Activity-based rehab news roundup.
Two articles came out in print and online in recent days, both featuring the clinical application of rehabilitation strategies that have evolved from years of laboratory studies. The first is “Spinal Stimulation Gets Paralyzed Patients Moving
,” from Spectrum, a publication of the IEEE, Institute of Electrical and Electronics Engineers, an organization that goes back to the mid 18th century, to Thomas Edison and Alexander Graham Bell.
The piece, by freelance science writer Emily Waltz, offers rich detail to the story of Dustin Shillcox, the fourth patient to get an epidural stimulator implant at the University of Louisville lab of Susan Harkema
. Shillcox was spinal cord injured three years ago in Wyoming. Eventually he heard the buzz about Rob Summers, Harkema’s first patient to get the epidural stim application and subsequently, the poster boy for unprecedented recovery.
Shillcox got invited to Louisville and qualified for the experiment. Waltz reveals much about how the work is done, the equipment used, and with an eye on the electrical engineer nerds in the readership, the specific limitations of the technology.
From the article:
Choosing the right electrode configurations for standing requires both a tremendous amount of intuition and plenty of trial and error. “That’s the challenge: to create the electrical field that’s going to give you the desired behavior,” says Harkema.
The possible electrode combinations are daunting; technicians at CalTech are hoping to develop predictive algorithms to make this easier. From the piece:
Each time Harkema changes the configuration of electrodes, she has to turn off the electric field they generate and start over at 0 V. It’s a safety feature of this off-the-shelf stimulator, but it destroys the body’s neural momentum. “You can get really close, and you think the person is almost standing independently, and if you could just shift the field a little you would have it. But you can’t. You have to go to zero. And then everything starts over,” says Harkema. The limitation makes it especially difficult to induce a stepping motion in her patients. “It’s a left-to-right problem. If we get the right leg to step, the left is doing nothing,” she says.
It doesn’t help that there are something like 4.3 x 10 to the seventh power possible electrode patterns she can try and that each can be tried with a range of frequencies and voltages. Without an algorithm to help her choose parameters, Harkema must rely on her experience, some limited neural mapping data, and what she sees on her monitors. “I have to look at the EMG data whizzing by and then make decisions about what I can change out of these 4.3 x 10 to the seventh combinations to get it better,” says Harkema. She’s gotten pretty good at making adjustments, but she acknowledges that no one can fully interpret the nuances of all that EMG data.
If Waltz knew whether or not the epidural stim was successful in Shillcox, she’s not saying -- I’m assuming out of respect for Harkema’s reluctance to reveal data ahead of peer-review. I haven’t seen data either but Harkema’s team has said publicly that all four patients in the epidural stimulation experiment, including Shillcox, regained significant autonomic function, including bowel and bladder sensation.
From the article:
Shillcox—subject No. 4—remains hopeful, but he’s trying to keep his expectations realistic. “I don’t want to be too optimistic, and I’m trying to be prepared for no results at all,” he says. “I hope that whatever they find from this research will at least benefit other people.”
The other publication of note is a four-part series in the Denver Post called “Stepping Toward Hope,” about innovative activity based rehab strategies being utilized at Craig Hospital, located in a Denver suburb.
The series began on Sunday
, telling the history of locomotor training and activity based rehab through the experiences of James Nall, a paraplegic who found his way to Craig. Again, the work of Susan Harkema takes center stage: Craig added a bunch of new rehab equipment and recently joined the NeuroRecovery Network
, a Reeve Foundation effort to establish best practices and clinical guidelines for locomotor training
(assisted ambulation suspended above a moving treadmill).
Part two, “Rehab centers adopt motion-based treatments for spinal-cord patients
,” takes on the big question: Will I walk again.
The reporter, Michael Booth, quotes Dr. John McDonald, who made a name for himself ten years ago by encouraging Christopher Reeve to embrace a full-on activity program, and who now runs an aggressive rehab program in Baltimore.
"Even those who don't get movement recovery can offset those huge quality-of-life issues from accelerated aging," said Dr. John McDonald of Johns Hopkins' Kennedy Krieger Institute.
"Will I walk again?" McDonald quotes his patients' immediate question. Since he began practicing in 1998, McDonald said, "The answer is quite different: There's a chance of recovery, and the only thing I can tell you is that the probability of your recovery is 100 percent dependent on your effort. We won't know unless you try."
Booth covers the brief history of locomotor therapy, pluses and minuses. He also offers a long sidebar on Amanda Boxtel
, who uses an exoskeleton device, indeed. to walk again.
"When you sit, the body atrophies," Boxtel says. "Now there are no excuses. No reason for us to ever hear the words 'You'll never walk again.'
"Instead, the doctors will say, 'You'll just walk differently. ... Let's show you how.' "