Exercise is vitally important for spinal-cord injury (SCI) individuals – it just may take a different form.
A few weeks ago at an editorial meeting someone said to me: “You should write about passive exercises; they’re important.”
Passive exercises? I wouldn’t know where to begin, so I Googled it and, sure enough, there were a multitude of sites explaining what they were. But there was nothing on why they had to be done.
And so I find myself in the Netcare Rehabilitation Hospital’s Spinal Gym across a table from Linda Hunter, a physiotherapist in the hospital’s spinal unit. I kick off with my burning question: “Why do we need to do passive exercises?” “Well, actually we call them passive movements, they are not really exercises,” she gently corrects me.
She continues: “It’s mainly to maintain movement in the joints. So, if you are paralysed and unable to use your muscles to move your joints, you need to move them with another part of your body, or get someone to do it for you. This allows you to retain some flexibility in your muscles, nerves and joints, without which your posture in your wheelchair, and your ability to perform functional activities such as putting on your shoes, will be negatively affected as the joints contract. It helps you to maintain your independence, be comfortable and do things for yourself.”
I can understand the need for passive movements in spastic paralysis but what about flaccid paralysis? It turns out that passive movements are equally important here because it helps the person to retain some sort of position sense and not just flop back into a position of least resistance. It also prevents the joints from stiffening. “But how can joints stiffen if the muscles are flaccid?” I wonder. Linda explains that, because muscles are made to stretch and contract, if we stop stretching (and contracting) them, they will be influenced by gravity and contract, into non-functional positions. Similarly, tendons and joint capsules stiffen and the entire joint becomes frozen.
How frequently should these movements be done? “If the joint range is reasonable, once a day is enough,” says Linda. “Short spells, of about five to 10 minutes a day, are usually sufficient.”
What about a person whose joints are contracted beyond acceptable levels? In this case movements should be done more frequently until a reasonable range has been achieved. Stretching exercises, and even splinting, can be considered. (Note: while passive movements can comfortably be done by the person with the paralysis or by a caregiver, stretching is best handled by a trained professional such as a physiotherapist: the bones of persons with paralysis often become thin and osteoporotic, causing them to break relatively easily. Stiff, contracted muscles can also tear easily.)
Are there any dangers? “Definitely,” Linda replies. “For example, with the flaccid joint the danger is that you overstretch the joint – forcing it beyond its normal capacity. That’s quite easy to do because there is no spasticity to overcome and the person feels no pain because of the lack of sensation. If you are in any doubt, look at what your own joint can do and make sure that you don’t go beyond that. With spasticity the danger lies in trying to force the joint. You can damage the muscle because you are fighting a contracture or you could possibly damage the bone and cause a fracture.”
She adds: “The movements should be done rhythmically and within the range of movement of the joint, possibly with a little bit of a stretch at the end so that you make sure you are not losing range of movement of the joint.” Linda emphasises that the nature of the passive movements should be aimed at countering the specific “pulls” of gravity and the body. If, for example, hamstrings are particularly spastic, the focus would be on countering the pull of the hamstrings by working on the range of straight-leg raises.
A word of caution: a straight-leg raise is not just a muscle and tendon stretch, it also stretches the nerves. Overstretching can cause pain, headaches, dizziness and nausea. If you notice that the knee is buckling or the leg is tightening up, ease up. The key words are: Be gentle, be alert and feel the resistance of the limb to the movement.
Passive movements must be tailored to the specific needs of each individual. The aim is to maintain posture, flexibility and range of movement. There is no “one-size-fits-all” manual. The best approach is a session or two with a physiotherapist who will then draw up a series of movements to be followed. At the Netcare Rehab Hospital the physiotherapists teach the person with the paralysis together with the caregiver. They take photographs of how the movements should be performed and these are then included in a tailor-made Passive Movement Plan.
Finally, any dos and don’ts with passive movements? “We recommend that our clients do them six days a week. Have one day off. Plus, the more you can change your position each day, the better. As you sit in your wheelchair, your hips and knees are bent and your ankles are stretched. When you get out of the wheelchair, make a point of lying on your stomach for a while. This allows your hips to stretch and your knees to straighten out. If you can, stand in a standing frame for a while – this also stretches your body in the opposite direction.”
And don’t forget about the trunk of your body – it’s the centre of everything. If it gets bent or rotated, it becomes difficult for you to sit in a wheelchair. Apart from the discomfort, this increases the chance of developing pressure sores, because the pressure distribution is abnormal.
The message of passive movement is this: although you may have a broken body, it remains the vehicle through which your mind, spirit and soul function. Don’t give up. Nurturing our bodies is the first step toward applying our minds, allowing our spirits to soar and enabling our souls to reconnect with God.
Ida’s Corner is a regular column by George Louw, who qualified as a medical doctor, but, due to a progressing spastic paralysis, he chose a career in health administration. The column is named after Ida Hlongwa, who worked as caregiver for Ari Seirlis for 20 years. Her charm, smile, commitment, quality care and sacrifice set the bar incredibly high for the caregiving fraternity.