Real advances in Rehab Medicine

This Memorial Day, let's bring the vets some good healing

It is Memorial Day weekend. Time to recognize and honor all those who sacrificed for our freedom and constitutional rights. We owe them so much. I thought this day would be a perfect opportunity to highlight some advances in the rehabilitation of traumatic and combat related injuries.

Many amputees suffer from phantom limb pain. New IRP research has shed light on the neurological mechanisms underlying the condition and could help tailor treatment for patients living with it.

Mirror Therapy for Phantom Limbs

I described mirror therapy for phantom limb pain in my book, Be the Rainbow * Bridge Heaven and Earth: How-to Manual for Integrating Alternative and Evidence-Based Medicine. It illustrates well, where the body sensation is perceived in the brain, irrespective of the peripheral neuronal inputs. And, that the brain can be ‘fooled’ into pretending the good limb is still intact, thus stopping aberrant neuronal firing misinterpreted as pain.

Altschuler is now bringing mirror therapy to Walter Reed National Military Medical Center in Washington, D.C., to investigate its effects for patients with complex orthopedic and peripheral nerve injuries. Study participants, all combat veterans with injuries to two or more joints, muscles or nerves in the same limb, will be asked to undergo 15 to 30 minutes of therapy five or six days a week,both at the hospital and at home. The pilot study will examine whether the treatment reduces pain, spasms and stiffness while helping the patients regain mobility.

Mirror therapy has been widely adopted and is now used by physical therapists around the world. “The scientific literature is extensive, with more trials than many drugs on the market,” he says. He believes the therapy’s next frontiers might be reflex sympathy dystrophy and complex regional pain syndrome, conditions which affect many patients and—like stroke hemiparesis and phantom limb—are unresponsive to other treatments. - news.temple.edu

The mirror therapy seemed miraculous to chronic sufferers of phantom pain, who felt immediate relief, even after years of pain resistant to all usual therapies. The results are long lasting, but can be boosted with frequent intermittent practice.

But where is this change in pain occurring? Recent research used fMRI to examine brains of lower limb amputees while they went through 4 weeks of activity using the mirror. Results were compared with those from matched healthy controls.

The amputees lit up their sensorimotor cortex when they saw images of feet during their first two fMRI scans. This brain area was also much more active when the patients viewed foot images than when they viewed hand images; no differences seen in the healthy controls. At the 4 week final scan, the patients’ fMRI scan showed brain responses to both hand and foot images that were similar to their healthy counterparts. Normal! And there seemed to be a dose effect in that the most active sensiomotor activity correlated with the amplitude of pain reduction.

Direct Stimulation of Spinal Cord

University of Washington researchers tested physical therapy combined with a noninvasive method of stimulating nerve cells in the spinal cord, on injured adults, helping them regain some hand and arm mobility. Six months post treatment, evaluation showed persistant benefits.

At the beginning of our study, I didn't expect such an immediate response starting from the very first stimulation session. As a rehabilitation physician, my experience was that there was always a limit to how much people would recover. But now it looks like that's changing. It's so rewarding to see these results. - Fatma Inanici

Both people who had no hand movement at the beginning of the study started moving their hands again during stimulation, and were able to produce a measurable force between their fingers and thumb, … That's a dramatic change, to go from being completely paralyzed below the wrists down to moving your hands at will. - Chet Moritz

https://medicalxpress.com/news/2021-01-treatment-people-spinal-cord-injury.html

Super Powered Prosthetics

So far we have used ‘brain power’ and direct electrical stimulation of spinal cord through noninvasive skin contacts, to help heal the injured. Now let’s look at neural controlled self-powered lower limb prosthetics and their effects on the amputees quality of life.

This image shows the study participant performing a squatting activity with different prosthetic devices. When the participant used his daily prosthesis (left picture) he had a limited range of motion and had to bend his back significantly to lift objects off the ground. When using a neural controlled prosthetic ankle (right picture) he was able to voluntarily control his prosthesis ankle joint force and angle and keep a healthy posture while lifting weight from the ground. Credit: Aaron Fleming.

The powered prosthesis in this study reads electrical signals from two residual calf muscles. Those calf muscles are responsible for controlling ankle motion. The prosthetic technology uses a control paradigm developed by the researchers to convert electrical signals from those muscles into commands that control the movement of the prosthesis.

After training, the study participant was able to do a variety of tasks that had been difficult before, such as going from sitting to standing without any external assistance or squatting to pick something up off the ground without compensating for the movement with other body parts. But one of the most pronounced differences was the study participant's stability, whether standing or moving. This was reflected in both empirical evaluations—such as testing the patient's stability when standing on foam—and in the patient's level of confidence in his own stability. - North Carolina State University

Hormone Therapy in Acute Brain Trauma

Well, I had to throw in a hormone study before we go…

Increased intracranial pressure happens with acute brain trauma, and standard protocols usually use hyperventilation, carbonic anhydrase inhibitors and mannose infusions. Now we have another one to add to the armament fighting this complication. GLP1 analogues.

Graphic illustrates research led by the University of Birmingham. Credit: University of Birmingham

We have shown that the GLP-1 agonist extendin-4 significantly reduces brain pressure rapidly and dramatically, by around 44 per cent with significant effects from just 10 minutes of dosing - the biggest reduction we have seen in anything we have previously tested. What's more, we found that the effects last at least 24 hours.

"These findings are rapidly translatable into a new novel treatment strategy for IIH as GLP-1 agonists are safe and widely-used drugs used to treat diabetes and obesity. They are also potentially game-changing for other conditions featuring raised brain pressure, including stroke, hydrocephalus and traumatic brain injury. - H.F. Botfield et al.

All these advances are so encouraging to see. May there be many more to come. And may you all have a very Happy Memorial Day.

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REFERENCES

https://news.temple.edu/publications/temple-magazine/2016/winter/sleight-hand

https://irp.nih.gov/blog/post/2019/07/mirror-therapy-alters-brain-response-in-phantom-limb-patients

https://medicalxpress.com/news/2021-01-treatment-people-spinal-cord-injury.html

Fatma Inanici et al. Transcutaneous spinal cord stimulation restores hand and arm function after spinal cord injury, IEEE Transactions on Neural Systems and Rehabilitation Engineering (2021). DOI: 10.1109/TNSRE.2021.3049133

Study shows powered prosthetic ankles can restore a wide range of functions for amputees (2021, April 13) https://medicalxpress.com/news/2021-04-powered-prosthetic-ankles-wide-range.html

Aaron Fleming et al. Direct continuous electromyographic control of a powered prosthetic ankle for improved postural control after guided physical training: A case study, Wearable Technologies (2021). DOI: 10.1017/wtc.2021.2

https://medicalxpress.com/news/2017-08-scientists-common-obesity-diabetes-drug.html

H.F. Botfield el al. A glucagon-like peptide-1 receptor agonist reduces intracranial pressure in a rat model of hydrocephalus, Science Translational Medicine (2017). https://stm.sciencemag.org/content/9/404/eaan0972

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