A stab at stimulating dead muscles

: How do you set a dying muscle back on track again? Get it to throb, pulsate, contract, expand and generally do its thing. Dying muscle is obdurate; no amount of cajoling, pleading or even pummelling will get it back on its feet; what it needs is a bit of a shock. That’s what Nagarajan Muthialu, London-based consultant paediatric cardiothoracic surgeon, recently did for a 50-year-old patient in Chennai with debilitating Motor Neuron Disease (MND).

The patient, Janakiraman (name changed) had been diagnosed with MND five years ago, but the wasting process had begun by the time he got to a doctor. He went to a doctor when he found he could not tie up his lungi . Eight months ago, the ‘paralysis’ crept up and spread to his cardio thoracic region, freezing up the muscles that helped him inhale and exhale. “When he could not do that any more, doctors gave him a tracheostomy – an incision in the windpipe to enable him to breathe,” explains Dr. Nagarajan. And that’s how he has been, in bed and hooked to a tube that allows him respiration.

Things might have remained the same had Janakiraman’s childhood friend Senthil Rajan not entered the picture then. Dr. Senthil, a sonologist, and Dr. Nagarajan had been in Stanley Medical College, and knew of the work he was doing in the UK. Working at the Great Ormont Street Hospital, Dr. Nagarajan had implanted ‘diaphragm pacers’ in children that would deliver measured electrical impulses to the diaphragm to stimulate the muscle into performing the motions that aid breathing. “I’ve done it for children, a few times, but the devices all had leads – wires that stuck out from their chest, connected to a battery device. It has worked in them.”

As the idea matured in his head, he was convinced that a diaphragm pacer was the answer for Mr. Janakiraman. “We decided to go ahead, because it would massively improve quality of life for the patient. His mental faculties are perfect, and being on a ‘permanent’ tracheostomy was annoying him greatly. If we could only allow him to breathe on his own, maybe he could be on a wheel chair, get out of home and play with the children,” Dr. Nagarajan said. Besides, a tracheostomy could also fail at any point.

A self-contained unit

Technically, two things could be done. Electrical impulses could be used to pace the nerve or the muscle. But the chances of enervating a nerve are zero if the nerve is already dead, so plan b – to pace the muscle – was put into action.

“It is like a pacemaker that’s used in the heart – we implanted some electrodes on both sides of the heart, at the nerve end where it meets the muscle,” Dr. Nagarajan explains. These are then connected to a small generator placed under the muscle in the chest cavity. And the whole unit is self contained. There are no protrusions outside, and the generator has also been placed just under the muscle so that it could be retrieved easily in case there is a problem, he added.

The battery comes with the promise of 10 years of life, but practically might last anywhere between five and seven years, depending on use. The patient’s muscles, that have been still so long, will have to be ‘re-trained’ and it is a lengthy process, taking up to six months. Mr. Janakiraman, who was operated on at a city hospital, will have to undergo monthly check ups to see how his muscle is coming along.

Dr. Senthil explains that the device, costing nearly Rs. 40 lakh, was procured free of charge for the patient, thanks to help from a London-based charity. Dr. Nagarajan also helped with the rather steep clearing and forwarding charges incurred while importing it. It will be a while before Mr. Janakiraman will be ready to be discharged, and even longer before he can go for a spin on a wheelchair. The device has been switched on and the sparks are flying, though not literally. The dying muscle has been jolted enough to budge. Now, it just has to get used to the heaving and ceasing, all over again.