The focus of today’s post will be physical therapy at the Kunming Walking Program. I’ll approach this challenging subject from two perspectives:
- Western vs. Chinese physical therapy practices
- My personal physical therapy experience here in Kunming
Contrasting Physical Therapy Systems
In Western Europe and North America, movement of patient limbs is typically done very slowly, the thinking being that one does not want to move joints, ligaments or muscles too quickly to avoid risk of further injury.
However, here in China the philosophy appears to involve moving limbs very quickly with sharp bursts of motion, whether stretching, massage, or weightlifting. The best explanation for this I have been able to get from the physical therapists here is that they were taught this technique in school, and they think that the faster you move the body the more blood flow rises to the surface resulting in keeping the muscles warm and perhaps faster healing.
While I can understand why with certain massage techniques there might be benefit to improving circulation throughout the body, it has been hard for me to grasp the therapeutic value of repeated abrupt movements.
Anyway, I have taught my assigned physical therapist to stretch me very slowly, but it does concern me to look over toward other patients and see their paralyzed legs being violently thrown forward and backward.
Interestingly, compared to Western countries, the Chinese do not place as much emphasis on upper body weight training. With the few surviving innervated muscles we have, paraplegic and quadriplegics need to maintain upper body strength through weight training. I’m the only patient who has a daily stationary upper body weight routine in my chair.
When I do see other patients pick up the weights, they usually just fling them around in the air and have no idea what they’re doing. While the physical therapists do sometimes come over to try to help them, it is clear that there’s not much understanding here of what is really involved in weight training.
I have learned that the field of physical therapy is a relatively new area of study in China, and students attend newly-commissioned physical therapy schools where there is no real specialization in spinal cord injury. Presently there are 8 full-time therapists working in the Tongren SCI program, and throughout the year we get physical therapy students coming in for an internship for several months at a time. I don’t think many of these students have previously worked with anybody in a wheelchair, let alone understand which muscle groups are not functional when a person suffers a spinal cord injury.
To give you an example, a few months ago several of the physical therapy interns were asking about different muscle groups, and a couple of the most experienced physical therapists had trouble answering these interns’ questions. Honestly, I found this pretty astonishing, since some of the therapists have been with the program for over 10 years. I’m not quite sure they understand the concept of motor function recovery vs. adaptive behavior, basic anatomy or how different muscles are innervated.
My Kunming Experience
As many of my regular readers know, I have been unable to actually participate in the Kunming Walking Program – basically for two reasons. The first is that my leg was broken last summer and never healed correctly. The other is that peripheral nerve damage that resulted from spinal cord surgery last May has still not healed, causing me such severe pain I am unable to support myself in the walking frame. Today I’ll focus only on the broken leg, as that had to do with a physical therapy accident.
Because an SCI patient is mainly confined to a wheelchair, there is already a 60% to 80% increased chance of developing osteoporosis. This is because when you do not stand, you obviously do not bear your own weight, so standing helps prevent osteoporosis by strengthening bones and muscles.
When you are paralyzed and confined to a wheelchair, you do have the option of standing in a supportive frame or a special kind of standing wheelchair. However, in general many SCI patients do not stand, and if they do it is usually only for about an hour a day several times a week.
With the above mind, patients who join the Kunming Walking Program typically have brittle bones to begin with, so when one starts standing or assisted walking the risk of a slight fracture, break or strain are higher than one might think.
When I broke my leg, this might have been due to brittle bones. However, I had been standing 4-5 days a week for an hour a day for the last 2 1/2 years before moving to Kunming. My point is that accidents do happen. But the pain challenges and frustration I ran into after the injury were largely unnecessary.
The local physical therapy team decided to start me in the walking program only a month after my May 2013 surgery … that is, in the beginning of June 2013.
Initially, I was okay standing stationary, but as the attending therapists pushed my legs forward, suddenly I started to feel very dysreflexic, and I began to sweat on the left side of my neck. As I discussed in earlier posts, dysreflexia is a condition suffered by SCI patients, which basically is your body’s frustrated response to pain when you do not have normal sensory feedback to your brain.
For example, if an able-bodied person broke a leg, that person would feel severe local pain at the site of the injury. In an SCI patient like me, I do not feel pain in my legs, but my injured leg sends garbled signals to my brain, which translates this input into different symptoms for every SCI patient. In my case, neuropathic pain goes skyrocketing, I sweat profusely only on the left side of my neck and my blood pressure rockets up to near-stroke levels.
So, after a few steps of forced “walking” I knew something was seriously wrong, and I asked to sit down immediately. By nightfall, my right knee was seriously swollen. I figured my body had simply not adjusted to the walking program and that I might’ve pulled a ligament or twisted a muscle.
The next day my leg was even worse, and I told the physical therapists that I wanted to get an MRI of my knee to see what was going on, never suspecting for a moment that my leg has actually been broken!
When the MRI came back, I had a meeting with the top physical therapists and program leaders here to discuss the situation, only to have them assure me there was nothing to worry about. I asked them what would have caused the swelling, and they said I most likely just had fluid buildup in my knee because I was not used to standing and walking. At the very end of the meeting, they did mention that they noticed an “old fracture” in my knee but asserted in the same breath this had occurred several years ago.
Initially I was very confused, because if I had previously broken my leg I’m sure I would’ve remembered a severe dysreflexia reaction and lots of other complications. Anyway, weeks passed but the severe dysreflexia and neuropathic pain responses did not abate. Every time I bent my knee, I started sweating profusely, crying, and was just generally a pretty miserable person. No one at Tongren was not quite sure what was going on.
After about a month of this, I’d had enough of the excruciating pain and lying in bed days at a time. And when my caregivers picked up my heel of the right leg, it bowed backward from the knee as if made of rubber!
(Picture of Bowed Leg)
An Independent Second Opinion
So I decided to send my MRI + subsequent X-ray images to several top orthopedic surgeons in the United States to get a second opinion.
To my astonishment, highly-confident and unqualified second opinions from top orthopedic surgeons were that I had very recently suffered a fracture of both my tibia (shinbone) and of my femur (the major upper leg bone) the two biggest bones in my body!
They asked what had been done to set the bones … what kind of cast had been fitted. I replied that no cast had been fitted!
The U.S. surgeons suggested I take another MRI about eight weeks after my leg had been broken, but they told me that unfortunately, there was nothing I could do at this point. The corrective 6-week window was closed. My leg had healed in a permanently deformed and weakened position.
These surgeons did advise that the leg could be re-broken and reset, but with the pain I went through this idea was a non-starter with me. Instead, at their suggestion, I ordered a very well designed knee brace from Germany, which I now use on a regular basis whenever I stand.
Summing up the broken leg fiasco, I would say any patient participating in the Kunming Walking Program risks some level of injury … simply straining a ligament more likely than breaking a leg. But most patients do not experience serious injuries, so far as I can see.
The challenge I had, and continue to have, is that when I did finally offer proof that my leg had actually been broken very recently during the walking program, this conclusion was met with complete denial and still is to this day! They still claim to think my leg was broken several years ago, despite all the orthopedic evidence to the contrary.
A Cautionary Tale
The reason I have gone into so much detail about this whole broken leg fiasco is because I think it is directly related to physical therapy practice here in Kunming. For reference, I worked for a couple years with several top-notch physical therapists in Miami and am myself knowledgeable about anatomy and physical therapy. So, in my frank opinion, a properly trained physical therapist should have easily been able to identify a problem as serious as a broken leg!
My experience here in China is therefore a cautionary tale about physical therapy technique and safety. On the other hand, the Kunming Walking Program does offer a robust, 6-day rehab work-out for those fortunate enough not to have any mishaps in the beginning.
The physical act of standing and assisted walking provides 100% weight bearing, improves balance, especially for paraplegics, and is an overall general great form of exercise for somebody in a wheelchair. On the other hand, as I discussed at considerable length in my previous blog post, the benefit of the actual walking with respect to motor function is, in my view, no more than speculation.
The last point I want to make today is that I still have not observed any direct evidence that walking is preferred over simply standing. Weight-bearing is weight-bearing. Both activities allow you to bear weight for long periods of time, which is beneficial for every SCI patient.
In my next post I will dive into the world of spinal surgery here in Kunming.
Can we see how the brace works on your knee
Hi Ali: thank you so much for writing this entry. I wonder how long you will stay in Kunming. I wanted to visit the program this year but have not yet been able to do so. Tony graduated undergrad yesterday and will start his master’s program in Fall at NYU. He is doing the Ekso at Mt Sinai in NYC 3 days a week. It’s a great program! Your blog is always so helpful and interesting and I appreciate the information very much. Are they using the Ekso or Re-walk in Kunming? It seems like those devices, assisted, would help prevent injury. They are fully braced and the Ekso provides more upper body support with a handle on the back to allow the Therapist to hold and help. I wonder about your thoughts on those. Thank you for writing your blog! I enjoy it very much.
Loveely blog you have