Tina Mann: The Body Electric
February 2009 Issue
"I sing the body electric, I celebrate the me yet to come..."
(Walt Whitman, 1819-1892, via the musical, Fame )
Tina Mann had no interest in getting around for the rest of her life in a wheelchair. But after a snowboarding accident in January 2001, her medical team at the Cleveland Clinic in Ohio gave her exactly that prognosis.
"I was 16 when the accident happened," Mann says. "I had been skiing since I was seven and was getting bored with it. So I tried a friend's snowboard. When it hit a piece of ice, the board stopped and I kept going. I knew I was hurt."
She was right, but she was diagnosed as having only a broken arm. Her physician set her arm and sent her home to heal.
"A few days later, I developed bilateral drop foot, and three months after the initial injury, I was paralyzed from the waist down," Mann says. "I spent June and July in the hospital."
The damage had been caused by a hyperextension injury to the spinal cord in thoracic vertebrae 10, 11, and 12, and resulted in paraplegia.
"It was so hard for my family to watch," she says. "You can't convince someone else that you are going to be better, but it was my reality. My goal was to walk across the stage and graduate with my class."
With the help of braces (and ugly shoes), Mann stepped up to receive her high school diploma and graduate with her class. She was 18.
"I got a standing ovation. Everybody was crying," she says. "But I knew that I would have to keep raising the bar if I was going to really beat the 70 percent odds against my recovery."
Although in retrospect Mann regards her path to becoming an orthotist as inevitable, it took her a little time to find the map.
"After I graduated, I went to college for a semester, and then I began teaching at a preschool," she says. "What I was really working on was three days of physical therapy a week. I did that for five years. I also volunteered at the Cleveland Clinic two days a week. I worked with patients one day and worked in the lab making braces the other. I fell in love with the field."
For the first year and a half after her accident, she wore full braces when she was not getting around in a wheelchair. Then she progressed to smaller KAFOs. By then she was ready to go back to college, where she earned an associate degree that prepared her to move into a four-year course of study. It was her good fortune that St. Petersburg College (SPC) of Orthotics and Prosthetics in Florida had just launched its bachelor of applied science degree.
The program accepts only 24 students each year to study human anatomy and physiology, biomechanics, and gait analysis. Now a graduate, Mann has begun her yearlong residency in orthotics and prosthetics, after which she will sit for the national boards.
At the time she entered the SPC program, Mann was still getting around in short braces and wearing ugly shoes. She recalled that about four years into her accident, she had reached a point where she could recover no further with braces and determination.
"I could look at my foot all day long and not get it to move," she says. "Then I heard about the WalkAide and had to try it."
In early 2007, she went to Hanger Prosthetics and Orthotics' facility in Clearwater, Florida, to see Dan Stephen, the WalkAide representative for Tampa-St. Petersburg and one of the first technicians trained in programming the device.
"The WalkAide was approved by the FDA in May 2006, and I started seeing patients immediately," Stephen says. "It is amazing technology, but it doesn't work for everybody. And frankly, I didn't think Tina would test well because the injury to her spine caused bilateral damage. With a stroke victim, typically only one side of the body is affected."
However, it is Stephen's policy to test anyone that the technology might help.
"When I saw how Tina had to drag her feet across the rug when she wasn't wearing her braces, it was painful to watch," he says. "But we had to try. And to do that we needed to borrow a second WalkAide because the test unit only comes with one."
Because Mann is a bilateral patient, the procedure for testing her was a little different from the standard.
"For Tina, we put the WalkAide on the better leg and put a brace on the [weaker] leg," Stephen said. "From there, we programmed leg one."
The first step for programming the WalkAide involved Stephen's following behind Mann, sending the stimulation to the common peroneal nerve by hand.
"Once we got a good walking trial, we dumped the data we had into the WalkAnalyst software on a laptop computer to program the tilt sensor in the WalkAide," Stephen says. "The use of the tilt sensor to trigger stimulation eliminates the need for external wires or remote heel sensors."
Once Stephen got the program he liked, he sent the data back to the WalkAide device and began to adjust Mann's gait.
"Programming two WalkAides was a long process," Mann says. "It took almost two hours walking up and down the hall. I came in the next day to adjust the program a little, and after a week, I was walking faster and stronger and had to get it adjusted again."
Stephen was "blown away" with how well it worked for Mann.
"Her story is one of the most amazing so far," Stephen says. "She is the first bilateral patient in the state. She could not bring her feet up at all. Now the 'stim' tells her foot to come up, and she walks in a natural gait."
For Mann, one of the real pleasures associated with the WalkAide-aside from being able to walk barefoot on the beach and wear nice shoes-is her regained sense of where she is in space.
"I know where my legs are and what they're doing," she says. "All this device is doing is lifting my foot. It allows my hips and knees to move more freely and not have to overwork."
In Stephen's view, the renewal of normal relationships between the muscle groups involved in walking is part of the magic of the technology.
"Here is the mysterious part," he says. "When other muscles, such as the hip flexors, start to work normally, then hip, leg, and back pain begin to disappear. As long as the hip flexors have to lift the entire leg in a high-stepping gait, they stay fatigued."
Like Mann, some patients respond quickly and definitively to the "stim." The restored nerve-tomuscle signals effectively lift the foot at the appropriate time. However, there are some whose conditions fall outside the reach of the device or the FDA's approval.
"You cannot be fitted for a WalkAide if you are pregnant or wear a pacemaker," Stephen says. "If you have had seizures, you have to get special permission."
Those are the FDA's limits. Nature, for now, imposes others. To work as designed, WalkAide stimulation requires a complete pathway from the brain to the peroneal nerve; those who have damage to the lower motor neurons and peripheral nerves have lost those pathways.
A barrier of a different sort also exists. The device is expensive, and while the Centers for Medicare & Medicaid Services recently established an E-Code for the WalkAide, the reimbursement rate has not yet been set. However, that barrier is not as large as it once was. According to Hanger, Medicare coverage has been granted for incomplete spinal cord injury patients, and "pricing will be set over the course of the year...." Regarding private insurance company, Hanger says, "Private insurers have realized that upper-motor-neuron lesions or central nervous system disorders can cause foot drop. For this reason, payers are paying for indications other than what Medicare has indicated."
Mann is walking into the future on her own two feet, aided by a device that combines neurology, systems biology, microprocessors, and accelerometers.
"This is great for the field of orthotics," Mann says. "It seems like new and great prosthetic devices pop up every year, but orthotics hasn't really seen many 'wow!' products."
After her residency is completed, Mann will enter the profession she has come to love. And in the short term? She is ready to get back on a snowboard.
Jane Albritton is president of Tiger Enterprises, Writing Consultants. She is a contributing writer for the Northern Colorado Business Report and Edibles Front Range. She is also an editor for a 50th Anniversary collection of Peace Corps stories. She can be reached at www.peacecorpsat50.org