Chapter 8: Create Connection
Framework for SCI Recovery, part 2
This discussion + podcast is the eighth 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 8 of the book, but some vocabulary or context may not be fully defined.
In the Framework for Recovery after SCI, ‘connection’ comes after building body awareness. It is the subtle sensation of the body responding to voluntary activation - which is often described as tingling, burning, “waking up,” energy in the directed area. It’s like something is happening there but not necessarily as dramatic as a full contracting muscle or dynamic leg movement.
The connection phase feels elusive because it feels like we are asking you to create something from nothing. However, if you have done the diligence of learning your body (the first phase of the Framework for Recovery - see Chapters 6 & 7), you will be able to perceive and appreciate the small changes that come with the connection.
This phase may be the most frustrating and most gratifying at the same time. This is the phase of the framework that gives rehab exercises the opportunity to ‘stick’ for the long term. And there are a few ways we can support body connection after SCI.
Neuroplasticity in spinal cord injury rehab: The foundation for lasting change
For hundreds of years, the brain was considered fixed in structure and function “like a complex machine, made up of parts, each of which performs a specific mental function and exists in a genetically predetermined or hardwired location” (Doidge, 2007, p. 12). We used to think the brain didn’t change through life, or at least not after development. This long-held notion, localizationism, has been challenged by a wave of arguably incontrovertible evidence of the plasticity, malleability, and ever-changing nature of the brain.
You might have heard the phrase “neurons that fire together, wire together.” This is how the brain evolved to efficiently manage its many demands: by consolidating tasks into neural routines. Execute such a routine, and its sub-routines all happen together.
Driving a car holds many examples of neuroplastic learning: with a manual transmission, you learn to combine shifting gears with working the clutch. They become paired such that the motion is a singular ‘neural routine’, rather than two separate ones. “Fire together, wire together” is part of how our brain internalizes (and externalizes) our movement, habits, speech, and relationships, and it’s a characteristic that can help us in SCI rehab.
Individuals with SCI can take advantage of brain plasticity to more rapidly – and permanently – redevelop their movement.
We discuss specific ways to leverage neuroplasticity for efficient motor learning after SCI - making the exercises “stick” - in our online workshiop Coaching Integration after Paralysis online workshop.
Apply additional pressure through joints with paralysis to stimulate awareness & connection.
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.
SCI exercise “variations” are neuroplastic stimulus
We have often referred to the SCI rehab process as constant troubleshooting. If an exercise isn’t helping the athlete find a connection, what creative solutions can save the exercise? Suppose you observe that muscles don’t seem to be connecting; try removing support, switching postures, or introducing gradual variation in the joint angle.
The relative ‘newness’ of an experience is one reason the brain remembers some things and lets others go. The more variation of kinesthetic experiences, the more richly detailed the brain maps, and the better chance of making a connection.
Variations for fine-tuning and individualizing SCI rehab exercises:
Add or subtract grounding inputs
Change the working surface
Adjust support, or degrees of freedom
Experiment with ranges of motion
Vary the tempo
Modulate load
Increase endurance demands
Refine movement origin
We’ll look closely at #3 & #4 here. The rest are covered in detail in From the Ground Up!
Variation #3: Adjust the level of support in SCI rehab exercises
External supports that limit the range of motion both direct a movement and define a range of motion. They can also unintentionally provoke overuse of the support, training the individual to over-rely on it. Unstable external supports drive athletes to cultivate the necessary internal stability needed to generate the movement. As the athlete’s kinesphere expands, so do the demands on internal support.
The triad below illustrates a seated hip hinge, where the athletes hold onto progressively less supportive equipment. The same exercise, with a different set-up, challenges the athletes to connect to deeper internal stability.
The supports offer a 1-2-3-dimensional progression for this seated exercise:
One-dimensional: a rigid push-through bar mounted on a pivot swings only forward and back. The athlete only needs to focus on moving and stabilizing in one, sagittal plane.
Two-dimensional: the canvas straps allow movement forward/back, left/right, and diagonally. The straps do not stretch, so the athlete can lean his weight as much as he needs to into the straps (a physioball would be similar here).
Three-dimensional: the springs add one more layer of a challenge because they stretch when too much weight is placed on them. The athlete must be able to hold himself up through core support when reaching the springs and torso forward without collapsing into the spring.
A seated progression for SCI athletes with various levels of support. The freedom increases from a one-dimensional bar, to two-dimensional straps, to three-dimensional springs.
During upright, load-bearing exercises (kneeling and standing), help athletes rely less on the upper body by changing the level of support. Imagine replacing a supportive bar with spring handles while standing: if the athlete pulls too much on the springs, they will fall backward. This strategy helps them understand how much they rely on supports on versus connecting to the legs and hips to be stable.
Variation #4: Experiment with ranges of motion
Range describes the fraction of the total movement available at a joint. Some joints have hard stops – like an elbow in extension. Whereas the ranges of others are dictated by tissue tightness – like spinal rotation (limited by paraspinal muscles, spinal ligaments, and torso myofascia). Changing an exercise’s range of motion has a huge impact on connection.
Individuals with SCI benefit from both extra-large and extra-small exercise ranges:
Large ranges stretch tissues. They help the athlete with limited sensation sense (from internal stretch sensors) where the body should be activating. This stretch reflex can also reflexively cue muscles to contract.
Small ranges are best for self-supported, independent movement and allow athletes to explore their own balance points/thresholds of strength. They are harder to feel where sensation is limited because the tissues do not get stretched.
We recommend performing a few repetitions with an exaggerated (large) range to show the athlete kinesthetically where to focus their efforts, and then shorten the range to focus on self-supported connection. Explore connections in different segments within the full range (see image).
Explore various ranges of motion to help individuals with SCI connect to the movements.
By leveraging principles of neuroplasticity, such as relative newness, focus and constant feedback, we can create deeper connections in the body that stick with the individual long after a rehab session has ended.
Work cited:
Doidge, Norman. The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. New York: Penguin, 2007. Print.
Get From the Ground Up, our book on human-powered healing after spinal cord injury in hardcopy or in e-book format to explore these concepts in greater detail.
Chapter / Episode 8 topics include:
What exactly characterizes “connection” in muscles with paralysis? How can you sense and measure it?
How does connecting to paralyzed muscles feel different than traditional connection?
Our secret sauce: accessing muscles through the myofascial network
Neuroplasticity: how to create environments to leverage plasticity for lasting change
Why springs are better than weights for establishing new connections in SCI exercises
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