Monday, July 15, 2013

Rehabilitative Strategies in Cerebral Palsy: Understanding Hierarchy

The title is quite a mouthful...but it is a very precise description of an otherwise overlooked reality.  Hierarchical structures not only provide a sense of structure and organization (where things exist in relation to others) but they give a rather profound demonstration of perspective...or to be more precise, a sense of direction and flow.

As the colourful image explicitly demonstrates, each component has its own individual identity and purpose...however, it exists within a larger framework.  Although each has its own intrinsic operation and purpose, it essentially serves the larger whole.  This is likely intuitive to most, however this intuition seems to be put aside as soon as a therapeutic or rehabilitative context is in play.

Although exponentially more complex, the developmental process can be thought of as a very sophisticated and comprehensive hierarchy.

The most basic and fundamental elements of any human organism (for the simple sake of survivial) are the vital functions.  Without coherent establishment of the systems that sustain life, any other consideration(s) are irrelevant.  Further, proper functioning (or interaction) of the human organism within the environment REQUIRES that these vital functions be well-established in order to generate productive results.

The primary dilemma with this fundamental perspective is that these critical components are somewhat difficult to measure in the quantitative essense, they are QUALITATIVELY measured.  The conflict between what "can" and "can't" be measured is quite prolific in the rehabilitative context...meaning that thise elements that have no quantitative measure are very often dismissed or disregarded.  However, the reality still exists:  without the development, maintenance, and nourishment of systemic homeostasis there is no life...even if the operating level / coherence is poor, there is still an overwhelming need to develop these fundamental elements to their best potential. 

Mobility and closed-chain can easily be confused and inter-changed within the neurodevelopmental disorder (NDD) context.  In more practical terms, it referes to the selective independant mobility (freedom) that exists within each of the diverse segments of the body.  This includes ALL of the traditional "joint-like" articulations as well as the equally important fascia larticulations within the body.  Therefore, the term "mobility" is used, not to define movement as such, rather to describe some level of intrinsic elasticity and adjustment to positional changes.  If we extend this description further, we arrive at the term "closed-chain"...which can understandibly refer to a vast number of specific movements and dynamic activity.  But, once again, when we consider the NDD context, a closed chain activity refers primarily to postural characterisitics such as independant sitting, balance, and counterbalance.  These considerations MUST be addressed and developed before any consideration or focused strategy regarding more dynamic (open-chain) function. 

It isn't until we reach the "peak" of this schematic that we entertain the notion of what would be considered "traditional movement-based strategy".  If we consider this generic illustration, it clearly suggests that any and all movement-based strategy must be "earned" via the establishment of coherence between the elements that preceed it.

In summary, the general "landscape" of the rehabilitation strategy should reflect the natural process of development and growth.  This is indeed an obvious over-simplification of the reality...however working frameworks only require a solid philosophical basis from which to operate.  Effectively, a simple framework can be a valuable tools when assigning treatment strategy and protocols...and most certainly yields some enhanced clarity and perspective.


Monday, July 8, 2013

DIS-stress VS EU-stress: Fundamentals in Neurodevelopmental Disorders

I have recently come to realize that despite the best attempts at providing detail and in-depth analysis, it is often the more simplified analogy or "generalized" understanding that has the most resonance.  Therefore I think it is important to present complex systems (at least at the beginning) in more simplified terms...or in this specific case, outline basic frameworks and fundamentals when it comes to neurodevelopmental disorders.

In the current conventional understanding, STRESS is widely considered as a negative term...however, its true definition is neutral.  Stress can either promote improvement and well-being or contribute to various forms of deterioration.  Within the Fascia Therapy context, eustress is a positive response to any specific stressor.  This can be demonstrated in the biomechanical sense, for example, via the process of mechanotransduction...which is the healthy adaptation and response by a cell to an imposed mechanical stimulus.  In the systemic sense, it is quite easily illustrated in the form of vaccinations...which are essentially carefully moderated doses of select viruses (systemic stressors) which therefore solicit a physiological adaptation and ultimately a stronger immune system.

Until this point, all of this is likely to seem somewhat "un-amazing" and ultimately quite intuitive...but when we consider the challenges of neurodevelopmental delay this simple intuitive understanding needs to evolve into another level of understanding.  Within each of us, there exists an essential repetoire of available systemic and mechanical resources that essentially serve as a "converter"...converting imposed stresses into positive responses or potentially negative ones.  The fundamental reality within the neurodevelopmental disorder context is the following:

There exists an underlying neurological, systemic, and mechanical deficit that essentially "shrinks" the repetoire of available resources.

In more simple terms:  the "converter", or available range of potential eustress response is much more limited. 

  When the systemic and mechanical "converter" is reduced, each imposed stimulus can potentially contribute to deficient or incomplete adaptation, which can result in exaggerated compensatory responses, as well as produce high levels of irritability which ultimately generate a very sensitive and volatile environment.  Therefore, we are confronted with an alarming dilemma:  if imposed stimulus (chemical, emotional, environmental, or mechanical) can generate volatility and DIS-stress response, how do we go about the task of rehabilitation?  The intuitive answer, and the one which is BOTH correct and the overwhelming default, is to attempt to deliver these stresses in th most careful and deliberate fashion.  The specific "doses" of chemical, mechanical, environemental stressed are gauged by what are essentially predetermined standards of application and procedure.  Although I do not disagree with this approach, the effort to enhance and BROADEN ones perspective on the subject only serves to contribute to more effective and diverse strategic options and ultimately better rehabilitative outcomes.

One of the fundamental pillars of the Fascia Therapy concept and philosophy is the incremental and focused strategy of potentiating interstitial fluid flow and the promotion of healthy connective tissue remodelling.  Both of these "targets" are independant of the specific strategy or "technique" because they effectively exists on a more comprehensive and "primitive" level.  In essense, they are the essential elements to the development and maintenance of enhanced systemic and mechanical resources...therefore they contribute to an amplification and broadening of the stress "converter".
This allows for a more diverse range of stimuli being converted into a stress that is efficiently absorbed and distributed...and consequently elicits a positive adaptive response.

In summary, the precise "how" this is done falls into a secondary does not matter as to what specific "technique" is used to stimulate these two fundamental pillars, it only matters that it is done efficiently and with additional focus and attention.