In recent years, a variety of aggressive physical rehabilitation programs have emerged that seem to restore significant function for many people after spinal cord injury (SCI), even years after injury. This article discusses several of the programs, as well as key issues surrounding their use.

Introduction

Increasingly, such aggressive rehabilitation is being used to maximize restored function after cell-transplantation or other innovative surgeries that are surfacing throughout the world, including those discussed in previous articles. Often videos are produced to document improvement, and given the impressive nature of the physical activities that could be done after but not before surgery, it is assumed that the new-found abilities prove the intervention’s efficacy.

However, this assumption may not be valid; in fact, in some cases, perhaps little of the restored function is due to the surgery but rather to the rehabilitation aggressively pursued after the intervention but not before. If post-surgical functional recovery depends upon slowly regenerating neurons reaching an anatomically distant target site, it will take a relatively long time for improvements to appear. If during that period, the patient is enthusiastically working out, the true cause of any ensuing improvement is questionable. As such, some surgical interventions now require patients to aggressively rehabilitate before, as well as after, surgery.

Furthermore, if patients believe with heart-and-soul conviction that the surgery will help him, it will shift their consciousness from the prior “you-will-never-walk-again” attitude that is often imprinted on the patient’s consciousness by our medical authorities to a self-fulfilling belief of what may be truly possible through hard work. Their will propels them to new functional levels, perhaps only a small amount of which is actually due to the surgery.

Even by itself, aggressive physical rehabilitation is a complicated area in which improvements may be due to many causes and mediating physiological mechanisms. First, such rehabilitation most likely stimulates some function-restoring neuronal regeneration, adaptation, and/or reconfiguration (i.e., plasticity); and also may activate dormant but intact neurons that transverse most injury sites, even injuries clinically classified as complete. Studies suggest that only a small percentage of “turned-on” neurons are needed to regain significant function.

Second, the spinal cord by itself possesses intelligence and is not completely subservient to brain oversight. Specifically, the spinal-cord’s “central-pattern generator” can sustain lower-limb repetitive movement, such as walking, independent of direct brain control. With training and braces, impressive ambulation may be observed through physically stimulating this neural network.

Third, many muscles above the injury site indirectly affect ambulation, especially through the use of leg braces. For example, the latissimus dorsi (i.e., the lats), which are innervated from the cord’s cervical region, influence pelvic-area movement and, in turn, ambulation.

Fourth, aggressive physical rehabilitation is often initiated in the first year after injury, a period in which appreciable recovery potential exists. As such, critics have suggested that any functional recovery, no matter how dramatic, would have happened anyway.

Finally, in paradigm-expanding speculations, experts knowledgeable in Eastern and esoteric-healing traditions believe that it is possible for brain-directed function below an anatomically complete injury site. Specifically, a sophisticated interaction takes place between our body’s electromagnetic energy meridians, systems, and fields and neurological systems that can bypass the injury site. As such, it has been suggested that martial-arts or qigong study, which emphasize energy-flow and control, facilitates this potential.

Summaries are provided below on various aggressive, function-restoring rehabilitation programs:

Neuro Institute

Arnie Fonseca was the driving force behind the creation of the Neuro Institute in Tempe, Arizona (www.theneuroinstitute.com). An exercise physiologist and former coach, Fonseca motivates clients with SCI and other neurological disorders to regain sometimes amazing function. I met Fonseca and was impressed with his drive, can-do spirit, and commitment to his rehabilitation mission, which became personal after his son Brandon sustained a serious head injury from an auto accident.  (Photo: Arnie and Cari Fonseca, with son Brandon, co-founded the Neuro Institute)

Fonseca describes his program as immersion therapy. He believes that the best way for a neurologically compromised patient to get positive results is to be immersed in goal-oriented rehabilitation therapy for at least three hours a day for 3-5 days a week. There is no magic technique; the program uses a variety of rehabilitation approaches ranging from electronic equipment (e.g., FES bikes) to old-fashioned, low-tech weight training. Through his “just-do-it” motivational prowess, Fonseca encourages patients to replace entrenched defeatist attitudes with a new conviction of what is possible if they work hard.

Several impressive success stories are documented on his Web site. One of the more notable involves Andrea, whose experience represents a good example of how function-restoring surgeries are being combined with aggressive rehabilitation. Briefly, an omental/collagen bridge was used to bridge a 4-cm gap in Andrea’s cord that resulted from a skiing accident (see Neurological Research 27, 2005). Since starting Fonseca’s program, Andrea regained considerable function, including some ambulation. Time-sequential MRIs indicate ongoing development of axonal structure through the once huge, spinal-cord gap. Although we cannot distinguish surgical from rehabilitation contributions, this is the sort of synergistic programs that we are going to see much more of in the future.

Project Walk

Many people with SCI who have committed to Project Walk (www.projectwalk.org) have accrued function much beyond what was considered possible after injury. The intensive exercise-based recovery program, developed by Ted and Tammy Dardzinksi in Carlsbad, California, attempts to re-educate the damaged nervous system through physical stimulation. Because each injured system is unique and each patient has different capabilities, the program is tailored to individual clients.

Briefly, Project Walk focuses on developing muscle potential below the injury level. The Dardzinksis believe standard rehabilitation programs not only ignore this potential but contribute to its extinction by “tossing-in-the-towel” focusing on non-paralyzed body parts needed for adaptation to wheelchair living instead of ambulation.

They also believe the extensively administered anti-spasticity medications are the equivalent of pouring water on the flickering embers of regeneration that often still exist after injury. In contrast, Project Walk’s goal is to fan these embers into a phoenix-like reemergence of functionality.

Underscoring their reservations with prevailing rehabilitation thinking, the Dardzinksis note: “If you were to place an able-bodied person in a reduced gravity environment, tell them they can’t move for a year, heavily medicate them, and give them no hope, what do you think the outcome would be? Bone density, muscle mass, and nervous system activity would begin to shut down and disappear. That able-bodied person would have the same symptoms of a paralyzed person. So, is it just the injury or the treatment that keep some SCI paralyzed?”

Believing there is a post-injury therapeutic window in which the recovery potential is greatest, Project Walk ideally would like to start treating patients relatively soon after injury. The program believes that without proper stimulation and load bearing, a newly injured person will soon start losing bone density, muscle mass, and CNS functioning, which makes future recovery even more difficult. Although the program has treated many after this window, sometimes with dramatic improvements, much more effort is needed.

Although the training schedule depends upon a person’s function, the average client works out three hours every other day.  For people returning home, individually tailored, home-based programs are designed. Although intensive, the program encourages clients not to embrace it exclusively at the expense of overall life balance achieved through involvement in areas such as career, school, social life, etc.

The program combines strengthening activities for all muscles in the extremities and core (abdominal, back, and pelvic), balance work, and coordination drills. Exercises are structured to activate paralyzed areas and strengthen weak muscles. Specialists facilitate active and passive motions in various planes of motion to reactivate and reorganize the nervous system. This includes floor exercises, assisted or unassisted work on Total Gyms^®, and body-weight-supported ambulation. The common component is weight bearing through the body’s long bones.

Functional improvements include increased muscle mass, CNS activity, health and well being, sensation and function below the injury level, occupational skills, and sweating, as well as decreased drug dependence and pain.

Project Walk encourages the use of synergistic healing modalities, including acupuncture, hyperbaric oxygen therapy, standing frames, FES bikes, and other electrical stimulation that helps to maintain muscle mass and circulation; and emphasizes good nutrition.

Additional aggressive physical rehabilitation programs will be discussed in Part 2.

Adapted from article appearing in February 2006 Paraplegia News (For subscriptions, call 602-224-0500) or go to www.pn-magazine.com).