Framework for SCI Recovery:

BUILD AWARENESS, part 2

This discussion + podcast is the seventh of a 10-part series that accompanies our book on SCI recovery, From the Ground Up: A Human-Powered Framework for Spinal Cord Injury Recovery. It will introduce the uninitiated reader to topics discussed in Chapter 7 of the book, but some vocabulary or context may not be fully defined.

Because paralyzing injury results in the loss of movement, SCI rehab programs tend to focus on the generation of movement above all else. It makes sense that you are eager to create motion after this kind of injury, however, we can’t neglect the importance of stability (essentially non-movement) in this endeavor.

Proximal stability (core strength) is essential for efficient movement of our limbs. Without even thinking about it, an able-bodied person reaches their arm to lift an object and unconsciously and reflexively stabilizes through the legs and torso to avoid falling over - an integrated pattern developed during early years and strengthened proportionally through life. 

However, paralysis, particularly in thoracic level SCI, causes a discrepancy here that is frustrating and often confusing for those recently injured: suddenly, upper limb strength and torso stability are disproportional. This person may still be able to bench press 75 pounds but now has trouble simply passing a basketball without knocking themselves over (sitting on the edge of a table without the support of the wheelchair).

We argue that a focus on proximal stability and the integration of this stability with movement generation and outward force production is a priority in SCI rehab. Understanding the relationship between stability and movement generation makes learning to move much easier in the long run. 

Why should SCI rehab focus on stability?

Stability is the ability to resist being moved, whether the force comes from the outside (extrinsic) – such as a heavy backpack on your shoulders pulling you backward – or from your own limbs (intrinsic) – the weight of your arm as you reach forward. 

Each of these scenarios involves forces that pull the body away from its center of gravity. Through stability, we are able to resist being moved because we can absorb and re-distribute these forces, instead of falling over. We also use stability, specifically in the trunk, to support the production of movement elsewhere.

Athletes are often frustrated early on when they find that intrinsic forces, such as the weight of an arm, are enough to overtake paralyzed back muscles. Counterbalancing and “arm hooking the back of the wheelchair” strategies offer short-term solutions.

However, these “survival strategies” not only deprive the individual of the opportunity to develop proximal stability (isometric core strength), but it also occupies an arm that could otherwise be available for interactions – ultimately an inefficient pattern when working for long-term gains. An SCI rehab focus, then, is to establish greater internal stability to move in efficient ways.

Explore these concepts in greater detail in our book, From the Ground Up: A Human-Powered Framework for Spinal Cord Injury Recovery, available in print & e-book format.

In what order should stability & mobility come during SCI rehab?

Stability and mobility are always in a relationship, with human movement requiring each at various places and times. We have adopted a strategy for helping athletes develop this relationship step-by-step; the progression might take place within a single session, or across several weeks in a program.

The progression for developing stability & mobility in paralysis rehab:

1. Achieve a passive range of motion (mobility)

2. Develop active stability

3. Generate voluntary movement (mobility)

4. Control movements (stability)

Achieve a passive range of motion. Some SCI athletes begin rehab with so much muscle tone and spasticity that they are unable to move even in places where muscle activation is present. This rigidity, stiffness, or hypertonicity is acting to protect the joints from unsafe ranges but it also prevents movement from happening at all. If we are looking to generate movement, we need to decrease this tone before we can begin anything else. (Strategies for decreasing neurological tone are discussed in Chapter 11 of From the Ground Up).

Develop active stability. Athletes who have recovered some passive range now need to develop internal stability which does not rely on involuntary tone. Athletes who have little-to-no tone will begin the process here. 

Indicators of sufficient stability include the ability to resist the intrinsic forces of moving an arm or leg without falling over or holding a position against gravity with no extra support. At this stage, the athlete can actively mediate their body’s response to an applied force, like resisting being pushed from the side, but may not yet produce movement. This stage is largely under-celebrated because it still appears like the athlete can’t do much, and it is difficult to show progress to family or friends who may not understand the importance of stability. However, the foundations are being set for the next stage.

Generate voluntary movement (mobility). This is the stage everyone seeks, the ability to transmit stability forces in order to produce movement voluntarily. Although it’s not spastic or reflex-driven, the motion is not yet integrated into the athlete’s broader movement patterns.

Control movements (stability). The balance between concentric and eccentric actions creates control and fluidity. This ceaseless alternation between stability and mobility allows us to move efficiently throughout the day.

Through our implementation of this model, some athletes discover an extra inch of reach; others perform squats with slightly less support. 

We should also note that you can be at different stages of the stability progression in different regions of your body at any one time. For example, you might use your legs to support your seated position (active stability) while working to lift your spine upright (voluntary mobility). For effective programming, it’s important to use these areas with established active stability (or some portion of it) to support work in other areas

We discuss and actively explore this progression of stability for mobility in our Practical Posture for SCI online workshop. The workshop breaks down this concept with exercise demonstrations and a movement routine to practice.

Awareness through Anatomy

The first stage of our Framework for Recovery, “building awareness,” encourages a foundation of basic anatomy. The majority of Chapter 7 reviews relevant anatomy in the context of SCI recovery. Not only does anatomy help you better understand what’s happening in the body during movement and healing, but it also offers a common language for the SCI athlete to discuss sensations and actions with their practitioner. 

For those relatively new to the world of anatomical speak, we’ve included some diagrams to help you develop some  “movement vocabulary” to help you discuss and describe exercises for spinal cord injury rehab.

The location of something, relative to something else is described as:

The direction of movement of a joint is described with:

Chapter / Episode 7 topics include:

• Stability: Why it is required for mobility in the body, as it pertains to paralysis rehab

• The base of support: understanding where stability comes from in order to create movement

• Tone & spasticity: protective mechanisms and strategies to alleviate them

• Fascial lines for SCI rehab: our guide to paths of force transmission through the body

• Relationships within anatomy are more important than focusing on individual bones &  muscles

Sign up for the FTGU Book Club to get these insights on spinal cord injury rehab delivered to your inbox every week, for ten weeks.