Dr. Wise Young could this actually happen or has it happened?

[mj23]

I'm a walking quad who suffered a TBI & SCI (Brown Sequard Syndrome) on 7/28/02 and been walking since March 2003. My question is that my family was told by doctors that with me suffering a sci brown sequrd type of injury that it is possible to one day wake up and everything be back to normal. I really doubt this could happen, but I don't know. Could it?

Thank You

[Wise Young]

I'm a walking quad who suffered a TBI & SCI (Brown Sequard Syndrome) on 7/28/02 and been walking since March 2003. My question is that my family was told by doctors that with me suffering a sci brown sequrd type of injury that it is possible to one day wake up and everything be back to normal. I really doubt this could happen, but I don't know. Could it?

Thank You

mj, I am not sure what your doctors said but I do know that motor recovery doesn't suddenly occur and by itself. It always requires time and work. I noticed that you spoke about how well you walk in other posts. I had a very good friend, Carey Erickson, who was injured in 1981 (if my memory serves me correctly) and was one of the first patients that we treated with methylprednisolone. He had only a little sensation on his left leg. He had severe central cord syndrome with slight better function on the left leg. I did weekly somatosensory evoked potentials on him for over 3 months and saw his recovery come back a little bit each week.

Over 2 years, he recovered walking to the extent that people who met him would not be able to tell that he had spinal cord injury. He was a dancer and choreographer. One day, he came into my office and told me that he was unhappy. I asked him why, saying that I know so many people who would love to be in hijs shoes, to have recovered as much as he did. He told me So, we use to talk about how much he actually recovered. He told me that even though he looked okay, his coordination, strength, and stamina was much less than before his injury. His dancing career was over. I offered him a job ad he worked for me for 7 years, being the patient liaison for the NASCIS methylprednisoloe study. While he worked on that study, we had very few patients turn us down.

Carey taught me several very important lesson. First, recovery is never over. Second, even though recovery can occur, it is not "normal". Third, recovery does not occur without hard work. I believe that Carey recovered so wll in part because he worked very hard at it. If he had not done so, he may have remained in the wheelchair.

Wise.

[Doug Wilburn]

dr young

if your patient recovered so much why did you not treat oother or stop treating?

[Eric.S]

Did he have sensation in his limbs before you began to treat him? I ask this because I want to know when the decisions are made whether or not to take a therapy farther. When i was in rehab they didn't even attempt anything towards walking or function returns. what are the hints that a person may see farther progress? did your patient ever lose or regain bowel, bladder, and sexual function...

[antiquity]

Wise is referring to methylprednisone. It's already routinely administered by emergency personnel and is the standard of treatment for acute SCI at most trauma centers.

"Somatosensory evoked potentials" isn't a treatment. It's used to measure electrical activity/response.

Eric, if a person is incomplete they'll have rectal sensation which is an indicator of sacral sparing. The potential for recovery in incompletes is very good.

[Eric.S]

Eric, if a person is incomplete they'll have rectal sensation which is an indicator of sacral sparing. The potential for recovery in incompletes is very good.

every incomplete has rectal sensation?

[Wise Young]

Did he have sensation in his limbs before you began to treat him? I ask this because I want to know when the decisions are made whether or not to take a therapy farther. When i was in rehab they didn't even attempt anything towards walking or function returns. what are the hints that a person may see farther progress? did your patient ever lose or regain bowel, bladder, and sexual function...

Eric,

If somebody is an ASIA B, C, or D, I think that they should undergo aggressive locomotor training. Carey was an ASIA B. He had some sensation on the left lower leg. His sensory recovery occurred first in his legs and that is why I think that he is a "severe central cord syndrome". He recovered full rectal and bladder function. I don't know about sexual function.

The study by Bruce Dobkin and others suggest very strongly that people with ASIA B have more than a 30% chance of regaining unassisted walking. A person with ASIA C has 90% chance of regaining unassisted walking.

Wise.

Wise.

[Wise Young]

every incomplete has rectal sensation?

Eric, the definition of complete spinal cord injury is absence of peri-anal sensation and absence of voluntary rectal sphincter contraction. This usually correlates closely with rectal sensation. Wise.

[shak]

in my opinion dancers have the most complete and elite nervous system training of all athletes . this should be considered in the case of this guys recovery , along with everything else wise says to of course. check out the picture of the two dancers on fave pic thead , buddie's got enough cns voltage to power a BC/DC concert.

[Eric.S]

Eric, the definition of complete spinal cord injury is absence of peri-anal sensation and absence of voluntary rectal sphincter contraction. This usually correlates closely with rectal sensation. Wise.


so if you have no bowel or sphincter function or sensation you are considered complete?

[Wise Young]

so if you have no bowel or sphincter function or sensation you are considered complete?

If you have no perianal sensation (pinprick or touch) and if you have no voluntary anal sphincter contraction, you are an ASIA A or "complete". The definition of "complete" is to have some level of the spinal cord below which you have no motor or sensory function.

By the way, bowel function is often okay in people with spinal cord injury. It need not be paralyzed.

Wise.

[Eric.S]

If you have no perianal sensation (pinprick or touch) and if you have no voluntary anal sphincter contraction, you are an ASIA A or "complete". The definition of "complete" is to have some level of the spinal cord below which you have no motor or sensory function.

By the way, bowel function is often okay in people with spinal cord injury. It need not be paralyzed.

Wise.


does being asia a say anything in particular about the degree of harshness of your injury? I dont have parianal sensation or bowel function.

are you saying that some sci's have bowel function and others don't and it has nothing to do with there sci causing it to work or fail?

[Wise Young]

does being asia a say anything in particular about the degree of harshness of your injury? I dont have parianal sensation or bowel function.

are you saying that some sci's have bowel function and others don't and it has nothing to do with there sci causing it to work or fail?

Eric,

Bowel function is mostly automatic and in fact the bowel has its own neurons. The spinal cord of course does influence bowel function. Injury to the cervical and thoracic spinal cord (i.e. T12 or above) should not affect eliminate bowel reflexes. Injuries to the sacral spinal cord (i.e. L1 or below) may affect the bowel or anal sphincter.

Many people use suppositories to set the timing of bowel movements and then digital stimulation of the rectum to "pull the trigger". In my opinion, if one doesn't care about the timing of bowel movements, one can effect avoid using suppositories and the food itself can stimulate the gut to move. Feces in the rectum by itself can stimulate bowel movements.

Animals (such as rats) with T11 or higher injuries usually recover spontaneous bowel movements within several days after spinal cord injury. Of course, the rats don't care when they have their movements.

Wise.

[Eric.S]

Eric,

Bowel function is mostly automatic and in fact the bowel has its own neurons. The spinal cord of course does influence bowel function. Injury to the cervical and thoracic spinal cord (i.e. T12 or above) should not affect eliminate bowel reflexes. Injuries to the sacral spinal cord (i.e. L1 or below) may affect the bowel or anal sphincter.

Many people use suppositories to set the timing of bowel movements and then digital stimulation of the rectum to "pull the trigger". In my opinion, if one doesn't care about the timing of bowel movements, one can effect avoid using suppositories and the food itself can stimulate the gut to move. Feces in the rectum by itself can stimulate bowel movements.

Animals (such as rats) with T11 or higher injuries usually recover spontaneous bowel movements within several days after spinal cord injury. Of course, the rats don't care when they have their movements.

Wise.

Oh, ok. I found what you said to be correct in my case personally... why do they push the use of suppositories in rehab? I take it incompletes can actually feel the need to move the bowels and actually move it themselves?

[Cory-M]

If somebody is an ASIA B, C, or D, I think that they should undergo aggressive locomotor training.

The study by Bruce Dobkin and others suggest very strongly that people with ASIA B have more than a 30% chance of regaining unassisted walking. A person with ASIA C has 90% chance of regaining unassisted walking.

Wise.

What specifically do you mean by locomotor training? Could it be any agressive excercise and movement of the limbs or something more specific like the harness that holds you up and stimulates walking? And do you mean agressively right after injury or could it be years later?

I think technically I'm Asia C, I have good sensation everywhere and movement of my toes, left foot, some abdominal, my left hand and fingers plus all the normal C5 movements of my arms etc. Also I do this thing where I control my spasms and can move my legs pretty much any way I want to.

I had pretty good therapy after I was hurt, and I still excercise and do what I can, but I always feel like I'm wasting what potential I have with the movement I have and I should be doing more.

Thanks

[Wise Young]

What specifically do you mean by locomotor training? Could it be any agressive excercise and movement of the limbs or something more specific like the harness that holds you up and stimulates walking? And do you mean agressively right after injury or could it be years later?

I think technically I'm Asia C, I have good sensation everywhere and movement of my toes, left foot, some abdominal, my left hand and fingers plus all the normal C5 movements of my arms etc. Also I do this thing where I control my spasms and can move my legs pretty much any way I want to.

I had pretty good therapy after I was hurt, and I still excercise and do what I can, but I always feel like I'm wasting what potential I have with the movement I have and I should be doing more.

Thanks

Cory,

Locomotor training is exactly what it suggests... Spending hours walking on treadmill or overground. Walking exercise is difficult for people with spinal cord injury for obvious reasons. We are working with a Chinese group that has a rolling platform that people can support their weight, use of elastic bands to prevent footdrop, and ropes held by a person behind to pull and lock the knees. People start standing with this device, progress to stepping with assistance, and then stepping without assistance. In the U.S., they emphasize parallel bars and orthoses; I like the Chinese way better because it is more convenient and people can spend hours walking. In the Army General Hospital in Kunming, people walk 1-2 hour twice a day and often 6 days a week. This is a more intense schedule of walking than most U.S. centers.

Your current status does sound like an ASIA C. However, I was referring people who are ASIA C shortly after their injuries. Those are the people who typically recover unassisted walking. The Dobkin study showed that 90% of people with ASIA recover unassisted walking within a year whether they trained with treadmills or with overground walking. Earlier studies in Germany showed that over 75% of people who are ASIA C and have never walked after injury can be trained to walk without assistance on weight-supported treadmills. I don't know what the percentage success rate is for people who become ASIA C many weeks or months after injury. Several SCI walking programs have been set up in the United States and they have had some success in getting many patients to walk but perhaps I should allow the people who have been to these places to speak for themselves.

I have met people like Pat Rummerfeld who was paralyzed for years but who not only recovered walking but went on to compete in marathons, triathelons, and 150 mile Gobi Desert running races. Obviously, the more severely injured the person, the less likely recovery will occur and I know of some people who have worked every day for years and have not regained walking. Hard work alone is not sufficient. I believe that one does need connections to the lower spinal cord. But, of course, this is why we are working so hard to test regenerative therapies for the spinal cord. We want to take patients who are ASIA A and convert them to ASIA C, in hopes that they will recover.

The mechanisms of walking recovery are fairly well understood. We now know that there the central pattern generator (CPG) for walking is located in the L2 spinal cord. This center contains all the programs for walking, running, trotting, etc. It doesn't take many axons to activate or to modulate this center. It is a matter of retraining this center to be active again and then for your brain to learn how to turn this center on and off. By the way, the center can be activate by electrical stimulation of L2. Such stimulation may in fact help with the retraining of walking.

I am sorry that I am writing fast and not taking the time to reference and link all my statements above. However, I have written extensive posts on everything that I am saying here in previous posts over the last couple of years.

Wise.

[DeeLove]

Cory,


.... We want to take patients who are ASIA A and convert them to ASIA C, in hopes that they will recover.

The mechanisms of walking recovery are fairly well understood. We now know that there the central pattern generator (CPG) for walking is located in the L2 spinal cord. This center contains all the programs for walking, running, trotting, etc. It doesn't take many axons to activate or to modulate this center. ....

Wise.

Dr Wise,

My boyfriend has suffered a SCI in motorcycle accident recently, Feb 2008. His injury level is T4 and is classified as ASIA A complete. Is it possible for him to improve to some other ASIA class and/or become incomplete (that is ... with extensive PT sessions etc)?

I'm asking because we recently went to a SCI gym that has all sorts of rehab equipment. He tried the an active/passive bike (w/o elec. stim) and was able to continue pedaling when the bike was switched to the passive mode. He was also able to stop pedaling with considerable effort. Everyone in the gym said it was a great sign. We still aren't sure what to make of it. But, we know it was some signal which at this point it is was some of the better news we have recieve in the past 6 weeks. I know it's still early etc etc ... But in your opinion what does this mean? Is his ASIA class changing? Also, what other types of excerise should he concentrate on (while discharged in his brace and waiting to be re-admitted to the hospital rehab for more PT & OT)?

Thanks

[Wise Young]

Dr Wise,

My boyfriend has suffered a SCI in motorcycle accident recently, Feb 2008. His injury level is T4 and is classified as ASIA A complete. Is it possible for him to improve to some other ASIA class and/or become incomplete (that is ... with extensive PT sessions etc)?

I'm asking because we recently went to a SCI gym that has all sorts of rehab equipment. He tried the an active/passive bike (w/o elec. stim) and was able to continue pedaling when the bike was switched to the passive mode. He was also able to stop pedaling with considerable effort. Everyone in the gym said it was a great sign. We still aren't sure what to make of it. But, we know it was some signal which at this point it is was some of the better news we have recieve in the past 6 weeks. I know it's still early etc etc ... But in your opinion what does this mean? Is his ASIA class changing? Also, what other types of excerise should he concentrate on (while discharged in his brace and waiting to be re-admitted to the hospital rehab for more PT & OT)?

Thanks

Your friend needs a careful neurological examination by an experienced doctor who knows how to apply the ASIA classification system. It is possible that he has converted from ASIA A to ASIA C. This happens in about 15-20% of cases. As I pointed out earlier, getting to an ASIA C from an initial ASIA A does not have the same prognostic significance as having an ASIA C shortly after injury. On the other hand, it is a good sign.

It is important that I emphasize that exercise alone will not necessary improve function in people if they don't have enough connections. This is of course why it is necessary for us to have therapies that regenerate and regmyelinate the spinal cord. That is why we must do clinical trials to test therapies that have been reported to be beneficial in animal studies. I am optimistic that these therapies will regenerate part of the spinal cord.

Wise.

[Cory-M]

Thank you so much for the response it was more than I expected. I do fall more into the category of being a B that later became a C.

I am a regular forum reader so I'm up on most of your other posts on the subject, I just wanted a more specific definition and your answer was perfect.

I have used a locomotor training device where I was suspended upright in a harness over a treadmill, but I only got to do it twice. It was a place in Dallas near UT Southwestern and they lost funding or something it was almost 8 years ago.

Thanks

[Wise Young]

Thank you so much for the response it was more than I expected. I do fall more into the category of being a B that later became a C.

I am a regular forum reader so I'm up on most of your other posts on the subject, I just wanted a more specific definition and your answer was perfect.

I have used a locomotor training device where I was suspended upright in a harness over a treadmill, but I only got to do it twice. It was a place in Dallas near UT Southwestern and they lost funding or something it was almost 8 years ago.

Thanks

Cory,

People who have some preservation of sensation far below the injury site may recover walking. I have known several people who have done so. Below, I describe Carey Erickson who was ASIA B and became ASIA D. In fact, he is the reason why I defined "cure" of spinal cord injury as when a third party cannot tell whether the person had been spinal injured. Carey could walk well enough that most people would not know.

In China, I became convinced that a rolling walking platform is the best way to practice walking. A treadmill is not only expensive but requires too many people. A rolling platform requires only one person using ropes to lock the knees from the back. An elastic band can be used to prevent footdrop. They do not use other orthoses, which tend to limit movements. But, even the most intensive training did not restore walking in many patients.

We are now working on developing a standard set of walking exercises that would become part of our clinical trial protocol. This is obviously quite an ambitious task but I have become convinced that it is a necessary part of any regenerative clinical trial.

Wise.

[DeeLove]

Your friend needs a careful neurological examination by an experienced doctor who knows how to apply the ASIA classification system. It is possible that he has converted from ASIA A to ASIA C. This happens in about 15-20% of cases. As I pointed out earlier, getting to an ASIA C from an initial ASIA A does not have the same prognostic significance as having an ASIA C shortly after injury. On the other hand, it is a good sign.

It is important that I emphasize that exercise alone will not necessary improve function in people if they don't have enough connections. This is of course why it is necessary for us to have therapies that regenerate and regmyelinate the spinal cord. That is why we must do clinical trials to test therapies that have been reported to be beneficial in animal studies. I am optimistic that these therapies will regenerate part of the spinal cord.

Wise.

My boyfriend's neurologist did classify him as ASIA A - complete. But, I was more wondering if it was possibile for him to change to a different ASIA level and/or convert from complete to incomplete. Especially, since on the active/passive bike, he showed signs of some signals getting through to his legs....

Lastly, at this point in time, isn't extensive rehab excerise the best thing that a person CAN DO to help with recovery, if it only gets them in better shape both physically and mentally? (Besides flying around the world to try experimental cures etc.)

[Wise Young]

My boyfriend's neurologist did classify him as ASIA A - complete. But, I was more wondering if it was possibile for him to change to a different ASIA level and/or convert from complete to incomplete. Especially, since on the active/passive bike, he showed signs of some signals getting through to his legs....

Lastly, at this point in time, isn't extensive rehab excerise the best thing that a person CAN DO to help with recovery, if it only gets them in better shape both physically and mentally? (Besides flying around the world to try experimental cures etc.)

Let me repeat my answer again in greater detail. First, published statistics indicate that about 5% of people with initially complete ASIA A do convert to ASIA B or C. In my opinion, I think that number is higher, on the order of 15-20% if one waits long enough. Second, people often change from ASIA A to B or C more than 2 years after injury. For example, Christopher Reeve went from ASIA A to C after 2 years. In my opinion, sensory recovery can occur without much exercise or other activities. However, substantial motor recovery including walking requires systematic and daily exercise. Some people don't recover no matter what and how much exercise they do, because they don't have enough connections.

By the way, "complete" does not mean total loss of all connections. It just means the absence of voluntary motor and touch/pinprick sensory function below some level of the spinal cord. Many people with so-called "complete" spinal cord injuries still have axons crossing the injury site but the axons are not working properly. It is possible that some people may be spontaneously regenerating connections. Finally, it doesn't take many axons to restore function. Many studies of both animals and humans suggest that about 10% of the axons in the spinal cord is necessary and sufficient to restore substantial function, including walking.

Wise.