Newswise — According to the Spinal Cord Injury Association, an estimated 11,000 new cases of spinal cord injuries occur each year in the United States. Recovery following spinal cord injury was the focus of an important study published in the September 2002 issue of the Journal of Neurosurgery: Spine.
The three-year case report, "Late Recovery Following Spinal Cord Injury," reported functional recovery from chronic spinal cord injury. The single case study was led by John W. McDonald, MD, PhD, at Washington University School of Medicine in St. Louis and co-authors included: Daniel Becker, MD; Christina Sadowsky, MD, John A. Jane, Sr., MD, PhD, FRCS (C), Thomas E. Conturo, PhD, and Linda M. Schultz, PhD. This report of actor Christopher Reeve (who consented to be identified as the subject of this report) provides the first evidence that substantial recovery of motor and sensory function is possible five to eight years after traumatic spinal cord injury in an individual whose progress had been dormant.
"Delayed recovery is not unheard of, however the time frame for delayed recovery is typically between one and six months after injury for large improvements," said John Jane, Sr., MD, a member of the American Association of Neurological Surgeons. "Mr. Reeve's progress of recovery is extremely promising, and has substantially improved his quality of life."
Christopher Reeve was 42 years old when he sustained a spinal column fracture on May 27, 1995. He was injured when his horse stopped suddenly, his hands became caught in the reins, and his 6 ft 4 in., 215-lb. body was catapulted over the horse's head. He landed directly on his helmet in a near-perpendicular position. When he was discharged from the University of Virginia hospital on June 28, 1995, he was dependent on a ventilator and his spinal cord injury was classified as ASIA (American Spinal Injury Association) Grade A (individuals classified with the least remaining function and little hope for recovery), at the C2 level.
In the first five years after his injury, Reeve experienced no substantial recovery. Clinical experience and evidence from scientific literature suggested that no further recovery would take place.
"We had been investigating the role of patterned neural activity on physical conditioning and the potential for functional recovery in the lab and in the clinics since 1997," said Dr. McDonald.
In October 1995 Mr. Reeve began a regimen of physical therapy, which included electrical stimulation of muscle groups, use of an FES bicycle and stepping on a treadmill while suspended from a harness. He also practiced breathing when disconnected from his ventilator. Five and a half years after his injury, Reeve began a series of evaluations by Dr. McDonald and his team. Based on these evaluations, Reeve's therapy was adjusted to promote recovery. "The theory was that patterned neural activity might be important for optimizing spontaneous reorganization and regeneration, as it does on similar substrates during development," said Dr. McDonald.
When the study began in November 2000, Reeve was quadriplegic (paralysis of both arms and both legs) and unable to breathe without assisted ventilation. Based on recommendations from McDonald's team, Reeve increased the variety and intensity of activity-based techniques in his rehabilitation program. This consisted primarily of training on the functional electrical stimulation (FES) bicycle that uses computer-controlled electrodes to stimulate the leg muscles in specific patterns. The goal was one hour of activity (up to 3000 revolutions) per day, three times per week.
Electrical stimulation to activate muscle groups, including paraspinals, abdominals, wrist extensors, wrist flexors, deltoids, biceps and triceps, continued to supplement the bicycle therapy. Once muscle recovery began, aquatherapy was incorporated into the program, with a goal of a single, one-hour session per week.
Reeve first noted the ability to control a twitching movement of his left index finger in September 2000. Twenty-two months after first meeting with McDonald's team, Reeve's light touch sensation improved to 52 percent of normal. It recovered even further to 66 percent of normal in 2002. Motor recovery was first evident in the left fingers, then the right hand, and then the legs. Movement is now possible for most muscles of the upper and all the major muscle groups in the legs.
Over a three-year period (five to eight years after injury), Reeve's condition improved two ASIA grades from ASIA Grade A to ASIA Grade C. He now has movement in most joints, including the elbows, wrist, fingers, hips and knees. An increase in muscle mass was also associated with this recovery. In addition, spasticity decreased, the incidence of medical complications fell dramatically, and the incidence of infections and use of antibiotic medications was reduced by over 90 percent.
Although the authors cannot conclude with certainty that the activity-based rehabilitation techniques produced the functional benefits, they would like to believe these methods were responsible for the physical benefits. The report demonstrated that substantial recovery of function (two ASIA grades) is possible in a patient with severe ASIA Grade A injury at the C2 level, long after the initial spinal cord injury. Less severely injured individuals may achieve even more meaningful recovery.
"Retrospective and prospective randomized trials are currently underway at Washington University School of Medicine in St. Louis," said Dr. McDonald. "We have begun to uncover some of the mechanisms underlying activity-based optimization of spontaneous recovery of function in laboratory studies that will be published soon."
"We hope this work will ignite additional clinical investigations into the effects of long-term rehabilitative and medical interventions for individuals with spinal cord injury, and other disorders involving immobility," said Dr. Jane. "Those interventions might enable individuals with spinal cord disabilities to achieve life-altering physical and functional benefits that previously were not thought possible."
Because this study was based on only one case, the role of patterned neural activity in regeneration and recovery of function after spinal cord injury represents an emerging area for further investigation
Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with over 6,500 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurosurgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the spinal column, spinal cord, brain and peripheral nerves.
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