Fractionated and single-dose radiotherapy for heterotopic bone formation in patients with spinal cord injury. A phase-I/II study.

BACKGROUND: Heterotopic ossifications occur in about 20% of patients with spinal cord injury and may seriously compromise the rehabilitation process. Aim of the present study was to evaluate if radiotherapy administered early in the course of the disease prevents the manifestation of heterotopic ossification and if in patients whose bone formations have been resected recurrence can be avoided. PATIENTS AND METHODS: 52 patients (44 males, eight females, median age 33 years) and 75 joints were irradiated between December 1989 and March 2000. 49 patients (70 joints, 65 hips, three knees, one shoulder, one elbow) were evaluable. Median follow-up was 11 months. In 58 joints radiotherapy was performed as a primary treatment in the inflammatory phase of soft tissue swelling that precedes manifestation of heterotopic ossifications. Twelve joints were treated after resection of manifest heterotopic bone, two patients had primary and postoperative irradiation in different joints. The dose was 10 Gy in single fractions of 2-2.5 Gy in 34 joints and 7.5-20 Gy in six joints. From July 1996 on, 30 joints received single-dose irradiation with 8 Gy. RESULTS: 50/70 joints (71%) remained free from progression. This was the case for 47/65 (72%) hips, whereas in 18 hips (27%) the Brooker score increased for 1-2 grades and caused a moderate decrease of mobility in five joints. Out of the other five joints, two knees developed progression. No relevant side effects occurred. CONCLUSION: The present results suggest that radiotherapy is an effective local treatment option for spinal cord injured patients with heterotopic ossifications.

Radiotherapy as a local treatment option for heterotopic ossifications in patients with spinal cord injury.

OBJECTIVE: Heterotopic ossifications (HO) occur in about 20% of patients with spinal cord injury and may seriously compromise the rehabilitation process. The aim of the present study was to ascertain whether radiotherapy (RT) administered early in the course of the disease prevents the manifestation of HO and whether in patients, whose HO have been resected, recurrence can be avoided. METHODS: Thirty-six patients (46 joints) were irradiated; 33 patients were evaluable. Mean follow up was 23.6 months. In 27 patients RT was performed as primary treatment in the inflammatory phase of soft tissue swelling that precedes manifest HO. Eleven patients were treated after resection of manifest HO, while two had primary and postoperative RT in different joints. The dose was 10 Gy in fractions of 2-2.5 Gy in 25 patients. Four patients were treated with total doses between 7.5 and 20 Gy. Seven patients received single dose irradiation with 8 Gy. RT was performed with 8 MV photons after simulation on the basis of CT scans. RESULTS: The mean duration of follow up was 23.6 months. Thirty of the 36 irradiated patients showed no progression of HO. In three patients reossifications after therapy caused a moderate decrease in joint mobility. No relevant adverse effects were observed. CONCLUSION: These results suggest that RT is a safe and effective local treatment option for spinal cord injury patients with HO.

Laufband (treadmill) therapy in incomplete paraplegia and tetraplegia.

Recent reports indicate that intensive training of upright walking on a treadmill (German: Laufband, LB), significantly improves walking capability in spinal cord-damaged persons. The aids provided initially are body weight support by a harness and passive setting of one or both limbs by therapists. To facilitate stepping and evoke motor automatisms, "rules of spinal locomotion" need to be applied during training. The effects of this novel locomotion therapy on patients with chronic and acute incomplete paralysis are summarized and discussed here. Many patients with chronic paralysis, still wheelchair-bound and not capable of walking without help from others, became independent and learned to walk for some distance without help. Assessment of voluntary muscle activity in resting position before and after the period of therapy often showed only small increases, rendering the involvement of complex motor reflexes (motor programs) and better utilization of remaining muscle function during walking as main sources for the improvements in locomotion. This idea is supported by electromyographic recordings. Follow-up assessments performed 0.5 to 6.5 years after discharge from the hospital show that the significant improvements achieved by LB-therapy in patients with initially chronic paralysis can be maintained under domestic surrounding. Patients with initially acute paralysis improved their walking capabilities even further. It is suggested that LB therapy may be generally applied in the motor rehabilitation of persons with acute and chronic incomplete paraplegia and tetraplegia. Its use in other diseases is discussed.

Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies.

Recent reports indicate that walking capabilities in spinal cord damaged persons significantly improve--as compared to conventional rehabilitation therapy--after intensive training of aided (Laufband) treadmill-stepping. In the present report, follow up investigations on two collectives of spinal cord injured (sci) persons are described who had undergone (Laufband) treadmill therapy either during a period of renewed rehabilitation months or years after spinal cord injury (35 chronic patients) or during their first postacute rehabilitation period (41 acute patients). Among the initially chronic patients, 20 from 25 still wheelchair-bound before the onset of (Laufband) treadmill therapy, ie not capable of raising from the wheelchair and walking without help by other persons, became independent walkers after therapy. Assessment of voluntary muscle activity in resting position before and after the period of therapy had shown only small increases in most patients, indicating the involvement of motor automatisms and better utilisation of remaining muscle function during walking. Follow-up assessments performed 6 months to 6 1/2 years after discharge from the hospital revealed that the walking capabilities achieved by (Laufband) treadmill therapy in the 35 initially chronic patients were maintained in 31 persons, in three they had further improved, in only one it was reduced. These results indicate that the improvements achieved under clinical conditions can be maintained in every day life under domestic surroundings. From 41 initially acute patients, 15 had further improved and none had reduced his walking capability 6 months to 6 years after discharge from the hospital.

[The radiotherapy of heterotopic ossifications in paraplegics. The preliminary results]. / Strahlentherapie heterotoper Ossifikationen bei Querschnittsgelähmten. Präliminäre Ergebnisse.

BACKGROUND/AIM: Mobilisation of patients with paraplegia is frequently associated with acute inflammatory processes of soft tissues and muscles in the neighbourhood of joints, where subsequently heterotopic bone formation develops. Rehabilitation is then seriously compromised. For this clinical situation, no local therapeutic options exist so far except extensive resection. To evaluate if radiotherapy early in the course of the disease prevents heterotopic bone formation or if--in case of already manifest ossification and consecutive resection--recurrence can be avoided. PATIENTS AND METHODS: In 20 patients with paralysis, 25 regions were irradiated with (mostly) 10 Gy in single fractions of 2 to 2.5 Gy using 8 MV photons. In 15 patients radiotherapy was performed as a primary treatment in the status of myositis; 7 patients were treated after (subtotal) resection of already manifest ossifications (2 patients were treated twice, primarily and postoperatively). RESULTS: In a minimum follow-up of 12 weeks, none of the 20 irradiated patients showed any progression of the developing or already manifest ossification; thus mobilisation and rehabilitation could be carried out as desired. No side effects occurred. CONCLUSION: The preliminary results of the present study suggest that radiotherapy is an effective local treatment with minimal side effects for the prevention of heterotopic bone formation in patients with paraplegia. Treatment should be started early in the course of the disease. Further evaluation in a prospective study seems desirable.

Laufband therapy based on 'rules of spinal locomotion' is effective in spinal cord injured persons.

Rehabilitation of locomotion in spinal cord (s.c.) injured patients is unsatisfactory. Here we report the effects of a novel 'Laufband (LB; treadmill) therapy' based on 'rules of spinal locomotion' derived from lower vertebrates. Eighty-nine incompletely paralysed (44 chronic and 45 acute) para- and tetraplegics underwent this therapy, then were compared with 64 patients (24 chronic and 40 acute) treated conventionally. The programme consisted of daily upright walking on a motor driven LB initially with body weight support (BWS) provided by a harness and assisted limb movements by the therapists when necessary. Forty-four chronic patients with different degrees of paralysis undertook the programme for 3-20 weeks (median = 10.5), 0.5-18 years after s.c. damage. At the onset of LB therapy 33/44 patients were wheelchair-bound (no standing and/or walking without help by others) whereas at the end of therapy 25 patients (76%) had learned to walk independently, 7 patients with help [corrected]. Only 1 subject did not improve. It was striking that voluntary muscle activity in the resting position was still low in several patients who had gained walking capability. Eleven patients who could already walk before LB therapy improved in speed and endurance. Of the 44 patients, six were capable of staircase walking before LB therapy compared with 34 afterwards. In order to validate the apparent superiority of LB therapy two types of comparisons were performed. In a 'temporal' control 12 spastic paretic patients, still wheelchair-bound after the period of postacute conventional therapy, performed LB immediately thereafter. After completion of LB therapy nine of these patients had learned to walk without help from others.(ABSTRACT TRUNCATED AT 250 WORDS)