Tuesday, January 04, 2005

STEADY AS SHE GOES: Spinal cord patient Erica Nader makes progress after experimental stem cell surgery

BY PATRICIA ANSTETT - FREE PRESS MEDICAL WRITER
January 4, 2005

A world of patients with spinal cord injuries is watching Erica Nader.

Her recovery may be theirs, too, someday.

Nader, 26, of Farmington Hills was the first American to travel to Portugal, in March 2003, for experimental surgery for a spinal cord injury.

She was injured in July 2001 in an auto accident as she and her brother headed out on a fast-food run after their parents' 25th wedding anniversary celebration. The car flipped off the dark, winding road in the subdivision and the air bag went off. She was paralyzed from the top of her arms down.

Nader and her father, Fred, spent months checking out a Portuguese procedure before she underwent the five-hour surgery.

In the procedure, which is performed nowhere else in the world, a team of doctors opened Nader's spinal cord to clear out any scar tissue or debris at the site of the injury.

Then, using a long tube, they took a sample of olfactory mucosal cells from the ridge inside her nose, the same cells that provide the sense of smell. These cells are among the body's richest supply of adult stem cells and are capable of becoming any type of cell depending on where they are implanted. In this case, these adult stem cells were to take on the job of neurons, or nerve cells, once implanted in the spinal cord at the site of an injury.

Animal studies show that the cells "express developmentally important proteins," says Dr. Steven Hinderer, specialist-in-chief at the Rehabilitation Institute of Michigan in Detroit, which is collaborating with a team at Lisbon's Egas Moniz Hospital to evaluate and follow up with patients such as Erica. And after three years, magnetic imaging resonance tests (MRIs) show that the cells indeed promote the development of new blood cells and synapses, or connections between nerve cells, says Dr. Carlos Lima, chief of the Lisbon team.

Because the cells are most plentiful in younger people, the Portuguese team limits the surgery to people no older than 35, six months to six years after a spinal cord injury.

The surgery is "feasible, safe and beneficial," Lima told a Detroit audience last fall as he answered questions from people interested in the procedure. There have been no deaths or infections, he added.

Dr. Pratas Vital, one of two neurosurgeons on the team, calls the transplanted cells spinal cord autografts, a term that indicates the cells come from a person's own body, not fetal or embryonic stem cells used in experimental procedures elsewhere.

The team has performed 30 operations -- about three a month -- since July 2001. But aggressive rehabilitation is as important, if not more so, than the surgery, Lima says.

"One thing we know already," Lima says. "This is a very slow recovery process. We thought it would take a year, now we're thinking it's at least two."

Two of the biggest drawbacks to the surgery are the cost and lack of published results, though the Portuguese team expects to take care of the latter this year. For now, the 300,000 people in the United States with spinal cord injuries rely on Internet chat rooms and media reports for answers. They gobble up every scrap of information they can find. Some people e-mail Nader or call her at home. She chooses the few she believes she can help the most. For the rest, she's agreed to let a Free Press reporter follow and report on her progress, so others will know what to expect from the surgery and afterward.

The operation costs $47,600 and often is not covered by insurance, leaving it as an option, at least for now, for those who can afford it or who have lawsuit awards from accidents sufficient to pay for the surgery.

Dr. Wise Young, director of the W.M. Keck Center for Collaborative Neuroscience at Rutgers University in New Brunswick, N.J., updates visitors periodically on the Portuguese procedure at his Web site, www.sciwire.com.

"Several people on these forums who have had the surgery appear to be recovering some function," Young wrote recently about the Portuguese procedure. "Unfortunately, to date, there has not been a publication of the results so that we do not know what proportion of the people recover function, to what extent, and for how long. . . . I have not heard of any case where there has been loss of function or death, but the lack of information does not necessarily mean that these have not occurred."

Gaining strength
Erica Nader's recovery has been slow but steady. She has been tireless and patient, demanding more of herself each week.

She works out like an Olympian in training: five hours three days a week and at least two hours a day the rest of the week.

She can sense the days when she can push a little more and others when she shouldn't press too much.

To stand, let alone walk, Nader demands that every muscle in her body feel just right.

Her hips must be centered, her feet spaced apart just right, her back straight. And when she moves, her weight must land on her heels, not her toes.

Too much tingling is a sign not to push too much. She waits, minutes sometimes, before taking another step, her physical therapist in front of her, a close friend behind.

Walking is her goal. For now, she settles on knowing that she is much stronger and much more capable of lifting her arms, bending her knees on a slanted exercise board and standing erect. She works for every inch of her recovery.

"It seems, just when I get discouraged, I feel or experience something new" that tells her more gains are ahead, she says.

Once, she was paralyzed from her biceps down.

Now, she can push herself off an exercise ball, do arm lifts and help raise herself off a floor mat.

Three years ago, she had no finger movements.

Now, she can lift a water bottle to her mouth for a swig, or feed herself.

In the last six weeks, she's started to walk in leg braces with a walker or on a treadmill, tasks assisted by a therapist, friend or family member. She uses full-length mirrors to gain visual clues to assist her movements.

Some days are better than others.

"It's hard work," says Bill Thornton, her physical therapist at the Rehabilitation Institute. Typically, gait patterns take three to seven years to learn, he says.

Nader left Dec. 30 for San Diego to continue her rehabilitation in the warmer climate preferred by many other people with spinal cord injuries.

But she stays in close touch with the institute and the work she and her father, a technology consultant, started there. They have helped raise thousands of dollars for spinal cord research at the institute as well as set up a scholarship program to help pay for rehabilitation therapy, often uncovered by insurance.

She also takes time to e-mail a few of the many people who want to communicate with her. "I look for someone I think I may connect with," she says.

The biggest question she's asked: Should I have the surgery?

"I can't make that decision for people," she says. "There are a lot of things to look into. There are always risks, but there are rewards, too."

Fred Nader, whose life has been consumed by his daughter's recovery since her accident, is studying ways to steamroll spinal cord advances. And he calls Erica a stimulant, a champion.

"It takes a spark for progress to happen, and that's what she is," he says.