Saturday, January 9, 2016

Functional Range Conditioning for Cerebral Palsy: Introduction


This post has taken quite awhile to "come to print"...for no other reason other than it is the result of many rounds of formulation / implementation / re-formulation.  In essence, it is meant to be an evolution to the more common question raised both here in this blog and within the Cerebral Palsy (CP) landscape in general: Is stretching good or bad?   This is a question that I broach in an earlier post from 2012 called Stretching and Cerebral Palsy: What you should know.  If you have not read that entry yet, it goes into the specific challenges of stretching strategies in CP...but more importantly, it sheds some light on the actual biomechanical realities of this intervention.  As you will read (or may have already read) in that post, I don't identify a "clear winner" as to whether stretching is good or bad (or whether people should or shouldn't)...rather that it is something that requires some significant thought and formulation.  Additionally, we should be very careful when we attempt to "import" rehabilitation strategies we use in the healthy population to the world of CP.  The biomechanical and architectural realities are so different that we need to approach mechanical issues with significantly more care, analysis, and formulation. 

Taking all of this into account, I will begin the process of sharing a strategy I have called Functional Range Conditioning for CP.  It is a relatively comprehensive set of skills from the objective observers perspective that is based in an equally "heavy" physiological foundation...but at the same time, it is something that lends well to the "end-user".  This means that it has been specifically formulated to resonate well with any parent / care-giver and therefore serve as a valuable tool that can be used directly in the home.

The term "Functional Range Conditioning" is something I have essentially borrowed from an already established methodology used in athletes that efficiently and effectively frames an essential (and fundamental) reality:

In order for functional performance to improve (and thus reach maximum potential), we must first ensure that joints actually behave as joints.  If the singular articulations are dysfunctional, then the movement potential of the entire body is limited.  

Therefore, the strategy --- when addressing the issue of restricted / reduced ranges of motion --- is to first identify the dynamic behaviour of the joints before engaging in any active (or aggressive) stretching protocols.

Mitigating the challenges and risks of stretching

Challenges and risks??!  These specific things are identified in detail in the earlier stretching post, but once you have absorbed these risks and challenges, the next practical question becomes: 

"How do I (we) navigate and reduce them?

One of the MANY architectural challenges in CP is the inherent "mismatch" between the excessive strength (tightness) of the muscle fiber and the relative weakness of the connective tissue "anchors" (tendon, tendon attachment to the bone).  In other words, when we import a standard stretching protocol to CP, it is impossible to confidently be sure that the stretch itself is actually stretching muscle or in fact stressing / straining the tendon and/or the attachments to the bone. 

Therefore, before any angular (dynamic) movement is done, we should first provide some essential "nutrition" to the joint itself.  This is the first step in Functional Range Conditioning:

1. Joint Health and Nutrition

In order to achieve true productive range of motion, the joints MUST be healthy (or as healthy as possible) and formally behave (perform) as they are designed.  The reality in CP is that the majority of the synovial joints manifest moderate to profound stiffness.  In other words, the joint capsule (the connective tissue that covers the entire joint like a sac) manifests a certain fibrosis.  This means that rather than being a pliable and adjustable membrane, it is tight, fibrous, and relatively unforgiving. 

"Sponge Analogy"

I have used the Sponge Analogy on many occasions and I can honestly say that it is one of my most favorite ways of explaining joint behaviour in a way that is almost instantaneously understandable. 

Joint require a certain level of fluid...not only within the joint itself, but within the layers of tissue and even down to the cellular level.  This fluid essentially "bathes" the joint...providing not only lubrication and movement freedom, but also NUTRIENTS.  When a joint is fibrotic, it can formally be related to a dry sponge.  

The image above essentially demonstrates the 3 states that joints can manifest.  They should not be considered as 3 separate states, however...this should be looked at as a continuum.  Meaning that there is a gradual change in state when we move from one extreme to the other. 

Dry Sponge

The dry sponge represents the fibrotic joint.  It is rigid, in some cases distorted, and very much devoid of nutrients. 

Moist Sponge

This is meant to represent the "ideal homeostatic state" of a joint.  There is sufficient amounts of interstitial fluid to maintain its integrity as well as provide it with the required amount of nourishment.

Wet Sponge

The wet sponge represents the joint that has experienced some form of trauma...whether it be an acute injury or the result of long-term chronic stress.  Think of this as swelling or edema.

If we consider this analogy, then imposing angular dynamic movement (stretching) around this joint can potentially (if not likely) run the risk of unseen (and potentially de-stabilizing) injury or insult.  As a matter of strategic wisdom, when we are dealing with the challenges of CP and stiff / fibrotic joints...

The first "order of business" is to implement those techniques and interventions that are the most efficient at moving and mobilizing Interstitial Fluid towards the joint itself.

These techniques and interventions are part of the specific skillset and toolset used within the Fascia Therapy framework and are easily delivered during our training sessions. 

2. Functional Range Development

This step is implemented after (or in some cases, concurrently) the joint health and integrity step.  This step has 2 fundamental aspects:  a)  use specialized manual techniques to relax stiff and tight muscle...and b) impose progressive multi-joint movement patterns (using varied tools such as pilates balls and stability balls) to engage and activate the entire neuromuscular chain just as it would be engaged and activated in a real-life environment.

These movement patterns are quite varied and are essentially dependant on the individuals intrinsic movement competence and abilities...however, they are implemented based on the process of natural human motor development and formally help to potentiate movement through the developmental process in a more efficient and timely manner. 

In summary, this is only an initial overview of the framework of Functional Range Conditioning.  As with any approach, it should not be considered as a magic bullet...nor does it's existence and/or implementation negate or diminish the outcomes of other strategies.  It is meant to serve as a viable and realistic adjunct to all long term rehabilitative strategies...more specifically, a safe and effective way to develop, activate, and nourish better movement coordination and performance. 

More to come!