Archive for the ‘Spine Injuries’ Category

FES Equipment Coming to Baltimore’s Mount Washington Pediatric Hospital

Thursday, September 8th, 2011

Author - Sarah Keogh

Back in February, Jon Stefanuca wrote about a study in the Journal of Neurorehabilitation and Neural Repair about Functional Electrical Stimulation (FES) and the benefits it can provide to those individuals who have suffered spinal cord injuries. He explained how FES is able to provide electrical impulses to stimulate paralyzed muscles. The study’s authors found improvements based on using FES that led them to recommend using stimulation therapy in conjunction with occupational therapy for patients with incomplete spinal cord injuries. This technology is now also being used to help people with a wide range of injuries and illnesses including, stroke, multiple sclerosis, traumatic brain injury, and cerebral palsy, in addition to spinal cord injuries. According to the Christopher and Dana Reeves Foundation website, FES works by applying “small electrical pulses to paralyzed muscles to restore or improve their function”. The benefits can be extensive:

FES is commonly used for exercise, but also to assist with breathing, grasping, transferring, standing and walking. FES can help some to improve bladder and bowel function. There’s evidence that FES helps reduce the frequency of pressure sores. From: Christopher and Dana Reeves Foundation website

Improved Technology To Be Locally Available

Since FES was originally developed, the technology improved from being something that was typically integrated into large expensive equipment, such as exercise bikes and wheelchair based equipment, into smaller more portable devices. The good news for individuals with neuro-motor injuries in Baltimore City and the surrounding areas is that this type of FES treatment is about to become more available locally. At the end of August, Mount Washington Pediatric Hospital announced that they have received a “Quality of Life” grant from the Christopher and Dana Reeve Foundation. The article explains:

The money will help Mt. Washington Pediatric Hospital purchase Bioness® equipment for its Adaptive Equipment Rehabilitation Clinic (the clinic). The clinic works with patients with neuro-motor disorders to maximize their movement as much as possible given their physical limitations.

From Bioness.com

The Bioness website explains that they produce a variety of “medical devices designed to benefit people with Stroke, Multiple Sclerosis, Traumatic Brain Injury, Cerebral Palsy, and Spinal Cord Injury. These products use electrical stimulation to help people regain mobility and independence, to improve quality of life and productivity.” While I do not know what particular equipment will be available at the Mount Washington Pediatric Hospital, Bioness makes equipment to assist patients with hand paralysis, foot drop and thigh weakness among other conditions.

MWPH Uses Interdisciplinary Approach Combining FES and Therapy

The article about the grant explains some of the many wonderful things available for patients at the Mount Washington Pediatric Hospital (MWPH):

  • …[an] interdisciplinary approach to the assessment and management of adolescents and children with neuromuscular impairments, paralysis and/or movement disorders
  • … [a] team of 21 experienced specialists in physiatry, occupational therapy, and physical therapy.

The new equipment at MWPH will be used along with the other occupational and physical therapy options available to patients. A study described in US Neurology looked at stroke victims and found the combination of FES and traditional therapies that include repeated motion provide the best results:

Stroke patients with limited voluntary movement could now benefit from technologies such as functional electrical stimulation (fes) combined with necessary repetition of functional tasks (use-dependent plasticity) to enhance the neural repair process and improve outcomes, thus enabling them to begin to overcome their previous limitations and to improve their physical capabilities.

From Bioness.com

The goal at MWPH for children and adolescents is based on a similar idea:

Patients whose muscles can be retrained will require several months of therapy to gain normal range of motion and strength. For those patients with more severe conditions where muscles cannot be retrained, the Bioness® equipment will be used to augment their range of motion. Using these two therapy modalities, patients will acquire greater functionality, range of motion, muscle strength, and the ability to move independently.

This multi-disciplinary approach should allow these children and teens to have the best chances of improved motor use and the most independence in their future lives.

Related Articles:

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Wednesday, July 20th, 2011

image from msstrength.com

The online version of the journal Nature publishes an article today about a potential breakthrough in the treatment of spinal cord patients. While I do not have access to the full article, medicalnewstoday.com provides an overview of the research work. The highlight is that the researchers from Case Western Reserve University School of Medicine were able to restore breathing in rodents with spinal cord injuries.

This research provides optimism for similar success in humans (clinical trials with humans are hopefully forthcoming). In the recently released studies, the scientists combined “…an old technology a peripheral nerve graft, and a new technology an enzyme” to be able to restore 80-100% of breathing function in the rodents.

Using a graft from the sciatic nerve, surgeons have been able to restore function to damaged peripheral nerves in the arms or legs for 100 years. But, they’ve had little or no success in using a graft on the spinal cord. Nearly 20 years ago, [Jerry Silver, professor of neurosciences at Case Western Reserve and senior author,] found that after a spinal injury, a structural component of cartilage, called chondroitin sulfate proteoglycans, was present and involved in the scarring that prevents axons from regenerating and reconnecting. Silver knew that the bacteria Proteus vulgaris produced an enzyme called Chondroitinase ABC, which could break down such structures. In previous testing, he found that the enzyme clips the inhibitory sugary branches of proteoglycans, essentially opening routes for nerves to grow through.

In this study, the researchers used a section of peripheral nerve to bridge a spinal cord injury at the second cervical level, which had paralyzed one-half of the diaphragm. They then injected Chondroitinase ABC. The enzyme opens passageways through scar tissue formed at the insertion site and promotes neuron growth and plasticity. Within the graft, Schwann cells, which provide structural support and protection to peripheral nerves, guide and support the long-distance regeneration of the severed spinal nerves. Nearly 3,000 severed nerves entered the bridge and 400 to 500 nerves grew out the other side, near disconnected motor neurons that control the diaphragm. There, Chondroitinase ABC prevented scarring from blocking continued growth and reinnervation.

“All the nerves hook up with interneurons and somehow unwanted activities are filtered out but signals for breathing come through,” Silver said. “The spinal cord is smart.”

Three months after the procedure, tests recording nerve and muscle activity showed that 80 to more than 100 percent of breathing function was restored. Breathing function was maintained at the same levels six months after treatment”

From medicalnewstoday.com

This could be life-changing for those spinal cord injury patients who currently need ventilators to survive. If human studies prove the efficacy of such treatment, patients would have the hope of being able to breath on their own again. Not only would this dramatically improve these patients’ quality of life, but it would also provide a dramatically improved outcome for these patients. Currently, “[r]estoration of breathing is the top desire of people with upper spinal cord injuries. Respiratory infections, which attack through the ventilators they rely on, are their top killer.”

The BBC is reporting that “[r]esearchers hope to begin trials in humans. They are also investigating whether bladder function can be restored, which can be lost when the lower spine is damaged.”

The CDC’s most recent statistics, which are a few years old, suggest that there are currently about 200,000 people in the United States who are living with spinal cord injuries. This number increases by approximately 12,000-20,000 new patients annually. If some portion of these individuals could be provided hope for breathing on their own and or regaining bladder function, their lives could be dramatically improved.

Related Articles:

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Why early settlement is a win-win for all

Friday, May 20th, 2011

There is an old adage in the law that cases settle on the courthouse steps. There is a reason for that. When the parties are actually walking into court to try their case, they seem to suddenly recognize that there are significant risks to going to trial, and that there is serious money at stake. When you go to trial, only one side can win. The other side goes home a loser. Faced with such a stark outcome, both sides tend to become more reasonable in their assessment of their case and more willing to talk settlement. After all, despite all the years of experience that trial attorneys amass, no one can ever predict what a jury is going to do in any specific case. As one mediator I know likes to tell the litigants, going to court is like going to Vegas:  you roll the dice and you take your chances. So often times, the closer a case gets to the trial date the more motivated the two sides are to talk settlement. But is there a better way?

A couple of recent cases made me start to think about settlements and how they come about. (If you missed it, Brian Nash wrote an excellent piece on the frustrations of mediation and trying to settle cases). I’ve recently handled two cases that illustrate how settlements work and how two cases can go down dramatically different routes to ultimately get to the same place. Both of these cases are subject to confidentiality agreements so I can’t divulge the names of the parties or the settlement amounts, but they were both seven-figure cases with significant injury.

In the first case, the patient alleged that her doctor failed to timely diagnose stomach cancer over a period of several years. By the time the patient was properly evaluated by another physician, the cancer had progressed to the point that there was virtually no chance of a cure, and the young woman was likely going to die in the next few years. In the second case, the patient alleged that he suffered serious neurological complications (motor and nerve dysfunction in his arms and legs) as a result of post-operative complications that were not treated quickly enough. In both cases, a lawsuit was filed in court.  At that point, the two cases diverged.

Case Example #1 – Getting it done early

In the cancer case, before any depositions had taken place, the defense attorney called and asked if we might be able to talk about resolving the case. That’s always a great call to get as a plaintiff’s lawyer because it means there is a good chance that you will be able to get a nice result for your client, which is always the ultimate goal. Within a matter of weeks, we had reached an agreeable number and the case was over.

Case Example #2 – Grinding it out to the courthouse steps

In the second case, there was no early talk of resolution. The case proceeded through the normal course of litigation, which in the District of Columbia usually means about eighteen months of discovery, depositions, expert meetings, etc. Twenty-five experts were hired to review records and testify. Twenty-seven depositions ended up being taken. The case got all the way up to the Thursday before trial was scheduled to start on the following Monday morning. At that point, the parties finally reached agreement on a number and the case was settled.

Why the difference in approach?

So we have two cases, both with significant injury and both with questionable care. One case settled right away, and one dragged on for almost two years before settling. Is there a simple reason why? Not that I’ve been able to figure out. After years of doing this, I, like every other attorney, get a gut feeling as to what cases are worth, which ones will likely settle, which ones will go to trial. But it’s still a gut feeling; there’s no science involved.

It’s usually a combination of factors – the quality of the medical care, the severity of the injury, the likeability of the plaintiff and the defendant (more important than most people realize), the specific jurisdiction you’re in, etc. On top of these factors you have a myriad of psychological reactions that pop-up in lawsuits and there is no predicting those. Sometimes people get entrenched in fighting for no other reason than to fight. Some people get a number in their head for what a case is worth and don’t want to budge. So even though I can’t sit here and explain why certain cases settle early and some settle late, I do want to talk about the value of early settlements to all sides.

Common Sense and good economics say “get it done early”

It is easy to see why early resolution of cases benefits everyone, and it comes down to the costs of litigation. In today’s world, it can easily cost $75,000 to $100,000 (if not more in many instances) just in expenses to take a case to trial; it can easily be much higher in complex cases. (I know of one attorney who spent $300,000 on a case that he took to trial; he lost the case). These expenses consist primarily of expert fees paid to doctors to review records and testify. Expert doctors routinely charge at least $400 per hour and oftentimes more for their time. For trial testimony, doctors usually charge around $5,000 per day (some substantially more). If it runs into two days, that’s $10,000 just for one witness. It’s not unusual to spend tens of thousands of dollars for expert fees alone.

On top of that there is the cost of court reporters for each deposition, copying charges, obtaining medical records, long-distance calls, travel expenses, etc. Going through litigation is an expensive undertaking, and the longer the case goes on the more expensive it is. On the plaintiff side, all of those expenses are usually advanced by the attorney (in jurisdictions where this is permitted), but they all get paid back by the client at the end of the case (assuming the plaintiff wins; if there is no recovery, the plaintiff’s attorney “eats” those costs). So every dollar spent on litigation comes straight out of the client’s portion of the recovery.

On the defense side, insurers and self-insured institutions (like hospitals) have those same expenses, but on top of that, they also have to pay legal fees to their attorneys. Defense attorneys charge by the hour for everything they do on a file from reviewing records to meeting with clients to talking to experts to taking depositions. The complexity of medical negligence cases means long hours of work on each file, generating substantial legal fees. Those fees get paid to the defense lawyer whether the case is won, lost or settled at the last minute. The longer the litigation lasts, the higher the legal fees.

Of course it always costs money to investigate a case. There is no avoiding that.  Records need to be obtained and reviewed. Experts need to be retained for an initial opinion. But instead of spending $75,000 or $100,000 (or more) on a case, it may cost only several thousand dollars to work-up a case to get it ready to file – that is, to be in a position where early resolution can be discussed with the defendant. If a case can be settled early on, all of those thousands of dollars that would have gone to litigation costs go straight to the client. That is a huge benefit to the client.

The defendant benefits too. No hospital or insurance company wants to spend money needlessly. Early resolution means that the defendant doesn’t have to spend tens of thousands of dollars in expenses and tens of thousands more in legal fees. The only way it makes sense to spend that money is if, at the end of the day, the “defendant” (read insurer/hospital) believes it can either win the case or settle it for less down the road. But here’s the thing – a case can usually settle early on for less than the case would be worth had the case gotten closer to trial. This isn’t always true, of course, but as a general rule, a good case does not become less valuable over time.

Plaintiffs’ attorneys don’t undersell their cases to get an early settlement, but in practical terms, attorneys and clients are usually willing to consider some discount because they know that an early settlement is to their mutual benefit.The plaintiff gets a guaranteed financial payment now rather than waiting eighteen months for a trial and then a possible appeal that may drag the case out another two years. In that circumstance, the plaintiff is usually willing to take a little less money now because it is certain. It’s the age-old question: would you rather have X amount of money now, or wait eighteen months for the chance of getting more? For most plaintiffs, it’s an easy answer. Also the defense can pay less on a case than it would have ended up paying anyway and save thousands in expenses and legal fees by doing so. It’s a win-win for all parties.

Just do the math!

The big secret with early settlements (and which can sometimes be difficult to explain to a client) is that even though an early settlement might be for less than what a jury might award, the client can actually put more money in his or her pocket with a lower settlement amount. Again, we’re back to the issue of litigation costs. If a firm spends $10,000 to investigate a case and get it ready to file rather than $100,000 to take a case to trial, that is an extra $90,000 that goes straight to the client. Also, some law firms will have a contingent fee agreement in which the fee is higher (usually from 1/3 to 40%) when the case goes to trial, which serves to compensate for the additional time,  risk and expense of going to trial. When you consider the higher legal fees and the increased costs of litigation that have to be paid back, it can actually take a substantially larger jury verdict to put the same amount of money in the client’s pocket as he or she would get with a smaller early resolution.

Some cases may just need to be tried

I don’t mean to imply that every case that gets filed should be settled early. Far from it. Some lawyers undoubtedly file cases that are simply without merit and should be defended vigorously. Other cases – while they may be defensible – fall into a middle category where the care may not be the best but the plaintiff has problems with his/her case too. Some cases can be difficult to evaluate without further investigation and discovery to gauge the strength of the case. In those cases, it is entirely appropriate to proceed with litigation – even on a somewhat limited scale through discovery. No doubt there are instances where insurance companies do need to protect the interest of their doctors, and sometimes that means vigorously defending a case all the way through trial.

Some cases, however, – the cases where the medical care is truly egregious and the damages are clear – need to be looked at early on to see if the two sides can be reasonable and find some middle ground. If a case is going to ultimately settle (and believe me, experienced attorneys and claims adjusters can usually identify those cases early on), it makes sense to talk sooner rather than later. It requires compromise on everyone’s part, but the value to both sides is so great that it makes sense to talk early and get it done.

What has been your experience?

I’d be curious to know the experience of our readers. Has anyone been involved in a lawsuit that settled? Did it resolve early on or did it stretch out for years? Do you think the time involved had any impact on the amount of the settlement? Any tips or tricks you might suggest? Let’s hear from you – maybe we can all learn how to get these cases resolved earlier and stop wasting time, resources and money.

You may also want to read these related posts:

Frequently Asked Questions (FAQ’s)

A View from the Shady Side – The Defense Perspective

Every bad outcome does NOT a malpractice case make! Some practical advice

 

Laughing Gas Making Its Way Back Into The Labor And Deliver Department

Thursday, April 21st, 2011

According to a recent article published by MSNBC, laughing gas or nitrous oxide is making its way back into labor and delivery units in American hospitals. Although laughing gas has long been used as a pain relief in various countries, including Canada and the U.K., it has lost its popularity in the U.S. Well, maybe not for much longer.

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future. Dartmouth-Hitchcock’s plan is currently being reviewed by the federal government, and arrangements are presently being made for the procurement of delivery equipment for laughing gas. Vanderbilt University Medical Center may begin offering laughing gas as well later this year.

History

Laughing gas is not a new pain relief method. Its use had become very common in hospitals when Joseph Thomas Clover invented the gas-ether inhaler in 1876. Particularly, its use in the labor and delivery setting had been very common before the introduction of epidural and spinal anesthesia. Because laughing gas is unable to eliminate pain to the same degree as epidural or spinal anesthesia, it simply could not compete with the more sophisticated pain relief alternatives, which entered the marker in the 30s and 40s.

What is laughing gas?

Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula N2O. It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic effects. It is known as “laughing gas” due to the euphoric effects of inhaling it, a property that has led to its recreational use as a dissociative anesthetic.

Laughing gas as an important pain relief alternative

Although laughing gas can only take the edge off pain, it just might be an important alternative to other more conventional pain relief methods. The patient does not have to rely on an anesthesiologist to administer the gas. The patient can herself choose how much gas to administer at any time. The effects of the gas are not long-lasting. Therefore, the patient does not have to recover in a post anesthesia care unit. Importantly, there is no associated loss of sensation and motor function during the delivery process. As such, the gas does not interfere with the woman’s ability to breath and push during labor. Laughing gas is also not known to have any adverse effects on the baby in utero.

The administration of laughing gas does not require any invasive medical procedures. By contrast, consider epidural anesthesia: An epidural requires that an epidural catheter be threaded into the epidural space, which is only about 2 mm wide. Any mistake and the consequences can be catastrophic. Epidurals have been known to cause spinal cord injury secondary t0 toxicity, spinal cord infarcts, severe hypotension, paraplegia, epidural bleeding, and even death. None of these complications are associated with the use of laughing gas.

: httpv://www.youtube.com/watch?v=1TO4sOgiIeU]

According to Suzanne Serat, a nurse midwife at Dartmouth-Hitchcock Medical Center:

We have a number of people who don’t want to feel the pain of labor, and nitrous oxide would not be a good option for them. They really need an epidural, and that’s perfect for them. […] Then we have a number of people who are going to wait and see what happens, and when they’re in labor, decide they’d like something and then the only option for them is an epidural but they don’t need something that strong. So they would choose to use something in the middle, but we just don’t have anything in the middle.

Nitrous oxide may just prove to be that middle option for many women who prefer to give birth without the use of powerful and potentially dangerous analgesic/anesthetic agents. If you are an expectant mother, ask your obstetrician if nitrous oxide is a pain relief option that may be available to you during labor.

Image from cartoonstock.com

For more information about epidural anesthesia and epidural complications, you may want to read these posts too:

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

5 Questions to Ask Your Obstetrician Before You Go to the Hospital

Epidural Analgesia – What Should an Expectant Mother Consider? What are the risks?

The daily struggle of raising a disabled child

Thursday, February 24th, 2011

Parents must cope with daily concerns of special needs children

Like many parents, I am blessed to have healthy children.  I take it for granted that my kids are smart, active, well-adjusted.  I don’t even have to think about their health other than the occasional cold or earache or sprained ankle. Others are not so fortunate.

This past weekend I was reading in Maryland Family Magazine an article about a local college professor who wrote a book about raising a son with severe autism.  After writing the book, he assumed that a major publisher would have interest. He ended up being turned down by some agents who told him that without a happy ending or a cure, there was no way they could market the story. Apparently, the public wants stories about disability to have a Hollywood ending. (A publisher finally did come along that agreed to publish the book).

This, in turn, made me think of a good friend of mine (I’ll call her Jane), who has a disabled son (autism spectrum) in addition to three normal children. I hesitate to use the words normal and disabled for two reasons:  1) we live in a politically correct world where deciding what label to apply to anything means stepping into a social minefield; and 2) on the spectrum of mental or physical ability, it can be difficult to say what exactly is normal versus abnormal. I never want to suggest that children with limitations are abnormal. Some parents even bristle at the term “disabled.” Others use the more cumbersome term “neurotypical” rather than the term “normal.” You can see that it can be hard to discuss the topic of disability when we don’t even have terms we can all agree on.

Jane and I often discuss our kids and parenting. She has been very candid with me in describing how incredibly hard it is to raise a disabled child. She believes that no one really wants to hear the negative side of raising a child with special needs. Like the publishing agents that the professor encountered, some people only want to hear about the inspirational side of the story. Truth is, there is not always a happy ending or miracle cure when raising a disabled child, be it autism or cerebral palsy or paraplegia. These are life-long disabilities. There are happy moments, of course, as well as accomplishments both major and minor, but for parents raising a disabled child, it is a daily struggle to make sure that the child gets the medical care and therapy and attention that he or she needs. Parents undertake this monumental and thankless task not because they hope for some Hollywood ending, but because they love their child and they do what they need to do, even if they never knew they had such strength and determination in them.

It’s not all negative, of course. Jane tells me all the time how much she loves her son and how he has taught her so much about herself and about life. She says she cannot imagine who she would be without her son. At the same time, however, she also feels a lot of pain and loss and regret about what she and her family have had to sacrifice in order to care for her disabled son. The daily struggle can truly be overwhelming at times. Jane believes that parents often feel unable to express these feelings for fear of being branded a less-than-stellar parent. As she told me, “There isn’t a safe place to express one’s own doubts about being able to effectively take care of another person who requires so much care. It’s daunting, hard and stressful and for some reason it’s not completely OK to admit that.”  Jane is careful about the sentiments she expresses in public versus those she tells to her friends:

There is the aspect of autism that you are allowed to talk about versus not allowed. I’m allowed to admit it’s hard, but I can’t really say how hard or I’m too negative. I’m just supposed to say it has changed my perspective and I’m blessed.  It has changed my perspective but I’m not blessed. Shut up about being blessed.

While disabilities are all different and every parent’s story is unique, there is a common thread that runs through them all – raising a disabled child takes its toll on the parents and the family as well as the child. The challenges can be enormous. Some of the more common challenges include:

  • Financial:  Finding ways to afford medical care, therapy, services;  working with insurance companies and various state agencies;
  • Educational:  Struggling with teachers and school administrators to make sure that your child is getting an appropriate education and Individualized Education Program or IEP.
  • Medical:  Finding doctors who are willing to take the time to listen to your concerns and diagnose your child; getting referrals to specialists; sorting through the myriad hoops of insurance; finding therapies that work for your child;
  • Social:  The loss of normal everyday activities like going out to dinner, taking trips, seeing friends; not having anywhere to turn to talk about what they are going through.
  • Marital:  A couple often experiences difficulty because of all the other stresses that are created by having a disabled child, as well as the substantial time investment that is required.
  • Family: Other children in the family can be affected because mom and dad have to devote so much time to the disabled child and because the family’s usual routine and activities are disrupted; money can often be tight.
  • Psychological: Many mothers experience feelings of guilt, wondering if it was something they did during pregnancy that caused their child to have this disability.
  • Legal: Figuring out what rights you and your disabled child have, what services you are entitled to.

I can’t say enough about those parents who take on these challenges on a daily basis.  It is difficult to even imagine the level of devotion and commitment that is required.  I welcome all parents to share their stories — the good and the bad — so that the rest of us can try to better understand the reality of raising a disabled child.  In future blogs I will talk about some of these challenges in more detail and where parents can turn for assistance.

Image from metroparent.com

New Treatment Holds Promise for Patients With Spinal Cord Injuries

Wednesday, February 23rd, 2011

According to a recent article in Medical News Today, Functional Electrical Stimulation (FES) can significantly reduce disability caused by spinal cord injuries. The study was originally posted on line in the Journal of Neurorehabilitation and Neural Repair.

This relatively new treatment applies small electrical impulses to stimulate paralyzed muscles. The treatment has been shown to measurably improve a patient’s ability to pick up and hold objects. Dr. Popovic and his team concluded that FES should be used in conjunction with traditional physical therapy.

To see how this works, here’s an incredible demonstration by Children’s Hospital of an FES bicycle.

httpv://www.youtube.com/watch?v=27vIfWdB3wk

Here are some key facts about this study:

  • FES therapy uses low-intensity electrical pulses generated by a pocket-sized electric stimulator.
  • Unlike permanent FES systems, the one designed by Dr. Popovic and colleagues is for short-term treatment. The therapist uses the stimulator to make muscles move in a patient’s limb. The idea is that after many repetitions, the nervous system can ‘relearn’ the motion and eventually activate the muscles on its own, without the device.
  • The randomized trial, believed to be the first of its kind, involved 21 rehabilitation inpatients who could not grasp objects or perform many activities of daily living. All received conventional occupational therapy five days per week for eight weeks. However, one group (9 people) also received an hour of stimulation therapy daily, while another group (12 people) had an additional hour of conventional occupational therapy only.
  • Patients who received only occupational therapy saw a “gentle improvement” in their grasping ability, but the level of improvement achieved with stimulation therapy was at least three times greater using the Spinal Cord Independence Measure, which evaluates degree of disability in patients with spinal cord injury.
  • Based on their findings, the study’s authors recommend that stimulation therapy should be part of the therapeutic process for people with incomplete spinal cord injuries whose hand function is impaired.
  • Dr. Popovic’s team has almost completed a prototype of their stimulator, but need financial support to take it forward. Dr. Popovic thinks the device could be available to hospitals within a year of being funded.One limitation of the study is that the research team could not get all participants to take part in a six-month follow-up assessment. However, six individuals who received FES therapy were assessed six months after the study. All had better hand function after six months than on the day they were discharged from the study.
  • Dr. Popovic stresses that FES therapy should augment, and not replace, existing occupational therapy.
  • Another study, now underway, will determine whether stimulation therapy can improve grasping ability in people with chronic (long-term) incomplete spinal cord injuries.

If you or a loved one suffer from spinal cord injury, please consult with a physician about FES. In conjunction with physical therapy, this non-invasive medical procedure promises tremendous benefits to patients with spinal cord injuries. If you are aware of other studies or treatment relating to rehabilitation from spinal cord injuries, we encourage you to share your knowledge with our readers.

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Friday, February 11th, 2011

Hope for those with paraplegia?

Researchers in the U.K. have developed a revolutionary microchip muscle stimulator that will enable patients with paraplegia to exercise multiple muscles at the same time. According to the Engineering and Physical Sciences Research Council (EPSRC), the microchip developed by Professor Andreas Demosthenous from University College of London and his team is truly unique.

The microchip chip is small enough (approximately the size of a child’s fingernail) that it can be implanted directly into the spinal canal. Unlike previous models, the new implant incorporates the muscle stimulator and the electrodes into a singular unit.  The unit is properly sealed to protect against moisture, which could lead to corrosion of the electrodes.

The creation of the implant has been made possible by new laser processing technology, which enabled researchers to micro-pack all components into one unit. With this new laser technology, researchers were able to cut much tinier electrodes from platinum. The electrodes are then folded into a 3D shape that resembles pages in a book. Each electrode can be wrapped around a nerve root. The electrode is then welded to the microchip located in the spinal cavity.

Because the implant comes with multiple electrodes, which can be connected to multiple nerve roots, it is capable of controlling entire muscle groups. In patients with paraplegia, the devise can be used to stimulate or trigger multiple paralyzed muscles at the same time. Researchers also claim that the new device will also be used in patients with bladder or bowel incontinence.  Because the device has multiple electrodes, some electrodes can be connected to nerve roots that control bladder muscles or nerves that control bowel capacity.

Although all of this may sound a bit scifi, the implant will be available for pilot studies sometime this year. If you or someone you know is paraplegic, this research is worth following. It clearly promises to offer life-chaining benefits to patients with paraplegia. If you know of other research on similar devices, we’d love for you to share that information with our readers. We’ll try to keep an eye on the progress and implementation of this device from the UK and keep you posted if and when developments occur.

Neck & Back Pain: When is it something more serious?

Wednesday, December 22nd, 2010

Statistically, 4 out of every 5 adults under the age of 50 have experienced at least one episode of neck or back pain.  For most people, the symptoms resolve in a reasonable period of time with or without intervention.  For others, the symptoms become chronic, often leading to surgical procedures and even disability.  Sometimes, there is a specific identifiable incident that incited the pain while in other cases, no particular injury or overuse syndrome could be identified.  Neck and back pain are one of the most common complaints leading to medical evaluations in the emergency room, urgent care center or primary care physician’s office; they are also a significant cause of lost time from work, lost wages and productivity, and high expenditure from a healthcare perspective.

Neck and back pain are symptoms of an underlying problem.  The majority of the causes (~97%) are purely mechanical, that is related to the mechanics of movement of the neck or back, involving the bones, muscles, ligaments, discs and joint spaces.  They include such diagnoses as lumbar strain/sprain, degenerative disc disease, herniated discs, spinal stenosis, spondylolisthesis, osteoporotic compression fracture and traumatic fractures.  Some of these, obviously, are more serious with potential neurologic sequellae than others.  Any condition that results in compression of the spinal cord can cause permanent neurologic injury, including paralysis; these include fractures, stenosis and significant spondylolisthesis. Causes include acute traumatic injuries (car accidents, falls, direct blows), overuse syndromes, poor lifting techniques, poor posture, chronic degenerative arthritis leading to spinal stenosis and spondylolisthesis, and osteoporosis.

The remaining 3% of causes of neck and back pain are considered non-mechanical, but they can be further divided into non-mechanical spinal conditions (1%) and visceral (internal organ-related) conditions (2%).  Of the non-mechanical spinal conditions, neoplasias/malignancies comprise 0.7% while infections and inflammatory arthritides (inflammation of joints due to infectious, metabolic, or constitutional causes) comprise the remaining 0.3%.  Of the 2% visceral complications, etiologies are potentially due to vascular problems (aortic aneurysms, retroperitoneal hemorrhage, coronary syndromes, etc.), prostatitis, endometriosis, pelvic inflammatory disease, kidney stones/infections, pancreatitis, cholecystitis or ulcer perforation.  Thus, the sub-categories of non-mechanical neck and back pain have very small incidences in the global sense, but they are potentially more serious with more ominous consequences, including paralysis and death, making them diagnoses not to be missed or ignored.

So, how can one tell the difference between mechanical versus non-mechanical neck or back pain?

As a general rule, mechanical neck/back pain, since it is related to movement, is typically worse with movement or specific body positions and better with rest or lying supine without the burden of one’s weight causing an axial load on the vertebral column.  Non-mechanical neck/back pain is relatively constant and not related to body position or movement.  Pain in either case can be sharp or dull/aching, and each can have instances in which there is neurologic involvement causing pain to radiate along the nerves that exit the spinal column.  In the neck, nerve pain typically radiates to the arms causing pain, numbness and sometimes weakness.  In the upper to mid-back, nerve pain typically radiates to the anterior chest and abdomen.  In the lower back, nerve pain typically radiates into the pelvis, genital area, and especially the legs.  Radicular pain can be either one-sided or bilateral, the latter of which is more ominous and indicative of spinal cord compression as opposed to a single peripheral nerve root.

What are the “red flags” that raise concern for more serious problems?

There are specific risk factors that, when present, raise concerns for more systemic disease processes.  A history of cancer, for instance, increases the likelihood of the pain being related to a metastatic lesion or tumor.  Presence of a fever increases the likelihood of the pain being related to an infectious etiology.  Unexplained weight loss increases the likelihood of the pain being related to either a primary malignancy or metastatic cancer.  A history of intravenous drug use or even diabetes increases the risk for an acute or chronic infectious cause.  Blood in the urine can indicate a malignancy or other kidney-related problem.  Swollen glands can be indicative of a malignancy or infectious problem.  Anemia can be indicative of an underlying malignancy or vascular problem.  Rashes are often associated with rheumatologic or auto-immune problems that often involve the joints.  Chronic steroid use or other immunosuppression can increase the risk of infectious causes or osteoporosis with compression fracture.  Obviously, a history of trauma increases the risk of fracture, disc rupture/herniation and ligamentous injury leading to spinal instability, but it can also be a cause of intra-abdominal injuries or retroperitoneal injuries that present as back pain.  Any time there are neurologic deficits (numbness, tingling, weakness, muscle atrophy, etc.) beyond sciatica, the risk of nerve compression or spinal cord compression becomes higher.  Abdominal pain associated with back pain can be related to an intra-abdominal process (infection, abscess, aneurysm, ulcer perforation, etc.).  Neck pain that is associated with headache, fever and neck rigidity is often indicative of menigitis.

Overall, there are a plethora of potentially serious causes of neck and back pain.  One can see that the diagnosis of more serious conditions can be a little more complicated, especially since they are much rarer than the  common, everyday, garden-variety mechanical back pain without complications.  There are, however, a variety of clues that can lead one to an accurate and relatively rapid diagnosis.  The intention of this blog has been to introduce the topic and the dilemma faced by a provider when diagnosing these conditions.  Since the topic is broad and more complicated, a series of blogs dedicated to some of the more devastating etiologies of neck and back pain will follow.  The key to diagnosing any condition is an accurate and in-depth history and physical examination with keen attention to specific clues that are typically present.