Thursday, February 25, 2016

The Importance of Recovery in Cerebral Palsy

In the race to achieve developmental milestones, promote dynamic movement, and improve overall function, I have found that the "larger picture" is sometimes clouded if not lost completely.  By this I mean that the human organism operates (oscillates) within what I like to call a specific Biophysical Continuum.  In other words, we are not simply "ON" all the fact, we exist within specific "states" of activation.  By activation, I refer to what is the predominant systemic / biomechanical system operating at any given time. 

This perspective is an attempt to provide some clarity on the human organism (person) as a whole...or as a "Supersystem" that is something more than just the sum of separate individual systems.  Rather, it is an exponentially complex and inter/intradependent piece of evolution and engineering.  In effect, it is likely beyond our current capabilities to truly comprehend...which is why the Biophysical Continuum is a valuable tool in navigating the journey through neurodevelopmental challenges. 

Biophysical Continuum

 As shown in the graphic above, we can effectively separate a full day into 3 formal "states":

1. Activation
2. Relaxation
3. Recovery

Being a continuum, there is no explicit "point" at which one state becomes another...rather that we "slide" seamlessly from one state to another, and at many times during the day, we exists in a state that can be a hybrid "blend" of either activation / relaxation and relaxation / recovery. 

Activation can be formally identified as "exercise and movement".  To be precise, it is manifest by HIGH levels of muscular, neurological, and mental resources.  There is a higher rate of catabolic activity which contributes to increased levels of metabolic build-up (lactic acid, etc...) which is toxic to the body and needs to be flushed, and there is a greater stress on biomechanical architecture and neurological resources (concentration).  Relaxation can be misleading, however within the context of this post, I refer to it as those mental and physical activities that take place during the course of the day.  In other words, the "routine" that takes place when we are not either sleeping or exercising.  In this phase, the mental / neurological / physical requirements are well within tolerable limits...mainly because they are likely to be habits that have become somewhat "automatic" and are essentially done within any real conscious effort or concern.  More importantly, systemic function is essentially at a "net zero" level...meaning that there is a sufficient amount of "input" to satisfy the required "output".  Recovery is most accurately defined as "sleep" (and in many cases, meditation as well).  It is during this phase that our systemic "oscillation" (respiration, digestion, lymphatic system, microcirculation) plays a primary role while the neuromuscular "engine" reverts to a primitive and formal "off" state.  This is THE state at which our evolutionary development and "operation" are hard at work.  We slip from any voluntary / conscious influence and are essentially operating on the autonomic / involuntary / primitive level. 

This is where we formally enter into our most valuable self-healing, self-regulating, and recovery phase.

If we assign a generic amount of time during a 24-hour day, we are presented with a breakdown that approaches something like the graphic above.  If we assume an average amount of sleep that centers around 8 hours (a lot for some and too little for others, but you get my meaning), an average of 30-60 minutes of what could be considered as "exercise / movement" based activity, and the remaining 15 hours manifested as "daily activity"...we are left with a "colour-code" that looks like that.  In essence, this is an example of an environment that is sustainable.

If we consider the realities in CP (and all neurodevelopmental disorders, in fact) we get a vastly different picture.  Disorders of movement and posture require extremely high levels of muscular activation (even to accomplish those tasks that we generally consider "easy") as well as high levels or mental resources.  To be precise, many if not most of what we normally classify within the context of "daily activity", falls into the category of "athletic exercise" in the individual with CP. 

The ultimate outcome is an environment that stresses ALL systemic and biomechanical resources...the result of which are those common challenges we see with alarming and consistent regularity:

-low bone density
-digestive distress
-muscle wasting
-immune system dysfunction
-altered respiratory mechanics
-low circulating oxygen
-hormonal imbalances
-etc, etc...

All of this taking place under the influence of (in most cases) irregular and/or insufficient sleep patterns.

The "bottom line" is that the mechanical and systemic equivalent in a healthy individual is something akin to exercising 14 hours a day, sleeping about 4 hours a night, and leaving approximately 6 hours to accomplish everything else we would attribute to daily function (eat, shower, leisure, study, work).  When placed within THIS context, the stress on the CP body becomes more is an enormous challenge to a growing organism

The body does not have adequate time to engage in the process of self-healing and self-regulation...meaning that recovery is insufficient and incomplete.

In summary, my primary message is intended to reflect the following:

ANY strategy that contributes to relaxation and enhanced sleep potential is a valuable and VITAL component to all rehabilitation plans.  Although all of the efforts to improve movement, balance, coordination, fine motor skill, etc...are critically important, they also ADD to the biomechanical, systemic, and neurological daily requirement.  Therefore, a careful and focused effort to potentiate the "rest and recovery" of an individual with CP will result in a Biophysical Continuum that is more harmonious and consistent with a sustainable supersystem.

In essence, the "investment into recovery" pays HUGE dividends within the realm of movement and dynamic function.  A system that is rested, fresh, and fluid will perform significantly better...which ultimately results in a better rate of progress.  More importantly, it "raises the ceiling" of potential and greatly enhances the prognosis and opportunity for a best-case scenario.


Friday, February 12, 2016

Early Detection and Intervention: Strategies for Immediate Action

One of the most frustrating realities within the context of Cerebral Palsy (CP) is that "diagnosis", as such, is generally made around the age of 2 years old.  In other words, although it may be known that there is SOME level of neurological damage (or at the very least the POSSIBILITY of neurological damage), the "call to action" with respect to a definitive rehabilitation plan is generally deferred until after an official diagnosis is confirmed.  To be clear, this is not to say that nothing is being done nor does it mean that best interests are not taken into account...what it does mean, however, is that specific strategies and action plans become significantly more defined and clear once the diagnosis has been made.  The logical question people are likely to have after reading that last statement is:    what's so strange about that?  The answer comes back in the form of another practical question:

Why must we wait until things are so "black" before we act?

In other words, there are many things that can be done within the "grey areas" that do not necessarily require a "diagnosis" in order to confirm viability.  Further, the first 12-24 months of life present enormous opportunities to implement profound change due to the high level of neuroplasticity and biomechanical compliance.  The need for a diagnosis goes well beyond the practical debate and extends into issues of liability and systemic function of the medical be precise, almost the entire rehabilitation plan is pre-set  based on the diagnosis.  Although I agree with the necessity for standardization over customization (especially when we are speaking about providing a service to a larger mass of people), it does not mean that there is no room for individual strategies to be formulated that will result in a plethora of tangible (and intangible) positive outcomes. 

The next level of questioning is likely to be quite intuitive: 

If we don't have a diagnosis, how will we know where to start?

From a broader and more global perspective, we simply need to understand the fundamental reality that, regardless of whether there is a specific pathology involved or not, every human being requires healthy and robust systemic function (vital functions) in order to sustain life.  More specifically:

-Respiratory Mechanics
-Lymphatic Function
-Microcirculation (blood and interstitial / intercellular fluid)

Regardless of the diagnosis (or even the presence of a pathology), these are considerations that can be addresses and potentiated in a more immediate fashion.  This lends to the "organic" perspective as a precursor to the "mechanistic" perspective.  In other words: 

The diagnosis establishes the mechanistic strategy ("what is not working and how do we fix it") while early intervention establishes the organic strategy ("what is working and how can it work better").

It should be said that both of these perspective play a role in an effective and efficient rehabilitation strategy...however, the insertion of an organic perspective is what (in my opinion) is generally lacking and even overlooked completely. 

Early Detection:

One of my most proud accomplishments with respect to Fascia Therapy is the fact that it addresses these specific "voids" within the strategic options that parents / families / care-givers have.  Beyond being a viable "standalone" platform, adjunct / complement, and tactical management strategy, it has a well defined protocol for early detection and intervention.

Over the last 3 years, I have been fortunate enough to work with Dr. Veronica Delgado who is a well known physiatrist and doctor in Chile.  She has essentially formulated an "Early Detection Protocol" that uses a simple scoring system to identify potential markers for neurological impairment.  In addition (and in conjunction with), I have formulated a specific evaluation protocol that identifies postural and structural markers as well. 


Using both the neurological and structural metrics, we are better able to identify levels risk and therefore set a proper early intervention strategy. 

Early Intervention:

As stated earlier, as well in a few of my earlier posts on the importance of respiratory mechanics in neurodevelopmental disorders Part 1 and Part 2 , addressing and potentiating improved respiratory function extends not only into the systemic understanding, but has PROFOUND implications on the development of the pelvis and shoulder girdle...thereby having direct influence on health and function of the hips, legs, and arms.  This perspective is something that is worth a read / re-read. 

The Fascia Therapy concept addresses this consideration with what is called the Respiratory Protocol which has proven to be a valuable complement to early intervention strategies as well as part of a larger management strategy for all ages with neurological challenges. 

Along with the respiratory protocol, there are a group of specialized techniques that potentiate and enhance microcirculation, more specifically interstitial fluid.  To put it briefly, interstitial fluid is essentially the medium by which waste product is transported from the bloodstream to the lymphatic system...therefore having a profound impact on systemic health and homeostasis.  On addition, immune system function depends greatly on robust interstitial fluid flow.  In CP, microcirculation is greatly diminished and effectively manifests in poor tissue quality (colour, texture) as well as overall systemic deficits (chronic illness, stiffness, injury).  Being able to properly identify priority "targets" using these techniques greatly enhances systemic homeostasis and ultimately produces a stronger and more resistant organism. 

In summary, this post is intended to underscore the reality that, although "black and white" situations do indeed exist, the "grey areas" are exponentially larger...and they should be looked at as opportunities to implement profound, permanent, and lasting improvement.