Questions and Answers about Christopher Reeve's Recovery of Movement and Washington University's Spinal Cord Injury Rehabilitation Approach

1) How much has Christopher Reeve recovered from his spinal cord injury?

When Mr. Reeve damaged his spinal cord in 1995, experts predicted that he would never be able to feel or move below his head. But, in November 2000, he began to regain both sensation and movement in the majority of his body. He now can feel a pin prick on the majority of his body and can move some of his joints voluntarily and others against resistance.

Since his injury, Mr. Reeve has maintained a consistent regimen of exercise. In 1999, he began a series of four evaluations at Washington University School of Medicine in St. Louis. Based on these evaluations, Mr. Reeve's home therapy program was adjusted. Though he still cannot walk and has not regained bowel or bladder function, his delayed recovery defies previous scientific expectations and has had a dramatic effect on his daily life. Mr. Reeve's classification has progressed from ASIA A to ASIA C on a five-point scale (see ASIA definition in question #10).

Very importantly for Mr. Reeve, his slow but steady improvements have made him feel better about his life. He can once again feel his wife's touch and his children's embrace, boosting his emotions and dramatically improving his quality of life. He also can commit to a variety of work projects, confident that he can devote uninterrupted time to them.

All of these improvements are particularly impressive since Mr. Reeve did not regain any motor function below his shoulders until five years after his injury. Even the most optimistic experts previously thought that recovery was possible only within the first 6 months to 2 years.

So far, it is not possible to know why Mr. Reeve has recovered or the biological basis of his improvements. But Washington University researchers are conducting scientific experiments to determine if the long-term activity-based therapies optimize self-repair of the nervous system.

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2) Please describe Washington University's approach to spinal cord injury rehabilitation.

Washington University's spinal cord injury rehabilitation effort is directed by John W. McDonald, MD, PhD, a Washington University Neurologist at Barnes Jewish Hospital. After he evaluated Mr. Reeve, Dr. McDonald continued work on the hypothesis that individuals with spinal cord injury can recover some of their lost abilities by completing specific forms of rehabilitative therapies.

The university's approach has three main goals: First, to help paralyzed individuals exercise and thereby receive the strength and cardiovascular benefits of physical activity; second, to help any undamaged nerve cells function as best they can; and third, to encourage new cells to grow. To reach these goals, the team incorporates methods such as functional electrical stimulation (FES), aquatherapy, bone density treatment and brain research.

a) Functional Electrical Stimulation (FES). Mr. Reeve exercises an average of three hours a week on an FES bicycle. When someone without injury rides a bike, their brain sends electrical messages down the spinal cord to their feet, which then pedal the bike. But the brain's messages can't travel down a damaged spinal cord. That's where FES comes in: A computer sends electrical messages to the legs, similar to what the brain does normally. Mr. Reeve's physicians hope that simulating normal biking will encourage spinal cord cells that still are intact to "remember" what it's like to be involved in leg movements. Also, regular exercise provides basic, physical benefits, including building muscle mass and bone density, reducing spasticity and providing a cardiovascular workout. Devices to provide FES to other body parts such as the arms, hands and trunk also are available.

b) Aqua therapy: Aqua therapy is physical therapy done in water. The effects of gravity are greatly reduced under water so that in a pool, small body movements can be more easily detected and health-care professionals can determine a patient's maximum ability to move without the full resistance of gravity. Also, when patients are beginning to recover movement, water makes
practice easier. Mr. Reeve does aqua therapy approximately once a week for approximately two hours.

c) Bone density treatment. Since people with spinal cord injuries typically don't use their limbs, their bones tend to weaken and often develop osteoporosis. Mr. Reeve has been evaluated by the Division of Bone and Mineral Diseases at Washington University. He has also undergone medical treatment. With drugs and exercise on the FES bicycle, Mr. Reeve has reversed his previously severe osteoporosis and now has normal bone density.

The application of the therapies is not a one-size-fits-all plan. Therapies are selected and tailored to each individual's needs. In addition to the program's potential for helping patients regain movement and sensation, the techniques have physical benefits. For example, they help patients maintain, and often improve, muscle mass, bone density and cardiovascular endurance.

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3) Please describe the recovery of function that Mr. Reeve has experienced. How much movement does he have and what parts of his body can he move?

Mr. Reeve has regained some motor abilities and substantial sensory function.

a) Sensory. Mr. Reeve's daily life has most greatly been affected by the fact that he now can feel a light touch or pin prick over most of his body and can discriminate between the two types of sensations. This means that he not only can feel a cotton swab on his skin, but also can tell the difference between cotton's soft touch and the sharpness of a pin. Being able to feel allows him to know when he has pain, when he is uncomfortable or when he needs to do a seating adjustment.

b) Motor. Mr. Reeve has regained the ability to move his right wrist, the fingers of his left hand and his feet. When gravity is removed, for example in a pool or when is lying down, he is able to straighten his arms and legs against resistance, but he has no balance control for sitting, standing
or walking. In addition, he can move most of his joints in his arms and legs, particularly when the effects of gravity are reduced (for example, under water).

c) Other movement. In his book, Nothing is Impossible, Mr. Reeve states that he can move his arms in a flying motion and walk in a pool. These movements are possible in water because gravity is significantly reduced in a pool.

When gravity is reduced in a pool or by lying horizontal in bed, Mr. Reeve can move much more than he would be able to otherwise. For example, he can move his arms only if he is lying flat or floating in a pool, but cannot move them while sitting upright, such as in his wheelchair. He also can initiate a step while standing in a pool by moving his leg forward and shifting his weight, but to do this requires the assistance of many individuals to hold him in a standing position and maintain his balance.

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4) How has Mr. Reeve's recovery changed his life?

Mr. Reeve's recovered ability to feel people and objects has dramatically impacted his life. For example, he now can feel his wife's touch or his children's embrace. He also can tell when he needs to readjust his seating position and therefore can sit in his wheelchair for much longer periods of time (up to 16 hours). He can speak much louder and longer. His overall health has improved and, in the past three years, he has not been hospitalized and has had only a few minor medical complications.

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5) How long did it take him to regain movement?

Mr. Reeve's movements have come back in small stages since he suddenly discovered he could move his left index finger on command in the fall of 2000. Other movements began as flickers and then gradually strengthened. He now can feel a pin prick on the majority of his body and can move most of his joints when gravity is reduced. His strongest joints are his right wrist, left fingers and knees, where he has enough strength to oppose resistance. But Mr. Reeve still is in the process of relearning both how to move and how to feel - it is a long and challenging road.

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6) Is Christopher Reeve cured?

No, though he has regained a surprising amount of sensation and movement for someone with his kind of injury. If full recovery of function is possible, it likely will involve more than one medical or rehabilitative treatment. Researchers now are trying to understand precisely how physical rehabilitation therapies help mend the spinal cord to see if it is possible to reverse the effects of quadriplegia.

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7) How long will it take for Christopher Reeve to regain full movement?

It is not possible for anyone to predict what further recovery may occur. Keep in mind that no one thought it was possible for someone as severely injured as Mr. Reeve to recover this much feeling and movement, particularly when no recovery was evident in the first 2-years after his injury. Also, everyone responds differently to treatment. return to top

8) Is activity-based therapy related to stem cells or therapeutic cloning?

No.

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9) What is a spinal cord injury?

Most spinal cord injuries result from a pinched, dented or bruised cord, not an actual "break." The spinal cord is about the same diameter as the thumb and is filled with gel-like material, much like the brain. Because the gel-like filler makes the spinal cord very elastic, it would take a projectile, like a bullet or knife, to actually separate, or sever, the cord. More often, the cord is traumatically damaged, not broken. When a spinal cord is injured, the cells in the center of the cord die and the cord becomes hollow, leaving a donut rim of tissue on the outside. Without enough cells, the spinal cord cannot function properly.

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10) What is the ASIA scale?

Developed by the American Spinal Injury Association, the ASIA scale is the most widely used method for classifying the severity of a spinal cord injury. By using the scale, health care providers have a consistent way of measuring the status and/or change in individuals with a spinal cord injury.

The spinal cord has four sections, or levels, relating to bone structure - cervical (around the neck), thoracic (the chest region), lumbar (the small of the back) and sacral (the pelvic region). Cervical levels are numbered C1-7, thoracic levels are T1-12, lumbar levels are L1-5 and sacral levels are S1-5.

There are five ASIA categories of spinal cord injury:

ASIA A-complete: No motor or sensory function in levels S4-S5.
ASIA B-Incomplete: Sensory but not motor function is preserved below the injury and includes the sacral segments S4-S5.
ASIA C-Incomplete: Motor function is preserved below the injury, and more than half of key muscles below the point of injury have a grade less than 3.
ASIA D-Incomplete: Motor function is preserved below the injury, and at least half of key muscles below that point have a grade of 3 or more.
ASIA E-Normal: motor and sensory function is normal.

Often individuals hear the word 'complete' in discussions about their spinal cord injury. They then will think this means their spine has been severed. However, the spinal cord rarely is severed. The word 'complete' is just part of the classification system and does not refer to anatomy. It simply refers to whether there is sensory or motor function responses in sacral spinal cord segments.

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11) What classification was Christopher Reeve on the ASIA scale after his accident in 1995 and what does that classification mean?

Mr. Reeve was classified as C2 ASIA A after his accident. In his case, that meant he had no sensory or motor function below his shoulders. He remained in this classification for 5 years.

• What is Christopher Reeve's classification now?

Mr. Reeve now is classified as C3 ASIA C. This means he has more neck function, has intact motor and sensory function in his lowest spinal cord level (sacral region), and that more than half of the key muscles below the injury are graded 3 or less on a 5 point scale.

• Why was Christopher Reeve reclassified?

Mr. Reeve was reclassified because he gained a significant amount of feeling and movement. He did not make a jump from one level to another, but had incremental improvements over the past 3 years.

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12) How does Christopher Reeve's recovery relate to the body of scientific work in spinal cord injury?

Mr. Reeve's case - published in the September issue of the Journal of Neurosurgery, Spine - is the first documentation of someone improving two ASIA grades more than two years after injury. It is the first scientific evidence that late recovery can occur in a worse case scenario.

According to the scientific literature on human recovery from spinal cord injury, most recovery occurs in the first six months and generally is complete by two years after the injury. Although continued recovery can occur later, it is small in magnitude and typically confined to individuals who demonstrated early recovery.

Mr. Reeve's results, however, are consistent with some of the more recent studies on spinal cord injury, which suggest that the nervous system may be capable of recovering from injury under the right conditions. In particular, studies show that encouraging patients to use their injured body parts helps them recover lost function. For example, several groups have found that patients with less severe spinal cord injuries who still can move their legs appear to benefit from gait training, where patients practice walking with the help of harnesses, therapists and other supportive equipment. In addition, studies with stroke patients suggest that encouraging patients to use their semi-paralyzed limbs helps the limbs recover their lost functions.

Researchers at Washington University believe that this tactic - encouraging individuals to use a partially paralyzed limb - is effective because forced movements stimulate damaged nerve cells to relearn their jobs. While it is impossible to know what specifically caused Mr. Reeve's physical recovery, researchers at Washington University School of Medicine are conducting laboratory experiments to determine whether the rehabilitation approach he used actually promotes new cells to grow and damaged cells to recover.

A growing body of work supports these concepts, including international research completed by the following laboratories: Dr. Barbeau and Dr. Rossignol (Montreal, Canada), Dr. Dietz (Zurich, Switzerland), Dr. Edgerton (Los Angeles, California), Dr. Gage (San Diego, California), Dr. Schwab (Zurich, Switzerland) and Dr. Wernig (Bonn, Germany).

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13) What other research is currently underway to investigate the role of activity-based therapy in recovery from spinal cord injury?

Researchers at Washington University School of Medicine in St. Louis are conducting several types of basic and clinical research to further investigate whether activity-based therapies lead to functional recovery in individuals with spinal cord injuries. For example, larger clinical trials will help determine if these techniques are effective in a larger group of individuals. Also, basic science research is underway to investigate whether these therapies trigger the growth of new cells.

The effect of SCI on the brain also is being examined. In order for someone to move parts of their body, the brain must send signals to those parts. However, when a person has a spinal cord injury,
messages between the brain and the body often cannot travel up and down the spinal cord. Brain imaging techniques like fMRI (functional Magnetic Resonance Imaging) let researchers measure brain activity as the brain directs the body. Imaging studies led by Maurizio Corbetta, MD, Harold
Burton, PhD, Thomas Conturo, MD, PhD, and John McDonald, MD, PhD, at Washington University are currently investigating the organization of sensory and motor regions of the brain in individuals with spinal cord injuries to determine whether lesions in the spinal cord produce changes in brain activity.

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14) Is this therapy covered by insurance?

The amount of coverage provided is unique to each individual's health insurance policy. To find our about your eligibility, call your benefit's representative, whose number is on the back of your insurance card.

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15) How can I get this therapy?

To be evaluated at Washington University School of Medicine in St. Louis you first must be evaluated by a physician who specializes in spinal cord injury. This will ensure that the program is safe for you.

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16) Can this therapy help other patients such as victims of stroke, MS and other central nervous system disorders?

Yes, in theory, the same approaches may help people with other neurological conditions. But, scientists need to test these techniques in other patient populations to know for sure.

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17) Where is this treatment available?

The therapies are available at Washington University School of Medicine in St. Louis. Patients who enroll receive a combination of therapies tailored to their individual needs. The University's clinical partners are Barnes-Jewish Hospital, Mallinckrodt Institute of Radiology and the Rehabilitation Institute of St. Louis, all members of the Washington University Medical Center. For information or to enroll in a clinical trial, please go to http://spine.wustl.edu.

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18) How can I find out more about these activity-based therapies?

Information about therapies at Washington University School of Medicine in St. Louis can be obtained in the following ways:

Spinal Cord Injury Restorative Treatment and Research Program
Department of Neurology, Campus Box 8518
Washington University School of Medicine, Suite E226
4444 Forest Park Ave.
St. Louis, MO 63108
Medical Director: John W. McDonald, MD, PhD

Spinal Cord Injury Nurse Specialist: Linda M. Schultz, PhD, CRRN-A
Email: spine@neuro.wustl.edu
Phone: 314-454-8633
Fax: 314-454-5300

Website: http://spine.wustl.edu

Media Inquiries:
Washington University Medical Public Affairs
(314) 286-0100
reckessg@msnotes.wustl.edu

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19) Is Dr. McDonald a part of the Christopher Reeve Paralysis Foundation's Research Consortium?

No.

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20) Did the Christopher Reeve Paralysis Foundation fund this program?

No.

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21) Are other physicians or centers currently using this or a similar program?

No. Washington University is the only institution currently using this particular combination of therapies. However, other major rehabilitation centers provide related treatments, such as walking therapies, functional electrical stimulation, and aquatherapy.

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22) Are the activity-based therapies Mr. Reeve used responsible for his recovery?

It is not possible to determine a relationship between therapies and results in any one patient.