As a refresher, my neurologist sent me to the hospital to undergo both auditory and somatosensory evoked potential tests. These tests are designed to measure the response times of nerve impulses. The auditory test measures nerve strength from the ear to the brain stem, while the somatosensory test measures electrical signals from various parts of the body to the spinal cord and then up to the brain.

The results are in....there's nothing right in my left brain, and there's nothing left in my right brain! (rim shot, please!)

All jokes aside, I received mixed news today. Mixed news seems to be a way of life in the medical field. I am sure it stems from a desire to not have patients get too high or too low emotionally, but it can get frustrating at times.

All the measurements from my nerve testing came back in the 'normal' ranges. That is exceptional news! Most of the signal measurements are taken as impulses travel through specific systems. The impulses can be measured as they enter and exit each system, and the elapsed time between the two measurements represents the potential for the nerve to function. It is this measurement that repeatedly came back in 'normal' ranges from stimuli at each ear, both wrists and each ankle.

While this is positive news without a doubt, I have to keep in mind that the test only measured potential. The nerves could still regrow incorrectly or 'plug in' to the wrong tissue. Then I would have a nerve that works, but still a loss of functionality.

My fiancee and I discussed this discrepancy with my neurologist and he offered the honest opinion that he did not expect me to fully recover all physical functionality (back to pre-surgery levels). In his opinion, the evoked potential test results indicate that I will continue to see progress in my recovery, but they were not to be misinterpreted as a guarantee of how far I might advance.

The neurologist was also less positive about my most recent MRI than my neurosurgeon was. The previously unexplained spot seemed to worry him, and his office is scheduling a new MRI for November. Today, the spot was labeled as possible tumor remnants, scar tissue or even necrosis (dead brain tissue damaged during surgery). Since he is just becoming involved in my case, the neurologist thought it was appropriate to monitor the spot closely for the remainder of the year.

Where does all this information leave me? Good question!

I am undoubtedly getting better as noted in 'Weekly Wins'. I believe I will continue that trend for the foreseeable future.

How much better will I get? I can't distract myself with those concerns. I can manage expectations that today is better than yesterday. I have faith that tomorrow will be better than today.

While I would never wish my condition on anybody, I do sense the curiosity in others to know "what it's like". I would want to know, if the roles were reversed!

To satisfy your curiosity, I have put together a list of things you can try at home, at work or in the car. Let's have a little fun with this - y'all can report back on how well you did and we will see who is able to master these mock therapy exercises!

1. DOUBLE VISION: I can't change your vision to help you experience what double vision is like. What I can do is provide you with a couple of examples, so you can see how things look in my world. It turns out that Mitsubishi Motors has done an advertising campaign that comes pretty close to the mark.

When watching these two commercials, pay particular attention to all of the 'mirrored effects'. When you see multiple cars, roads or any of the same images that are essentially reflections of each other - that is what I see when not wearing my prism glasses. It's also noteworthy now that I am beginning to 'fuse' images that when the three cars mold into one (at the end of the first commercial), that is also very accurate for how things look when I acheive fusion.

For the record though, neither of those are my favorite commericial. That honor goes to the one below. Gets me every time!

2. INTELLIGIBILITY: Take a sip of water and then try to say your name aloud before swallowing. I still don't have full functionality of my tongue and this is the best way for you to try and replicate my speech. By holding water in your mouth, your tongue should reflexively raise in the back of your mouth to keep you from choking. By holding your tongue in place, you will feel the difficulties in forming proper sounds to articulate your own name.

3. DOMINANT HAND: Try a whole range of activities, including signing your name, shaving, brushing your teeth and driving - all with your non-dominant hand. Warning - this will slow you down tremendously, so only attempt these activities when you have extra time.

4. SWALLOWING: Try to make a meal last an hour. It will be tough, trust me. Take tiny bites of your food and chew each one at least 20 times. Oh yeah...don't talk while you eat either!

There really is not any good way to try and replicate my balance or gait issues (except for extreme intoxication!), so we'll leave those off the list for now.

Remember, let me know how it goes! Good Luck!

With the Central Texas heat beating down outside, my days consist of exercises for my eye muscle, Boeckmann exercises for my cheek and lips, push-ups, some light dumbbell work, handwriting, a heavy dose of oral motor and speech exercises and lots of walking around the neighborhood.

I am happy to report that it is not just the work and heat that have become easily patterned over the last 60 days. It also seems that I make one noteworthy gain each and every week! From a psychological standpoint, progress is a tremendous motivator...although a fast-approaching wedding date helps too!

Let's take a little closer look at the 'weekly wins' from the last couple of weeks:

*** Most recently (as in just this week), I have re-discovered how to whisper! I would describe my efforts as quiet but not soft, and about a subtle as a Bevo seated at the dining room table. But I am whispering again and my speech therapist seems very enthused by the development. The whispering is being attributed to greater control and functionality in my throat.

*** I was cleared by my eye doctor to begin driving in my prism glasses without my eye patch. This will be an enormous change and it is one I have not implemented yet. I carried a note in my glovebox explaining that it was medically necessary for me to wear my eye patch while driving. I am now awaiting receipt of a similar note about my prism glasses. First it was only having to tape my eye at night, now it has progressed to driving with binocular vision! I still see double without my glasses, but my left eye continues to improve.

*** I also got a clean bill of health from my PCP. Well, as he says, "it's clean except for that hatchet job your tumor did on your left side". My cholesterol is healthy, blood pressure is good, all my bloodwork was 'normal'....it was such a change to go to a doctor's office and hear nothing but positive news! When you consider everything I eat on my quest to gain weight, some of this news was a real shock!

Look for more news later this week as I will be heading back to see my neurologist for test results.

I did squeeze in a trip to the passport office to apply for paperwork for our honeymoon! I am unsure how they will react to a scary photo with my 'wandering eye' at the border, but you probably want to hear about the medical stuff, right? What have I learned in the last 11 days?

*** My eye doctor was extremely pleased with the health of my left cornea. So much so that I have been cleared to leave my eye untaped all day long! This will really help with my new glasses, as they were fitted with the prism overlays last week. I will still be taping my eye at night to help with moisture retention and I will still be wearing my patch while driving, but this was some very welcome news from the eye doctor. The prisms make my glasses a little blurry, but I only see one image while wearing them and as of today, that will be all day, every day!

*** My visit with the neurologist was rather uneventful. He had not received a copy of my most recent MRI and was not comfortable speculating on my recovery without seeing those images. He is also scheduling me for a BAER test (Brainstem Auditory Evoked Response). This test is designed to measure brain activity resulting from auditory stimuli and will be simliar to the vision testing I have undergone at therapy. For further detail on a BAER test, click here.

The neurologist did review a list of prepared questions I had and was able to provide some insight into some of the long-standing questions I have, such as:

Q: How long should I plan to be 'recovering' seeing as most timelines stop at 12 months?

A: I see a lot of cases experience nerve recovery pretty consistently over a two-year period. I have also seen patients make minor improvements over a five-year span.

Q: Fatigue seems to negatively impact all my deficits. I also have a very erratic sleep pattern. Do either of these statements come as a surprise?

A: No. Brain trauma patients almost always report increased fatigue as a side-effect. There is not a tremendous amount of knowledge about why this is the case, but neither statement is surprising in the least to me.

Q: Multi-tasking (ex: carrying a full glass of water AND going up the stairs) seems to negatively effect both activities. Is this normal?

A: Remember that activities that were 'normal' for your brain are now being re-learned on an individual basis. Taxing your brain by asking it to perform multiple tasks is definitely going to result in a decrease in proficiency in both activities.

Q: It appears to me, that my recovery is happening linearly (ex: eye improvements are followed by balance improvements and then by recovery of facial muscles) as opposed to multiple areas synchronously. Is this expected?

A: In short, yes. What you describe is most often the case for patients and their external improvements. Understand though that there is nerve regeneration happening in multiple locations at the same time. Your external experience relates to individual nerve endings making their connections, which  generally happens on location-by-location basis.

Q: Is there anything I can do to promote nerve regeneration?

A: No, there is no 'magic pill' to help speed the process along. Staying active and forcing your brain to try and perform the activities desired seems to be the only stimulus required and you are clearly doing a good job with that.

Q: There are lots of surgeries designed to aid in recovery (vocal cord surgery, palatal lifts, nerve reconnecting, etc). How do I make an informed decision on which options are available to me and when the appropriate time is to have them done?

A: So long as you continue to see recovery and improvements, I would counsel you to wait on having additional procedures done.

*** I also visited with a new PCP this week to discuss my overall health and some lingering non-neurological side effects from the craniotomy. His feedback was as follows:

- He thinks I am really healthy, "except for the hatchet job your tumor did on your left side"

- He thinks a lot of the subtle things I am experiencing (dryness on face, acne on back) are all probably inter-related to some kind of hormonal deficit from the operation

I left them with lots of blood to study in their lab and will return in a few weeks to discuss those results. Interestingly, the internist I saw knew the neurologist I visited today quite well. He opined that "he is the best neuro in town" and seemed anxious for me to get some input from the neurologist.

AUSTIN, Texas — A detergent solution developed at The University of Texas at Austin that treats donor nerve grafts to circumvent an immune rejection response has been used to create acellular nerve grafts now used successfully in hospitals around the country. Research also shows early promise of the detergent solution having possible applications in spinal cord repair.

The solution—combined with an enzyme treatment conceived at the University of Florida in Gainesville—is licensed by AxoGen, an Alachua, Florida-based company, and is used to create an acellular nerve graft from human cadaver tissue, called AVANCE Nerve Graft. Nationwide, nearly 100 patients suffering nerve injuries have received AVANCE grafts, all involving peripheral nerves which transmit sensory information between the brain and muscles.

Christine Schmidt, a biomedical engineering professor, developed the detergent solution in her lab with Terry Hudson and Curt Deister, chemical engineering graduate students at the time, who are now with Genentech in California and with AxoGen, respectively.

"Surgeons are reporting some early successes," she says.

These grafts are being used to treat people with traumatic injuries potentially resulting from lacerations, gunshots and everyday accidents, but it also has been used to treat cavernous nerves after the removal of the prostate. The AVANCE product has treated wounded soldiers and can treat the nerves in hands, arms, legs and the face.

Traditional treatment of these types of nerve trauma required harvesting an intact nerve from the patient's body and transplanting it to repair the damaged area. However, that requires two surgeries, is more costly and leads to loss of nerve function and possible infection at the donor nerve site, Schmidt says.

Synthetic, tubular grafts are another surgery repair option. However, Schmidt says they are limited to repairing very small injuries. She adds AVANCE nerve grafts are able to bridge long nerve gaps, provide a three-dimensional pathway supporting nerve regeneration and are easily bendable because they are human nerve harvested from tissue donors, making it easier for surgeons to handle.

"This method has broader applicability," Schmidt says. "Formerly a patient's only option was to use their own nerve or the completely synthetic grafts."

By using the detergent solution, the donor nerve is stripped of the cellular lipid components, which causes the immune rejection response when implanted. Schmidt's laboratory spent four years developing the solution to be strong enough to remove rejection-inducing factors, but mild enough to preserve the delicate physical architecture of the nerve essential for regeneration. The resulting tolerated transplanted nerve provides a type of scaffolding that serves as a bridge between the two ends of the severed nerve to promote regrowth. And because the immunogenic lipid components have been extracted, patients don't require immunosuppressant drugs.

AxoGen learned about the detergent processing work in Schmidt's lab, licensed it and combined it with the University of Florida enzyme treatment that removes other regrowth inhibiting factors, creating the AVANCE product.

"So they've taken something from our lab that works really well and made it work even better," Schmidt says.

Schmidt now is conducting spinal-cord lab testing in animals using detergent-treated peripheral nerve grafts. She is working with post-doctoral fellow Zin Khaing, a central nervous system expert.

AxoGen's AVANCE Nerve Graft was first used on a patient in July 2007, when a 38-year-old man underwent surgery to repair a facial nerve at the Mayo Clinic in Rochester, Minn. In a recent case, it was used to repair several damaged nerves in three fingers of a Dallas resident at University Hospital - Zale Lipshy.

On Thursday morning, I returned to the same therapy hospital where I spent most of 2007, to undergo a speech therapy evaluation. Since having vocal chord surgery about a month ago, there has been a flurry of paperwork in an attempt to get things set up properly. Those four weeks also allowed for some of the post-surgery swelling in my throat to subside.

The rehab hospital is not terribly convenient to our house in northwest Austin, but I could have put the Tahoe on auto-pilot this morning. I may be mistaken, but I think I saw tire tracks worn into the pavement from all the traveling we did along that route last year! While it was slightly unsettling to go back to that scene, it was also somewhat comforting.

I will be seeing my same speech therapist that worked with me previously - another comforting piece of consistency. In a year of countless doctors, nurses and therapists, it is nice to be connected with a professional that has familiarity with my case history. My therapist is also one of the few folks I have encountered since my dagnosis that seems deeply committed to her work and her patients. I am in good hands!

To start things off I was reassured by hearing her tell me how much my appearance has improved. She cited many of the facial improvements discussed in 'Fun with Picture Pages', and definitely agreed that I had more power and volume in my voice.

Before beginning the formal evaluation, we discussed my recent surgery and exchanged thoughts on the preliminary results. To begin testing, I read words, sentences and an entire paragraph into a tape recorder. That recording will be replayed for somebody else,  who will try to determine what words are being read. (An interesting side note: I re-read the paragraph with a metronome keeping time. I can comfortably read aloud at about 80 bpm.)

The session then progressed through sustained phonation exercises, a visual checkup of oral motor movement capabilities and a discussion of the goals for this chapter of therapy. The initial assessment of the evaluation is that my current difficulties with articulation stem from my body working hard to learn to talk for over a year while having no cheek or lip movement on my left side, no palatal function and poor control of my airflow. My voice adequately learned to compensate during that time, but now that nerves are reconnecting, I will have to unlearn everything and re-teach myself the correct way!

It was reassuring to be able to sustain phonation for two or three times longer than I had previously during therapy. I can manage to hold a "Z" for about 14 seconds, an "A" for about 18 seconds and an "S" for 38 seconds. (Go ahead - try it with the second hand on your watch, you know you want to!) This improvement is a direct result from the implant that was placed in my vocal chord. As the chord was moved out towards midline, my control of the airflow needed to make these sounds has greatly improved.

One last thing, I set a goal with my therapist to be able to hold a three minute telephone conversation, during which I am only asked for clarification one time. With some hard work and dedication I will get there. Then maybe you won't have to get so many text messages! 

It is coming back! It is certainly taking it's own sweet time, but it is coming back!

I have read as much as possible and gathered every willing doctor's opinion, and the consensus on the topic of nerve regeneration is "Data Not Conclusive". That translates to, "I have no clue" in layman's terms, but I have not found many medical professionals that are willing to admit that much. 

What exactly is coming back? My face!

Check out these pictures and we can go through step-by-step on what is different. Sure they are a somewhat scary and it is probably poor judgement to post these images on the internet, but silly emotions like pride and dignity were left behind months ago.

First things first - in both of these images I am trying to make a symmetrical face! As you can see, my right-side facial muscles are still much more responsive than the left. Particularly note how much more my right eye is closed and how the stonger cheek muscles are actually able to pull my nose off-center.

But to the trained eye, there is a tremendous amount of progress on the left side of my face! In the left image, you can clearly see that the muscle in my cheek is pulling back enough to form a small crease from my nose to the corner of my mouth. Also in that image, close inspection shows that the very corner of my lips are turned slightly upward. That is the biggest smile that side of my face has flashed in over a year!

In the right-side picture, note the beginning of muscle contraction at the bridge of my nose, near the corner of my left eye. Compared to the muscles on the right side, it is insignificant, but there is clear progress showing. You can also see how much my eye is closed in this shot, as well as a slight furrow at the inside edge of my eyebrow and enough muscle contracting between my eye and ear to cast a small shadow towards my sideburn.

In this clenched position it is also easy to see that the droop in my mouth has almost completely disappeared. At rest, a trace still remains, but with some contraction, it straightens itself.

I probably contract these muscles at least 20 times per day. While the visual evidence is just barely starting to show, I can feel a big difference during exertion. I am still unable to close my left eye without closing my right, so it does no good to practice in front of the mirror.

The most important lesson here is that this progress boosts hope that the "complete recovery" that has been projected over the past year is inching toward the surface. According to the "inconclusive data", as nerves continue to regenerate and connect further with muscle tissue, I will gain more movement and control.

For now, I am just content to be able to close my eye - well, almost close it. If you will excuse me, I need to go practice flexing my face!

1. Nerve regeneration is of paramount interest in my life these days.

2. This study is being led by researchers at The University of Texas at Austin, my alma mater.

AUSTIN, Texas — A hair strand-thin worm is providing substantial clues on how nerves regenerate, offering insight and hope to finding genes that affect nerve generation and ultimately new drugs and therapies for human neurodegenerative diseases such as Parkinson's or Alzheimer's.

Researchers at The University of Texas at Austin, with collaborators from the University of Michigan, discovered that during surgery to sever its nerves, the 1 millimeter-long worm (called C. elegans) regenerated nerves up to 12 times faster without the use of anesthetics.

 

"There was this interesting phenomenon," said Adela Ben-Yakar, assistant professor in mechanical engineering. "Without using anesthetics, the axon (which conducts electrical impulses from the neuron) regrew much faster. So we realized the anesthetics really did interfere with the regeneration process."

She noted that the axons regrew within 60 to 90 minutes without the use of anesthetics. Previously with the use of anesthetics, axons took as long as six to 12 hours to regrow. To study nerve regeneration, the axons, which connect neurons, were severed using ultra-short laser pulses to observe what promoted their regrowth.

Researchers observed this critical occurrence as they performed breakthrough, laser nanosurgery using a specially designed micro-fluidic microchip. The chip painlessly immobilizes the live worm using pressure from fluid within the chip and acts as both a tiny operating table and recovery room to examine the worm, which has been widely studied and has more in common with humans than one might think.

Their findings were published in the May issue of Nature Methods.

These results are a continuation of Ben-Yakar's work, which in 2004 showed for the first time certain axons in the roundworm could regenerate when severed or snipped using femtosecond (one millionth of a billionth of a second) laser pulses and was featured in Nature.

Previously, researchers had to anesthetize the worm, perform the surgery and place it in a recovery area. Then, they had to anesthetize it again to study the worm post-surgery. With the new micro-fluidic device and its recovery chambers Ben-Yakar said performing surgeries on the worms is faster, thus, speeding up the research process.

"It's now the best way in a living animal to provide information quickly," she said.

Ben-Yakar said the invention of the micro-fluidic device has far-reaching applications because it allows for faster genetic and pharmacological screenings, accelerating the discovery of new genes that affect nerve regeneration and new drugs and therapies. She said each surgery and imaging session took just 1/20^th of the time it took previously thanks to the new chip, which allows for quick funneling from the surgery table to the recovery area and eliminates the need for anesthetics.

The paper's co-authors include: Samuel X. Guo, Frederic Bourgeois and Nicholas J. Durr of the Department of Mechanical Engineering at The University of Texas at Austin; and Trushal Chokshi and Nikos Chronis of the University of Michigan.

(NOTE: The original article is posted on The University of Texas' website and is linked above.)

For additional information on the use of this nutrient for neuropathy and other conditions, see the NYBC entry on Acetylcarnitine.

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Acetyl-L-Carnitine Improves Pain, Nerve Regeneration, and Vibratory Perception in Patients With Chronic Diabetic Neuropathy: An analysis of two randomized placebo-controlled trials

Anders A.F. Sima, MD, PHD, Menotti Calvani, MD, Munish Mehra, PHD and Antonino Amato, MD

OBJECTIVE—We evaluated frozen databases from two 52-week randomized placebo-controlled clinical diabetic neuropathy trials testing two doses of acetyl-L-carnitine (ALC): 500 and 1,000 mg/day t.i.d. [tid = 3 times per day]

RESEARCH DESIGN AND METHODS—Intention-to-treat patients amounted to 1,257 or 93% of enrolled patients. Efficacy end points were sural nerve morphometry, nerve conduction velocities, vibration perception thresholds, clinical symptom scores, and a visual analogue scale for most bothersome symptom, most notably pain. The two studies were evaluated separately and combined.

RESULTS—Data showed significant improvements in sural nerve fiber numbers and regenerating nerve fiber clusters. Nerve conduction velocities and amplitudes did not improve, whereas vibration perception improved in both studies. Pain as the most bothersome symptom showed significant improvement in one study and in the combined cohort taking 1,000 mg ALC.

CONCLUSIONS—These studies demonstrate that ALC treatment is efficacious in alleviating symptoms, particularly pain, and improves nerve fiber regeneration and vibration perception in patients with established diabetic neuropathy.

Citation: Diabetes Care 28:89-94, 2005

None of this is "incredible" anymore - if it is, you've not been paying attention.

The researchers say this route for creating new nerves could be part of medical practice by the year 2011.

And if clinical trials on humans can proceed, probably sooner.

Stem Cells From Patient's Fat Used To Grow New Nerves

Stem cells from a patient's fat may be used to create new nerves that can repair severed peripheral nerves (nerves outside the spinal cord), say scientists from Manchester University, England. The researchers say this route for creating new nerves could be part of medical practice by the year 2011.

The scientists said their aim is to put the new nerve tissue inside a biodegradable plastic tube, insert in at the broken ends of the severed nerve, and rejoin them in a human. This procedure could help a considerable number of people. They say they have had promising results with rats.

You can read about this study in Experimental Neurology.

Current medicine offers very limited procedures to help restore peripheral nerves. Nerves from elsewhere can sometimes be used- however, the risk of additional damage is significant, and even when there are results they hardly ever restore perfect function, say the authors. continue