As discussed in Part 1, a variety of aggressive physical rehabilitation programs have emerged that restore some function for many people after spinal cord injury (SCI), even years later. In addition, with the recent development of various cell-transplantation or other innovative surgeries, these programs have become increasingly important in efforts to maximize restored function accruing after such surgeries. Part 2 summarizes two additional programs.  

Activity Based Restoration

Dr. John McDonald, who recently established the International Center for SCI at Johns Hopkins’ Kennedy Krieger Institute (Baltimore), has developed an activity-based-restoration (ABR) program. This program reinforces patterned neural activity, which, in turn, promotes the creation of function-restoring neuronal networks. ABR is based on the premise that considerable neuronal plasticity or adaptability can be exploited after injury but generally has not been under conventional rehabilitation. In most, even clinically classified complete, injuries, many intact neurons still transverse the injury site. Through rigorous physical stimulation, these residual neurons lay the foundation for creating new function-restoring, neuronal networks.

In this “if-you-don’t-use-it-you-lose-it” system, paralysis-associated muscle disuse over time results in a vicious-circle diminution of regeneration potential. In other words, the nervous system requires a certain amount of pattern activity to maintain itself; dormant neurons and nascent neuronal networks must be stimulated. Furthermore, McDonald believes that one’s inherent adaptive potential in response to patterned activity is compromised by commonly used anti-spasticity medications.

With McDonald’s ABR program, the pattern-activity stimulation is accomplished primarily through training on a recumbent functional-electrical-stimulation (FES) bicycle for one hour, three times a week. This one-hour effort corresponds to about 3,000 repetitions, which compares to the 12,000 steps the average person takes each day. Supplemental therapies include electrical stimulation of other muscle groups, as well as aqua-therapy after some recovery has accrued. Because of the need to maintain a three-session-per-week schedule, McDonald feels that the program ideally should be home based with Internet monitoring.

McDonald’s program acquired considerable visibility when the late actor Christopher Reeve regained some astonishing, unexpected function after starting ABR five years post-injury. This was well into the chronic phase of injury in which, from historical rehabilitation perspectives, significant functional recovery is considered unlikely. Reeve’s improvements were documented by McDonald et al, in a 2002 article (J Neurosurg (Spine 2), 97, 2002).

Five years after sustaining an ASIA-A complete C2 injury due to being thrown from a horse, Reeve started ABR, continuing it at home. As is the case with so many clinically classified complete injuries, MRI imaging indicated that Reeve had a doughnut-like rim of tissue (~25% of normal) surrounding an injury-site cyst. 

After three years of treatment, Reeve improved from an ASIA-A complete injury, which had been his status for the five years before treatment, to ASIA-C incomplete injury (the ASIA scale ranges from Grade A, representing complete injury, to Grade E, representing normal function). During this period, Reeve’s motor scores improved from 0 on a scale of 0-100 to 20, and sensory scores improved from 5-7 to 55-77 on a scale of 0-112. These improvements correlated with a regained ability to move certain muscles, including most joints in gravity-countering water. Sensation as measured by pinprick and light-touch evaluation improved to 50% and 66% of normal, respectively. This recovery was also associated with a reversal of SCI-associated osteoporosis, increased muscle mass, a greatly reduced incidence of antibiotic-requiring infections and other medical complications, and reduced spasticity.

Coordination Dynamics Therapy (CDT)

CDT was developed by Dr. Giselher Schalow, a German scientist who has established programs in Estonia, Spain, and Switzerland. At an SCI conference several years ago, I heard the enthusiastic Schalow present and noted many scientists in attendance were impressed with his results.

According to Schalow, CDT was developed for the “functional and structural repair of the lesioned or malfunctioning central nervous system (CNS).” This therapy, he says, “improves the self-organization of the neuronal networks of the CNS for functional repair by exercising extremely exact coordinated arm and leg movements on a special device and, in turn, the coordinated firing … of the many billions of neurons of the human CNS. Structural repair is achieved … by pushing the patient to the limits during exercise.” (www.cdt.host.sk/theory.htm)

Although underscoring that it’s the program and not the equipment per se that makes the difference, the device Schalow emphasizes is a Swiss-manufactured GIGER MD exercise instrument, which has become popular at many rehab centers. The patient powers the instrument in a standing, sitting, or lying-down positions. Arm and leg cycling is phased in a physiologically sequenced and coordinated pattern that promotes the creation and reorganization of function-restoring CNS neuronal networks. Basically, CDT’s gestalt-like approach to muscle movement emphasizes the neuronal plasticity or adaptability that is inherent in all. With CDT, the rhythm of the exercise patterns, not the exercise itself, is most important. Through a wave-like movement, all spinal-cord sections are sequentially affected.

Schalow compares the process to a computer, in which “the CNS neurons and connections represent the computer’s hardware, and the many different self-organizations of neural networks activated by volition and movement-induced input represent the computer’s software.” With this analogy, no matter how powerful your computer, if the software (i.e., neuronal circuits and networks) is not there, you are not going to have significant function. As such, efforts to regenerate neurons without adequate consideration on how they are organized will be inherently limited. 

Creating these nascent, function-restoring neuronal networks requires substantial patient effort; specifically, patients often train 20-30 hours per week for many months. Under this regimen, the sequenced movements are repeated many thousand of times.

In 2002, Schalow reported the results of treating 18 patients with three or more months of CDT (Electromyogr Clin Neurophysiol, 42, 2002). Patient age ranged from 7-55 years old, and the time since injury averaged five years. In addition to measuring increased ability to creep, crawl, springboard jump, walk, and climb steps, Schalow assessed improvements through a “coordination-dynamics” measurement that reflects CNS organization. After training, this measurement improved 53%, 32%, and 48% for patients with cervical, thoracic, lumbar injuries, respectively. Motor function improved in all.

The following year, Schalow reported the results of treating four patients with CDT for longer 6 to 13-month periods (Electromyogr Clin Neurophysiol, 43, 2003). He concluded “One patient with an incomplete spinal cord lesion was cured, two patients with clinically complete injuries were partly cured, and one patient with a complete spinal injury L3/4 became incomplete but showed only comparably little progress.”

Conclusion

This two-part article summarized four aggressive rehabilitation programs that have the potential to restore function after SCI. Periodically, I will update readers on similar programs. In spite of the sophisticated physiology involved in creating new exercise-driven, function-restoring, neuronal circuits, these are straightforward, non-glamorous, hard-work programs that probably have a better track record than the more iffy surgical procedures that so many in search of magic-bullet solutions are clamoring to obtain. 

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