Cerebral Palsy and the Pediatric Evaluation

Part 2: The Developmental Process: Primitive and Postural Reactions
The second installment in this series on Understanding the Pediatric Evaluation revolves around two fundamental elements of the developmental process that are critical in the greater understanding of the long-term rehabilitation plan. Primitive and postural reactions are characteristic of critical early development that effectively signal progression and movement towards improved development. They are the easiest, earliest, and more frequently used tools in assessing neurological and motor development in newborns and infants.

Primitve Reactions

Primitive reactions are mediated in the brainstem and are fully present at birth. They are characterized by automatic movement patterns that become more difficult to elicit after the first 4-6 months of life. Some examples below:

Moro Reaction: The Moro reaction is obtained by holding the baby’s head and shoulders off of the mat with the arms held in flexion on the chest. The examiner suddenly lets the head and shoulders drop back a few inches while releasing the arms. The arms should fully abduct and extend, then return towards the midline with the hand open and the thumb and the index finger forming a “C” shape. An absent or incomplete Moro is seen in upper motor neuron lesions.

Prone: In the prone position, the baby should be able to extend the neck to the point where the head can be turned side to side. When the arms are extended by the side of the trunk, the baby should be able to bring them forward into a flexed position. The buttock should be somewhat elevated because the hips are flexed and adducted. A baby that is flat on the mat and can’t turn the head back and forth has low tone and weakness.

Head Lag: Starting in the supine position, the baby is pulled by the arms to the sitting position. The head and the arms are observed during the maneuver. The arms should remain partially flexed at the elbow and the head may lag behind the trunk, but should not be fully flexed backwards. When the baby is in the sitting position, the head should be able to come to the upright position for at least a few seconds before dropping forward or backward.

Postural Reactions

Postural Reactions develop following / during the disappearance of the primitive reactions. They can be considered voluntary actions that are produced by multiple sensory and structural inputs. They are complex motor responses to afferents like tendons, joints, skin, internal organs, and even the eyes and ears. They are characterized by predictable postural adjustments to specific applied sudden changes in position. As the child develops, the postural reactions (or postural performance) improve and manifest in more comprehensive ways as he /she ages. Some examples below:

Head and Trunk Control: When pulled to a sitting position, a baby this age should be able to have only slight head lag and, when sitting, the head should be upright but there may still be some wobbling of the head. The back is still rounded, so the baby slumps forward.

Prone: In the prone position, the baby is now able to bring his head up and look forward with the head being 45 to 90 degrees off the mat. Weight is borne on the forearms. When the head and chest are well off the mat, the baby is ready to start to roll from the prone to the supine position. Rolling front to back usually occurs at 3 to 5 months of age. Rolling over too early can be due to excessive extensor tone.

Lateral Propping: Lateral propping or protective extension is essential for the baby to be able to sit independently. This postural reaction develops at 5 to 7 months of age. Anterior propping actually develops first, then lateral propping. For anterior propping the baby will extend the arms forward to catch himself and prevent falling forward. Lateral propping occurs when the baby is falling to one side or the other and he extends the arm laterally to catch himself.


The understanding of these reactions is fundamental in the effective and accurate assessment of the success of the rehabilitation protocol. To be more precise, Infants with cerebral palsy have been known to manifest persistence or delay in the disappearance of primitive reflexes and pathologic or absent postural reactions. Therefore, the emergence of postural reactions (and the reduction of primitive reactions) is the primary treatment goal and thus any protocol that promotes this will ultimately contribute to improved function.

Part 1 of this series identified the need to place primary focus on the developmental age rather than the chronological age. Although not age appropriate, the persistent appearance of primitive reactions in older children is simply an indication of their current status and placement along the developmental path. It should also be remembered that the actual "manifestation" of these primitive reactions may look significantly different in an older child than a 6 month old. The structural proportions (length, weight, mechanics, torque, etc) are very different, therefore the same "reaction" may subjectively appear to be more severe or, at times, appear to be something completely different.

What does this all mean and how does it apply to my understanding of Cerebral Palsy? The answer is quite simple and straight-forward: the developmental process is something that cannot be circumvented or skipped. If the child with Cerebral Palsy continues to manifest primitive reactions in conjunction with the absence of postural reactions,any expectations of higher order function (crawling, independant sitting, gross / fine motor skills) is unrealistic. Rather than a message of "gloomy reality", the fundamentals of the development of the human organism will allow you to understand the "right path" and therefore effectively reduce any unecessary anxiety and worry associated with the unknown. More importantly, it clearly identifies those interventions that are essentially "shortcuts" along the path...which initially produce increased levels of hope and expectation, but in the end reduce maximum potential.

I apologize for the relatively longer post...it has been quite the challenge to even keep it this short! The third installement: Cerebral Palsy and the Pediatric Evaluation: A Case Study Report will blend the theoretical elements of part 1 and 2 and demonstrate their application in a practical examination of the progress of an actual CP child. I hope that it achieves my goal of creating a link and close the loop of understanding.

Success story in progress

I am pleased to share a post from one of my ABR families who just recently finished a training session a couple of weeks ago here in Rosario, Argentina. Over the last couple of years, I have had the pleasure and honour to participate in Salvi's evaluations...and at each step he demonstrates continued progress and improvement. I recommend that everyone have a look at this post...but further to that, take time to browse the blog itself. The insight into a family's challenges and successes will be invaluable to anyone. Click the blue link below and enjoy. Cheers!

Creciendo con Salvi: Evaluación ABR noviembre 2011: Es muy difícil para mí intentar resumir todo lo que se habló en la última evaluación de Salvador. Fue muy intensa para mí, con muchísimo fun...

Cerebral Palsy: Understanding the Pediatric Evaluation

Part 1: Fundamentals in Perspective

I thought it would be a good idea to begin this series of posts with a certain aspect that, in my opinion, is typically missing from most people when entering into any form of evaluation or assessment. It is not my intention to pass judgement on parents, professionals, or any other group of people...it simply exists. What is the missing ingredient? Perspective. Quite simply, the expectations of every parent with a child with CP must be tempered by the proper perspective. Without it, expectations can often run wild and ultimately lead to dashed hopes and unecessary feelings of guilt, frustration, and desperation.

Therefore, the question becomes: "What is the proper perspective?". The answer has been right in front of our (parents and professionals alike) noses. Conditions such as Cerebral Palsy, West Syndrome, etc...fall under the umbrella of Developmental Delay. Simply put, there is a significant delay in the development of healthy motor function. This is a reality that is inescapable...as chronological age proceeds at a regular pace, the developmental process lags behind. Therefore, by definition, the progression of each developmental phase is the ONLY component that matters when gauging progress. It is essential to remember that EVERYONE must pass through these developmental stages...irrespective of their chronological age. The very definition speaks for itself: Developmental Delay (CP) is characterized by the persistence or delay in the disappearance of
primitive reactions and pathologic or absent postural reactions. The vast majority of parents are focused in on the chronological age of their child and therefore attribute "age appropriate" expectations for their child. As mentioned in one of my previous posts: focused attention to your child's developmental age will give you the proper perspective on how they are "hardwired" to develop and therefore foster realistic expectations going into each evaluation or assessment.

Hopefully this small introduction serves to facilitate efficient absorption of the elements in Part 2 (The Developmental Process: Primitive and Postural Reactions).

Cheers!

Pediatric Evaluation 101

I typically avoid back-to-back posts...prefering to let a post "marinate" in the minds of the reader for at least a week. However, I have recently been actively involved with my work with children with Cerebral Palsy (ABR) and it has only recently occured to me that alot of our evaluation protocol is still somewhat foreign to the many parents and family members. The purpose has become so integrated in my mind, that I haven't truly considered that anyone wouldn't understand, not only WHAT I'm doing, but WHY I'm doing it. In essense, I have overlooked an essential element of any successful assessment: UNDERSTANDING BY THE PARENT / CARE-SEEKER.

With this in mind, I have decided to post a series of "back to school" postings designed specifically to EDUCATE parents on the essentials of typical pediatric assessment protocols. It is my firm belief that, with understanding, you will become more involved in the process of your child's development. In this spirit, I have used a photo of Concordia University in Montreal at the beginning of this post. Not only did I receive my Bachelor of Science degree there, but I went on to teach as a laboratory instructor for 5 fun-filled years. So....class, attention please:

The first "class" is simply to familiarize you with a few basic tests and give you some insight into its purpose. Before I continue, I will remind you of an important point I raised in a posting from June (Trainers Corner: Back to Basics): Consider your child's developmental age in light of the chronological age. In children with disorders of movement and posture, improvement is gauged by the progressive movement through developmental milestones. Therefore, the normal developmental process is your guide. The following are some select tests, with their respective rationale and corresponding developmental stages:

The Prone Position: In the prone position, the baby is now able to bring his head up and look forward with the head being 45 to 90 degrees off the mat. Weight is borne on the forearms. When the head and chest are well off the mat, the baby is ready to start to roll from the prone to the supine position. Rolling front to back usually occurs at 3 to 5 months of age. Rolling over too early can be due to excessive extensor tone. In essense, any functional performance that includes rolling or propping on the hands is dependant on this prior stage.

The Landau Reflex: The Landau is an important postural reflex and should develop by 4 to 5 months of age. When the infant is suspended by the examiner’s hand in the prone position, the head will extend above the plane of the trunk. The trunk is straight and the legs are extended so the baby is opposing gravity. When the examiner pushes the head into flexion, the legs drop into flexion. When the head is released, the head and legs will return to the extended position. The development of postural reflexes is essential for independent sitting and walking. This particular test is not typically done, but can be valuable when more comprehensive discussion on sitting and walking become realistic.

Lateral Propping: Lateral propping or protective extension is essential for the baby to be able to sit independently. This postural reflex develops at 5 to 7 months of age. Anterior propping actually develops first, then lateral propping. For anterior propping the baby will extend the arms forward to catch himself and prevent falling forward. Lateral propping occurs when the baby is falling to one side or the other and he extends the arm laterally to catch himself. Asymmetric lateral propping can be an early sign of hemiparesis. The baby will prop on one side but on the paretic side he will not extend the arm to catch himself.

The Parachute Test (Flying Test): The parachute reflex is the last of the postural reflexes to develop. It usually appears at 8 to 9 months of age. When the baby is turned face down towards the mat, the arms will extend as if the baby is trying to catch himself. Prior to developing this reflex, the baby will actually bring the arms back to the plane of the body and away from the mat.

Traction Test: On traction, which is pulling to a sitting position, the baby has good head and trunk control. The head and shoulders are flexed forward and the arms are flexed. The baby actively helps himself to get to the sitting position by pulling with the arms. Also notice that the legs are flexed at the hips and are off the mat as the baby pulls himself to sitting. On being laid back down to the supine position, the baby doesn’t flop back, but is able to control the lowering of his head and trunk to the mat. This particular test should be very familiar to the ABR readers. How is "good head control" assessed? More importantly, what are the bare essentials needed to have minimal head control? The traction test is a valuable tool that gives excellent feedback and lends towards a more efficient treatment protocol.

In North America, coffee is just as important to the learning process as is a laptop...so, grab a cup of "Joe" (for my South American friends, un cafe con leche) and get to work.

Class dismissed.
Cheers! =)

The Anatomy of Function

This post is intended "for all audiences", however I have formulated it with all of my ABR families in mind. I hope that it sheds some light on a bigger picture...which is sometimes lost in the daily challenges of life.

I think the title gives this post an appropriate "flavour"...thats is to say, we are going to DISSECT function. To be more accurate, it is more of a "de-construction". Function (or better function) is, to say the least, the ultimate goal of any care seeker...and most certainly all of you ABR parents. Therefore, function is an "end"...or a destination. By definition, a destination (or end) must have a starting point and a middle. To be precise, the goal is DEFINED by the journey! Therefore FUNCTION is the sum of component parts. What are the component parts, you ask? STRUCTURE, STRUCTURE, STRUCTURE. You do not have function without structure.

We see this everyday...on every street corner...and in every aspect of our life, but yet it seems to elude us when we get into issues of the human organism. A simple stopwatch from the 1950's (see above image) is an excellent example. A simple function (telling the time) is dependant on hundreds or thousands of smaller structural components working together. For you ABR folks...remember this watch! Functional performance DEPENDS on each piece being in the right place! How would this watch perform if even one of its component pieces were slightly out of alignment? Of course, the human body is not a stop watch...it is exponentially more complex. This truth is precisely the point...if this applies to a "simple" mechanism, then it applies to more complex mechanisms as well.

Even down to the microscopic level, cells are structurally arranged in such a way to, not only function systemically, but to sense mechanical forces and convert them into biochemical changes. This phenomenon is called mechanotransduction. Therefore there is a hierarchy that starts at the smallest level (cells) and extends to the macrostructures (tissues, organs, etc) to reveal a fundamental reality: Structure and Function are seemlessly integrated. You cannot disentangle them...they are intimately related. Structure is the language of function.

So...attention all ABR families curious enough to read this far: Remember this intimate relationship and store it in your mental hard drive. This is precisely the reason we focus so intently on the shoulder blade...the clavicles...the circumference of the thorax, for example. These structural components are the "architectural" foundations of the performance of the arm!

Consider the tired watchmaker peering through the magnifying glass and putting each tiny spring and each tiny geer wheel in place. As each component is put in place, he is that much closer to a functional timepiece!

Re-defining The Joint: Part 2

This post is intended to supplement my earlier post "Re-defining The Joint: Part" and to continue the journey down the trans-anatomical road of discovery (or re-discovery, to be precise). If you haven't read part 1, I would recommend that you refer to that post before moving on with this one. It will certainly help in the understanding as well as give valuable insight as to what the main message is.

http://thescienceofphysicalrehabilitation.blogspot.com/2011/09/redefining-joint-part-1.html

To briefly summarize, I have proposed a revised definition of a "joint" as: Linear and/or angular displacement between separate biological elements . This definition is more precise and accurate...but it also opens up an entirely new perspective on what actually constitutes a joint. As previously mentioned in my blog, connective tissue has 2 appearances which are seemingly paradoxical: it connects AND disconnects! The connection element is the obvious one (tendons, ligaments, joint capsules, etc) whereas the "disconnection" function is somewhat more counter-intuitive. If you haven't seen Gil Hedley's Integral Anatomy Series videos, then I highly recommend you make a point to watch them. Using standard dissection methods, he intelligently demonstrates the fundamental role of fascia (connective tissue) in SEPARATING body compartments, muscular groups, and systemic organs so that they do not mechanically influence each other. In essense, it allows the elements to "slide" against each other. For example, the liver "articulating" with the diaphragm, deep muscles of the hand (flexor digitorum profundus, for example) sliding underneath the more superficial muscles in the forearm when the fingers are flexed. It doesn't matter whether we actually agree on the definition of a joint...the reality is that without this fundamental characteristic, we would not be able to move...period. We would be as mobile and functional as a Ken (or Barbie) doll..."watered down" to simple hinge joints mixed with a couple of ball and socket joints for good measure.

Therefore, we must add to the understanding and definition of what a joint truly is. This will require some additional qualifying of the term "joint" when making statements or comments. We can consider our typical understanding of joints as SKELETAL ARTICULATIONS...because that's what they are. Therefore, I bring in a new term: FASCIAL ARTICULATIONS.

Each separate colour represents an individual fascial "compartment" and therefore can be considered as a separate biological element. This concept is easily extrapolated into the extremities as well...each individual muscle, muscle group, etc. is compartmentalized as well. It is important to remember that, when we are active (moving), these elements are articulating between each other! Consider a typical tennis swing...with its significant rotational components within the spine. There is a considerable angular displacement between the endothoracic fascia (fascia of the thorax) and the extended fascia of the abdomen (peritoneum). In addition, the follow-through of the arm at the completion of the swing is achievable through, not only the skeletal articulation, but the fascial articulations in the neck (deep, middle, superficial cervical fascia), the shoulder blade (endothoracic fascia), as well as the inter-muscular articulations.

Although it may be difficult to integrate "fascial articulations" into your mental hard drive, it should be easy to understand the obvious role of fascia in human movement...in both connection and disconnection. This provides a "bridge" to a more complete understanding of biomechanics...which is essentially the Trans-anatomical understanding of movement. Fascia is both friend and foe...when it is healthy and strong, you are feeling good. When it is damaged or otherwise unhealthy, it can be your worst enemy. From the most highly conditioned athlete to the the most severely affected child with Cerebral Palsy (who are near and dear to my heart), fascia is THE key fundamental structure in their health, maintenance, and development...period.

I hope the journey to date has been productive...and to those who are still "on the bus", part 3 will go into specifics about trans-anatomical movement and fascial articulations by using an age-old standard test (straight-leg lift) as an example. Hopefully it will engage and enlighten!

Cheers!

Contextual Perspective on Orthotics, Splints, and Braces

The recent post by Leonid Blyum “Analytical Review: Cerebral Palsy and Forceful Devices-Orthoses, Splints, Braces” raised a number of fundamental important points regarding the use of “devices of external support”. One particular comment prompted some significant questions which then lead to some more evaluation and thought. Without going into detail about the actual thought process, I will simply get right to the point.
There seems to be a great deal of consensus regarding the benefits of the implementation of orthotics, braces, and splints. In fact, it is without question a “staple” protocol for almost every issue of mild to severe distortions of the feet. It goes without question that some form of AFO, KFO, lift, etc will be implemented as part of the rehabilitation plan. It isn’t my intention to debate “do they work or don’t they”…this question is far too simplistic and, quite honestly, a naïve way of approaching the topic. My intention is simply to take a step (or two) backwards and attempt to gain some perspective on the more fundamental question: “are these devices doing what I intend them to do?” To be precise, are they “fixing the feet”…are they preventing any further distortion…and are they creating a more “harmonious” environment for the user? These types of questions are either never asked or simply assumed to be yes, yes, and yes. Therefore, I would like to propose that the implementation of these devices be put into proper CONTEXT. By definition, my opinion as to their “therapeutic value” is completely dependent on the context they are being prescribed. The proper context is clearly explained in the video, therefore I won’t go into detail but I will expand on a very interesting analogy that was brought up that will offer some useful insight into what I have called “Contextual Perspective”.
Let us first consider a simple construct or continuum. Everything regarding biological systems can be classified as either “simple” or “complex”. For example, movement patterns can be considered simple or complex (in reality nothing is truly simple, but you get my idea). Let’s probe a little further and consider biological joints. You can argue that a hinge joint is a relatively simple joint…and a hip joint is relatively complex. You can also postulate that a single-jointed movement is simple and a multi-jointed movement is complex….there is an infinite amount of ways to organize this concept, but it should be relatively straight-forward.

If you accept this concept, then you must also accept that achieving biotensegral equilibrium in a simple joint is far simpler than achieving biotensegral equilibrium in a complex joint. If we look at an x-ray of a horses foot, we can easily see that the complexity of the horse’s “foot” (or hoof, to be precise) is relatively simpler than that of the human foot.

Although it is classified as “simple”, it most certainly is effective in performing it’s intended function.
If we move along this continuum a little more, we will move from the hoof to the more complex “paw”.

The paw (canine, feline for example) essentially contains the same general elements that the human hand and foot do, however it is organized in a very specific way which is clearly illustrated in the above image showing what could be considered metacarpals (purple bones) more or less fused together. However, there are more joints within it and therefore it’s organizational and proprioceptive demands are more involved. It can be assumed that the more complex paw can also perform more complex functions that are inherent in the feline and canine family (tigers, wolves, etc). These animals are extremely fast AND agile…the horse, although being fast, has a significantly poorer agility rating (if you have ever been around horses as much as I have, you will agree that horses trip a lot and are extremely uncomfortable on unstable and/or slippery footing).
Now we get to the human foot. When put into perspective, it is an absolute marvel of engineering. The human foot has 28 bones in it, therefore it has 84 separate potential planes of movement. This would most certainly deserve the classification of “complex”.

It’s complexity can be explained by evolution…we are biped and therefore have “two less points of contact with the ground”. Our horse, canine, and feline friends have the advantage of having four…therefore our 2 feet must be highly adaptable, sensitive, and capable of not only providing a stable platform , but allowing for multiple micro levels of movement that ultimately define our high level of agility.
What does all this mean and where does it fit into the issue of orthotics, splints, and braces??! If you’ve managed to get this far, then you are definitely worthy of some clarity! Given the obvious complexity of the human foot, it is somewhat naïve to assume that ANY adjustment at one SINGLE point of movement will produce any significant “improvement” in the condition of the foot. It is analogous to winning the lottery…yes, you may be extremely lucky and get the singular point of conflict that resolves all of your problems. However, the reality is that this is highly unlikely. Therefore my professional opinion as to the use of orthotics to “reduce distortion and improve the condition of the foot” currently remains highly skeptical at best. However, there is definitely a rationale for their use in improving comfort and reducing risk of further injury.

This statement can be explained as such: When braces are placed on the human foot, you essentially “block” the majority of the freedom within and “downgrade” the foot to a hoof. Obviously having a functional “hoof” is more productive than a distorted and painful foot. This is precisely what I mean by CONTEXTUAL PERSPECTIVE. It is also important not to stop there in this “contextual thinking”. The rest of the human body is designed with the idea that a “complex foot” is underneath…therefore, if we switch out a foot for a simpler “hoof”, there is a significant change in the force transmission to the knee and hip. Essentially, a significant amount of stress that was previously absorbed and distributed through the foot now bypasses it completely and impacts the knee and hip further up…keep this in mind when designing your treatment plan!!
This most certainly qualifies as a “rant”…so I will end with a very warm thank you for reading!!
Cheers.

Connective Tissue: Body-Wide Signaling Network?

Once again, i have caught the reading bug and have come across another intelligent article on the growing interest and study of connective tissue and it's implications in the human organism. I have found that the more you ask and the more you dig, you not only find answers but you uncover more questions! This particular article asks a very important and fundamental question: is connective tissue an immense signalling network? It was written 6 years ago and the more current research has shown this to be highly likely (if not true). It also makes another important point: the musculoskeletal system has been studied in relative isolation from the rest of the body...implying that connective tissue has no other function other than something mechanically based.

I am aware that not everyone has the time or energy to plow through scientific articles...it is an unlikely source of relaxation for me which most people do not share. Therefore, I have decided to insert the summary into my post because it very accurately captures the essense of the article. For those who are more curious...click the link and read on!

SUMMARY: Unspecialized ‘‘loose’’ connective tissue forms an anatomical network throughout the body. This paper
presents the hypothesis that, in addition, connective tissue functions as a body-wide mechanosensitive signaling
network. Three categories of signals are discussed: electrical, cellular and tissue remodeling, each potentially
responsive to mechanical forces over different time scales. It is proposed that these types of signals generate dynamic,
evolving patterns that interact with one another. Such connective tissue signaling would be affected by changes in
movement and posture, and may be altered in pathological conditions (e.g. local decreased mobility due to injury or
pain). Connective tissue thus may function as a previously unrecognized whole body communication system. Since
connective tissue is intimately associated with all other tissues (e.g. lung, intestine), connective tissue signaling may
coherently influence (and be influenced by) the normal or pathological function of a wide variety of organ systems.
Demonstrating the existence of a connective signaling network therefore may profoundly influence our understanding
of health and disease.

c 2006 Elsevier Ltd. All rights reserved.

Connective Tissue: BodyWide Signaling Network

“Analytical review. Cerebral Palsy and forceful devices- orthoses, splints, braces”

The link below will direct you to a very informative blog post from Leonid Blyum. The issue of splints, orthotics, braces, etc. when addressing the complex rehabilitation of children with Cerebral Palsy comes up with an alarming regularity. In my 6+ years of working directly with these special children and their families, it is undeniably one of the top 2 or 3 topics that always comes up. My main point is not that it SHOULDN'T be a topic of conversation, rather that it has become "standard operating procedure"...and that the use of these devices isn't even examined or questioned. To be more precise, the mere NOTION of asking "is this the best thing for my child and will it do what people are claiming it will do?" is sometimes beyond comprehension for alot of families. The reality is that these approaches have been in "mass circulation" for hundreds of years...the majority of the advancements being in the development of light, softer, and more durable implements...however there is still a fundamental question that remains: "What is the true biomechanical consequence of using these". There is far too much over-simplification when dealing with complex biomechanical disorders..."the foot is twisted in? Let's put on a hard brace to force it back" or "Oh, the hard brace hurts the foot? Ok, let's put a soft brace on". It would be ideal if it were that simple...and if it were, there certainly wouldn't be any need for therapeutic "experts". At any rate, the link to Leonid's post(with accompanying video) will prove to be extremely informative for ANY rehabilitation professional. The thought process and analytical approach extend beyond just cerebral palsy. It is in-depth and most certainly in my "must read" folder!


“Analytical review. Cerebral Palsy and forceful devices- orthoses, splints, braces”

Braces and orthoses in Cerebral Palsy ABR position Aug 2011 from BlyumABR on Vimeo.

Redefining the Joint: Part 1

Why in the world would I suggest that the word "joint" be re-defined? It's a simple thing, right? Let's look at the definition as quoted in the Merriam-Webster Dictionary: the point of contact between elements of an animal skeleton with the parts that surround and support it . This definition conjures up the image that likely popped up in your mind...2 bones, some soft tissue around it, and maybe a meniscus in between.

The above image is nothing new to anyone. You have the pivot joint, the ball-and-socket joint, and the infamous hinge joint. This image follows the quoted definition quite nicely. The unfortunate thing is that the mechanics of human movement cannot be compacted into a simple definition and certainly not be explained by simple mathematical models. "Well, what is the right definition then?"...I would be naive to suggest that this definition is "wrong" per se, rather I merely suggest that it is very simplistic. Complex systems, by definition, demand complex explanation and understanding...therefore a more global perspective is required. As per "Gavin's New Trans-anatomical Dictionary", a joint is defined as: Linear and/or angular displacement between separate biological elements . To many of you, this may seem like a fancier way of saying the same thing...however, you couldn't be further from the truth. The reality is that the skeleton (bones) has a "monopoly" on everything joint-related. Why is this so?...by convention! It's in the dictionary, Gavin. But if you look at my definition, the skeleton is only a PART of it. Linear and/or angular displacement indeed occurs at all of the "typical" spots you would think of (knees, elbows, shoulders, etc)...however, if linear and/or angular displacement is a key element in this definition, you need to consider EVERY area that experiences this displacement as a true joint!!

It is not sufficient to suggest that movement only occurs at the "joints" and the soft tissue is simply a "biological sleeve" that fit over it. It clearly involves sliding of specific fascial layers one on top of the other. For example, the tendons of the wrist actively slide against each other when activated...which, by definition constitutes a joint. As you flex your arms, the fascial layers (from the skin to the triceps) on the back of the arm slide against each other and along the humerus...this constitutes a joint. The fundamental question is: who decides that if there is no bone, there is no joint?". If you consider the scenario where these movements are restrictied or blocked (fascial layers are "glued" together), you would have NO PRODUCTIVE MOVEMENT AT ALL. Therefore, when you consider this fact, the whole idea of "assessing range of motion" becomes something quite daunting...and perhaps even seemingly impossible. We therefore come to a crossroad of sorts. You can either go one way down "Newtonian Anatomical Model Boulevard" and be quite happy and comfortable with the status quo (which is a completely acceptable decision)...or you can go the other way and travel on "Trans-Anatomical Model Road" and walk a path of some unknowns and new discoveries.

I will go into more detail on the transanatomical definition of movement in part 2. For now, i will let you pause at the "crossroad"...digest the concept...and for all of you who choose Transanatomical Road, see you around the corner!

The Underlying "Diagnostic Disability".

I recently came to realize that there is an underlying problem within the health care system istelf that leads to more challenges for those seeking our "professional expert guidance". Like most of my "revelations", this came to me by chance through some recommended reading given to me by a collegue (gracias, Daiana!). This very insightful articles effectively describes that one of the main challenges to overcome is our inability to establish a "common language" among rehabilitation professionals. In effect, we are "diagnostically disabled". As explained in the article, the role as diagnostician for the physical therapist is quite challenging and is met with many dilemma's such as lack of consensus among professionals regarding classification, rapid evolution of new knowledge, and the complexity of the diagnostic process. I believe this is at the heart of a fundamental "dysfunctional attitude" among professionals. There is a constant sense of "competition for diagnosis" which inevitably leads to more confusion and frustration for the care-seeker. They are given different and sometimes conflicting information depending on who they refer to. The neurologist will make his / her comments...which may differ from the orthopedic surgeon...then when it comes to the physical therapist, he or she is commited to a plan of action that is contraindicated by the surgeon or even perhaps counter-intuitive to the care-seeker himself!

The article below is an excellent example of how self-examination and consistent search for solutions from within can result in significant positive impact, not only on a personal practice, but on the system as a whole. It also presents some constructive ideas on how to reduce the negative implications of this diagnostic disability on the care-seeker. It was a refreshing read and re-affirmed to me that constructive information can come from anywhere at any time...so keep your eyes peeled and, more importantly, your mind OPEN!.

Disabling Our Diagnostic Dilemmas

Spastic Muscles: Victim or Perpetrator?

This is perhaps one of the most counter-intuitive questions I have ever asked...and the answer is almost unanimously the same: "The muscles are the bad guys, therefore we need to attack them with an aggressive campaign of stretching...and if that doesn't work we always have botox". I'm exaggerating somewhat, however the only option families are given is overwhelmingly skewed to these drastic measures. As a professional (or as a parent / patient) it is fundamentally critical to examine all other options and not to simply "refer to my favorite textbook to see what the 'experts' say". The fundamental question is: "Are the muscles victims or perpetrators?" To be precise, are they THE problem or are they a SYMPTOM of a problem. In the overwhelming number of cases, muscle tension is SYMPTOMATIC (in both disorders of movement and posture AND the healthy population, by the way). Therefore, by definition the "treatment" protocol should be focused on the SOURCE of the problem. Unlike a common cold or flu, treating the symptoms leads to dead-ends and will result in future problems down the road.

In disorders of movement and posture like Cerebral Palsy, the muscular tension is a reflection of the profound compressional weakness that exists within the entire structure. For a better explanation of compressional weakness refer to my previous post, but in brief, compressional weakness is the absence of fundamental hydraulic strength which is responsible for support under the forces of gravity as well as the weight of the body itself. Essentially, when this vital component is missing, the muscles are asked to take on "double duty". They are actively solicited to compensate for the lack of compressional (passive postural) strength and therefore must be used to maintain balance...AND they are also called upon to perform the dynamic movement-based functions they are originally designed to do. It is no wonder that movement is so chaotic and uncontrolled...imagine using all of your muscles to maintain your balance AND perform movement at the same time.

Don't worry...I'm getting to the point. A strategic and focused protocol to improve compressional strength will subsequently result in a reduction in general muscular tension and rigidity. Period. Therefore my message is simple: STOP FIGHTING WITH THE VICTIMS! It is perhaps the most instinctive and inuitive thing to do, but history shows quite clearly that doing this is is a dead end street filled with false hope and "irresponsible dreaming".

Some of you may be saying "sounds good, but can it be done?" As the response to my previous post is showing...pictures are worth a thousand words. In that light, I have posted more amazing transformations that are an example of the potential to address muscle spasticity / rigidity at its true source. And remember...working with fascia is far from glamorous. It requires a significant amount of time and effort...but it is well worth it!

Cheers.

Analyzing the Source of Muscle Spasticity

The Role of Fascia in Cerebral Palsy...you can't miss this!

I have recently returned from Chile where I was working with another amazing group of children (and their families). It never ceases to amaze me how fortunate I am to be allowed the privilege to enter into their world and contribute to their child's progress. Each and every evaluation provides me with greater insight into the wonders of the human body...and for that I am eternally grateful. For those who have been curious enough to continue reading this blog, you are by now fully aware of my fascination for fascia and all that it implies. Although words (lots and lots of them)effectively convey this message, it is (more often than not) the actual pictures that demonstrate the full power and implication of this wonderful, and highly underrated, structure. I have performed many evaluations with children with disorders of movement and posture over the years...and there is a common thread that binds almost all of their families together: "Gavin, I just want a better life for my child. I want him/her to be happy and healthy and ultimately give them the absolute most that can be given to help them". Something as simple as being able to sit independantly can seem trivial to us, but can mean the world for these special children and special families. Therefore, I put it to anyone who questions the implications that fascia has on movement and posture...look at this example and formulate an intelligent, articulate, and logical reason not to admit the enormous opportunity and potential for improvement that exists. Although I have a plethora of examples, the one I have posted is the freshest in my mind and is also without possibility of mis-interpretation. One year of specific focus and hard work can bring about life-changing results! I hope it inspires you, fascinates you, and most importantly...stimulates some constructive curiosity!


Fascial Strengthening in Cerebral Palsy

Coming Soon: Fascia and Fibromyalgia

I am very excited about this upcoming post because it will be the first look into some innovative techniques using the extended fascial paradigm in the treatment of a specific pathology. I recently stumbled upon an interesting article that outlines the role that fascia plays in Fibromyalgia. More importantly, how it may be a potential source of both the "problem" and the "solution" simultaneously. It is well known that massage has been a largely effective treatment for the reduction of symptomatic pain associated with fibromyalgia. Whereas some believe that the common "villain" is the muscle, there is growing evidence that fascial dysfunction is a more likely culprit. Therefore, any improvements to the delivery, absorption, and effective range of massage will help in relieving discomfort and pain. I will be outlining the Soft Ball Massage Technique in my next post, however I think it would be helpful to have a look at the article itself and get a fundamental look at the rationale behind this proposed technique. Enjoy and stay tuned for Soft Ball Rolling Massage!

Fibromyalgia and the Fascia Effect

Myth, Madness, or New Frontier?

Once again...another posting of an article on fascia. To be honest, it has been difficult to hold back on posting all of the wealth of existing study, research, and scientific evidence of the significance of fascia and connective tissue. I promise more original material, however I think my recent postings of Myers, Van der Wal, and Schleip will greatly enhance the general understanding that this is no myth...this fascia "stuff" is important! So it begs the question: is this myth, madness, or a new frontier? Some would agree that connective tissue is a simple "shrink wrap" for the muscles and just basically holds things in place and therefore considering it as an "active player" in musculoskeletal dynamics is pure MADNESS. Others, in their infinite ignorant wisdom, would tell you that it's purely MYTH..."studies are pure speculation and inconclusive". The reality is that connective tissue is not only the focus of increased in research protocols, but is proving to be quite relevant in the human organism. The potential implications give it the well deserved title of NEW FRONTIER. This was one of the first articles I read regarding fascial properties and it stuck with me throughout my formulations and developing understanding of the role of connective tissue and fascia. Paste it into your mental hardrive. Cheers.

Active Fascial Contractility

Fascia and the Locomotor Apparatus

What is the "Locomotor Apparatus"? It seems like a fancy word for the human body, but it is more appropriate than you think. Indeed, the human body performs thousands of distinct functions every second of every day of your life. Locomotion (movement) is only one specific function...but one that defines our everyday life and is undetachable from our very existence. Therefore, by definition, anything that regulates locomotion has an undeniable impact on our health and well-being.

One of the big pioneers in the scientific study of fascia is Jaap Van der Wal MD, PhD. He has been "on the fascia bandwagon" since the 80's and is one of the leading resources for the current scientific studie being implemented today. In his article "The Architecture of the Connective Tissue in the Musculoskeletal System" is a fascinating and equally relevant examination of the global implications of connective tissue "skeleton". In addition, it demonstrates that the traditional "anatomists" perception of human movement is somewhat primitive and is a simplistic attempt to explain a complex system.

There are some very enlightening points made in his article:

a) Connective tissue has separate paradoxical functions: It connects AND disconnects

Connection and Disconnection—Two Types
of Fasciae
This view of two types of connectivity is also applicable
to the anatomy of fasciae. In general, fasciae in
the musculoskeletal system exhibit two different mechanical
and functional types:
• There exist muscular fasciae adjacent to spaces
that are filled with loose areolar connective tissue
(“sliding tissue”) and, sometimes, adipose tissue.
They enable the sliding and gliding of muscles
(and tendons) against each other and against other
structures.
• There also exist intermuscular and epimysial fasciae
that serve as areas of insertion for neighboring
muscle fibers, which, in this way, can mechanically
reach a skeletal element via those fasciae
without necessarily being attached directly to the
bone.(9)

b) Connective Tissue has 2 functional appearances:

CONNECTIVE TISSUE IN THE
MUSCULOSKELETAL SYSTEM: TWO
FUNCTIONAL APPEARANCES
Not Only Anatomy, but Also Architecture
In principle, only two kinds of forces have to be transmitted
over synovial joints between the articulating
elements in the locomotor apparatus: forces of compression
and of tension. Compression forces between
the articulating elements are transmitted via the articular
surfaces of the adjacent bone elements. The tractive
forces and mechanical stresses over the synovial joints
are assumed to be transmitted both by passive and by
active components in the musculoskeletal system. Regular
dense connective tissue structures such as ligaments
convey (transmit) those forces “passively.”

As with my previous post, this article is lengthy...but well worth the read. Consider it as another essential addition to your library!

The Architecture of the Connective Tissue in the Musculoskeletal System - An Often Overlooked Functional Pa...

Fascial Fitness: Training in the Neuromyofascial Web

This is an excellent article written by Thomas Myers who is one of the pioneers of the "fascial movement". His book called Anatomy Trains is another essential text that every practitioner should own. It is through his work that the role of fascia in the human body is now being understood as fundamentally critical. It is also the scientific basis for the formulation of the Soft Plyometric concept. It is a lengthy article, but if you read it in chunks, it is more digestible. My thanks to Mr. Myers for a well-explained and comprehensive document.

Fascial Fitness Training in the Neuromyofascial Web

Fitness in the Extended Fascial Paradigm

I have gone ahead and posted a more "reader friendly" version of my first post regarding fascia and its role in athletic conditioning. This small pdf is actually intended to be true introduction to the fascia approach from which the Soft Plyometric concept is based. I should have posted this first, but I am sometimes over-anxious and don't pay attention to the order at which things are delivered...sorry about that. The second part of the Soft Plyometrics introduction and the future definition of specific concepts will all be based in the basic theory and central belief system within this document.

Coming Soon: A look into the analytical approach to muscle soreness and muscle stiffness. What is it? Where does it comes from? Are there any other approaches to rehabilitation? How do I approach it from a fitness perspective? Hopefully it will be informative!

Cheers!


Fitness in the Extended Fascial Paradigm - Copy

Breaking News

Although it will never make CNN anytime soon, I consider the following very positive and encouraging news. As per the blog description, my intention is to stimulate dialogue and the exchange of intelligent ideas between fitness and rehabilitation professionals. I am indeed happy to announce that the first step towards a joint pilot project has been confirmed today between yours truly and Rebecca Foss, owner and “Head Lunatic” at Fitness Asylum near Tampa, Florida USA.

Just what is Fitness Asylum? I can tell you quite confidently that it isn’t a place for those who consider fitness as a “social activity”. Don’t plan on reading a magazine while you are doing your cardio…and don’t bother with doing your hair before you go. It’s serious cutting edge fitness and “only serious applicants need apply”! Go the website http://www.fitnessasylumweb.com/ and you’ll see why: Kettlebells, training ropes, and medicine balls (among others) are the order of the day.  Paradoxically, it is well equipped with Special Population Training Programs as well. This is precisely the professional attitude and superior frame of mind that separates the true fitness professional from the rest…and I am glad to have the opportunity to share some of my ideas with the “lunatics” who roam the halls of Fitness Asylum.

The pilot project revolves around the implementation of the Soft Plyometrics concept and techniques into the protocols of the serious athletes at Fitness Asylum. As the project evolves, I will be sharing the observations and conclusions on this blog and using this valuable information to formulate improvements and new applications. In order to move forward, you need to push the envelope and step “outside the box”…ask the questions and seek the true answer…and most of all, work just outside your comfort zone.

Much more to come!

Gavin (newly admitted Lunatic)

Introduction to Soft Plyometrics

I have spent the last few years trying to formulate a way to bridge the gap between some of the rehabiliation based experiences I have had and the field of fitness and high performance training. What is the gap? Why is this gap relevant? These are two very good questions that lead to a fundamental response: People who exhibit weakness and injury provide the professional with an "inside look" into the structural, biomechanical, and physiological environment of the high performance athlete. It is through these people that we can observe measurable impact and effect of external stimulus on the tissues. Therefore, it is fundamentally essential to examine the entire spectrum of human performance. The examination and understanding of human performance at its weakest inevitably provides the professional with the intrinsic tools necessary to effect positive potential change in the "strong" individual.
This is an introduction to Soft Plyometrics...a term I have coined for the simple reason it has similar targets and objectives as plyometrics but at different points in the periodizaed program or fitness protocol. Specific exercises and application guidelines will follow in a second posting called Essentials of Soft Plyometrics. Cheers!

PS: I have used an external site called Scribd which is very useful...however you will need to allow a second or two to let the slide load as you flip through them.

Soft Plyometrics© - Copy

Coming Soon: Soft Plyometrics

For all the gym rats, fitness buffs, and intellectual fitness practitioners...I am currently generating a new post that will introduce what i call "Soft Plyometrics". I have spent some time formulating a way to introduce the fascial paradigm into the fitness world, and I think that Soft Plyometrics finally solves that problem. Keep an eye out for the next post which will hopefully be complete and readable next week. Although its "release" is hardly worthy of a motion picture analogy, consider this a teaser trailer! Cheers.

Book Of the Month Club

Perhaps I should say BOOKS...because there are 2 books I would highly recommend for 2 very different reasons. The first one could be perhaps the most enlightening text I have come across to date. Not only does it put human development into perspective, but it essentially bridges the gap between most therapeutic challenges and therapeutic solutions. It has proven to be a major eye-opener and I can comfortably classify it as my "new bible". This text is called "The Endless Web".



I am obviously a big fan of having a well-defined rationale for any and all rehabilitative protocols...therefore having a text such as this, in my personal and professional opinion, is essential in establishing solid fundamentals.

My second recommendation is more of a personal one. I have had the pleasure and honour of working with an amazing family from the U.S. who not only inspire me greatly, but have my utmost respect and admiration. People are shaped by their experiences...both good and bad...and subsequently have an effect and influence on those they meet. The family I am refering to is the Dzialo family. Although I only see them once a year, they continue to impress me with their work ethic, their attitude, and their superior frame of mind. Their story has recently been published in a book called "Ceramic To Clay".



This is Adam's story written by his mother, Sharon Dzialo, in the most thoughtful and insightful way. It isnt just a good read...it is a glimpse into the life of an amazing person and family that will teach you a good lesson (or lessons, to be precise) in life. It was indeed an honour when I recieved a copy of Sharon's book (sent all the way to my home in Argentina!) and I can't thank her enough for sharing her story with me. Everyone should upgrade their library and pick it up...I have read the book AND met the people, and I can tell tell you neither disappoint!

Happy reading!

Trainer’s Corner: Back to Basics

I think the title “Trainer’s Corner” is very applicable for two reasons: 1) This friendly post is coming directly from one of your trainers, and 2) It is analogous to a boxer’s trainer. A boxer’s trainer will do his best to provide the boxer with all the skills necessary to succeed. Your ABR trainers are charged with a similar task, so the analogy should resonate pretty well.

Round 1: Before going out into the ABR world, you should have a solid grasp of the fundamentals. In the ABR context, these fundamentals are numerous and sometimes overwhelming…however I will bring you through some of them step by step (round per round). During the majority of my evaluations, there is a common thread that weaves its way all the way through each family unit…they forget that this is a PROCESS. Process is “a systematic series of actions directed to some goal”…therefore by definition it should be clear that things have to go in sequence and in phases. The fact that you cannot skip over phases is not an arbitrary decision, rather a reality you have to understand and integrate.

Each phase is designed in preparation for the next phase and is structurally predetermined by the human motor developmental pattern…not by ABR. We are bound to this developmental path by mother- nature so any questions that relate to more complex developmental skills should be automatically answered.



In the past, I have found it useful to help parents differentiate between chronological age and developmental age. To be more precise, in healthy individuals the chronological age comes with some predictable developmental milestones. In effect, you can accurately estimate the chronological age by knowing (seeing) the developmental phase they are in.

In the above image, the developmental age (stage of development) is typically achieved at a certain age (for example: sits without support between 5-8 months). This type of chart can be somewhat confusing to many parents. Statements like “he / she is 4 years old so we have to stand them to help them develop the hips” come from this well-ingrained developmental chart. However, as mentioned before, if the previous stages have not yet been achieved (lifting and holding the head, rolling over, from prone position lifts chest with arm support, etc..) then any discussion (or statements) regarding more advanced skills is unproductive. Therefore, more emphasis and focus on the developmental age will be, not only helpful in understanding the big picture, but more accurate in assessing your child’s current progress.

If you have ever seen any of the Rocky movies, you can appreciate the image of the grizzled trainer, Mickey, yelling at Rocky and trying to motivate him through a seemingly insurmountable challenge. Although I obviously won’t yell and scream, the intensity is still there: “Get back to basics!! Remember the fundamentals, Rock!” The road is long and there will be challenges…however you have a trainer in your corner who will slap a towel around your neck in between rounds, sit you down, throw water on your face, and give it to you straight.

See you soon for round 2!