As my consultant at the Duke of Cornwall Spinal Injuries Unit, I came to see you the other week for the first time in eleven years (I have been injured for sixteen), to show you the progress I am making in rebuilding my body following an accident that left me a paraplegic. I presented to you a body that has changed enormously from the one you saw eleven years ago, changes that have dramatically improved my quality of life. You were impressed with the life I have built for myself, but sadly did not seem to be impressed with the improvements in my physical condition. You showed no desire for me to take off my t-shirt so that you could examine the structural changes nor for me to demonstrate the functional changes that have occurred as a direct result of structural improvements. You chose, instead, to suggest that there was no way of knowing whether the changes were due to the thousands of hours of work I have put in, through a strategy known as ‘Advanced Bio-Mechanical Rehabilitation’, or due to the spontaneous recovery of nerve pathways that may have happened regardless of any efforts I have made.
Despite the terrible damage I did to my spine and, according to the orthopaedic surgeon who bolted it back together, the damage inflicted to my spinal cord by the shards of bone imbedded in it, I would not conceive it impossible, although highly unlikely, that there could be some spontaneous recovery of nerve pathways years after injury. If this were the case, it would result in the ability to consciously tense a muscle, or muscles, and possibly the ability to produce a simple movement. To suggest that spontaneous recovery of nerve pathways could result in the structural improvements I presented to you defies all understanding of paraplegia.
When I entered into your care on the same day as my accident, I was paralysed from the waist down as a direct result of nerve damage, but you could not at that time describe my condition as ‘paraplegia’. My condition was one of a body in a state of trauma from physical damage, paralysis from nerve damage and shock. Paraplegia is the condition we arrive at following this state of trauma, the weeks (or months) of bed-rest and then rehabilitation through physiotherapy. Those that become paralysed without the trauma, for example from an operation to the spine or from poor osteopathic practice, often escape from entering into this condition of paraplegia and manage to walk out of hospital following rehabilitation. You may suggest that such patients recover form paralysis due to lack of physical damage to there spinal cord, but I would suggest that it has more to do with the retention of intrinsic capacity that tends not to be lost without the trauma of an accident.
It is true that nerve damage is a defining factor in paraplegia. What is more, a T4 paraplegic will be different from a T12 paraplegic and so the level of injury, resulting in a greater or lesser extent of nerve damage, will give us an indication of the condition of the paraplegic. However, nerve damage alone cannot describe paraplegia and I believe that lack of ‘Intrinsic Capacity’ is not only a factor but a better approach to describing paraplegia. In the trauma of an accident it is as though the power is switched off and all the circuits in the body shut down. If we were to get up the next day, shake ourselves off and carry on walking then everything would start back up again, but as we know this doesn’t happen. Unfortunately, with such a traumatic injury followed by a prolonged period of bed-rest, the body remains in shut down mode leading to deflation of the trunk and a dramatic loss of intrinsic capacity. Rehabilitation through conscious effort applied to a body incapable of supporting the proper use of skeletal muscles due to the lack of intrinsic capacity, not to mention the fact that much of those muscles are paralysed, results in deformation of the structure and eventually ingraining of these changes.
A ballet dancer or a top athlete may operate close to 100% intrinsic capacity, but your average person will operate from 90% down to 80%. From 80 down to 60% you will see signs of problems with walking. From 60 down to 45% the individual will be a paraplegic (without ability to support the use of the legs). From 45 down to 30% a tetraplegic (unable to support use of both the legs and arms) and below 30% unable to support breathing unaided. So paraplegia can be defined without reference to nerve damage and the obsession with nerve damage, that I find amongst both health professionals and the spinally injured population, is both misleading and unhelpful. Only when we see paraplegia in terms of intrinsic capacity can we arrive at a strategy necessary to address the situation and improve the condition. When you look at an active paraplegic, from a front view, you may see what appears to be a well formed body and it is true that the increased use of the arms can build substantial superficial muscle bulk, but when you view the same paraplegic from the side you will see a very different story. You will see a body with no depth to it, with the back apparently missing as though the rear third of the body has been sliced off. This is the real factor that defines paraplegia.
The body I left hospital with, as a paraplegic, was a body with no depth to it that provided insufficient foundation for the arms, let alone the legs. Every push of the wheelchair caused the body to hinge, so deforming the ribcage. The elements of the body were so collapsed upon themselves that the bottom rib actually sat below the top of the pelvis; there was no waist. The spine was taken out of the equation and floated around in the trunk and the shoulder blades were sunk in deep. The pelvis had little depth or width to it and the weaknesses and deformation extended up into the neck and head. This is the nature of paraplegia with depleted intrinsic capacity and deformed structure not only below but also above the level of injury.
You put great sway into your defining tests as to whether I can feel you tread on my toes or feel you stick your finger up my bottom, but such test tell us only what we already know, which is that the nerve damage is considerable. A friend of mine who was paralysed through an operation to remove a cancerous growth from his spine managed to walk out of hospital and to all intent and purpose made a full recovery (incidentally he never lost intrinsic capacity through this process), but years later still has no temperature sensation in his lower legs to the point that he managed to burn himself on a hot water bottle without knowing, and so it is possible to gain full functional ability while still lacking sensation. It is not the surface sensation of these tests that is important, but the deep awareness that comes from the improvements in structure; an awareness that is indicative of the brain once again recognising that the body exists. Once structural improvement has reached a critical level then this can, and is in my case, translating into functional improvements.
I am sure that there is a level of damage to the spinal cord itself whereby it is impossible for any recovery of nerve pathways, but I believe it is difficult to do that much damage and that in the vast majority of cases there is scope for improvement. However, improvement can only come by addressing the intrinsic capacity and structural integrity of the body and not through addressing the nerve damage itself. Nerve pathways can only be established when the body once again has sufficient quality for the brain to be able to recognise it. If we are to overcome spinal injury then we must learn to see the body through bio-mechanics.