Stride

The stride length and speed of my left leg is poor.  At physio, I’ve started a new exercise to address this – demonstrated in this video.

The concept behind the movement is this: Janice and I both hold a length of dowel, I’m leaning forward pushing against her with the dowel and she is resisting the push.  She gives in a little to my push and I have to take a sizable and quick step forward so I don’t fall.

I’m so glad I taped this activity because what I perceived to be happening and what was actually happening (in the video) were two different things.  I felt like I was really leaning into Janice and practically lunging with each step.  The video reveals a slight angle and what would be considered average steps. The footage is helping me reconcile reality in my mind.

I was nervous landing these larger strides on my weaker leg. However, with the dowel/Janice to balance into, it wasn’t a problem.  The same can be said for walking with the walker; stride length and speed increase when I’m able to balance with it.  However, I have no confidence landing that big stride with a cane or walking unassisted where there is nothing with which to adjust my balance or stop me from face planting.  I’m tempted, but a broken nose is an effective deterrent.  Slow increases it is then.

The Dog Days of Summer

I find myself at a crucial and exciting recovery point: on the verge of being a walker.  One with some limitations, sure, but walking none the less. I’d been making great strides, but found my ability to progress limited by my job.  Exercising at the end of the work day, my best energy was already tapped out.  To increase the quality of my workouts, I decided to use my holidays (4 weeks in August) and apply myself entirely to walking to push through to the next phase.

I set up a fairly intense schedule with physiotherapy every morning followed by independent exercise in the afternoon.  It turned out the schedule was a little too rigorous and I developed mild bursitis in my hip midway through week two.  I had to take things easy for over a week before I could resume at a more moderate pace.  This is frustrating because I’m experiencing results and can even see the end result not too far out of reach – which is ridiculous motivation to get there – but I have to pace myself to avoid injury.

I’ve been researching more about exercise and motor recovery and found a great article.  One of its key points is that different types of training – to build muscle strength and endurance – are great workouts and obviously good for anybody, however, where neurological impairment (SCI) affects walking, the greatest recovery of walking occurs in individuals who repeat walking patterns.  This repetition either allows the brain to overcome “learned non-use” (see other post for explanation) by relearning how to activate muscles used in the walking sequence, or it creates peripheral neuro-pathways to do this.   So, to summarize, cross training is beneficial, but the real neurological/motor progress will occur by walking, walking and more walking.

This discovery has changed some of my habits. I have walkers at home and work, which I’ve been capable of using for quite some time, but haven’t used extensively because it’s much slower to walk than wheel.  Knowing that repetition is the key to recovery, instead of waiting to use the walker until I’ve built enough strength and speed to make it efficient, I’m now trying to accept this slower speed as my new pace and walk more.    I’m having more success with this at work then at home.

I continue to work with two physiotherapists, Janice and Malcolm, who complement one another well.  With Malcolm I’m working primarily on balance and proprioception.  “Proprioception is the sense of the relative position of neighbouring parts of the body and strength of effort being employed in movement.” (Wikipedia)  In pursuit of achieving better proprioception, I do a lot of unaided walking with the addition that now I’m not to look at my feet.  The reason for this is that when I use my eyes, the visual feedback I receive establishes the moment-to-moment information of balance – so I’m not required to feel for balance with my body.  To feel proprioception at work yourself, try balancing on one foot with your eyes open, using visual clues to keep your balance.  Then close your eyes and keep balanced.  Much harder, yes? You’re now using feedback from your body’s proprioceptors to keep balanced.

In the beginning my proprioception was terrible and I stole too many glances at my feet. Malcolm threatened corporeal punishment, but, when I objected, we settled on a quick “hey” when I slip up.  I’ve started to overcome this bad habit and my brain is now better able to tell where and how my left foot moves without seeing it.  I still have much work to do on balance, which seems to improve only with practice.

Walking unaided is challenging, but it pays off when I use an aid.  I’m just so much more comfortable and confident – which brings me to my work with Janice.  We’ve been working on walking with a cane. In the limited amount of time we’ve had the opportunity to focus on this, my abilities and confidence have increased significantly.  See the video of my first August rehab walk.  We’re also working on the quality of my steps, certain basic skills that I’ve forgotten (like how to turn properly and remembering to shift weight from one leg to the other when standing still – yes, I forgot about that) and climbing and descending stairs.  I seem to be conquering everything we set out to do.  Next we’ll be working on strategies to achieve speed.

To conclude this update on my August rehab, I believe I have reached a new stage.  It’s a transition level; strength, endurance, balance and speed all need improvement, but the foundations necessary to become a full time walker are there.  The exciting news is that there is so much more improvement yet to come.

Philosophy 101

When I was first paralyzed, there was a numbness and disbelief factor  – the “I can’t believe I’m never going to walk again” emotion that crept up occasionally and overwhelmed me. This eventually subsided as routine and everyday life made wheeling normal.  I think my previous posts convey the similar numbness and disbelief factors associated with the “I can’t believe I’m going to be walking again” emotion.  Now that time has passed and I have progressed, I’ve pretty much accepted this too.  I’m no longer stunned or get so excited I can’t sleep.  It’s become routine knowledge.  Well, not quite yet, but this is where I’m headed.

I’m sure there’s plenty of research out there, but, having read absolutely none of it, I’m concluding that people have a resounding ability to adapt and accept life’s changing parameters and to thrive within them.  This conclusion is based completely on my own anecdotal experience, so feel free to comment if you have an opinion.

Pride Comes Before the Fall

I’ve been lucky enough not to fall while walking, but my luck ran out on a windy day this spring trying to exit my car.

I opened the driver’s door to get out when the wind caught the door.  I held on to it with both hands so that it didn’t swing too hard against the hinge, but the wind was stronger than me.  The door kept going and pulled me with it. Mary Poppins I am not.  There was no upward lift from the wind and gentle descent onto my feet.  Instead, I landed face first on the ground – my feet still in the car. Here I am four chin stitches and a raspberry later.

The only grace in the incident was my mid-fall acceptance of fate.

But…

I laughed when my physiotherapist asked me to work on core strength while sitting by reaching in various directions for objects at a distance.  Easily succeeding at the task I smiled and said, “My core is strong. I do oodles of crunches. I can see muscle definition.”

I cried when my physiotherapist asked me to work on core strength while standing by bending in various directions.  Failing miserably at the task – experiencing intense burning in my sides in the upright return from side bends – I frowned and said, “But my core is strong. I do oodles of crunches. I can see muscle definition.”

My point:
1.       The word BUT changes a sentence significantly.
2.       There is vast difference between abdominal and oblique muscle fitness.
3.       Adding balance elements to core strengthening changes the game.

Seeing Eye-to-Eye

I feel six feet tall.  I’m not. I’m 5’6”, but I feel so much taller.  The change in elevation and eye line from sitting to standing has a surprising effect on me.  I used to look up at everyone and almost everything.  I hadn’t put much thought into the impact this perspective had on me (other than the occasional sore neck).  In regaining height, however, I’m now aware that elevation creates differing perspectives of the world.  It affects how I assess situations, take on tasks and, more broadly, how I approach life.

Because the change in the angle of my eye line has been so dramatic, it actually feels like I’m looking down at people of equivalent height and meeting people much taller eye-to-eye.  The brain is a wondrous mystery.

This change also manifests in another way.  I’m afraid I can’t explain adequately the impact of speaking with people on an equal visual plane, so please forgive the simplicity of this statement and accept that it means so much more than the simple words state: I feel equal. I do not mean to imply that I feel unequal while seated.  For example, picture yourself seated behind a desk speaking to someone standing. Despite that you are speaking as, and are, in fact, equals, there is a different feeling derived from a conversation where parties are at different heights then where both are seated or standing. Maybe a more appropriate statement would be that I feel more equal?

So my take away from this post, for anyone interested, is to find a seat or crouch a little (in a respectful way, of course) to level the eye line when you chat with someone in a chair or anyone who is of a significantly different height.

Long time, no post

My fan base (aka my sister) pointed out that I haven’t updated my blog recently.  I hate to disappoint anyone willing to read my ramblings so here is the skinny on Laurie’s World-of-Walk.

Over the Christmas break I travelled to Florida to visit my parents. I was able to walk on and off the plane, which was just so convenient. I was also able to dance with my Dad on New Year’s Eve thus fulfilling a 15-year dream of his.     The irony is that I used to scold my Dad for maintaining hope that I would walk again. I mistook his hope for pressure or expectation or an implication that I was incomplete if I did not walk.

I was also lucky enough to get a referral for outpatient physiotherapy at a rehab hospital.  So now I’m up to 4 sessions a week: two with my original physiotherapist, Malcolm, and two with my new physio, Janice.   My progress has accelerated significantly. In fact, progress seems to be directly related to the amount of time and effort I put in. Now there’s a revelation.

Two significant things that I am working on are left leg strength and standing completely straight.  My right leg has been my pillar of strength, which means that I tended to let it do most of the work and give my left leg a pass on all but the most essential movements.  The primary reason for this is that muscle tone/spasticity creeps into my left leg when I put pressure on the ball of my foot. I have no idea why this is; it’s one of those strange things that happens when your nervous system is impaired.  Janice is forcing me to use my left leg to stand up and do squats.  The result is interesting; after the first few sit-to-stands in which I clumsily power through the tone, it seems to subside and allows my muscles to then work as they should, however weak they are.  I’m noticing improvement in strength and function, and the more I use my left leg, the less tone is present.  I wonder if tone is related to lack of use or to disruption in nerve signals?  It’s hard to tell as most people with SCI tone experience both.  Anyway, I’m sometimes caught by surprise, where I used to rely solely on my right leg, to find the left activating and making tasks easier and balanced.

I’m not sure if my videos demonstrate well the degree to which I walked slightly bent forward at the waist.  This is due to years in a chair and the back rigidity associated with it.  A specific stretch and balance exercise has been exceedingly helpful to straighten me out.  I stand with one foot ahead of the other, and place my weight on the front leg. Then I focus on standing straight on that front leg: pushing my hip forward and pulling my shoulders back (stretching the hip flexor), tucking my stomach in and my butt under (working out sway back).  I’m not quite straight 100% of the time, but I’m getting so close.  I’m fairly straight and flexible through my right side and getting close with my left.

I walk at home and work with a walker. Fluidity is coming along nicely, but I still lack speed.  I’ve actually tried out a cane as well, though I have the same speed issues.  Walking “hands free” is improving slowly too; I no longer have a silly walk but balance is something I still struggle with.  The stronger I get and the more I practice, the better my balance becomes.  See my latest video for a glimpse.

An Education

I am in the midst of a relatively unique learning experience. When we learn to walk as infants, we don’t have the capacity to understand how the process occurs.  Reflecting on it later in life is not helpful because we can’t remember the time when we started walking.  Even therapists and scholars who study neurology and anatomy and understand the physiology involved do not get to personally experience the learning.  Despite the bad fortune that landed me in this position, I now have the good fortune of experiencing the learning involved in making a body walk.

When my spinal cord was first injured, my brain sent signals to my muscles telling them to move but received no response because the signal was disrupted at my injury site.  Eventually, my brain decided sending signals was futile so it stopped doing so. This is called “learned non-use”. My spinal cord repaired itself to a certain degree, but, because my brain was no longer sending signals, my muscles still did not activate.

Now that I know these muscles are capable of receiving information from my brain, I’m trying hard to transmit messages.  This is where the learning process becomes interesting.  It seems that each movement requires a separate command from my brain.  To take a step with my left leg, I have to think about activating my hip flexor, then my quad to bend my hip. I have to think about pulling my leg through the stride and then raising my knee, but not too high. I have to concentrate on contracting my quad to extend my leg while moving my body forward and placing my foot on the ground with my heel first.

If I forget to specifically think about one of these movements, it doesn’t occur.  At least that used to be the case.  Some of these movements have started to become automatic.   I’m not sure at what point it occurred and do not understand quite how. In fact, I’m not terribly aware of which movements are automatic and which are not; somewhere along the way I just stopped thinking about some of them.  I discover what is not automatic when I try to talk at the same time as I walk.  With the distraction, certain movements become lazy or cease until I concentrate on them again.  The more I practice, the more automatic or natural the movements become.

I realize as I’m writing this that others can experience this type of learning when they try a new activity that requires undeveloped physical skill and capacity. New skiers, in particular, come to mind. Do you remember what it was like learning to turn, balance and control speed while traveling down a hill on two narrow skis?  How it took your entire concentration to lean the right amount, in the right direction, at the right time?  Even then, you needed to develop stronger muscles to become proficient.   If you can’t remember a similar experience, give it a try.  It’s quite exciting.

Return of the Heel Strike

I’ve had a couple of new physical breakthroughs.  First, I got my heel strike back.  “What’s that?” you may ask.  Well, when we take a step we typically land with our heel first then continue through the step and finally push off with our toes.  My left leg has been stubborn due to spasticity and inflexibility brought on by years in a chair.  When I took a step, my left calf would spasm causing my toes to point so my foot would strike the floor with my toes landing first.  Not good for momentum or balance.

Last week at physiotherapy I was able to concentrate on landing my step heel first and make it happen. They were kind of wonky, over-exaggerated looking steps. I was concentrating hard and using all of my effort so my leg lifted higher than expected and I was almost marching. I was able to work out most of the kinks this week as I settled into the technique and better understand how much effort to expend. So now my foot moves smoothly through a relatively normal looking stride.

I’m actually not sure what the reason for the improvement is yet because my physio and I have been trying many things at the same time.  For those interested, here are the things that altered:

1. Reduction in spasms/spasticity. I cut back on the drug I use to relax spastic muscles (baclofen) after learning from folks on the SCI web forum that it weakens muscles.  This provided increased strength in my legs, particularly my hipflexor which is key to pulling my leg straight through a stride.  Oddly enough, for people with paralysis who don’t or won’t progress due to the nature of their injury, baclofen is an incredible drug to help settle spasm and tightness.  For those who need more strength and move more, it just inhibits muscle function.  Ultimately my spasms have decreased anyway due to more walking & exercise, stretching my calf muscles/tendons, and using muscle stimulation to activate dorsiflexion in my foot.  Yesterday, for the first time, my calf was actually relaxed while I walked.  This was so enjoyable and made walking a piece of cake – at least while using a walker.

2. Gait training. After posting a video of me walking on the SCI web forum I received tips on how my gait was hampered: swinging my leg to the side so my foot would clear, foot inversion etc.  My physio and I applied the tips on proper mechanics.

3. Extensive exercise.  I committed myself to working out really hard to improve as much and as fast as possible. I’m up to 3 days spinning a week.  It is incredible exercise for the arms, but, more importantly it is great for my core stomach and back muscles which I use when I walk.  I notice my pants are tighter so I suspect (or at least hope) this is because I’m bulking up with muscle. I also continue with physio twice a week and beyond that perform specific exercises targeting my quad, hip flexor, hamstring and glute.

4. Recovery. The signal from my brain is reaching the correct muscles.  I’m not sure if this is new or if my muscles are now strong enough to perform what my brain is asking of them.

My second new breakthrough is achieving a better sense of balance.  In my last post I wrote about walking independently and how difficult that is without balance.  I continued working on this at physio and it seems that I’m regaining my sense of balance.  My brain forgets in between each stroll how to balance, so the first steps of each session are off kilter. Finally, my brain says, “oh, I recognise this orientation. It’s not right. I’ll send a signal to the appropriate muscle to correct it.”  Then I’m good to go.  With each walk, balance kicks in a little quicker.  The most challenging part remains the strength of my muscles (or the ability of nerve signals to reach those muscles) because having a sense of when you’re leaning too far or falling and actually being able to do something about it are two very different accomplishments.

The coolest thing about this process now is seeing steady, often exponential, progress.  The one thing that remains constant: quarter squats are the bane of my existence!

Dancing with Myself

I feel young again!  I was just standing at my desk doing some quarter squats when some fun music came on and I started dancing.  Whew, what a work out – but so much fun!  It’s a great way to get in those pesky squats, shift weight from side to side, rotate the body and practice balance.  I love it.  I think it’s going to become a part of my home workout routine. Anything that helps with the monotony of exercise is welcomed.

On that note, I’m hoping to borrow my sister’s Wii.  I think that trying to play some of the sports while standing will force me to use my quads and core muscles for balance – hopefully keeping my mind off of the actual work.

I’ve also started a spinning class once a week using an arm cycle. It’s been two weeks and, so far, I just love it.  It’s great cardio and strength training for arms AND core muscles.  My stomach is developing a six-pack.  Maybe more importantly, it’s fun and social which makes me want to keep going.

My left hip flexor continues to be the weakest link in the walking muscle chain.  It’s firing more consistently now, though nothing compared to that of an able bodied person.  I’ve come up with a new exercise that is starting to show some small results.  I’ll provide more on that later.

Finally, the newest element in my physio regime is walking unassisted.  This gets left to the end of the session because, when I’m done, I’m spent. My balance is terrible.  If I touch something with my right hand, I have no problem balancing. Even if I’m using the tip of my pinky finger, I’m cool.  Then I’m left only addressing muscle function issues.  Take away that aid and I have a difficult time.  I do it, but it looks hilarious. I rival John Cleese for the silliest walk.   I’ve gotten a little better each time as I become more familiar with the balance mechanics required to get my left leg through its uneven stride.  I tire quickly because when my balance waivers, my quads and core muscles engage and use all of my energy to stop me from falling.  As I get better with balance, that saved energy will go into walking further. I plan to record it so I can keep track of what I’m doing wrong and any improvements made.  I’ll post in the video section.

Until next time…