In my understanding and experience, both of which are still very much in formative stages, one has to approach the retraining of muscles in several different ways when recovering from a spinal cord injury. There is no way to say that one of the following always comes before another in the healing process, but one may be more of a primary focus at certain times. I will call them:
Note that the first three mean 'one.' This is to underscore their lack of hierarchy, and interdependency.
<Uno> involves simply getting movement of some kind out of the muscle. This does not necessarily mean that I would be able to command my quadriceps (or ‘quad,’ a large thigh-muscle) to contract to extend my leg a little bit. That would be great, but instead that ‘movement’ could mean that when someone presses on the bottom of my foot, which then pushes my knee toward my chest, the stretching of the quad muscle causes it to contract reflexively, to resist the outside force that is applied. This is a reflexive movement because the body’s message – “the quad is being lengthened” – gets sent from the muscle to the spinal cord and right back to the muscle without contacting the brain at all. This is the same action as the reflex test at a doctor’s office with the mallet *whack* below the kneecap.
In a variety of ways at the gym, my trainers and I get movement out of a muscle which I cannot yet voluntarily contract:
• Pinching on the arch of the foot can often produce a reaction in the hip flexors, bringing the knee
towards the chest;
• I cannot yet do an abdominal sit-up on my own, but if someone holds my wrists and tries to push me
back from sitting upright, I can resist quite a bit with my abs and oblique muscles;
• When I am standing, I have found that shimmying my hips slightly from side to side makes my abs,
gluteal muscles, and thigh muscles come to life much more.
The point is to urge the body to recognize that those muscles are there and want to be used – this means re-teaching the brain, spinal cord, and also the muscle itself, and its anatomical neighbors, the range of motion that the muscle can perform. In a way, it has to become reacquainted with itself and its ability.
Something that I am learning more about is the importance of correct body positioning when exercising. If I do not compensate for weak muscles with strong ones, which means focusing more on my technique,
I will spend far less time working to correct bad habits later on. Seems laughably obvious, right? But what would you do if you had an option between a) walking incorrectly, with lots of stress on the ligaments in the legs, and b) being confined to a wheelchair, but with happier ligaments? As I learn more, I know that some of my habits will need to change, so there will be more on compensatory movements in a later post...
It is often the case that a person must be able to get movement out of a muscle before he/she can begin to build strength. The methods for my body for this part in the process are evolving, again with respect to the importance of technique.
One way to go about building strength involves giving a muscle or muscle group as much attention as possible, and strengthening those muscle fibers through whichever methods work to generate movement (pinches, stretches, rubs, shimmys, whatever). Over time, the goal is to give the muscle so much love that a connection that is not reflexive but voluntary begins to appear. Keep reading for a different take on the order….
<Unum> involves developing a voluntary contraction: I think about firing the muscle, and it contracts, whether it is a barely perceptible tremor or a visible movement. The goal here, as some think of it, is to harness the strength that someone has already developed with the reflexive motion and convert it into firing that he/she can control without that pinch or shimmy. I am well on my way with my right quad and hamstrings, and especially…drumroll…with my right pinky toe. Success! That’s so functional! …there is no rhyme or reason, but almost without fail I can move that toe whenever I want: it is not strong, but it is connected. I think of it
as the manifestation of my body’s promise to me that everything between my brain and that pinky will be connected eventually. For some areas, especially my right side, this voluntary link just comes with more activity, but for other areas, this is the hardest part of the process.
Not only is it extremely mentally-exhausting to try over and over to make my thoughts connect to a paralyzed muscle, but there is no way to know when the coupling will happen, how much repetition it will take, or what the best exercise is to achieve this link. Part of my strategy right now to establish voluntary contraction in my left leg, is to do single leg squats on the total gym (see video) with much assistance, for 30-45 minutes at a time, every two days, just focusing on the left leg. This involves getting weight-bearing biofeedback through my foot, and practicing a pulsing motion where my leg never locks out and my muscles are continually engaged – the better for me to make a connection. Because I cannot push very much yet with that leg, it is incredibly physically taxing on the SCI-FIT trainers, who are terrific at making it all work.
Returning to the methods from <Ein> on movement before connection, a different strategy is to focus on acquiring the voluntary connection before getting stronger. The trouble is that it can be hard to connect where there is no strength, and it is certainly difficult when there is no movement. After all, how hard would it be to make movement if you weren’t able to connect to the muscle? Surely you have to move to gain strength, but you mustn’t move until you can connect to a muscle that is strong enough to move properly! You can see that this becomes a paradigmatic Catch-22. There is no way in, and there is definitely no way out! (Imagine trying to sort this in your head to ensure correct form while doing a circuit of reverse accordion crunches, hip bridges, sit-to-stands and pull-ups…)
Whew. Moving on.
The culminating element that interweaves this involved journey is the fine-tuning of the voluntary connection. This means working all parts of the muscle, through various ranges of motion, to ensure that the strength of the connected movement can be applied in any which way. Examples of this would include:
• Being able not only to press up when on the total gym, but to control the down movement, with a
squat-hold at the bottom;
• Proper hip stability when I am kneeling and standing, where in the former I do not have that valuable sensory
feedback through my feet;
• The ability to extend the back (bending upright) while engaging the abs as well, so that the pelvic and
lumbar areas are firing, rather than simply being led by a stronger upper back, as is currently the case for me.
Also part of this thinking is the coordinating of many different muscles to complete larger movements. When one stands up from a seated position, muscle firing occurs from the foot arch, through the calves, quads, and hamstrings, in the gluteals and back extensors, in the abdominals to keep the pelvis steady, and also in the upper-back and shoulders, as one shifts his/her momentum from bowing forward to a proper posture with ankles, knees, hips, and shoulders in-line. Although it may take longer to establish these correct movement patterns, the point is that by not compensating, I will get stronger in a way that is healthier for the system and hence sustainable for the rest of my life.
Zooming out, I began this post with a reference to my frustration with the lack of response from my left hand. I will discuss this in a later post. I wanted to illustrate how complex this process is and how my understanding of it is still developing, now more than a year from the date of my injury. The interdependency of it all often seems ridiculous and overwhelming and unsolvable when I am working through my technique at the gym, but we do find ways to progress. I suppose it’s a good reminder of the ability to move forward even when absurdity is all around.