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.