Hope, based on science
Juan Garcia first noticed the numbness in his feet around Halloween 2021. By the end of Thanksgiving weekend, the father of eight was unable to walk.
Garcia was admitted to the hospital — twice — and was discharged in December 2021 after several tests failed to produce a definitive diagnosis to explain his paralysis. Garcia and his wife, Johanna, left the hospital bewildered by the massive change in their lives and the lack of answers about what to expect in terms of recovery. At that point, Garcia could not sit up unassisted.
“He was essentially issued a wheelchair,” Johanna Garcia said.
Several months later, the Garcias learned about Selina Morgan, PT, DPT, NCS, an assistant professor in the Department of Physical Therapy in the School of Health Professions. Board-certified in neurologic physical therapy, Morgan has been researching spinal cord rehabilitation for almost 20 years. Her research focuses on motor control recovery in patients with stroke, traumatic brain injury, spinal cord injury and degenerative disease.
Morgan offers rehabilitation therapy to a small group of adult and pediatric patients with spinal cord injuries as part of an on-campus pro bono clinic she started in 2021. In March 2022, Garcia began seeing Morgan three times a week at the clinic and continued to work on his physical therapy on his own at home between sessions.
His progress has been swift, Morgan said. When Garcia began rehabilitation therapy, he used a wheelchair and needed help to get in and out of bed and to shower and dress. By September 2022 — about six months after beginning sessions in the clinic — Garcia still used a wheelchair at times but was increasingly able to walk with a pair of walking sticks, to dress and shower independently and to walk into the bathroom. In late January, Garcia was working on regaining balance and endurance while walking. He was able to walk on his own power with one walking stick and drive on his own without adaptive equipment.
Garcia explained his gains simply. “I wouldn’t have gotten to where I am without this kind of care. It’s hope, based on science.”
Second-year Doctor of Physical Therapy students volunteer in the clinic, scheduling patients and attending rehabilitation sessions. This gives them experience, including the chance to work with patients who have neurological injuries, before their third-year clinical rotations.
Because the clinic is considered a student experience, patients must be willing to allow students to be in the room, to ask questions and to work with them, Morgan said. The clinic makes it possible for patients to continue to receive services despite access issues, including a lack of or gap in insurance coverage.
Second-year DPT student Kolby Kolek said he has learned the power of perseverance by observing Morgan’s treatment methods.
“All the patients I’ve worked with, you can see the progress they’ve made,” Kolek said. “They put in the work and they are getting the rewards.”
The spinal cord can learn
Animal studies from as far back as 1911 have shown that the spinal cord can be retrained, Morgan said. From her perspective, people with spinal cord injuries need access to therapy that is based on a recovery approach rather than a compensatory one.
Morgan has been an affiliate of the Christopher and Dana Reeve Foundation’s NeuroRecovery Network’s pediatric network since 2021. UT Health San Antonio is the only NeuroRecovery Network affiliate in Texas, Morgan said. The approach taken by the NeuroRecovery Network aims to stimulate the spinal cord to learn in new ways by providing standardized, activity-based rehabilitation therapy.
In Garcia’s case, the therapy began with activities to help him gain trunk control, with Morgan and at least two DPT students supporting his body weight. Over time, Garcia progressed to sitting with best posture then to reaching, standing, shifting his weight and then to taking supported steps on a treadmill by August 2022.
“The NeuroRecovery Network is designed to provide standardized, activity-based locomotor training that has been successful in enabling voluntary muscle activation regardless of the severity of the spinal cord injury,” Morgan said. “The focus is recovery and not compensating for losses.”
Without this recovery training approach, patients who are capable of walking again would not know of their capability, Morgan said. With the recovery mindset, even patients who do not regain the ability to walk demonstrate other physical gains such as sitting balance, improved control of autonomic, or involuntary, function and improved fitness levels, she added.
“This is a very structured way to activate the central nervous system toward neuroplastic change, which means the spinal cord can learn in a task-specific way,” Morgan said.
Although significant gains have been made in spinal cord injury research and patient outcomes, Morgan said she recognizes that there are limitations. Still, it’s important to attempt rehabilitation through evidence-based therapies that have proven effective, she added.
“There are a lot of people who are not going to get up and walk, but we will not know who they are until we try it,” Morgan said. “People living with spinal cord injury deserve to try.”
In support of her research and rehabilitation work, Morgan has received an impact grant from the Christopher and Dana Reeve Foundation. She plans to use the grant to help pay for equipment used by NeuroRecovery Network members to collect data on their patients’ rehabilitation to add to the research, which spans the globe. In addition to providing the grant support, the foundation lists UT Health San Antonio in its National Paralysis Resource Center.
“This means people in our area with paralysis from any injury or disease will know we are a center for rehabilitation and research,” Morgan said.
Recovery versus compensation
There are two ways to treat patients who have paralysis, said Department of Physical Therapy Chair and Associate Professor Greg Ernst, PT, PhD, ECS.
“One way is to teach them how to compensate for their deficits — how to use a wheelchair correctly or how to transfer [to and from a wheelchair to a bed, chair, etc.],” Ernst said. “Some of that needs to be done, of course, but Dr. Morgan’s approach is more for recovery — so you have this paralysis or partial paralysis, but there is this possibility that you can recover. Her approach is to help facilitate that recovery rather than to adapt to those losses you have.”
A recovery approach gives patients the optimal chance to recover functional mobility, Ernst said.
Morgan’s involvement in the NeuroRecovery Network benefits the department, Ernst noted, including increasing competitiveness for grants and attracting patients seeking rehabilitation for neurological deficits. And Morgan’s pro bono clinic gives students an appreciation for a recovery approach, he said.
“Working on recovery instead of compensation rubs off on the students as well, and that can help multiply that positive approach as our students graduate and become practitioners,” Ernst said.
Morgan’s encouragement has inspired Juan Garcia, who said most people would never understand the effort required to achieve what might seem to be modest progress. Not so for Morgan, he said, who documents — and celebrates — it all.
“[Morgan] says, ‘You were able to raise your knee 2 inches farther than you were before,’” he said. “That’s motivating.”
Garcia scored 4.0 on the 12-point NeuroMuscular Recovery Scale (NRS) when he began working in the clinic with Morgan.
“The NRS is predictive of recovery, and he is now 11.37 out of 12,” she said.
Juan Garcia recently made chicken-and-sausage gumbo for the birthday of one of his sons and has resumed his role as the regular family cook. He helps get the kids ready for school, helps clean and completes small repair jobs around the house.
With so many goals reached, Garcia now dreams of the day he will be able to run and chase his boys.