Julian Boustead C6 and C7. Inclined Therapy Tracking Journal Spinal Cord Injury

SCI’s and the Importance of Gravity Dependence in Nerve Regeneration.

Case2:

Julian: Complete Spinal cord injury at C6 and C7.

Julian’s injury was caused by a diving accident.

Pre intervention

He has no feeling in his legs and suffers from a constant urine infection, which appears to flare up once a week and does not respond well to antibiotics. This urinary problem causes influenza-like symptoms and makes him feel very cold. He has had pneumonia 3 times since his accident. He is unable to use of feel his hands, which are locked up in very tight fists.
He has no normal reflex action in his legs. Curiously, his leg appeared to go back when his knee was struck. When I tried to cross his legs over to test his reflexes, they were extremely tight. So tight that I was worried about breaking his leg and decided to support his legs under the knee joint.
His legs are devoid of sensation and voluntary movement.
Each time he uses his standing frame he blacks out.

At one point Julian was told that he should have an operation on the tendons in his wrists in order to release them. Julian refused to have the operation at Salisbury, (Odstock), Spinal Unit. He also refused to have his bladder sphincter surgically cut.

He is devoid of sensation below the armpit level and has little control over his upper or lower body.
While in bed Julian suffers from feeling very cold. He lacks the ability to control or maintain his body temperature during the day or night. “I also suffer with headaches regularly.
Throughout the night, Julian requires turning several times, in order to avoid pressure sores.
He is unable to fight his children off when they play fight with him, while he rests in bed.

Two years prior to his spinal cord injury he broke and dislocated his right shoulder. Tjis caused him considerable pain and he was told that he would always have problems with it. One year later he broke and dislocated his left shoulder and the prognosis for ongoing problems was the same as the previous one.
Following Julian’s Spinal Cord Injury he still has problems (as predicted) from the damage he sustained to his shoulders. Two years from the time of his spinal cord injury and four years since his first shoulder injury, Julian has made little progress in this area. He still suffers from the pain.


Pilot Study Notes:

21-8-96 Body temperature has gone up, feet are warm now, muscle spasms have improved, legs feel less tight, hands feel warm, hands feel a if they want to move. Abdominal muscles more supple and bowels working better.

25-8 Upper body strength has noticeably increased. When using calliper, I noticed my legs were swollen as they normally would have been, however after one nights rest they returned to normal.
No lethargy. Aches and pains feel different now. Am able to do more physiotherapy.

31-8 Had my first tummy ache since the accident. Urine is clear now. Standing in the standing frame longer. Feet have been moving? Hands softer, urine leaking during the night. Feeling tired.

7-9 Change of sensation in toes. I feel well in myself. Have now developed tingling sensation in my knees, I feel like they want to move. When trying to raise my toes they go down? This is a very interesting observation, because when I tested his reflexes at the start his legs went backwards slightly? Upper body strength still improving.

9-9 Spent two nights lying flat to determine whether it was the bed which was improving my condition. I felt irritable and my muscle spasms increased. I also noticed a sweat odour.

14-9 Noticed twinges in my legs and now able to cross my legs with a little help. Which means that my muscles are more relaxed. Developed pins and needles feeling in my legs and I now have backache.

19-9 All sensation of pressing pressures now responding and I am able to feel pressure on any part of my body. Have not had any urine infections since raising my bed. Not drinking so much.
Calf stretching exercises now cause me to ache normally. I spent 2 hours upright in my full body calliper and I was OK the next day. I am ok in the mornings now and I feel like I can get up and walk. I now feel an uncomfortable pinching sensation when I am in bed. I am always as warm as toast now and my hands do feel warm.

5-10-96 80 over 40 blood pressure and my heart rate is 40 beats per minute, which incidentally was the same as my fighting fitness rates. (former boxer). I haven’t had bronchitis since I raised my bed, this is impressive because I have suffered pneumonia 3 times in the past since I had my accident.
Had a urine infection.
20-10-96 Received advice from Tromans at Odstock Spinal Unit, though did not have any use for it.
Headaches now gone.
Shins burning up and very sensitive to touch, sensitivity in my legs has now fully returned. Toes are now working correctly and like the rest of my body are more sensitive. I feel that I am able to do more sit-ups 3 lots of 40.

5-11-96 Hands now staying open, tingling has improved in hands and lower legs, sensitivity improving all the time.
On Sunday I stood for seven hours and didn’t go giddy at all. My legs were swollen though. Feet still a little swollen now. Toe nails growing faster, I cut them every five weeks.
My catheter is suffering every seven weeks now instead of every five weeks.

6-12-96 so much warmer now, both in and out of bed. Sat outside with just a T shirt on. Sat in my chair today, I am now able to take the weight of the brown board from under the bed.

3-1-1997 Hands more relaxed and warmer. I am able to stay warm despite the freezing weather. I am now able to throw the kids off me when they attack. Had no urine infections since October, I used to get problems once a week.
Bowels working better and I did not get ill this Winter. I would normally become very ill. “Everyone else has been ill though”.

19-2-97 Bladder infection, swelling is bad and have been sick for six days.

30-3-97 Everything OK. Had examination at Salisbury, (Odstock) All my internal organs are working fine/ Ankles aching, sensitivity OK all over, I can feel a creased sheet on any part of my body.

9-5-97 While out for the day in a T shirt, I suffered a severe bout of hypothermia and was determined not to end up in hospital, I felt very ill. I finally arrived home and within 3 hours of inclined bed-rest I was completely back to normal.

9-6-97 When asked to assess his improvements on a percentage basis, Julian insisted that he is a 100 % better than before he raised his bed. Julian travelled several miles the other day in his wheelchair and while going down hill he tipped it over. He waited twenty minutes for a passer by to help him back into his chair and then continued on his way.












DICTAPHONE RECORDED THIS CONVERSATION.
Andrew K Fletcher holds the master tape.

17-8-1997

The Conversation

Today’s date is Sunday August 17th 1997 and I am at the home of Julian Boustead, Sitting down, watching Julian writing with a felt tipped pen, on A4 sheets of paper. Julian appears to have control, he appears to have grip in his hands and he can feel the felt tipped pen, which is held in his fingertips. And Julian is forming letters and words in front of my eyes. Julian assures me that he couldn’t do this before raising his bed, which has been about 11 months ago.

I have left the tape on record now in order to monitor what is said during this exercise.

Recorded

So, just trying to get my head around what’s happening. When we started, before we raised your bed, your hands were locked up solid? Julian: “Yes”. You had no sensitivity in your fingers? “No, none at all, just numbness on the left,-well both sides really, exactly the same really and just cold on the arms.

How would you push yourself along in your wheelchair before? “With the palm of my hands”. And the hands were in the shape of a fist? “Basically yes”. They were forming a fist because they were too tight? “Yes, mainly spasm”. So they were locked up! How are your hands different now? “Nice and soft, lovely and warm and more relaxed and better sensitivity and feeling in both hands”.

So you can feel the pen that is in your hand now? “I can now, yes, well the only ones I can’t feel is my little fingers, that’s all really, you can tell” Julian points to skin damage to little finger.

I told Julian that this was similar to the way people with leprosy damage their fingers and toes, due to loss of sensitivity.

Could you just write your name and address and telephone number for me, I know that we have done it once before, but I’d like to see it once again? So Julian has started to write his name and address and the hand writing is readable. Julian has written his name. He is writing with his right hand. Interestingly his second attempt at writing appears to have improved by around 40%. Could you write the date down? “17th”? Yes, and its Sunday. “I know that”. August 97. Could you sign your name? Excellent!
Taking a new sheet of paper could we try again now using the left hand? Julian added, “I have never been able to write with my left hand”.
Julian is now holding the pen as he did with the right hand previously. Can you feel the pen in that hand? “Yes I can feel the same feeling in both hands really”. How are you gripping the pen? “I thought it was balance. I don’t know, I am holding it between my thumb and forefinger, it feels like.” You say it feels like, you can feel yourself gripping? “I can feel it but”. There’s no strength? “No strength, well I suppose there must be a little bit to hold the pen”. I see that from time to time the thumb is moving up and down. “Well to be honest with you, I suppose subconsciously your trying so therefore its trying, its sort of spasmodic movement through. Well it does move up and down slightly don’t it”? It does move up and down! Now, move the thumb up and down. The thumb is moving up and down, would you agree with that? “I would really”. Well we are not imagining what we are seeing here are we? “No, I suppose it is on the ends, definitely some improvement then, I’ll just carry on writing, I’ll never be able to write my name else. Its doing the letters back to front you see”. I can read Newton Abbot and Julian is writing his telephone number and I am able to read it. That’s amazing and Julian has just signed his name. “It looks like John”.

Amazing, Pretty damn excellent. “Well that’s the first writing I’ve done since I’ve been home!” Why couldn’t you have written before? “I couldn’t put enough pressure on the pen to make enough mark”.
Could I just shake your hand? “Ain’t making no deals.” No leverage and no trickery, how does that feel? “It feels normal.” Does it feel like you would expect it to feel if someone was shaking your hand?
Can you try to move the other thumb and again don’t try to lever. I can see the thumb moving can you keep the hand still. “The thumb is moving.” It is, It is, it appears to be trying to work doesn’t it, though there is only a small amount of movement, just a twitching of the thumb. “Yes but that’s controlled spasms, it’s just trying to get there.”

So if I shake you’re other hand, again no trickery. How does that feel? “It feels normal again., apart from the little finger, that’s all.” Now the thumb is definitely moving on this hand. There is a lot of effort going into that and I can actually see the thumb moving, its lifting up, are you trying to lift the thumb up? “Yes the thumb-I am, and that’s the hardest one to do, the left one is worse.” Try to push down on the thumb. The thumb is going down. Now try to lift the thumb. The thumb is going up, can you see that? “Yes, its doing very well.” That’s amazing! “Just something I just don’t take much notice of.”
You usually help with drawings now and you couldn’t do drawings before? “No a few months ago I couldn’t even hold a pen.” How long have you been able to hold a pen? “About 2 months. “You know that’s about the best I’ve done, normally the pen slips out of my fingers”. That pen’s not going to slip out! “No”. I saw you earlier grip a piece of paper, could you explain how you are able to achieve this? “Yeah you just put your hands around it –I don’t know really I just get my wrist and tend to flick it, and its there, it’s –I don’t know really.” Looking at you holding the paper it looks normal. “No I just take it for granted really.
You mention that your hands would be cold normally prior to raising your bed? “Yes but they are lovely, lovely and warm all of the time now, like normal body temperature.” You can determine this without touching your hands? “Yes, I know if they are warm or cold, they feel lovely!” That’s a definite link back to the brain! “Yes they do feel nice, whereas before they did feel cold and they were cold too! A sort of numbness feeling but all that’s gone, pins and needles, static, all that. The only thing that feels tight are my little fingers.” You said at one time that they felt like a fat lip? “Yes they still feel like that, funny enough, but not all of the finger now actually. All of the hands felt like it before though.”
“I have noticed that if I get pins and needles in my hands it usually affects the little finger more. Yes its like you have laid on it and it’s gone to sleep.” Previously I used to get a feeling that my hands and forearms were dead. It’s not half as bad now and only evident on my little fingers.

How is the sensitivity around the rest of your body? “The only bad sensitivity I have got is from the shins down.” When you say bad, do you mean that you can’t feel sensitivity below the shins? “I can feel all over, but it’s a bad tickling feeling and pins and needles from the shins down, whereas before it was from the armpits down.” “The rest feels quite normal internally and externally, apart from sharpened things and hot and cold objects really. But internally I feel lovely and warm, I feel normal, which is frustrating isn’t it.”
What about your upper body strength, are there any changes in that area? I know we have discussed this before. “I’m definitely stronger because we are talking about going on to heavier weights. “Upper body strength, well, I had a wrestle the other week, funny enough the week before last with the children, I was right as rain with them, so it’s a lot better for me because, before I could do nothing!”

I have seen you in your standing frame, you let your body go back and then pull yourself up. How do you achieve this, what are the mechanisms you are using? “If I can spasm the muscle, basically I can spasm it, -of I don’t know really, but I can feel it tensing, so I can make it work.” You can feel the muscles contract, is that what you mean? “Yes, I can make myself free stand, obviously from the waste up for about thirty seconds, by controlling the spasm as such, which normally is done subconsciously, whereas I am more aware of it. Sitting on the bed is so much better as well, I can feel the tightness in my back, whereas before it was so loose. So it’s nice in that area, which is improving vastly and goes from strength to strength. But I do feel my body gets tired though, that’s the trouble.” Would you attribute that to doing more? “Just doing more exercise, yes and for longer periods, although it is only ten or fifteen seconds longer on each exercise, my body just seems to find it a little more taxing really.”

What kind of exercises do you do in your workout? “Just stretch ones using the body in itself. Then free sitting on the side. Whereas it was usually for about ten seconds, My father in-law Vince helps me to do it for about thirty seconds now and that’s four different exercises and over that period it’s a much longer time.” What about sit-ups, you mentioned them, is that unaided? No Vince sits in front of me sort of aiding me, but I still have to pull up for myself. So I still try to spasm the stomach to help ease up as well, because if the muscles are tight there is additional friction.

What about your abdominal muscles, are they more supple or more tense? “Supple I’d say.”

When we first met your legs were really tight. “They’re very tight now actually, I can feel that they are tight now.” When I first met you they were like rigor-mortise had set in. “Yes, but they are quite natural now.” I was worried about breaking your lags, when I tried to test your reflexes. “They go tight at the moment but they need a good stretch to make them go alright again.

Do you think they are affected by sitting in your chair? “I think they are actually, it depends on the chair I’m in. It acts up behind the knee, its that sit down posture, I think.” “They just tend to tighten up during the daytime.”
I advised Julian to raise the bottom of his chair. Julian said that he would put an extra cushion under his seat. He commented that his wheelchair was like a bucket, but added that this posture was useful outdoors.
“This does make me feel worse than sitting in the other one, in this position, which says something’s not right with it. “No it feels its not right too.”
How does this alter when you get on your inclined bed? “Just a few strong spasms really, until I stretch out again and then I’m alright and quite happy, but this is uncomfortable all day long.”
What about waking in the mornings, is that improving? “Waking, No just normal! I get up normal every day. Don’t get that horrible giddiness either. So you used to feel giddy in the mornings? “Terrible, funny enough I felt giddy on the way back from when I met you, (down by the horses and in his motorised chair.) “My tube was blocked because of the way I’m sitting you see. I had to go for a pit stop and have an alteration because the tube was kinked and it was not flowing the way is should be.” But again it’s this bloody position!”

PAUSE

Would you like to repeat that? “I think the feelings in my feet have recently changed, they feel like a burning sensation whereas before it was like pins and needles.” If you touch your feet are they hot? “I don’t know really, Vince could tell you that, he never complains that they are cold now, because before they used to be freezing.” But now when the nurses come in the mornings they say my feet are like pieces of toast.” “But that’s the way they feel, they feel they are on fire, they really do they feel red-hot.”
Do you get spasms in your legs now? “I do get spasms in the legs. Funny, I had a bad night last night, well I say bad, it was just that I was really close to the edge of the bed. My leg spasm’d and just dropped down the side of the bed, whereas normally I would be able to control it and keep my legs straight. But normally with regard to spasms, I wouldn’t really have any problems at all. In fact I get my legs into position and they stay there all night and don’t move at all and I have a comfy night.” How were they before we put the bed up? “They were quite tight before and if I moved they would spasm more. And they would be jumping around all night, whereas they don’t do that any more. “They do spasm at times but very rarely.

First time I called my Wife down stairs in may weeks, whereas before she was down all of the time, you know, repositioning me. But last night was the first time in weeks, so its minimum really, wouldn’t say I don’t get any because I would be telling a lie.”
“But then again on no pills so its even better again isn’t it.” You say you have reduced your medication? “Yes, I’ve dropped it down again now, especially the muscle relaxants, I just don’t feel no need for it, You know its doing the job on its own and that’s another bonus.”

Your sitting I a chair now, do you actually feel like you are sitting down? “I feel like I’m sitting down and its as uncomfortable as hell, like I want to get up and move.” Again relating this back to how you were? No then I was just glad to sit and didn’t mind what position I was in.” Could you determine what position you were in then? Very vaguely and only visually because you knew you wasn’t square.”
“But now you feel uncomfortable. If my hips are under too far, I know because its pinching, my internal muscles feel like they are pinching as well. You feel like you are sat on them. You just move the hip out and then you feel more comfortable. So there is obviously some sensory improvement there”

What about bladder control? “Well no my bladder control is really iffy. I think just paralysed as it is but no infection so again that’s another bonus. “The last infection was months ago, whereas normally it was once a week or once a fortnight on a good period.”


One year before Julian’s accident, He broke and dislocated his left shoulder and was left in considerable pain. Julian has just realised that the pain has now gone and this is despite the fact that he was told that he would always suffer from this injury. Furthermore the year before that he broke his right shoulder and was given the same prognosis from his consultant.

Julian no longer experiences any pain from the two shoulder injuries, despite the fact that he still suffered from these injuries, up to the point we met and two years after his spinal cord injury.

I met Julian on the 13-3-1999 and found that although he has not made much more progress he has not deteriorated.

An interesting observation occurred around six weeks previously when he developed a pressure sore. This developed during one night’s stay in hospital while sleeping on a flat bed and not being rotated.
He was told that it would be around six months before he could expect to see some improvement. Despite this the sore had greatly improved in a couple of weeks, following his return to inclined bed-rest.

In order for Julian to progress further, he needs to alter his sitting posture, and to stand for longer periods. He also need to exercise more and informs me that he has become lazy over the winter months. He has also gained about 20 lbs. and needs to alter his diet accordingly.