.

    I thought the article was excellent and well done. Really pushes the rehab issue and pushing patients past plateau. The Insurance industry needs to hear this message. They can "PaY Now or Pay Later". In the long run this will benifit all with an SCI. There is now a scientifically proven Case study for longer rehab with positive health outcomes. Hopefully standing frames, FES and longer rehab will be the norm.

    "Don't worry about the world coming to an end today.
    It's already tomorrow in Australia!"----- Charles Schultz

    Every day I wake up is a good one

    Comment


      #3
      the same article was in the local paper. i got verbally beat
      down today with the 'seeeeee, you can walk if only you try harder'.
      'you dont need a doctor, do it yourself'
      'try working harder since the brain can repair the spinal cord.'


      thank you media, i wonder how much funding will we lose because
      of this.

      Comment


        #4
        Recovery is not going to happen overnight and if return does occur over time, it will be the result of customized and highly advanced rehab. techniques that just aren't available at most local rehab. centers.

        DA, remind them of the following:

        "He has shown that intense exercise is not only good for the healthy nervous system, it can bring body and brain back from the oblivion of paralysis."

        But the activity has to be specially designed to engage a mature nervous system, Dr. Merzenich said. The experience needs to be relevant and to have many components. It has to be broken down into very small steps and then pounded into the patient's body. Such therapy may have to go on for years before it will have an effect, he said. Because these therapies are still largely experimental, Medicare and most insurance companies will not cover their costs, which tend to be much higher than costs for conventional physical therapy. The weeks or months of rehabilitation typically paid for by insurance companies are rarely enough, scientists say.
        [This message was edited by seneca on Sep 22, 2002 at 10:44 PM.]

        Comment


          #5
          "With half a million dollars a year, perhaps you, too, can experience some recovery from spinal cord injury." Where's that headline?
          Alan

          Proofread carefully to see if you any words out.

          Comment


            #6
            I have seen many high level quads and the experience I have tells me that CR probably had this capibility from the onset of his injury, but just didn't realize he had this ability. I think most of the ability he has with his very limited movements come mostly from concentrating on these movements and making it happen. I believe he has had the connections in his cord all along to perform the feats he showed us all on T.V. I also think that had his son not been the producer we would not have seen this documentary and that because of his previous claims that he would walk by his 50 th birthday, he needed to show the world something. I am not knocking CR or the documentary. I think it was great and I think what CR has done for SCI is tremendous and more and more doors are opening, because he is spinal cord injured. DA made a great point in that now people think exercise and our own will to walk is our answer. Wrong assumption for sure. We need the science and we need the research over anything. Yes, we can go on exercising until we die, but our cords will not be restored. Please, whoever reads this post, be assured we need the funding and we need speedy FDA approvals for human clinical trials in the USA. Over the years I have willed new muscle groups to move will limited exercise, but no matter if I exercise 20 hours a day, I still need my nerves that were injured to function properly. The media aggravates me, and the stupidity of the suggestions, without the first hand knowledge of what SCI is all about.

            Comment


              #7
              Alan

              Exactly! I am grateful for all the attention SCI is getting because of CR and his tireless efforts, however, it is unfair that some people are only hearing "if you just try hard enough or want it bad enough....."

              Comment


                #8
                After My Stroke, 27 Years Ago

                After My Stroke, 27 Years Ago

                o the Editor:

                Christopher Reeve's regaining of sensation and limited motion has thrown into question decades of discouraging prognoses for victims of stroke and spinal cord injuries (news article, Sept. 22). I second his optimistic advice to people in wheelchairs.

                I suffered a major stroke because of birth control pills in 1975 and was told that I might never get out of a wheelchair. Various specialists predicted that most recovery would take place in six months, with perhaps additional improvement up to two years after the stroke. I got out of the wheelchair, continued physical therapy at home and am still recovering after 27 years.

                There were noticeable gains 15 years after the stroke, but I still had only partial use of my right hand. I recently adopted the two-handed Dvorak computer keyboard. I am developing new synapses and am thrilled by having greater use of my right hand in typing, piano playing and daily living.
                NANCY KOVALEFF BAKER
                Boston, Sept. 23, 2002



                Copyright The New York Times Company | Permissions | Privacy Policy

                ==============================
                "It was once written "To thine own self be true". But how do we know who we really are? Every man must confront the monster within himself, if he is ever to find peace without. .." Outer Limits(Monster)


                http://stores.ebay.com/MAKSYM-Variety-Store

                Comment


                  #9
                  regained sensation and movement of his fingers, wrist and toes

                  "Reeve and his physicians shocked the medical community last week when it was announced that the actor - best known for his movie portrayal of Superman in the '70s and '80s - regained sensation and movement of his fingers, wrist and toes."



                  I wonder ,why regained sensation and movement begin first fingers,wrist and toes.

                  WHAT IS THE MECHANISM THAT FIRST RECOVERY OCCURS HERE.FOR EXAMPLE WHY NOT FIRST BOWEL AND BLADDER

                  Comment


                    #10
                    Reeve is not God

                    Can we wrap up the REEVE WORSHIP SERVICE. I can see the offering plate coming down the isle and I left all my solid Gold Bars at home.

                    Enough already.

                    meeker

                    jrm design art studio

                    Comment


                      #11
                      Sure meek as soon as you stop worshiping and badgering everyone about Goldfinger and omentum.

                      People who live in glass houses...

                      Onward and Upward!

                      Comment


                        #12
                        There's one thing I'm curious about.

                        After we're injured, muscle atrophy can set in very quickly. What if the muscles are not able to move for many years simply because of the muscle atrophy? If a long period of time goes by before the spine is stablized after being injured, is it possible the connections could still be intact but the muscles unable to move because of atrophy? If this is true for some, extensive physical therapy sounds like just what they need.... or electric stim.

                        I guess in Christopher Reeve's case, he had been using electric stim for a long time, probably not an issue. But could it be for some people with SCI? Is this a part of "learned non-use"?

                        Comment


                          #13
                          this has become the perfect excuse to footdrag the real cure.

                          i guess the power that be is laughing to tears at how stupid the sci
                          community can be.

                          Comment


                            #14
                            Jan, in answer to your question I am posting comments by Wise on another thread concerning atrophy. To read the discussion on the subject, go to:


                            Link Here

                            posted Mar 28, 2002 03:53 PM
                            --------------------------------------------------------------------------------
                            Steve Oakes, yes, I was really quite excited about the restoration of atrophic muscles. Let me expand on that a little bit here and then hopefully cite some of the papers (unfortunately, the authors are mostly clinicians and have not been publishing their results and so this is word-of-mouth results).

                            • Dr. Ugo Carraro from Padova (Italy) is a pathologist who has been studying atrophy of the diaphragm. He denervated the phrenic nerve on one side of rats and then kept the rats from 1 year and, in some cases, longer. The denervated diaphragm was really quite thin and atrophic looking, compared to the innervated side which (from the pictures) were 5 times thicker. He talked about the microsatellite cells (these are cells in the muscle that generate new muscle cells that then fuse with the existing muscle fibers). He showed many pictures indicating that these microsatellite cells survive denervation for many years and appear to be still present even when the diaphragm is severely atrophic. In fact, he suggests that denervation initially causes a widespread dying of the muscle fibers but the microsatellite cells then will regenerate many of the muscle fibers. However, because the muscles were denervated, those regenerated muscle fibers really don't grow to be very big. He also pointed out that it was not necessary for innervation to be present for the muscle to grow, that passive stretching of the muscles will keep them alive. For example, he pointed out that the denervated side of the diaphragm continues to be moved by the innervated side. He also showed similar data for agonist and antagonist muscles, that if there is movement from a non-denervated antagonist muscle, the denervated agonist muscle will retain flexibility and muscle fibers. Finally, Dr Carraro pointed out that many of his colleagues believed that there are circulating stem cells that can move into the muscle but he was skeptical that this plays a major role in the maintainance of the muscles. Many of the doctors who discussed this issue clearly believed the functional electrical stimulation can and will maintain muscle bulk. To me the take-home lessons are that atrophic muscles can maintain themselves for long periods of time, so long as they are being stretched and stimulated.

                            • Dr. Helmut Kern from Wien (Vienna), Austria. He works in the same group as Milan Dimitrijevic. He used huge electrical currents, much much greater than those that are typically used for FES. This was because he found that one must use very intense trains of impulses from the surface of the skin to activate severely atrophic muscles. Please note that this is in humans with cauda equina lesions. He suggests that such stimulation can restore muscle in people as long as 25 years after injury although he did not present much data to support this statement. At the beginning of the symposium, I had asked Professor Giorgio Brunelli and the assembled clinicians whether a denervated muscle could be restored. Most of the people in the audience felt that a denervated muscle (that has undergone such severe atrophy that most of the muscle is connective tissue and fat) cannot be stimulated or restored. Dr. Kern therefore surprised everybody with his findings. On the other hand, I must point out the technical difficulties of the stimulator devices that he was using (he had to build the stimulators themselves). The amount of electrical energy that he used was truly enormous. Normal FES machines usually cannot deliver more thant 50-100 millijoules of electrical energy. Dr. Kern was using as much as 3 joules (30-100 times) more energy for his stimulus protocols, giving trains of stimuli. Many of the electrodes caused skin burns but he said that the electrical stimulation actually thickened the skin. By the way, such high currents would be very painful to people who have any preserved skin sensations and would cause tremendous spasms to people who have spinal cord injury. That is why the studies were done only in patients with peripheral nerve or cauda equina lesions. I discussed the issues with several of the people afterwards, including Reggie Edgarton (UCLA) and Michael Keith (Case Western) and they expressed some reservations about the safety parameters of such high currents. In order to reduce skin burns, the electrodes have cover a large surface area to minimize current density. The problem is that if the gel dries up a bit or the electrode does not get complete contact, it is very easy to get skin burns. I asked Dr. Kern whether he tried direct stimulation of the muscle, using implanted electrodes, which would cause less damage to the skin. However, he says that he tried direct muscle stimulation and found that the high currents can damage the muscles. We talked until 3 am one of the mornings trying to figure out a better way to stimulate the muscles. However, from the evidence that Dr. Kern shows (he had biopsies of the muscles before and after), it is possible to get completely atrophic muscles to regrow and bulk up again. Now that we know it can be done, it is time to work out the methods to do so safely.

                            Michaelm, the most painful sign of pessimism (at least for me) are the large numbers of procedures that are being carried out in patients assuming that they will never recover. So, for example, there were very large series of cases reported by several German, Italian, and Swiss units that placed the Brindley bladder stimulator after cutting the S2-S5 sacral dorsal roots. Likewise, there are still many doctors that were doing deltoid, biceps, triceps transfers to restore function to the hands, sometimes fairly early after injury. Lee Illis (a very good British neurologist) was the one who said that he did not think that there will be effective restorative therapies for spinal cord injury within his lifetime (although he then amended this by saying that he is older than most of the people in the room and that some of the younger people will see such treatments within their lifetimes. On the other hand, there were many people who are showing that FES, exercise, supported ambulation, and other therapies were restoring function in people long thought to be incapable of walking. One doctor, Giselher Schalow, from Nottwill, Switzerland, was incredibly enthusiastic and were using all sorts of innovative techniques to get the spinal cord "networks" activated. He has a machine that cranked both the hands and the legs at the same time. He put patients through creeping, crawling, standing, treadmill walking, springboard jumping, etc., a program that he called "coordination dynamic therapy". He does not believe in drugs and was very stalwart in his criticism of therapies that produced irreversible damage to the spinal cord.

                            Wise.

                            [This message was edited by mk99 on 10-06-04 at 07:38 PM.]

                            Comment


                              #15
                              DA

                              Who, exactly, is footdragging?

                              FES is a great way to stay healthy. And activity-based recovery shouldn't be sneezed at either. No recovery should be.

                              We're getting closer to the Fall Neuroscience and Neurotrauma meetings. I'm sure we'll all get a boost from those.

                              ~See you at the SCIWire-used-to-be-paralyzed Reunion ~
                              ~See you at the CareCure-used-to-be-paralyzed Reunion ~

                              Comment

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