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The paralysed man who can ride a bike

A man who was paralysed from the chest down after a knife attack in 2010 can now ride an adapted tricycle.  In 2014, surgeons in Poland announced they had reversed Darek Fidyka’s paralysis using cells taken from his nose to repair his spinal cord.  The former fireman says he has noticed a gradual return of feeling and muscle control below his injury.

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The surgical team are now launching a search for two more paralysed patients who they will try to help walk again.  Mr Fidyka told me: “I can tell that sensation is coming back and I am getting stronger. A year ago I would not have been able to ride a tricycle. Now I can feel each muscle and each press of the foot on the pedals.”

The BBC’s Panorama program told the remarkable story of Darek Fidyka and the 40-year research programme involving scientists in Britain and Poland.  The medical team are now launching the worldwide search as they are looking for patients with an uncommon type of injury, where the spinal cord has been completely severed, which can happen after a knife injury.  The head of the project, surgeon Dr Pawel Tabakow said: “If we can bridge the gap between two spinal cord stumps then there will be no doubt that our technique works and this will be historic – if we succeed we will have found a cure for paralysis.

“Then we will be able to help other patients with the most common type of injury, caused by a crush or compression.”

The Wroclaw Walk Again Project will be conducted in Poland, but patients anywhere in the world aged 16-65 will be able to apply via the team’s website, which will be officially launched on 8th March in Wroclaw.  All the treatment will be free, but to be eligible patients must have no feeling or voluntary muscle function below the injury and they must be prepared to spend around three years in Poland.  They will undergo extensive physiotherapy before and especially after the transplant surgery.

The medical team are expecting to be inundated with applications in the months ahead.  They will make an initial shortlist based on patient scans and medical notes and then invite a few potential volunteers for assessment in Poland.  Those selected will undergo the same pioneering surgery that was performed on Darek Fidyka.

Analysis

Scientists have spent decades searching for a means of enabling the paralysed to walk again. Motorised exoskeletons, which are strapped on the body, bypassing the injury, are now available commercially. Electrical stimulation techniques use implants to enable patients to flex their lower limbs. But neither method involves repairing the damaged spinal cord.  The approach in Poland aims to reconnect the brain with the lower limbs along the neural superhighway that is the spinal cord, enabling both motor control commands to travel down the body and sensation to travel up.

Darek Fidyka’s spinal cord had been almost completely severed as a result of a knife attack, apart from a thin thread of external connective tissue and prior to the transplant, he had no feeling or control below his injury.  Now he has had to re-learn how to control his muscles and interpret sensations. He said: “I realise how important the brain is while cycling, and that thinking is more tiring than the exercise itself.”  But the results from one patient, however impressive, would never be sufficient evidence on which to base a new approach to spinal cord injury.  The forthcoming trial in Poland will be crucial if the wider scientific community is to be convinced that a patient’s own cells can be used to regenerate their spinal cord.  It is also worth stressing that the patients selected will have to show enormous determination if they are to see the full benefits of the treatment.

In the first of two operations, surgeons will remove one of the patient’s olfactory bulbs, which sit above the nasal cavity at the base of the brain, and process the sense of smell.  The bulb contains specialist cells known as olfactory ensheathing cells (OECs) which act as a pathway that enables nerve fibres in the olfactory system to continually renew.  In a second operation the patient’s OECs will be injected above and below the injury and strips of tissue laid across the gap in the cord.  The team believe the OECs will enable nerve fibres to regenerate across the cord and so repair the damage.  An independent team of assessors led by neurophysiologists from Imperial College London will also be closely involved in monitoring the research.  Peter Ellaway, emeritus professor of physiology, at Imperial said: “I’m excited because this is a novel treatment with a lot of promise.”  But he cautioned that even if it works it would take some years to refine and so would not be immediately available for patients.

The treatment in Poland will cost £250,000 per patient and is being funded by a small British charity, the Nicholls Spinal Injury Foundation. It was founded by chef David Nicholls after his 18-year-old son Daniel was paralysed from the neck down in a swimming accident.  Mr Nicholls said: “I know how important progress is to people living with spinal cord injury and am optimistic that success with the next two patients will result in an announcement that paralysis is curable.”  NSIF and the UK Stem Cell Foundation both support the research of Prof Geoff Raisman, chair of neural regeneration at University College London (UCL), who has pioneered the use of OECs to repair the damaged spinal cord and leads the British side of the Walk Again project.

Prof Raisman said: “Darek’s latest progress demonstrates the extraordinary power of (neuro) plasticity. But it depends on the patient’s own efforts. It is like a baby learning to walk. We cannot teach it how. The progress comes from inside.”  Darek underwent his transplant in April 2012, and he still spends five hours a day undergoing physiotherapy.  He can now walk slowly using crutches or a small walking frame, but usually relies on a wheelchair as it is simply quicker and less tiring.  The return of sensation below his injury has brought other benefits like bladder control and the return of sexual function.

Darek was happy to discuss sex and explained that the reawakening of the erogenous zones was a crucial part of his recovery.  He said: “The return of sexual satisfaction – which travels along the spinal cord to the brain – is very important psychologically and is another part of my growing sense of independence.”

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hip

Rise in hip replacements for under 60s

The number of hip replacement operations on people aged under 60 has risen 76% in the last decade, NHS figures for England reveal.  In 2004-05 there were 10,145 hip replacements for people aged 59 and below, with 17,883 in 2014-15.  The Royal College of Surgeons says this is partly because doctors are now more confident that replacement joints will be more durable than in the past.  Patients are also said to be less willing to wait.

As a proportion of all hip replacements carried out, the rise among under 60s is small, but the Royal College of Surgeons says it is still noteworthy.  Demand for new hips across all ages has risen – there were 89,919 of the operations in 2004-05 and 122,154 in 2014-15.

Stephen Cannon, vice-president of the RCS, says as hip replacement techniques and prosthetics have improved, so have the numbers of younger patients undergoing this type of surgery.  “It’s no longer seen as a last resort.  “As surgeons, we now have more confidence about the wear rate of these prosthetics which allows us to be less restrictive on an age basis.”

‘Less arduous’

He said surgeons used to advise patients with hip pain to wait until they were 60 or 65 to have a replacement because the old-fashioned replacements had a shelf-life of about 15 years, meaning the operation might need redoing once in a lifetime – when the patient had turned 80.

“If you look at newer prosthetics, you could do the first operation at 55 and it is going to last for 20 years or more, so you would still only need one revision in a lifetime.”  He said another factor might be patient demand.  “Certainly, in my experience, patients do not get fobbed off. They don’t want to wait for an operation. They say, ‘I can’t play a round of golf or tennis and I want to.'”  Mr Cannon said concerns over the safety of a the metal-on-metal hip replacement in 2010 did not appear to have affected demand.  He said hip operations had become less arduous. Patients can be back on their feet with crutches on the same day or the day after surgery, and out of hospital within three days post-op. “They’re off crutches altogether by six weeks.”

‘Perfect storm’

Most hip replacements are done if the joint becomes damaged from arthritis or an injury. Many of the conditions treated with a hip replacement are age-related so hip replacements are usually carried out in older adults.  Mr Cannon says it’s not clear if conditions such as osteoarthritis are becoming more common and affecting people at younger ages, but it is worth exploring.  And with an ageing population, he says demand for hip operations could soon outstrip supply.  “The ageing population is a perfect storm. We are not there quite yet, but we might be in 10 years from now. It’s a continuing trend.”

A spokesman for the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man said: “The increase in numbers of under-60s undergoing primary hip surgery is entirely in line with the overall increase in provision of the operation.  “The orthopaedic sector must continue to work to get the first time surgery as right for the patient as possible – especially where younger patients are concerned as they are most likely to need at least one revision surgery in their lifetime.  “It is, of course, heartening and very encouraging that hip and knee implants are lasting ten years or more, with risk of revision lower than 5%.  “Joint replacement surgery offers significant benefits – getting patients back to their chosen lifestyle sooner, free from pain and with improved mobility.”

BBC News 3.3.2016

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