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.


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