Sunday, August 16, 2015

AFO's and Cerebral Palsy: Do or Don't?

Although it remains one of the main issues / topics discussed during almost every family meeting or training session, I haven't quite given AFO's (all orthotics in general) the attention it deserves.  The general perception on this issue is, for the most part, driven by untuition.  In other words, the feet are distorted so let's do something to straighten (or fix) them.  Despite this intuition, the same question arises with alarming regularity:

"Should we use them or not?"  

I have never been a big fan of blanket responses...meaning that there is very little I can answer with a short "Yes" or "No".  With respect to AFO's, the reality of what you should do will reveal itself once you walk yourself through a series of steps and practical questions.  This is to say that, the question of "should we or shouldn't we" is far to simplistic...this needs to be examined with a more comprehensive process and the "answer" is distinct for every family.

Every family will need to flash this question through their own "prism" and ultimately decide what is best for them and their shared value system...which is why I find it is much more efficient to avoid blanket responses and set a specific framework of understanding and examination so that every family will ultimately arrive at the most productive response.  The first practical question to ask yourself is:

What is (are) your specific intention(s) of using AFO's? 

AFO's (and orthotics) have been a rehabilitation option for hundreds of years.  The main difference / evolution has been that the materials used are lighter, customizable, and more efficient to manufacture...however the general mechanical premise is the same.  I mention this for a specific reason:

If the intention / objective of using AFO's is to reverse or "fix" a biomechanical distortion, this would be an over-simplification of a vastly more complex situation.  

Meaning that, historically there has been no significant evidence or research that points to the premise that AFO's reverse biomechanical distortion.  We then come to the next level of questioning and formulation:

If they do not reverse or fix anything, what use do they serve?

Again, the issue isn't whether they are good or bad, but how they are used and to what end.  AFO's are excellent adjuncts / complements to larger rehabilitation strategies for children who are either ambulatory or who demonstrate some level of weight-bearing (partial) directly on their feet.  Therefore...

AFO's are extremely valuable when the main objective is additional support and safety within a larger rehabilitation strategy for walking improvement / development.  

Foot Orthotic with Knee Orthotic
In other words, they can provide a significant window of opportunity to amplify and/or expediate the development process by imposing a small amount of support to otherwise weak articulations so that the ENTIRE biomechanical organism (the whole body) can engage and interact as a it is meant to do.

In some cases, this formulation can be overwhelming...and whereas more information is usually helpful, sometimes it can confuse as opposed to clarify.  Therefore, I can break down the process into something that is likely to be more user-friendly and easier to process.

Helpful "Do / Don't" Checklist

1. The use of the AFO associated with pain or discomfort.  DON'T

2. The use of AFO's results in more enagement and interaction with the environment.  DO

3. Is your child relatively functional and have some general weight-bearing ability already in place?
Yes --- DO
No --- DON'T

4. My goal is to reverse deformities in the foot. --- DON'T

5. The use of AFO's are part of a larger strategy. --- DO

In reality, this "checklist" is quite generic...but it serves to amplify the central premise that AFO's are neutral to the question of good or bad...right or wrong.  It is the specific intention that sets the framework for their efficient use.  It is easy to get caught up in the laws of contradiction...which is to say that, if their use is GOOD then their non-use is BAD.  The law of contradiction is a reality that simply states if one thing is 100% good all the time, then the opposite to that action is bad 100% of the time...which is far from the reality.

Again, this formulation is something that MUST be put through each family prism.  Therefore, it is perfectly acceptable that my very perspective is dismissed and discarded...but the issue is not convincing or "conviction" as such, rather to ensure that decisions are made VIA some form of analysis and exploration as opposed to the more simplistic (and perhaps convenient) mechanisms.  

Wednesday, August 5, 2015

Activating the hands in Cerebral Palsy

This post is a follow up to the previous post on sensory brain exercises for CP.  Although these sensory exercises are useful, they are somewhat limited when you are presented with a hand that is consistently (and/or rigidly) closed or fisted.  In addition, the closed fist is almost always accompanied and characterized by some distortion and asymmetry...both of which may make simple sensory exercises difficult and frustrating.  With this in mind, I wanted to shed some additional light on the issue of hands and (hopefully) provide some options and avenues for those parents and families that want to actively potentiate some improvement in the hands and, perhaps more importantly, provide some clarity on some realities about the developmental process...which always proves to be helpful and immediately useful.

"Don't put that in your mouth"

Words that every parent has said (or yelled) at one time or another, correct?  Although it is an intuitive understanding that babies / children will put things in their mouth, it is oftentimes difficult for parents (and people in general) to truly understand and formulate the reason why this is done...and universally across the board.  ALL humans do / did this!

 This type of behaviour is simply the manifestation of the natural developmental process of exploration and discovery.  In the first few months, a baby's visual field is still quite immature therefore in order to genuinely get "a sense" of themselves and their surroundings, they need to expose things to those senses that have reached a higher order.  In other words, they formally "feel" things with their mouths.  This includes hands, feet, and pretty much any object that is within reach. 

As a natural and healthy part of the developmental process, children will go through this phase during the first few months (and first year) and then when their visual competence and acuity begins to develop more, they will begin to actually grasp and hold things within their field of view.  Although they are still likely to put things into their mouths for "enhanced feedback", they will consistently stare at and track objects that enter their field of view. 

Missing Links and Activation in CP

When we put this into the context of CP (and neurodevelopmental disorders), the reality in many cases is that the opportunity to enter this exploration phase of "hands / feet / objects in the mouth" has never been experienced...whether due to direct neurological impairment, significant physical limitations, or both the hands (and even the feet) have never been fundamentally "woken up" or activated. 

Point of interest:  A new born baby will consistently manifest a closed fist (with the thumbs outside), but as he/she develops and begins the fundamental process of self-exploration, the hands and fingers are exposed to high levels of sensory input...essentially activating them, while at the same time the brain itself is formally "registering" the hands / feet and creating a working body map of them as well.    In CP, more specifically in those GMFCS Level 4 and 5 classifications, the hands seem to maintain some level of "closure" and (as the hands and fingers get longer and wider) distortion.  This is not to say that distortion and/or asymmetry in the hands is 100% due to this missing phase...however, the fact that fundamental activation VIA these mechanisms was limited or even absent is most certainly a part of the reason...and therefore, by definition, part of the solution. 

"Little things...BIG difference"

With respect to tangible and practical "things to do", this would vary greatly on an individual level...however there are certainly some standardized and "generic" ideas that are usually quite helpful and, paradoxically, nothing new.  Alot of what is done within the scope of Occupational Therapy fits quite well within this narrative, however as parents it is always strategically wise to potentiate and activate your own level of understanding, knowledge, and skill...for the simple reason that whatever is done in the home and by YOU is done with the most care, attention, and concentration possible.

It is not likely a realistic idea to attempt to literally put a hand into the mouth, but it is relevant to know and understand that the head and face are areas of high sensory competence...meaning that hands that are passively touching, brushing along, and/or placed onto the head and face (especially near the mouth) generate a very powerful sensory "activation".  Beyond some of the sensory brain exercises mentioned in my earlier post, massaging and rubbing the hands with creams, essential oils (Lavender), or balms will also impose useful and productive stimulus. 

If your child has relativilty good visual acuity, you can combine these with some active (relatively unstructured) play with tools / toys of varied textures (feathers, balls, etc...) that can be brought into their field of vision and (with help) encourage interaction. 

"Awareness before Activation"

One of the fundamental messages proposed in the previous post is the simple understanding that a "mechano-sensory awareness" must be developed in order for any productive activation can begin.  Extrapolating this idea, FUNCTION (which is the overall objective) is formally the manifestation of organized and coordinated activation...therefore starting at the root and addressing the fundamentals of awareness will provide significant help in achieving that objective.