Dr. Steven R. Hinderer

He's the medical director of Wal the LIne to SCI Recovery

Talk is called " How to Choose a Recovery Program"

I agree with Dr. MacDonald is that a cure is not needed to get to a lot of recovery of function . . . we only use about 10 to 20% of our physical capabilities to do everyday tasks, and a lot of people in this room would gladly take that much physical function.

Lots of medical pros will say that it's only okay to get involved in treatments that have been validated by clinical trials. But in 2001 -- 8 years ago -- only about a third of what goes on in medical practice was evidence based. What we're trying to do is change a paradigm. Innovation needs evolution and development BEFORE you can run clinical trials. It's a fact that evidence based treatments are not always best.

Showing a slide about the Wright Brothers, who endured countless failures and then decided that all the literature for wing design was wrong. They invented the wind tunnel so that they could test new ideas. We know how that worked out.

Okay, so what does the new paradigm look like? Start with FES, though it's not exactly new . . . it was applied for the first time to quadreplegics in 1967. Lots of advantages, and some disadvantages.

Nonresponders, can only vary the velocity, painful if you have sensation, risks fractures, muscles, or joint injuries, don't know the impact longterm of high intensity current (it's very different from nature) -- he thinks that it's a well-studied OLD technology . . .

For intact nervous systems, the small motor units are recruited first; well before teh small motor units reach their max firing rate, the midsized motor units are recruited, and well before they reach their max firign rate, the large motor units are recruited . . . but with FES, you go directly to the largest motor units, and there's no way to change that. FES therefore retrains the system somewhat backwards; it starts right at the large motor neurons, which is why it's so tiring.

What about weight supported training? In 1992, Wernig and Muller reported that body weight supported training, starting at 40%, improvd walking. It improved fitness, decreased spasticity, decreased contrctures, increased perceived well-being. There was also a study that showed BOTH weight supported gait training and over ground gait training resulted in improved walking.

Disadvantages of weight supported training: expensive, can only vary amount of weight supported and speed, doesn't include core runk muscles, must be able to tolerate upright position, onlyhelps with incomplete injuries.

His third alternative is load-bearing weight training. He's been setting us up for this one . . .

Paper by Giorgio Scivoletto . . . "The concept that restoration of a close to normal foot trajectory may be a very importnt goal of walking training and that this can be achieved provided the relative freedom of the other segments of hte lower limbs, trunk amd arms . . . " - anther paper to look up -- Here it is: http://nnr.sagepub.com/cgi/content/abstract/21/4/358

Okay, what are the principles that should be applied?

Repetition, repetition, repetition (with minor variations)
Nutrition and health maintenance
Core trunk strength and posture
Sensory inputs/integration
Dynamic coordination training
Activation of spinal cord motor nerve cells and the muscles to which they connect
Motivation to maximize performance
Mind-body connection

This is boot camp. You probably will have to have somebody like a coach or a therapist or a trainer . . . you're going to get sick of this damn quick. You need people to help you get your best game going every day.

Changes in neural pathways require
At least 3 hours per day
At least 3 days per week
More is better (within reason) -- some programs do 7 hours a day, 7 days a week.

Nutrition and health maintenance means
Hydration
Amino acids/proteins
Vitamin D
Adequate rest

What does core trunk strength and posture look like? He's got patients with better posture than a lot of AB people in the general population.

Sensory inputs -- this is interesting . . . vibration can either help or hurt. When it helps, it does so by improving bone density and stimulating sensory receptors.

Look at the Giger MD, made in Switzerland . . . http://www.gigermd.com/

How do you activate spinal motor nerves? full weight bearing, minimal use of orthotics, judicious use of localized FES (Bioness)

Know that this is years of work. It's Olympic level training, going for gold, and requires all the same kinds of support that an Olympic level athlete has to have.

Total Gym -- lots of sci exercise facilities use them.