“Will I walk again?” It’s a question that both patients and doctors ask, and the answer is never a simple one. But the latest treatments are upending long-held assumptions about paralysis and offering new optimism.
It is Day 1,097 since James Nall’s right leg stopped listening to him. Nall sits on a couch just 10 feet from the stairway where he fell and broke his neck. Moving on from a devastating spinal-cord injury is even harder when, a dozen times a day, you pass the basement stairs that tripped you. And Nall is ready to move on. That’s why he’s yelling at the leg.
“I hate you,” he says, grabbing the thigh muscle and kneading it hard. “You’d think I’d have patience by now. But I do not.”
The thing is, his leg may finally be listening. And talking back.
Months into in a new program at Craig Hospital in Englewood, Nall’s body is responding. He has shuffled 310 feet in a gym using a walker and can stand on his own for five minutes at a time.
The most promising development in decades of frustrating research on paralysis is that it now appears the spinal cord can learn, and legs can be retrained to walk. Cut off from brain instructions by a traumatic injury, the hyper-sensitive spinal column could become its own brain.
For Nall and a growing number of spinal-cord patients, progress comes after agonizing months strapped to complex movement machines and fitted into high-tech “exoskeletons,” with electrodes delivering painful shocks to dormant muscles. By reminding the spine of the proper motion, it remembers how to walk. Slowly the patient takes over.
The treatment, known as locomotor therapy, upends many long-held assumptions about paralysis and represents an advance for technology over medicine. In the absence of a miracle cure, recovery traditionally has focused on adaptation: Get finger movement back to grip utensils and clothing, build arm strength to jump a wheelchair over a street curb.
Locomotor therapy refuses to write off the injured parts. Advocates are reaching back to patients injured decades ago, and moving them from wheelchairs to walkers. From public buses to their own cars. From expensive home-health aides to transferring themselves into bed.
The goal of researchers at Craig and a handful of internationally-renowned spinal rehabilitation centers is to prove that recovery of movement in people like Nall is more science than hunch.
“There’s new knowledge that can attack the results of paralysis and is also leading us down the path of ultimately reaching that cure,” said Susan Harkema, a Ph.D. researcher at University of Louisville’s Kentucky Spinal Cord Research Center. Harkema has led much of the locomotor movement.
The Christopher & Dana Reeve Foundation, which knits together Craig and others seeking to transform locomotor training from philosophy to science, is cautiously hopeful.
Research director Susan Howley calls results so far a “potentially phenomenal breakthrough.” Yet, like most experts in the paralysis field, she quickly adds, “The field is enormously rich in possibilities, but sometimes it seems every time we have a new nugget of information, it reveals how much we still don’t know.”
–>ONE STEP AT A TIME. James’s therapists all know that if they ask him to do something 10 times, he’ll do it 15. A crawling exercise in Craig Hospital’s PEAK workout gym is his toughest task. “You gotta crawl before you can walk. I gotta retrain everything. I’m like a giant kid — a big baby.” (Craig F. Walker | The Denver Post)
Nall squeezes his wheelchair around the fateful stairs and into his bedroom to shows house guests what he does know. He pulls X-rays from a drawer, showing bars of titanium silhouetted against the ghostly lines of his fused neck.
In 2010, the 28-year-old Nall was a type-A manager for a chain steakhouse. Worked hard, partied hard, took pride in both. One year a shark bit him — on land — as he posed with warrior fishing buddies on the Jersey shore.
The next, he danced on a table at a work party and then danced off it, breaking his collarbone in two places that broke through skin.
That’s when another manager told him to buy accident insurance, and Nall did.
One August night after a late restaurant shift, Nall strode over his kitchen’s hardwood floors to the familiar basement stairs and a laundry run. Wearing heavy Doc Marten boots, he tripped and flew head first down the steep pitch.
His head buckled under his chest. He was in a fetal position, conscious but unable to move. “I knew it right away,” he said. His hands were locked into fists, his legs frozen and his chest hyperventilating as scrambled nerves confused every breath.
Nall’s spinal cord was compressed into a U. The fifth vertebrae below his skull smashed into the sixth, swinging the sixth off the spinal column nearly a full rotation. That made way for the fifth to shatter the seventh.
His roommate heard the fall and found him, but was frozen by the sight of Nall in a fetal position, clearly broken. Nall didn’t know what to do either.
But instinct told him to strangle out instructions to turn him on his back, and realign his head so he could breath.
–>WALKING. Despite the grimacing and pain, James was pleasantly surprised at his first October attempt to walk after a summer break from intensive physical therapy. With the aid of therapists and electrical stimulation on his balky right knee, he took three laps around the Craig Hospital gym. “Psychologically and emotionally, that’s a huge lift,” he said. “It’s awesome. It made my freakin’ week.” (Craig F. Walker | The Denver Post)
In a one-second fall to his basement carpet, Nall joined 1.3 million Americans paralyzed by a spinal cord injury. More than 4 million others report paralysis from stroke, multiple sclerosis or other diseases and injuries.
Like most of them, Nall’s brain became stuck on what patients and doctors alike call the one question: Will I walk again?
That query has haunted Craig’s Dr. Dan Lammertse for more than 30 years. The calm, reasoned Lammertse is one of the first faces patients see when they wake up from emergency surgery. In 1982, an emotion-wracked father asked Lammertse, “If we can put a man on the moon, why can’t we help my daughter to walk?”
The answer has not changed much in those three decades. The spinal column is a wondrous construction and an enduring mystery.
Nall’s shattered and loose-swinging vertebrae dented the spinal cord, a silvery sheath serving as the conduit for nerves responding to brain signals about walking, breathing, eating, reaching, bowel movements, body temperature and sexual function. Once the vertebrae are breached, the cord is hypersensitive. The bone-bruise on Nall’s cord was no bigger than a teardrop.
When a person’s skin is bruised, defense cells quickly surround the dangerous internal bleeding, and the cells themselves begin reproducing healthier cells for repair. “Bruises are trivial injuries in most places of the body. But not in the spinal cord,” Lammertse tells patients and families in a monthly lecture to the newly injured at Craig.
The sheath of the cord is like thousands of stretched rubber bands. Control signals from the brain move the sheath to limbs and organs. Banging it at full force is like taking scissors to the rubber bands. Deeper inside, cells killed by bleeding are walled off, blocking signals from the brain.
Those pathway cells do not reproduce inside the spinal cord. Some scientists speculate there was no evolutionary urgency for them to do so — for most of humans’ existence, a spinal blow was fatal.
–>I KNEW RIGHT AWAY. James Nall’s dog, LuLu, opens the door for him after doing school work. (Craig F. Walker | The Denver Post)
Finding a drug, a stem cell, or cell stimulator that could overcome those barriers in the spine has been a 30-year quest by international labs.
Locomotor therapy is born in part from that frustration. It has a hands-on immediacy that appeals to trainer and patient alike. The treadmills, the bikes, the weight-supporting harnesses are all here, now, ready to go.
Advocates feel an urgency to prove which locomotor machines do the most good, over how many hours of training, how many times a week, which muscles should be electrically stimulated and for which level of injury. Many suspect the final answer will be exercise combined with a cell injection or spinal implant, as yet undiscovered.
They also must find a way to bring the time-consuming, machine-and-labor intensive treatment to spinal cord patients with little money, tucked away in remote areas. And they must overcome skepticism among scientists and the paralysis community, who keep hearing the next miracle cure is nearly at hand.
Stem-cell implants were supposed to regenerate vital material inside the injured spinal cord, but have fallen apart when subject to rigorous trials. A swelling-reducing cold saline treatment made famous after a professional football player’s on-field injury in 2007 appeared to work wonders, and quickly spread into emergency medicine. Yet subsequent tests raised doubts, indicating the athlete’s initial injury wasn’t as damaging as originally thought.
When Nall woke up in the intensive care unit at the old St. Anthony Central, he could feel and control nothing below his waist. More urgently, his damaged nerves allowed only 70 percent of his breathing function, leaving him gasping for air for three days until swelling in his spinal cord began to recede.
An initial assessment indicated separation between his brain and key spinal segments was total.
But around day 3 or 4 in the intensive-care unit, as his breathing eased, Nall could feel light touch on his legs and toes. He was upgraded to “incomplete.” Incomplete is a better world, but ill-defined and highly dependent on an unscientific mix of treatment, individual biology and patient grit in recovery.
Eleven days at St. Anthony. Nall counts days like a restaurant’s freezer inventory. Ninety-two more at Craig Hospital, learning to use a wheelchair, a bathroom, a fork. How to get in and out of bed with legs as dead weight.
–>CONFIDENCE. James sometimes avoids clubs and the feeling of people looking down or tripping over his chair. Yet he is a successful flirt when he wants to be. In a pool game against Sadie Bassett and Whitney Rezendes, he told Rezendes, “If I make this shot you have to sit on my lap.” He made the shot. James reminds himself, “Don’t be someone you wouldn’t hang out with.” (Craig F. Walker | The Denver Post)
His mother died during those 92 days, and he had to watch the funeral on Skype. “I still feel the guilt for that,” he says, three years later.
Nall describes his transition back to his Arvada house with restaurant-kitchen expletives. It was the coda to a “horrible year,” of a breakup, then traumatic injury, losing his mom and coming home profoundly disabled.
He had to rely on roommates for bowel and bladder help, his Type A personae dying a little inside each time.
Learning to walk again is paramount. But there are other things, from breathing to urinating to sex to sweating, which the spinal cord takes care of in healthy people.
“Most people don’t realize that aspect,” Nall said. “The toughest part is having and wanting that independence.”
The next six months, he said, were 13 hours a day of TV and feeling sorry for himself.
Craig Hospital, meanwhile, was pushing hard on the “movement is good” philosophy at the heart of locomotor training for paralysis.
The hospital acquired elaborate stimulation-and-movement treadmills, elliptical and bicycle trainers. It opened the movement philosophy to the wider spinal-cord community, launching a gym membership called PEAK. The newly injured or those in wheelchairs for 20 years could come to a gym designed for their needs, and use anything from an electrical-stimulation bicycle to standard dumbbells.
Nall heard about Craig’s direction from a therapist. He’d tired of his depressive TV marathons and was making plans. The accident insurance he’d bought three months before the fall would now pay him a six-figure settlement. He could stay in his house, take accounting at Metro State and throw himself into rehab in Craig’s new gym.
–> The titanium rods that bolted James’s neck, and his life, back together in 2010 are easily visible in an X-ray he keeps in his desk drawer. Learning to walk again is one challenge, but the constant lingering pain from a catastrophic spine injury is another major obstacle in the life of James and other spinal patients. (Craig F. Walker | The Denver Post)
Nall enrolled in the official “neuro-recovery” program: two hours a day, five days a week, plus hours more of his own weight training. He hooked electrodes to his muscles and turned up the amps, reawakening nerve endings with the jolts.
On the labor-intensive Locomat treadmill, most of his weight was suspended from a hook while four physical therapists moved knee joints and ankle joints to create a normal walking pattern on the rolling tread.
He did 500 sit-ups a day to strengthen his core. It takes strong stomach muscles to hold the buttocks in place for a proper stepping motion.
“If you can’t feel that much, it doesn’t hurt that much,” Nall said.
All the while, it was hard to tell what part of the work was Nall’s and what was assistance from the hulking machines. He arrived and left in the same wheelchair.
Candy Tefertiller pointed her video camera at Nall one afternoon in the spring of 2012. The head of physical therapy at Craig had been watching Nall grunt his way around the gym for months, training her eye on specific muscles and body movements. She had a hunch.
James, she said as she filmed, show us that move your leg makes.
Nall looked at her from his wheelchair, then used his elbows to lift his weight a bit. At the same time, he slid his left side forward, barely perceptible on film.
Suddenly his left leg kicked out in a spasm, as if it couldn’t resist punting an imaginary soccer ball.
A spasm is less than walking. But it’s more than paralysis. Emanating from somewhere in Nall’s spine was a signal that the leg should move. And the leg did move.
“We can work with that,” Tefertiller said.
Michael Booth: 303-954-1686, mbooth@denverpost.com or twitter.com/mboothdp
