Try a Little Tenderness...
Spinal Cord Injuries and Soft Tissue Rehabilitation

By Karrie Mowen

Walking up to this unfamiliar door, Joanie Heart was uncertain her abilities as a massage therapist would make a difference. For one of the only times in her career, intimidation was looming. It was 1997 and behind the door was a 25-year-old man, not so much unlike other massage clients she'd seen in her 14 years of practice, except for one thing - he was a paraplegic.

"I was afraid I couldn't help him," said Heart. "I've always been very confident in my work, but for a few moments I was uncertain. I was standing in the wilderness with no map of where to go."

This was the beginning of what has become a life's work for Heart - developing her own "map" to soft tissue rehabilitation for those with neurological damage.

Heart walked through the door that day and eventually lost her uncertainty for a greater sense of purpose, something today she calls her destiny. "It's work from which we can offer hope, where hope has been forgotten," Heart said.

Coming from a background of neuromuscular therapy, Heart began that first session with an assessment of the client's soft tissue. "As I worked with the principles of neuromuscular therapy, I began to see immediate physiological changes happening below the level of injury (a shattered 12th thoracic vertebra) in what is sometimes referred to as the Ôdead zone'," she said.

After observing those changes below the injury site, Heart continued treatment on the client's abdominal area. "I palpated a mass of scar tissue - superficial to the liver - and began very gently to treat the ischemia and rigidity." During the treatment, the client began telling Heart of frequent, prolonged, excruciating spasms affecting his quality of life. After this flagship session, the client reported his spasms and pain had been tremendously reduced.

"Learning of the positive results we accomplished, I asked if he would be willing to work with me, to give of his time, knowledge and personal experience," said Heart. "We would become explorers...seeking answers and solutions to this devastating condition." Heart and her client devoted two days a week to exploring this new territory.

It wasn't much longer before word spread and the spinal cord injury population began calling on Heart to demonstrate her new work. She eventually opened her doors every Thursday to anyone with spinal cord injury (SCI), ultimately seeing 20 SCI clients consistently over the next six months.

What she learned has helped guide the evolution of her work. "I observed that each case was somewhat unique in the way the person's physiology responded to their injury," said Heart. "Some had pain, others not. Some could feel temperature, others not. Some could sense a need to urinate, others not. Some could lie flat, others had to be sitting up."

It was evident that to work with this diverse population required a tracking system of progress and an evaluation protocol therapists could follow to address the myriad of issues that arise from this injury. After garnering encouragement from the SCI community and some of its medical components, including the Miami Project to Cure Paralysis, Heart began documenting her work and developing her system.

The Treatment
Heart defines her work simply: A soft tissue treatment looking to normalize and mobilize tissues which have become ischemic and locked into contraction. This area of rehabilitation picks up where the others leave off, systematically addressing nearly 50% of a damaged system - the soft tissue. It is non-invasive, working with the body's own innate wisdom." The first and foremost goal of soft tissue rehabilitation, specifically with SCI clients, is to improve quality of life. "If obvious obstacles (i.e. ischemia, postural distortions, TMJ pain) are removed, or at the very least, reduced, my educated guess is that the body will always seek homeostasis, or its optimum state of health," said Heart.

The foundation of soft tissue rehabilitation, said Heart, is a combination of neuromuscular therapy, refined palpatory skills and patience. The latter is critical. The process therapists must go through when working on clients with spinal cord injuries can best be described as "letting go of the attachment to the outcome," said Heart. "The key to success in working with neurological damage is patience. Your opportunity to see results is directly dependent upon your ability and willingness to allow the tissues to respond in their own time, without forcefulness of any kind on the part of the therapist."

Heart has used the nugget of several theoretical laws on which to base this therapy. "In order to treat a neurological deficit, I turned to familiar neurological laws, such as Arndt's Law - strong stimulus arrests physiological processes, mild stimulus excites." She said she looks at the injury site and the subsequent surgical interventions as the strongest stimulus, to which she must apply a mild stimulus in order to see results. Heart also incorporates Hilton's Law (the nerve supplying the joint also supplies muscles and skin over that joint), the Law of Facilitation (having passed through a certain set of neurons to the exclusion of others, an impulse tends to subsequently take the same course), Newton's Law of Relativity (equal and opposite reactions), and the Law of Generalization (nerve impulses are propagated upward toward the medulla).

"These laws, combined with appropriate palpatory skills, are the keys to successful treatment," said Heart. "These laws are applied over and over again above and below the area of injury within any given session."

Putting it to Work
Each step of the soft tissue rehabilitation program builds upon the last, said Heart. She begins with a 14-step evaluation protocol, assessing everything from postural distortions and biomechanical dysfunction to lymphatic system function and dural tube restriction.

Next she puts the plan to work. "It may be necessary to focus on a small area at a time," Heart said. "The smaller contributors to the pattern often lead to greater opening of the larger pattern." She goes on to say that when treating the soft tissue component of the nervous system, it is important to recognize there are times when it is necessary to work above and below the injury site, often shifting focus as you "surround the dragon." Heart offers these treatment guidelines to consider with each session, whether all are utilized or not:
¥ Cranial Cradle - This movement is intended to free restrictive patterns at the cranial base, mobilizing the atlanto-occipital joint.
¥ Cross Thumb Technique - This addresses the soft tissue over cranial sutures and cranial joints.
¥ Eliminate Hypercontraction, Ischemia and Spasm in the Tissues - Concentric-eccentric ratio at least 3-1.
¥ Treatment of TMJ, Muscles and Tendons (external and internal).
¥ Treatment of all Glossal Muscles and Tendons.
¥ Treatment of Anterior, Lateral, Posterior and Cervical Muscles (including constrictor pharyngeals).
¥ Treatment of Fascia, Ligaments, Tendons and Muscles of the Thorax.
¥ Therapy for the Internal Organs (digestive system and accessory organs).
¥ Therapy for the Lymphatic System.
¥ Treatment of all Ischemic Fascia, Tendons, Muscles and Ligaments of Arms, Hands, Legs and Feet.
¥ Restore Flexibility to the Tissues - Traction, active and passive ROM.
¥ Incorporate "Feather Light" Stroking Over All Areas Treated that Session.

"After the pattern has begun to show beneficial changes, begin to add gentle movement therapies designed to support more functional biomechanics. Then rebuild strength and endurance," Heart said.

Working the Tissues
When working with a client who doesn't possess 100% sensation, Heart said it's imperative to have another barometer for the therapist to "address soft tissue below the level of sensation, to avoid further trauma into the system." Heart developed a palpatory assessment plan that looks at the tissues in terms of "climate." Resistance climate is what predominately will be found in the client's body. This describes the level in which tissues have a subtle resistance and are non-responsive. Eventually the body will allow access to the deeper levels when a receptive climate exists, where there is a softening or yielding of the tissues, revealing yet the next layer of tissues to be treated. "Keeping in mind the concept of tissue climate, assess the condition of the fascial tissues in the area which you are treating," said Heart. "Initially, fascial restrictions may need to be treated only a small area at a time, until mobility is restored to that area. Once mobility has begun to be restored, longer and deeper fascial planes, as well as muscle-tendon units, can be assessed and treated."

Heart suggested gently using compression, moving the fibers toward each other, on the fascia being worked. Then cross vector, using your fingertips, thumbs or palms. Repeat this process at least four to five times until you notice the signs of receptive climate. If tissues do not respond, you are encountering resistance climate, said Heart, at which time you must adjust, or lighten, your approach until receptivity is achieved.

In her work, Heart declines to place quadriplegics in a prone position. "Although I recognize the value of being able to contact certain tissues from this position, I feel the potential risk and discomfort of the person outweighs the value." Instead, she places her quadriplegic clients in either supine or side-lying positions. Paraplegic clients, when prone, must be supported with soft pillows or bolsters under the thoracoabdominal area.

Common Problems
While the trauma caused to the psychological, physiological, emotional and societal self after a spinal cord injury is often forgotten or overlooked, it's undeniably the devastation to the physical self which is most evident and life-altering.

Varying degrees of paralysis are predicated by the location of the injury on the spinal column. An injury at the C2 level often necessitates the use of a ventilator (some can be weaned from the ventilator for a period of time). Those with cervical injuries below C2 also have restriction in their ability to breathe as innervation to the diaphragm is inhibited or non-existent. Those incurring a thoracic injury are often completely paralyzed below the nipple line or below the umbilicus. If the injury is to the lumbar region, patients are likely to recover to some degree and may regain the ability to walk.

With most clients, surgical intervention has already taken place. Some will have had "simple" spinal fusions, while others will present with various wires, hooks or rods in their bodies. Heart said in cervical injuries, a common sight is cervical fusion with decompression - a process ensuring the cervical vertebrae won't collapse post-trauma. Thoracic injuries are often fused throughout many levels of vertebrae, often beginning at T1/T2 and continuing through L1.

"When treating these tissues, one must be extraordinarily aware that these surgeries and subsequent scarring must be approached with extreme caution," said Heart.

"In all the cases I've worked with so far, the predictable soft tissue components in cervical injuries are rigidity, ischemia and severely restricted ROM. In quadriplegics, the rehabilitative adaptive pattern syndrome includes predominantly the following: SCM, suboccipital group with subsequent compression of A/O joint; cranial distortion patterns with sensitivity along cranial sutures; all facial muscles; muscles, tendons, ligaments of the temperomandibular joint, contributing to mechanical misalignment of the joint; floor of mouth and all glossal musculature; all scalenes; subclavius and clavicular and thoracic attachments, posterior cervicals with their thoracic attachment sites and trapezius."

Heart said because people with thoracic spinal cord injuries use their arms for maneuvering wheelchairs through various terrain, as well as to initiate body transfers, she can usually predict with a degree of certainty that she'll see rigidity and ischemia in this client's serratus anterior; obliques and all attachment sites; latissimus dorsi; quadratus lumborum; all rotator cuff muscles and attachment sites on the humeral head; pectorals, major and minor; intercostal muscles; rhomboids; and serratus posterior.

The list goes on. Other issues include inability for normal bowel/ bladder function and neurogenic bladder; restricted water and fluid intake (for above reasons); spasticity; contractures; heterotopic ossification; reduced breathing capacity with an inability to cough; sexual dysfunction; constipation; pressure sores; emotional and societal challenges due to lifestyle change; edema in legs, ankles, feet and toes; potential early on for deep vein thrombosis. And unfortunately, persons with SCI are often prescribed a variety of medications which can lead to inevitable side effects.

Contraindications
When working with SCI clients, it is always appropriate to speak to their physician about the work being done, Heart said. She also recommends not only an extensive intake process with the client, but thoroughly reviewing the client's medical records.

Precautions for SCI work are much the same as with an able-bodied client, but with a few items of extra importance. Heart said therapists must be extremely observant and meticulous about hand-washing. "Many clients are prone to acquiring infection," she said. "It is not uncommon for me to wash my hands several times during a session."

Heart reminds us that treatments should never be forceful or aggressive. "Quick ROM movements have the ability to compromise ligaments in joints with contracture," she said. "Deep muscular therapy, if too aggressive, causes post-treatment pain and stiffness that lasts for a prolonged time. There is also risk of deep vein thrombosis. It is always best to err on the side of caution. It is too risky to apply deep pressure into circulatory structures which have been dormant for long periods of time."

Another major concern for therapists and clients is Autonomic Dysreflexia, a life-threatening condition sometimes seen in spinal cord injury at or above T6 when there is an irritation below the injury level. "These irritations can be caused by an over-full bladder or bowel, pressure sores, lying on a surface that is too hard or too flat and extreme temperature changes; even a toenail stuck on a sock can induce a potentially life-threatening situation," Heart said. "It's important to know the signs.

Autonomic Dysreflexia is characterized by extremely high blood pressure which triggers an automatic contraction of the blood vessels in the body. The brain is then unable to compensate by controlling heart and blood pressure. "The system goes haywire and blood pressure can go as high as to cause a stroke." Symptoms include severe headache, flushed face and dizziness.

The Outcomes
From that very first client, Heart has known the advantageous nature of her work. Still, the results reported by her clients are impressive:

¥ Increased sense of personal dignity.
¥ Easier bowel and bladder movements with greater production upon voiding.
¥ Better, deeper REM sleep.
¥ Reduced necessity for medications routinely taken for sleep, spasm or incontinence.
¥ Increased respiratory capacity, with greater function and mobility of the muscles associated with breathing.
¥ Greater balance and stability.
¥ Reduced pain.
¥ Reduced spasticity.
¥ Increased venous circulation.
¥ Increased lymphatic circulation.
¥ Improved digestion.
¥ Improved joint mobility, function, ROM.
¥ Increased strength.
¥ Increased endurance, stamina and energy to meet daily demands.

The testimonials lay out the benefits in even greater detail. Injured in a motor vehicle accident at age 38, Michael Glaser suffered immediate paraplegia with a T12-L1 fracture translocation. During the three years following the accident, Glaser improved to an L3 level of function. Still, after 10 years of physical therapy, this client couldn't improve any further - until he met Heart. "Right from the onset of the first treatment I noticed a marked difference in my circulation of both legs. My feet weren't pooling with blood and they were warm to the touch."

After receiving his third treatment, Glaser recalls an unusual moment. "I was lying in bed and mentally working on exercises Joanie had prescribed for me to do, when all of a sudden I realized I was getting a voluntary muscle contraction below L3 (level) in both calves of my legs."

In addition to several notable physical changes, client Matthew Chatowsky had his own unusual reaction to Heart's soft tissue work. He writes: "Several times while receiving treatment from Ms. Heart I have perceived a sensation below my Ôdefined level of sensation' that I can only describe as Ôless than something and more than nothing' about the area she was treating. Then, approximately one minute later, she would notice the area becoming much warmer to the touch than the surrounding areas."

As Heart professes, it's never too late to start addressing spinal cord injuries and client Jerry Warmuskerken is proof. Injured in a 1974 swimming accident, this client was 23 years post-injury when he first saw Heart. "Her approach to therapy was intriguing because it went beyond stretching, using a combination of techniques to begin to reverse the pattern my body had adapted to over years of being stagnant," Warmuskerken said.

"She began to treat all the elements of soft tissue individually and this showed results early on. My knees were unable to extend beyond 80 degrees when we started; that has increased to 150 degrees." Warmuskerken said that the attention Heart has given to the tissues around his knees, hips and ankles has increased the circulation and eliminated swelling in his legs and feet. "Work on the chest and diaphragm has improved my breathing and stamina. We were also able to eliminate heart palpitations - a terrific benefit."

Alignment and posture awareness are important elements of the work Heart and Warmuskerken are undertaking, and one of the most understated benefits has been the reduction of Warmuskerken's Valium prescription, for spasms and pain relief, by half. "

All of these things have a direct daily benefit on my quality of life. More than that though, Joanie's concentrated approach has helped me to reconnect to my body. It's easy to ignore parts of yourself that won't function as you would want them to, but her soft tissue therapy reconnects mind and body...This improved sense of self, physical self-esteem, should not be underestimated. It's half the battle to being well."

Heart reflects on her work this way: "I have observed over and over that it is possible to positively influence the reversal of the downward spiral of health and secondary dysfunction (of spinal cord injuries) through mobilizing whatever can be mobilized; to gradually nudge the entire organism toward the grand design. Humans are meant to be mobile, not locked into a dysfunctional pattern of contracture and to be left that way forever..."

Stemming from a career as a fitness instructor, Joanie Heart became a licensed Florida bodyworker in 1986. With a specialization and certification in neuromuscular therapy, as well as certification as a breath facilitator, Heart joined the teaching staff of St. John Neuromuscular Therapy Pain Relief seminars and worked with Judith Warker-Delany. For anyone who's worked with SCI clients, Heart has set up a SCI Research Hotline (800/999-6991, ext. 499) to hear successes or failures. For more information about Soft Tissue Rehabilitation (18 CEU credits), call Heart at 561/219-4361 or e-mail to joanie.heart@att.net.

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