Ramblings on healthcare, medical education, and life with a spinal cord injury
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Baby’s First Steps

That’s right, I’ve moved up in the world from merely crawling on the ground or standing on the parallel bars.  As I’ve said before, recovering from a spinal cord injury can be a lot like being a baby again.  I’ve been fortunate enough to slowly regain functionality throughout my lower body, which was more unexpected than expected by those who know the field and my case well.  This past week, I took my first steps on the parallel bars in physical therapy.  They weren’t pretty steps.  In fact, they were barely steps at all.  But they were still steps nonetheless.

I’d taken steps in the pool before, and the lagging right quadriceps have continually been the single thing preventing me from making more progress walking.  Although Melissa, my physical therapist, had previously shared my frustration at the right leg keeping me from starting to walk, she proposed giving it a shot with the aid of a brace on the right leg.  Not a heavy, terribly stiff brace, but one open at the front of the knee that covered from midway down the leg to midway up the thigh.  It allows for some range of motion in the knee, but keeps my leg from completely collapsing on itself.

The left leg has been weight-bearing for a while now, aided in part by some moderately occurring activity in the quadriceps that result in extensor spasms.  These spasms cause the leg to straighten completely, sometimes while sitting and sometimes while standing.  They’re not overly violent spasms, and I can predict right before they occur.  Imagine your left leg slowly kicking upward without you having control over it.  Usually they happen after I start a kicking motion, but far from every time I try to kick.  They’ve been a minor annoyance, and have been somewhat helpful when standing.  When they kick in while I’m standing, the spasms effectively lock my left leg in the extended (straight) position.

So upright I went on the bars, standing up as I’ve been regularly doing for the past few weeks.  For some reason, my posture has also gotten better.  A few people had been suggesting I looked more like a little old lady, hunched over a shopping cart.  But fortunately that was gone this past week.  I started with the right leg, putting all my weight on the left leg and using the right hip flexors that served me well in crawling to lift and advance the right leg.  It moved awkwardly forward, and I was able to properly rotate my pelvis slightly.  With the assistance of the brace and both of the bars, I started to transfer my body weight onto my right leg and attempted to advance the left leg.

Nothing.

I tried again, and my left leg stayed planted firmly behind me.   It seems the downside of knee extensor spasms in the quadriceps is that they inhibit hip flexion.  I should be more proper.  It’s not that the spasms exactly inhibit flexion, but when extended, the rectus femoris becomes a very weak hip flexor and is unable to carry out flexion.  This is because it is already shortened due to extension and is unable to shorten further to facilitate hip flexion.

I tried to swing the leg a bit, and in the process of doing so the knee extension broke a bit and I was able to advance the leg slowly.  After taking three steps with each leg, I collapsed backward into my wheelchair.  I backed up to the start of the parallel bars, rested, and we gave it another shot.  The left knee extension continued to be an issue throughout the three trips down the bars, but I was able to make it all the way each time.

What a feeling!  Eight months after dislocating one of my cervical vertebrae so severely that my spinal cord literally was making a vertical figure eight, I have taken my first steps again.  I spent the rest of therapy in the standing frame and on the mats working my legs and torso further.

On Wednesday when getting back into the pool, I thought walking wasn’t going to go as well as it had the week before.  After all the work I’d done on Monday, I worried that my legs would be too tired or stiff to really move in a steplike fashion.  But at least I would get a good workout and continue to put more into the legs.

To my surprise, not only were the legs functional but they were even stronger than they’d been the last time in the pool.  My posture was completely upright, with my left arm on the edge of the pool and my right arm around my therapist.  She had to block my right leg a lot less than she had before, commented on how much more fluid everything was and how the right leg was noticeably starting to bear weight.  I walked twice as far in the pool as I’d been able to just the week before, totalling what I guess would be about twenty to thirty feet.  An no more hunched-over walking, either.

After a bit, though, my left leg started to lock at the knee again.  This is starting to become very frustrating, as it’s another one of those little hurdles which makes progress that much harder.  I paused for a minute, took a deep breath and tried to relax and re-center myself.  Right at that moment, something clicked and I realized how to relax and unlock the left knee.  It doesn’t lead directly to the hip flexion necessary for walking, but it relaxes the muscle enough that I can start to lift my left leg up a bit.

That realization helped me when I got on the bars again in therapy on Thursday and did some more walking.  I was again surprised with how well my legs responded, because when I woke up on Thursday my legs were stiffer than they’d been in as long as I can remember.  I spent nearly two hours stretching them, and figured that walking wasn’t going to happen.  But happen it did, with five trips down the bars, if I recall correctly.

The stiffness in the legs has made me think a lot about nerve pathways.  Since the moment of injury, I have always retained light-touch sensation throughout my body.  This indicated that there was nerve activity going at least from the bottom of my body back to my brain, and thus resulted in my injury being classified as ASIA B, an incomplete spinal cord injury.  I’ve previously reviewed the ASIA impairment scale in some fair detail, and it’s worth revisiting at this point.

Although I retained light-touch, I have lacked pain sensation since injury.  This is because light-touch and pain travel through completely different parts of the spinal cord.  Additionally, I’ve lacked temperature sensation since those are neurologically related to pain (they travel through the same lateral portion of the cord, as opposed to the anterior, or front, pathways that transmit motor movement, and the dorsal, or rear, portions that transmit light touch).  One of the tests that is often done with incomplete spinal cord injuries is for pain sensation.  Often, the return of pain sensation is a precursor to regaining motor control.

While an inpatient, tests for any return of pain sensation were mixed.  I was often able to discern the difference between two stimuli, but the painful stimulus didn’t “hurt,” per se.  When I started to move my toes, my attendings felt the painful stimulus test no longer offered much clinical value.  But I continued to check for pain response, pulling the occasional hair out of my legs to no avail.

This has all been compounded by the reduced sensation in my right leg, which I have had since injuring my right quadriceps back in April.  Although at times I think it’s slowly becoming more normal, I am regularly reminded that light touch does not feel normal in that region of my right leg.  Below that level, light touch is fine – suggesting that the damage resulting in this diminished sensation is localized and not a cord issue.

A good friend asked me recently if it was really not that bad not feeling pain.  I have some fairly deep cuts on my feet that show why, as I may feel my legs brushing against something when they’re really being sliced open by a sharp metal edge.

Recently I had a metal box on my lap, resting on my two quadriceps.  I knew the corners were fairly sharp, but didn’t pay too much attention.  Out of nowhere, I suddenly felt a sharp, painful sensation in my right leg.  I quickly recoiled and lifted the metal box, to see a red impression on my leg.  It wasn’t bleeding, but it certainly wasn’t normal looking.

Then I realized, for the first time in eight months, I’d felt pain below my level of injury.  I was ecstatic.  I’ve never been so happy to feel pain in my life, because it’s further return to normalcy.  Feelings of pain in subsequent tests (read: me pulling hair out or scratching myself with something) have been mixed, so it’s not light a switch was flipped and all of a sudden I feel pain again.  But it’s an indication that things are still healing inside.

So to recap, I’m taking steps for the first time since January and have felt pain, but continue to have diminshed sensation in my right thigh.  I was told that it’s always the incompletes that have the most seemingly random assortment of symptoms, but only now am I starting to really comprehend how random they can be.  It doesn’t make logical sense (although I’m sure it would if I could see the extent of functional  damage to the spinal cord), but I’m not complaining.  Just trying to move forward.

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