Cord Injuries: Science Meets Challenge
by Audrey T. Hingley

After days of cramming for college mid-term exams while
holding down a full-time job as a security guard, Marc Miller
needed a break. So Miller and two friends made the rounds
of three Richmond, Va., nightspots before going their
separate ways at evening's end.

"I was more tipsy than normal, but I felt fine. I drove out of
the parking lot where we had left our cars, and reached over
to roll down the passenger window. That's the last thing I
remember," Miller recalls. "It was so quick. Suddenly my
whole life was changed."

In that instant, his '84 Toyota pickup truck had crossed to the
other side of the road, slamming into a telephone pole. On
that April 1989 evening, Miller went from carefree college
student to paraplegic, joining the 10,000 Americans paralyzed
by spinal cord injury each year. After a two-month hospital
stay, he returned to college, earning an associate degree in
architectural engineering. Now 26, he works full-time as an
engineering technician, and lives in Richmond with his wife,
Kimberly, 24, whom he met on the job.

"I'm lucky. I have a good job, I play wheelchair basketball, I
can still have sex, and I found someone I really love. I
couldn't have made it without my friends and family. I wasn't
very close to my mother before the accident; now we're really
close. I also got very close to my faith in God. Being in a
wheelchair gives you a different perspective," he says. "But
life is harder. You battle bladder infections. If you get sick,
it's harder. I get irritated more easily, and occasionally I get
depressed. Life is more of a struggle. It's a struggle to get in
and out of cars--just driving to Hardees for an iced tea is
exhausting."

Comebacks like Miller's would have been unheard of as
recently as the World War II era, when 90 percent of spinal
cord-injured patients died. It wasn't until the late 1960s and
early 1970s that survival rates began approaching 90 percent,
primarily due to advances in handling bladder problems.
Today, estimates of the number of people living with spinal
cord injuries vary from 200,000 to 500,000.

Spinal Cord Complex
Spinal cord injury is devastating because of the complexity,
delicacy and importance of the spinal cord itself. Containing
more than 20 million nerve fibers, it is the major conduit for
transmitting motor and sensory information between brain
and body. It runs vertically within the spinal column,
composed of 33 vertebrae separated by rubbery disks.

The nerve signals that travel the spinal cord help regulate
sensation, movement, and bodily functions, such as bladder
control. When the spinal cord's axons (long fibers that nerve
cells send out) are damaged, paralysis can result. Axons
transmit nerve signals from cell to cell, so when they're
destroyed the cells can't communicate, causing loss of
functions controlled by the affected cells.

Spinal cord injury affects a number of body functions.
Bladder control is usually impaired, and sometimes
completely destroyed. Some people retain involuntary reflexes
that help empty the bladder, but others have completely
flaccid bladder muscles. Urine left in the bladder breeds
infection, which can become chronic and cause kidney
damage. Bowel management is another challenge, since
messages from brain to bowel to empty don't get through,
and anal sphincter muscle control is lost. Then there are skin
problems like bedsores, common to wheelchair patients.
The location of a spinal cord injury helps determine the level
of disability: The higher the injury on the spinal cord, the
more extensive the paralysis. Injury above the C7 vertebra
results in quadriplegia-- impaired function in arms, trunk,
legs, and pelvic organs. Paraplegia results from damage done
to the thoracic, lumbar or sacral regions of the spinal cord.
Although arm function is spared, the trunk, legs, and pelvic
organs may be involved, depending on the level of injury.

Advances Bring Hope
For many years, medical experts considered extensive
recovery of body function after spinal cord injury hopeless.
This is because in most mammals, nerve cells of the central
nervous system (brain and spinal cord) show little evidence of
being able to regenerate when damaged. But today,
researchers and clinicians alike share optimism about
improvements for people with spinal cord injuries. Electrical
stimulation of muscles, use of restorative devices, drug
therapy advances, and advances in nerve regeneration
research are bringing hope to an area long deemed hopeless.
"Since the Vietnam war, there have been significant clinical
advances as research centers across the country learned how
to care for severely debilitated quadriplegic patients," says
Paul R. Beninger, M.D., M.S., acting director for the Food
and Drug Administration's division for general and
restorative devices. "For example, use of automated
wheelchairs became commonplace after the Vietnam war,
and the pulmonary care of patients improved."
FDA regulates devices like motorized wheelchairs, but does
not regulate accessories like mechanized van lifts for
wheelchairs. A stair-climbing motorized wheelchair that FDA
approved three years ago is a recent advance in devices for
patients with spinal cord injuries. The sophisticated chair has
sensors that monitor the steepness of stairs, altering both
position and speed depending on incline. But the chair is
expensive (about $20,000) and heavy; home stairways need
inspection to verify their capability for handling the weight.

Muscle Stimulators
Muscle stimulators using electrical currents that stimulate
muscles to contract, especially FES systems (functional
electrical stimulation), have been the focus of much media
attention. Some FES systems under development are
enabling paralyzed people to walk again. Such systems
operate as a kind of complex prosthetic device, meaning that
although the stimulation can cause muscles to contract and
legs to move, it is a kind of  "artificial" walking, since no
actual movement has been regained by the patient and there
is no sensation of movement.
Other FES systems stimulate nerves to give hand movement
so quadriplegic individuals without hand function can feed
themselves. But FES systems are not without drawbacks:
They aren't for everyone, they're costly and still largely
experimental, and surgery to implant electrodes is required,
which can pose possible complications.
Stimulators aren't just for walking or movement. For
example, FDA-approved phrenic nerve stimulators allow
people with high-level spinal cord injuries to breathe without
respirators. (The phrenic nerve goes from the spinal cord to
the diaphragm, and activating it causes the diaphragm to
contract). But again, there are use limitations; the phrenic
nerve has to be healthy. Robert F. Munzner, Ph.D., chief of
FDA's neurological devices branch, estimates that only a few
hundred people nationwide can use the device.
According to Marie A. Schroeder, a physical therapist and
chief of FDA's restorative devices branch, many muscle
stimulators have been cleared for marketing, but not
specifically for functional purposes.

"For example, if some muscles are not totally paralyzed and
doctors want to see how much improvement in movement or
feeling someone will get, they may use a stimulator to
maintain range of motion to help provide muscle reeducation,
until they see how much voluntary control the patient gains,"
she explains. "But using stimulators for functional purposes
gets into the investigational area. The only functional use of a
muscle stimulator that has been cleared are those stimulators
that might be used for a patient with a localized nerve injury-
-for example, a patient who can't lift his foot up. However,
we consider the stimulation of muscles needed for the
purpose of walking to be investigational."

Physicians surveyed say electrical stimulation is not being
widely used on a routine basis because the technology is not
yet "user-friendly." William O. McKinley, M.D., director of
spinal cord injury and rehabilitative medical services at The
Medical College of Virginia, notes that devices that assist
paralyzed patients in coming to a standing position, for
example, are "very expensive, very time-consuming to learn,
and usefulness has to be determined on a patient-by-patient
basis."

Many other uses of stimulators are not common or remain
investigational. For example, although stimulators that offer
pain prevention and electro-ejaculation to collect sperm to
enable paralyzed men to become fathers are used clinically,
their use is not widespread.

F. Terry Hambrecht, M.D., head of the neural prosthesis
program at the National Institutes of Health's National
Institute of Neurological Disorders and Stroke, says such
systems are still technologically limited, but he is optimistic
about the future.

"The problem now is that we're in the Model-T stage. We
don't yet have the sophistication and reliability we need," he
admits. "But there's no doubt in my mind that eventually
functional stimulation devices will be developed for spinal
cord-injured patients. We're funding quite a few projects for 
people who are paralyzed."

Hambrecht says one current project involves electrode
implantation to restore bladder and sexual function to
paralyzed men and women. He anticipates the first implants
will be done within five years.

Drug Treatment
Muscle stimulators have provided drama, but the steroid
methylprednisolone, experts say, has actually changed the
face of clinical treatment for people with spinal cord injuries.
A recent report of a 1985 to 1989 study of 487 patients,
funded by the National Institute of Neurological Disorders
and Stroke, showed that patients given high doses of this
cortisone-like drug within eight hours of injury regained an
average of 20 percent of lost motor and sensory function.
Experts cite the study as the first evidence that a medication
can improve the outcome of spinal cord injury, and today the
drug is widely used for acute spinal cord injury.

Surgeons use the potent drug, which was approved some
years ago by FDA as an anti-inflammatory agent and is also
approved to treat swelling around the brain, to manage acute
attacks of multiple sclerosis and for a variety of allergic
conditions.

Wise Young, M.D., Ph.D., part of the methylprednisolone
study team, is a professor of neurosurgery, physiology and
biophysics and director of the neurosurgery research lab at
New York University Medical Center. Young points out that
the drug does not enable patients to immediately "leap out of
bed." Beneficial effects are usually not apparent until at least
six weeks after the drug is administered. Yet he believes the
use of the drug is a landmark development.

"It has changed the attitude of doctors toward spinal cord
injury. They no longer see it as a hopeless condition, and
patients are rushed to hospitals earlier," he explains. "It also
has tremendous implications for chronic spinal cord injury,
since the finding that you only need a few axons to get
function back means you don't have to regenerate as many
axons."

"Currently there are over two dozen drugs reported to be
neural-protective in animals," Young says. "The leap that was
made in 1990 was between absolutely no hope to some hope.
There is a real sense of optimism now; it's not a matter of if,
but when, a drug will be available to aid regeneration of the
spinal cord."

Treatments Under Study
Another drug under study is GM-1 ganglioside. Fred H.
Geisler, M.D., Ph.D., a neurosurgeon at the Chicago
Neurosurgical Center, headed a team at the University of
Maryland Shock Trauma Center in Baltimore that studied 34
people with paralyzing spinal cord injuries in a placebo-
controlled, double-blind, randomized study.

The study results were reported in the June 27, 1991, New
England Journal of Medicine. Within three days of injury, 16
of Geisler's patients began daily injections of GM-1 for 18 to
32 days, while the rest received placebo injections. Patients
given GM-1 had improved recovery of motor functions in the
arms, and later in the legs. About half of the improvement
occurred at the  two-month mark. Most of the improvements
happened within four months of patients' receiving GM-1
injections, but some improvements continued for up to one
year after GM-1 treatment.

Researchers theorize that GM-1 ganglioside, naturally
present in cell membranes of the spinal cord and brain, helps
protect against additional nerve cell death after spinal cord
injury and also stimulates nerve-fiber growth and repair.
"We saw some major improvements. ... In many cases, people
were walking where they could not ambulate at all before,"
Geisler says. He is now heading a new study of this
investigational drug, following 166 patients given GM-1 at 22
medical centers in North America. Geisler says the goal is to
enroll 720 patients.

Neural grafting, or transplantation of tissue into the brain
and spinal cord, is still highly experimental. Possible sources
of grafting material include genetically engineered cells,
human fetal tissue, and other tissues from a patient's own
body. Neural grafts are being tested in animal models of
brain and spinal cord injury to find out if they can induce
growth or replace damaged areas.

Other Improvements
Other factors besides drug advances and technology are
improving the outlook for people with spinal cord injuries.
Car accidents by far remain the number one cause of spinal
cord injuries (47.7 percent), followed by falls, gunshot
wounds, and recreational sports, particularly diving accidents.
Spinal cord injury happens mostly to young people, and
mostly to males (82 percent).

MCV's McKinley says improvements in on-site emergency
medical management, with better-trained technicians skilled
in stabilizing the spine to prevent further injury, means
doctors are seeing more patients with "non-complete" injuries,
or injuries where some function and motor sensation is
preserved.

"We are also doing a better job of educating people in how
to protect against spinal cord injury, such as wearing seat
belts, buying cars with air bags, and not diving into shallow
water," he says.

In rehabilitation, the emphasis remains on regaining as much
functional ability as possible.

"Chronic patients and rehabilitation are the real challenge.
Research is exciting and potentially part of the future, but it
still has a long way to go," McKinley says, pointing out that
helping patients through the adjustment period after injury
remains challenging. "They need to know how to self-
catheterize, how to detect bladder infections," he says. "Are
the doors at home wide enough for a wheelchair? Do they
need a ramp?"
McKinley says the first thing newly injured patients ask about
is their ability to walk, but questions about sexuality are not
far behind.

"Paralysis can affect the ability to have an erection. ... But
with adaptations, sexual relations are very possible. So I tell
patients yes, it's possible, but different. Loving and caring and
other means of sexual gratification take on new priority for
injured patients," he explains.

 Hope and patience may be the most important factors
regarding the future treatment of spinal cord-injured people.
Hope comes from optimism about recent advances in
treatment, but research complexity and funding issues make
patience necessary as well.

"For at least the last decade, research papers have shown that
spinal cord injuries can be improved, or that the amount of
injury can be decreased," Geisler says. "My hope is that lab
findings will be able to move to the clinical area."
Marc Miller, like many people with spinal cord injuries, is
both optimistic and philosophical about the treatment
advances.

"I think in the next 10 years they will find treatments that
reduce the impact of spinal cord injuries. But I think it's
important for people to remember that we're just normal
folks who can't walk," he says. "I have a better grasp of who I
am now; being in a wheelchair gives you a different
perspective. I'm not disabled, I just can't walk. I play
wheelchair basketball, I want to learn to water ski and to
snow ski. ... I just want to do all I can do now." n

Audrey T. Hingley is a writer in Mechanicsville, Va.
For More Information
The American Paralysis Association, an organization
dedicated to eliminating paralysis, provides a 24-hour toll-free
information and referral hot line, at (1-800) 526-3456. The
hot line helps callers search for support and resources on
everything from sexual concerns to selecting a rehabilitation
facility.

The National Spinal Cord Injury Association also provides
information and resource help at (1-800) 962-9629. 
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