The inspiration for this brief post came quite randomly while searching for connective tissue images online. I came across this puzzle image with the very profound "finding the beauty in disconnection" title associated with it...then a small floodgate opened.
One of the most overlooked and under-appreciated tissues in the human organism is connective tissue. When you consider the implications of the connective tissue newtwork, this oversight goes "beyond wrong". When you actually perform a paradoxical "step back and zoom" into fascia / connective tissue as it relates to both mechanics and systemic function...you can't help but be amazed, startled, or otherwise fascinated. Although I can go into many different discussions on many different levels, I will focus on 2 very straight-forward, yet fundamental, functional appearances of connective tissue in the human body (as per Van der Waal). Before I do this, I will share a very insightful image that effectively demonstrates the extent of the connective tissue "web" of influence:
I have already shared this image on the One Giant Leap Facebook page, but it most certainly is worthy of another appearance. The image is self-explanatory and illustrates how connective tissue is more than important, rather an essential and vital contributor to mechanical and systemic competence.
Finding the Beauty in Disconnection:
The term "connective" tissue generates an obvious and intuitive thought in almost everyone's mind: it is a specialized and differentiated tissue that connects muscle to bone, bone to bone, and organs to the lining of the internal wall. The paradoxical reality is that the second architectural appearance of connective tissue has the functional role of disconnection! To be precise, the intramuscular and extramuscular connective tissue is engineered to allow for proper gliding and sliding between adjacent muscles and muscle bundles (Hyaluronan). It is also very prevalent in articular cartilage allowing for proper movement and protection against compressive forces.
When you consider this paradoxical "duality", in addition to the mechanical and systemic contributions illustrated above, the relative "importance" of connective tissue within the living organism becomes quite astounding. More importantly, when rehabilitative strategies are formulated, connective tissue should be considered as a primary focal point as a means to improvement and restoration of structural and systemic homeostasis.
This perspective goes hand-in-hand with interstitial fluid which will be part of a larger discussion in the very near future...and in combination, they encompass the entire spectrum of rehabilitative success.
Although brief and "reader-friendly", I hope it was educational and insightful!
Cheers!
Tuesday, September 25, 2012
Monday, September 24, 2012
Hip Subluxation and Cerebral Palsy
I have made a somewhat delibrate decision to stay away from potential "hot topic" discussions, however the issue of hip subluxation remains the top "talking point" in the overwhelming majority of the discussions I have with parents of children with Cerebral Palsy (CP).
It is with this fact in mind that I will attempt to instill what I feel to be a fundamental understanding of the larger perspective of this greatly debated (and largely misunderstood) issue. As always, the intention is simply to expand the panoramic and give some insight so that parents and extended families can more efficiently filter out the "noise" of information that floods their daily lives...and enable some clarity when making important decisions.
Diagnostics: The very term "diagnosis" seems to somehow generate some relief and/or sense of progress...however, a diagnosis as such only serves to classify the particular symptomatic manifestations. The reality is that the challenge still exists. With respect to hip subluxation, the actual "diagnosis" is unfortunately dependant on a relatively primitive device: the x-ray. Although the term "primitive" may be taken as somewhat controversial, it none-the-less reflects a very real and undeniable truth. I will expand on my rationale in an effort to frame this particular philosophy with more clarity.
1) X-Rays are 2-Dimensional
This is perhaps the most alarming reality to me...the fact that an assessment of a dynamic, 3-dimensional organism is being performed with a static, 2-dimensional image. To be more precise, the human organism exists in 3-dimensional space and within a specific gravitational field. Therefore, to look at it in 2-dimensional space with little or no gravitational forces placed on it seems somewhat primitive and certainly limits it's representation of the true reality.
2) "Looking at the room through the keyhole"
I absolutely love this analogy...and for those who know me, you have heard me use it quite often. The x-ray (in addition to the static / 2-dimensional limitations) is only representative of a very small area of the body. This would be analogous to giving an estimate of a large conference room by looking through the keyhole of the door. The unconscious assumption is that everything beyond the scope of the x-ray is fine...and in most cases, the pelvis (which is even INSIDE the x-ray image) is completely overlooked....and even worse, disregarded completely. This is dangerously naive (if I may speak frankly) and further "waters down" the diagnostic reliability.
3) Bones and the diagnostic "monopoly".
The x-ray itself perpetuates the idea of the bones as the singular determinant of functional performance. The reality is that without the soft-tissue contribution, the bones would simply clatter to the ground into a large pile of useless struts. The human organism is a complex marvel of engineering that is charatcerized by biotensegrity. Biotensegrity is essentially a term to describe the architecture of complex systems. These systems are characteristed by BOTH tensional and compressional elements. The bones are the compressional contribution to the system, while the soft tissue (muscles, tendons, connective tissue, fascia, etc...) contribute to the tensional component. Therefore, given the obvious variables that contribute to functional performance, why have the bones been given such a diagnostic monopoly?
Architectural Realities:
The reality with CP children (despite the diagnosis) is that they reliably demonstrate profound joint weakness. Even in the mildest cases (Level 1 GMFCS), it is quite easy to demonstrate the significant soft-tissue / fascial weakness that exists. The hypotonic individual demonstrates this in the most obvious way...however the spastic CP child can challenge this understanding. The excessive muscular tension in essense "masks" the joint weakness behind an artificial shield of tight muscle. However, in both cases there can be a reliable expectation of some level of joint weakness.
Protocol / Procedural Flaws:
Given all of the realities mentioned above, perhaps the most glaring flaw is in the actual performance of the x-ray itself. I am not making any direct comment on the people performing the x-rays, rather on the age-old paradigm of the "proper x-ray protocol" that has been formulated within a very narrow perspective and framework.
The typical procedure plays out as follows...DESPITE the architectural / structural manifestations of the child, they are placed on their back, one person holds them down to the table with force from the top of the body to prevent any movement. Then...another person actively grasps the ankles, PULLS the legs straight, TWISTS the legs into internal rotation, and holds them in place. Although I was always aware of this protocol, it never actually "clicked" until I had an x-ray done on my 6 month old daughter. Even in the case of a healthy child, the mere act of applying stress to forcibly move a child from their neutral position in an effort to acquire the "proper position" was (in all truth) absurd. This was obviously uncomfortable and traumatic for such a young child, but when you compound the biomechanical distortions of a CP child into this framework...the result, at best, is highly unreliable.
Fact #1: The CP child demonstrates profound muscular imbalance, irregular muscle activation, and asymmetry...therefore the "straight" position is obviously one that is derived.
Fact #2: A flat examination table is completely inadequate at enabling complete relaxation for a CPchild. The proprioceptive feedback in a CP individual is significantly distorted, therefore a flat surface generates a great deal of sensory "confusion" and can, at times, trigger an exaggerated reaction. Even in ourselves (healthy individuals), the first few seconds of lying on a flat surface requires some adjustment...imagine the challenegs within a CP child.
Fact #3: This is perhaps the most important concept to remember and evaluate for yourself: If all of the joints are weak...if one end of the body is being held down...and the other end is being held down at the ankles / lower leg...the only area available to manifest movement is the hip joint. In other words, the inevitable muscular contraction and activation (whether it is voluntary or involuntary) will "exit" through the most proximal (closest) open chain...the hip joint. Therefore, head of the femur will actively move within the acetabulum and, depending on when the image is actually taken, you may get vastly different images.
Final Question:
Although up until this point, I may be delivering a focused "condemnation" of the entire propcedure, but this would be a relatively narrow perspective. I do not question whether they have a role in the effective and efficient formulation of competent diagniostics...I question the relative weight x-rays are assigned. The implications of a "Hip Subluxation" diagnosis are enormous...therefore common sense only dictates that the diagnostic process by very exacting and comprehensive. Therefore, the final question remains: can the x-ray effectively confirm hip subluxation with an acceptable level of reliabilty? The answer only comes through the prism of each specifc families value system...however, the above mentioned realities should have at least been given consideration.
The True "Subluxation" Test:
The relative implications of hip alignment become more prominent when there is significant amounts of load-bearing (weight-bearing) involved...therefore when children are non-weight bearing, then alignment can even be considered as secondary. However, a very simple "litmus test" can be implemented when this issue is brought up:
1. Is he/she in pain?
2. Are they weight-bearing?
3. Is the muscular mass within the leg decreasing?
4. Is range of motion reduced/reducing?
5. Is functional competence reducing?
If the answer to all of these questions is "NO"...then the subjective image of the x-ray is completely secondary. The reality is that a hip that is subluxed will manifest in reduced range of motion, depletion of the muscular mass of the entire leg, reduced functional performance, and often times manifest pain or discomfort. These are the real signs of a hip in a deteriorating condition.
In all fairness, the x-ray can be included as a 6th consideration within the subluxation test simply because it can provide some useful information that contributes to the overall 3-dimensional reality...but as the only source of information from which potentially drastic decisions are made, it fails due to it's primitivity.
I hope this has been somewhat helpful and insightful...and more importantly, given some clarity to an already confusing situation. I think it merits repeating that my true intention is merely to open different levels and perspectives...not to convince or persuade...rather to provide an amplified understanding so that the chosen path is determined with more conviction and confidence as well as with an overall sense of well-being.
Cheers!
It is with this fact in mind that I will attempt to instill what I feel to be a fundamental understanding of the larger perspective of this greatly debated (and largely misunderstood) issue. As always, the intention is simply to expand the panoramic and give some insight so that parents and extended families can more efficiently filter out the "noise" of information that floods their daily lives...and enable some clarity when making important decisions.
Diagnostics: The very term "diagnosis" seems to somehow generate some relief and/or sense of progress...however, a diagnosis as such only serves to classify the particular symptomatic manifestations. The reality is that the challenge still exists. With respect to hip subluxation, the actual "diagnosis" is unfortunately dependant on a relatively primitive device: the x-ray. Although the term "primitive" may be taken as somewhat controversial, it none-the-less reflects a very real and undeniable truth. I will expand on my rationale in an effort to frame this particular philosophy with more clarity.
1) X-Rays are 2-Dimensional
This is perhaps the most alarming reality to me...the fact that an assessment of a dynamic, 3-dimensional organism is being performed with a static, 2-dimensional image. To be more precise, the human organism exists in 3-dimensional space and within a specific gravitational field. Therefore, to look at it in 2-dimensional space with little or no gravitational forces placed on it seems somewhat primitive and certainly limits it's representation of the true reality.
2) "Looking at the room through the keyhole"
I absolutely love this analogy...and for those who know me, you have heard me use it quite often. The x-ray (in addition to the static / 2-dimensional limitations) is only representative of a very small area of the body. This would be analogous to giving an estimate of a large conference room by looking through the keyhole of the door. The unconscious assumption is that everything beyond the scope of the x-ray is fine...and in most cases, the pelvis (which is even INSIDE the x-ray image) is completely overlooked....and even worse, disregarded completely. This is dangerously naive (if I may speak frankly) and further "waters down" the diagnostic reliability.
3) Bones and the diagnostic "monopoly".
The x-ray itself perpetuates the idea of the bones as the singular determinant of functional performance. The reality is that without the soft-tissue contribution, the bones would simply clatter to the ground into a large pile of useless struts. The human organism is a complex marvel of engineering that is charatcerized by biotensegrity. Biotensegrity is essentially a term to describe the architecture of complex systems. These systems are characteristed by BOTH tensional and compressional elements. The bones are the compressional contribution to the system, while the soft tissue (muscles, tendons, connective tissue, fascia, etc...) contribute to the tensional component. Therefore, given the obvious variables that contribute to functional performance, why have the bones been given such a diagnostic monopoly?
Architectural Realities:
The reality with CP children (despite the diagnosis) is that they reliably demonstrate profound joint weakness. Even in the mildest cases (Level 1 GMFCS), it is quite easy to demonstrate the significant soft-tissue / fascial weakness that exists. The hypotonic individual demonstrates this in the most obvious way...however the spastic CP child can challenge this understanding. The excessive muscular tension in essense "masks" the joint weakness behind an artificial shield of tight muscle. However, in both cases there can be a reliable expectation of some level of joint weakness.
Protocol / Procedural Flaws:
Given all of the realities mentioned above, perhaps the most glaring flaw is in the actual performance of the x-ray itself. I am not making any direct comment on the people performing the x-rays, rather on the age-old paradigm of the "proper x-ray protocol" that has been formulated within a very narrow perspective and framework.
The typical procedure plays out as follows...DESPITE the architectural / structural manifestations of the child, they are placed on their back, one person holds them down to the table with force from the top of the body to prevent any movement. Then...another person actively grasps the ankles, PULLS the legs straight, TWISTS the legs into internal rotation, and holds them in place. Although I was always aware of this protocol, it never actually "clicked" until I had an x-ray done on my 6 month old daughter. Even in the case of a healthy child, the mere act of applying stress to forcibly move a child from their neutral position in an effort to acquire the "proper position" was (in all truth) absurd. This was obviously uncomfortable and traumatic for such a young child, but when you compound the biomechanical distortions of a CP child into this framework...the result, at best, is highly unreliable.
Fact #1: The CP child demonstrates profound muscular imbalance, irregular muscle activation, and asymmetry...therefore the "straight" position is obviously one that is derived.
Fact #2: A flat examination table is completely inadequate at enabling complete relaxation for a CPchild. The proprioceptive feedback in a CP individual is significantly distorted, therefore a flat surface generates a great deal of sensory "confusion" and can, at times, trigger an exaggerated reaction. Even in ourselves (healthy individuals), the first few seconds of lying on a flat surface requires some adjustment...imagine the challenegs within a CP child.
Fact #3: This is perhaps the most important concept to remember and evaluate for yourself: If all of the joints are weak...if one end of the body is being held down...and the other end is being held down at the ankles / lower leg...the only area available to manifest movement is the hip joint. In other words, the inevitable muscular contraction and activation (whether it is voluntary or involuntary) will "exit" through the most proximal (closest) open chain...the hip joint. Therefore, head of the femur will actively move within the acetabulum and, depending on when the image is actually taken, you may get vastly different images.
Final Question:
Although up until this point, I may be delivering a focused "condemnation" of the entire propcedure, but this would be a relatively narrow perspective. I do not question whether they have a role in the effective and efficient formulation of competent diagniostics...I question the relative weight x-rays are assigned. The implications of a "Hip Subluxation" diagnosis are enormous...therefore common sense only dictates that the diagnostic process by very exacting and comprehensive. Therefore, the final question remains: can the x-ray effectively confirm hip subluxation with an acceptable level of reliabilty? The answer only comes through the prism of each specifc families value system...however, the above mentioned realities should have at least been given consideration.
The True "Subluxation" Test:
The relative implications of hip alignment become more prominent when there is significant amounts of load-bearing (weight-bearing) involved...therefore when children are non-weight bearing, then alignment can even be considered as secondary. However, a very simple "litmus test" can be implemented when this issue is brought up:
1. Is he/she in pain?
2. Are they weight-bearing?
3. Is the muscular mass within the leg decreasing?
4. Is range of motion reduced/reducing?
5. Is functional competence reducing?
If the answer to all of these questions is "NO"...then the subjective image of the x-ray is completely secondary. The reality is that a hip that is subluxed will manifest in reduced range of motion, depletion of the muscular mass of the entire leg, reduced functional performance, and often times manifest pain or discomfort. These are the real signs of a hip in a deteriorating condition.
In all fairness, the x-ray can be included as a 6th consideration within the subluxation test simply because it can provide some useful information that contributes to the overall 3-dimensional reality...but as the only source of information from which potentially drastic decisions are made, it fails due to it's primitivity.
I hope this has been somewhat helpful and insightful...and more importantly, given some clarity to an already confusing situation. I think it merits repeating that my true intention is merely to open different levels and perspectives...not to convince or persuade...rather to provide an amplified understanding so that the chosen path is determined with more conviction and confidence as well as with an overall sense of well-being.
Cheers!
Friday, September 7, 2012
Cerebral Palsy Guidebook: Developmental versus Chronological
For those who know me well, this discussion will be a familiar one. It had taken quite awhile to find an effective way to create a mindset that would, not only resonate and increase understanding, but also facilitate more effective learning and understanding with respect to the journey taken by CP individuals and their immediate and extended families. I refer to the term "journey" because it most accurately describes the life-long path which is sometimes relatively smooth, sometimes filled with obstacles, and almost always evolving. Because the "finish line" is never predictable, it is the journey that defines success...therefore it is only logical to make every attempt to instill the proper perspective and overall frame of mind that will ultimately sustain you throughout. Although there are many different "angles" and ways to approach this topic, I have found that when there is a fundamental understanding of developmental age versus chronological age, the mindset is automatically "re-booted" into a different "mental software".
Mental Software: DOS 2.2 to Windows 7
I use this familiar comparison in an attempt to illustrate the relative "leap" in perspective...in many ways, it can be considered a mini-paradigm shift. Throughout human society, there has always been an underlying understanding / expectation with respect to human behaviour. To be more precise, behaviour is almost always assessed against the "age appropriate litmus". Behaviour is defined as either appropriate or inappropriate based on that persons age. Without going into any complex sociological rant, this is no different within the sphere of Cerebral Palsy. Moreover, it is equally as rampant in the professional medical mindset as it is within the general population. In some ways, this is to be expected...we all see life through the same relative prism, therefore why wouldn't this apply to an individual with CP? This is where the "re-install" of the mental software needs to take place.
The proper perspective is not something that is (or has ever been) elusive...in fact, it has been under our noses from the beginning. Alarmingly enough, we have seen and read it over and over again...and never truly latched onto it. To be more specific, we only need to refer to the definition itself to get a better understanding of the CP journey. Cerebral Palsy can be considered as a condition that falls under the umbrella of neurodevelopmental delay (NDD). This is a relatively large umbrella that includes West Syndrome, Miller-Diekers Syndrome, etc...therefore this perspective has implications far beyond CP as well. By definition, neurodevelopmental delay is a condition that is characterized by the absence or delay of natural developmental milestones. It is also defined as the persistence of primitive reactions and the absence of postural reactions. To put this all into very straightforward terms: In the CP individual developmental age does not correspond with chronological age.
Mental Software: User Tutorial
Now that this perspective has been installed, it will require some basic orientation and familiarization. The reality in the vast majoriy of cases is that children are "evaluated" based on their chronoligical age and the corresponding developmental achievement. For example, a CP child of 2 years old is typically assigned strategies and tools that are intended to achieve the essential functional goal of "walking". However the fundamental reality is that the developmental age of the pelvis, hips, knees, and feet are likely much "younger" and therefore unprepared for any load-bearing activities. This is a simple example, of course, but it speaks to a very complex problem. Let me illustrate an even more precise example: Up until the age of 10-14 months, there is a tremendous amount of developmental milestones that take place...development of head control, increased strength and stability in the shoulder girdle, stability in a seated position, crawling, standing, etc... These are all developmental stages that every human must pass through in order to achieve proper functional competence. In a healthy child, all of these (and more) are achieved by 10-14 months. In addition, the primitive reactions (Moro Reflex, Landau Reflex, etc...) have all disappeared by the 8-9th month and have been replaced by postural reactions such as lateral propping and counterbalancing. In the CP individual, these primitive reactions persist long after 14 months of age...and can even be seen into their teens.
Therefore, the use of chronological age as a template for functional competence / expectation or to assess other important concerns such as bone density...is fundamentally flawed and fundamentally incorrect. The realistic "litmus" standard should always refer to developmental age rather than chronological age. If primtive reactions (Moro, Landau) are still present, no matter what their chronological age, the individual's developmental age corresponds to that of a child of 0-14 months.
There is no debating the internal conflict that exists when a parent is asked to consider their 4, 5, 6 year old as an infant...however the architectural reality and developmental competence is precisely that. If there is an implied understanding of the definition of neurodevelopmental delay...why does this understanding fail to reach beyond the words on the page? The developmental age of the individual defines the appropriate therapeutic intervention best suited for the progress of the child. Although this may be quite a leap in perspective, the fortunate reality is that this concept makes assessing progress much easier. The gradual disappearance of primitive reactions and the progressive development of postural reactions signal progression through the developmental process. What is almost ALWAYS overlooked is that functional competence is the spontaneous reaction to a maturing structure! In a healthy individual there is no need to "train" the muscles or "train" the brain to achieve functional maturity...it is spontaneous.
Power Down:
Although it may take some time for this perspective to truly integrate, I hope that it at least stimulates some "error messages" popping up when you come to important decisions regarding rehabilitative strategy. I wrote a few posts on Primitive and Postural Reactions which served as a follow up to a basic post on fundamentals of proper perspective that will contribute to the internalization of this important concept. I hope it proves insightful and, more importantly, helpful.
Cheers!
Mental Software: DOS 2.2 to Windows 7
I use this familiar comparison in an attempt to illustrate the relative "leap" in perspective...in many ways, it can be considered a mini-paradigm shift. Throughout human society, there has always been an underlying understanding / expectation with respect to human behaviour. To be more precise, behaviour is almost always assessed against the "age appropriate litmus". Behaviour is defined as either appropriate or inappropriate based on that persons age. Without going into any complex sociological rant, this is no different within the sphere of Cerebral Palsy. Moreover, it is equally as rampant in the professional medical mindset as it is within the general population. In some ways, this is to be expected...we all see life through the same relative prism, therefore why wouldn't this apply to an individual with CP? This is where the "re-install" of the mental software needs to take place.
The proper perspective is not something that is (or has ever been) elusive...in fact, it has been under our noses from the beginning. Alarmingly enough, we have seen and read it over and over again...and never truly latched onto it. To be more specific, we only need to refer to the definition itself to get a better understanding of the CP journey. Cerebral Palsy can be considered as a condition that falls under the umbrella of neurodevelopmental delay (NDD). This is a relatively large umbrella that includes West Syndrome, Miller-Diekers Syndrome, etc...therefore this perspective has implications far beyond CP as well. By definition, neurodevelopmental delay is a condition that is characterized by the absence or delay of natural developmental milestones. It is also defined as the persistence of primitive reactions and the absence of postural reactions. To put this all into very straightforward terms: In the CP individual developmental age does not correspond with chronological age.
Mental Software: User Tutorial
Now that this perspective has been installed, it will require some basic orientation and familiarization. The reality in the vast majoriy of cases is that children are "evaluated" based on their chronoligical age and the corresponding developmental achievement. For example, a CP child of 2 years old is typically assigned strategies and tools that are intended to achieve the essential functional goal of "walking". However the fundamental reality is that the developmental age of the pelvis, hips, knees, and feet are likely much "younger" and therefore unprepared for any load-bearing activities. This is a simple example, of course, but it speaks to a very complex problem. Let me illustrate an even more precise example: Up until the age of 10-14 months, there is a tremendous amount of developmental milestones that take place...development of head control, increased strength and stability in the shoulder girdle, stability in a seated position, crawling, standing, etc... These are all developmental stages that every human must pass through in order to achieve proper functional competence. In a healthy child, all of these (and more) are achieved by 10-14 months. In addition, the primitive reactions (Moro Reflex, Landau Reflex, etc...) have all disappeared by the 8-9th month and have been replaced by postural reactions such as lateral propping and counterbalancing. In the CP individual, these primitive reactions persist long after 14 months of age...and can even be seen into their teens.
Therefore, the use of chronological age as a template for functional competence / expectation or to assess other important concerns such as bone density...is fundamentally flawed and fundamentally incorrect. The realistic "litmus" standard should always refer to developmental age rather than chronological age. If primtive reactions (Moro, Landau) are still present, no matter what their chronological age, the individual's developmental age corresponds to that of a child of 0-14 months.
There is no debating the internal conflict that exists when a parent is asked to consider their 4, 5, 6 year old as an infant...however the architectural reality and developmental competence is precisely that. If there is an implied understanding of the definition of neurodevelopmental delay...why does this understanding fail to reach beyond the words on the page? The developmental age of the individual defines the appropriate therapeutic intervention best suited for the progress of the child. Although this may be quite a leap in perspective, the fortunate reality is that this concept makes assessing progress much easier. The gradual disappearance of primitive reactions and the progressive development of postural reactions signal progression through the developmental process. What is almost ALWAYS overlooked is that functional competence is the spontaneous reaction to a maturing structure! In a healthy individual there is no need to "train" the muscles or "train" the brain to achieve functional maturity...it is spontaneous.
Power Down:
Although it may take some time for this perspective to truly integrate, I hope that it at least stimulates some "error messages" popping up when you come to important decisions regarding rehabilitative strategy. I wrote a few posts on Primitive and Postural Reactions which served as a follow up to a basic post on fundamentals of proper perspective that will contribute to the internalization of this important concept. I hope it proves insightful and, more importantly, helpful.
Cheers!
Saturday, September 1, 2012
Helical Tensegrity as a Structural Mechanism in Human Anatomy
HELICAL TENSEGRITY AS A STRUCTURAL MECHANISM IN HUMAN ANATOMY
International Journal of Osteopathic Medicine 2011;14:24-32.
Graham Scarr
ABSTRACTTensegrity is a structural system popularly recognised for its distinct compression elements that appear to float within a tensioned network. It is an attractive proposition in living organisms because such structures maintain their energy-efficient configuration even during changes in shape. Previous research has detailed the cellular cytoskeleton in terms of tensegrity, being a semi-autonomous system amenable to such analysis because of its size. It has also been described at higher levels in the extracellular/fascial matrix and musculoskeletal system, but there are fewer syntheses of this.
At a fundamental level, the helix and tensegrity share common origins in the geometries of the platonic solids, with inherent hierarchical potential that is typical of biological structures. The helix provides an energy-efficient solution to close-packing in molecular biology, a common motif in protein construction, and a readily observable pattern at many size levels throughout the body. The helix and tensegrity are described in a variety of anatomical structures, suggesting their importance to structural biology and manual therapy.
1. INTRODUCTION
The world of biology is full of weird and wonderful shapes, some with no obvious purpose, and others that suggest some hidden meaning. Even human anatomy has its fair share of the bizarre in the shapes of bones and limbs. How and why does each one develop its characteristic form, and how does that relate to function? Is there more to shape than genetics and Wolffs’ Law?
Tensegrity (tension-integrity) is a structural mechanism that potentially integrates anatomy from the molecular level to the entire body, and is popularly recognised for its distinct compression elements that appear to float within a tensioned network. It is a most attractive proposition in living systems, because such structures automatically assume a position of stable equilibrium, with a configuration that minimizes their stored elastic energy. Tensegrity structures allow movement, with the minimum of energy expenditure, without losing stiffness or stability.1,5-7
This contrasts with the orthodox view that explains the musculo-skeletal system through classical Newtonian mechanics, using pillars, arches and fixed-fulcrum levers to counteract the force of gravity. In this approach, bones stack on top of one another like a pile of bricks, restrained by soft tissues that permit movement in a local piece-meal like way.8 Comparisons of tensegrity and biological structures show them both to have non-linear visco-elastic properties, with fluid-like movements that result from integration of all components in the system.1,5,6,9
The molecular helix provides an energy-efficient solution to close-packing in biology and also displays tensegrity properties. It is a common motif in protein construction, and a readily observable pattern at many size levels throughout the body. It is proposed that helical tensegrity is a key mechanism in structural biology and consequently has significance for manual therapies.
2. THE HELIX
Globular proteins, often containing multiple helical domains, can themselves polymerize into helixes (fig. 1a,b).12 Similar helixes can wind around each other to form coiled-coils (Fig. 1c),13 and assemble into mechanically rigid rods or filaments, or further combine into more complex structures with specialized functions (fig. 2).
In collagen type I, repeating sequences of amino acids spontaneously form a left-handed helix of procollagen, with three of these helixes combining to form a right-handed helix of tropocollagen. Five tropocollagen molecules then coil in a staggered helical array,14 which lengthens longitudinally by the addition of more tropocollagen to form a microfibril, with higher arrangements forming fibrils, fibres and fascicles.15 Collagen appears at several different hierarchical levels within bones, tendons, ligaments and fascia (fig. 2).
2.1 Structural hierarchies
2.2 Helical tubes
The tubular nature of the helix scales up into blood vessels,25 the urinary system and intestinal tract.26,27 Carey (1920) observed left and right-handed helical patterns in the epithelium during formation of the oesophagus and trachea, respectively, in the early embryo.28 In the walls of elastic arteries, such as the aorta, helical collagen reinforcement resists high loads from the pressure of blood. The middle layer organizes into lamellar units, with the orientation of collagen fibres and smooth muscle cells forming a continuous helix. Collagen is more dispersed in the outer adventitia, but still forms two helical groups of fibres.25
Within the spine, the intervertebral disc contains collagen arranged in concentric lamellae, with opposing orientations in alternate helical layers of 65o (axial).29 The inner lamellae of the annulus fibrosus consist of collagen type II fibres, cross-linked to type IX on the fibre surface, within a highly hydrated proteoglycan matrix; gradually changing to collagen type I fibres in the outer lamellae.30,31 The higher proteoglycan/water content in the inner lamellae acts as a thick-walled pressure vessel containing the nucleus pulposus, while the higher concentration of collagen type I in the outer lamellae provides tensile reinforcement during bending and torsion.29,32
Cardiac muscle fibre orientation varies linearly between inner and outer walls, from 55o (axial) in one direction to 55o in the opposite, with tangential spiralling in a transverse plane.36 The entire heart has also been described as a helical coil of muscle with contractions that cause clockwise and anti-clockwise twisting motions.37 This typically produces a left ventricular ejection fraction of 60%, for a muscular contraction of just 15%,38 confirming the mechanical efficiency of a helix.
2.3 Tubes within tubes
Traditionally considered as mere packing tissue, fascia has been shown to exert considerable influence over muscle generated force transmission.39-42 It naturally develops into compartments, or ‘tubes within tubes’, particularly noticeable in cross-sections of the limbs. Within muscle, a delicate network of endomysium surrounds individual muscle fibres and is continuous with the perimysium ensheathing groups of fibres in parallel bundles, or fasciculi. Perimysial septa are themselves inward extensions of the epimysium that covers the muscle and is continuous with the fascia investing whole muscle groups. All these sheaths (tubes) coalesce and transmit the force generated within muscle fibres through tendons and inter/extra-muscular fascial attachments.39,42 These fascial tissues are all reinforced by two helical crossed-ply sets of collagen,36 with the ‘ideal’ resting fibre orientation of 55o (axial)33 that varies with changing muscle length.
Stecco (2004) described helical fascial sheaths that transfer tensional forces within and between themselves, and control movement in a way that the nervous system is incapable of.48 Anecdotally, palpatory phenomena with a helical component are observed within the soft tissues of the extremities.49 A normal pattern exhibits right-handed helical motion in the limbs on the left side, and left-handed helical motion on the right, although current anatomical knowledge is unable to explain this.
The helix has long been recognized in joint motion,8 and its widespread appearance at multiple size-scales throughout the body suggests that it has some special significance. At a fundamental level, the helix and tensegrity are linked through a common origin in the geometries of the platonic solids.1,4,50
SIMPLE GEOMETRY
3.1 The platonic solids, geodesic geometry and close-packing
The icosahedron differs from the other platonic shapes by packing spheres around a nuclear space to form the geodesic dome (Fig. 3d).50 It is also triangulated and has multiple symmetries which allow it to stack in a column or helix and form more complex patterns and shapes.1,2 Some naturally occurring structures based on the icosahedron are carbon fullerenes; pollen grains and ‘spherical’ viruses.22-24
Both the tetrahedron and icosahedron spontaneously form through the interactions of natural physical forces, and are the basis for appreciating complex shapes in human anatomy.2,4,51
3.2 Chirality and Equivalence
Tropocollagen (fig. 2) has been described as three stretched quasi-tetrahelixes surrounding a central core.53,54 Each glycine residue, from the three procollagen peptides, contributes a hydrogen atom that forms the corner of a regular tetrahedron, and together they form the right-handed tetrahelical core of the tropocollagen molecule. The left-handed procollagens are the sub-helixes shown in figure 5b; and this configuration also gives rise to a stack of slightly contorted icosahedra.53,54 Most (if not all) molecular helixes are geometrically related to the tetrahelix and icosahedron,12,22,53,54,56 including the alpha-helix of DNA, which has been described as a [triple stranded] tetrahelix with one strand missing.53
Molecules automatically assume a state of minimal-energy as they balance the attraction and repulsion of their constituent atoms. As the helix is a more efficient close-packing configuration it is understandable that it should be such a common structural shape. At a larger scale, the bacterial cell wall contains actin homologues arranged as a structural helix determining cell shape and elongation.57,58 Plants display similar configurations in their cell walls59 and geometric patterns at a higher level.
3.3 Fibonacci and the Golden Mean
4 TENSEGRITY
Descriptions of tensegrity in biology have appeared in the literature since the early 1980’s,64,65 and include the cellular cytoskeleton;5 developing neurites66 and cerebral cortex;67 spider silk6,68 and wasp arcus;69 mammalian70-72 and avian lung;73 fascial matrix;74-76 shoulder;75 spine;51 pelvis77 and cranium.78
Fuller (1975) described a tensegrity structure as a set of struts under compression, and an arrangement of cables under isometric tension, that always balances in the most energetically efficient configuration.50 It is geodesic by its very nature, because tension always acts in straight lines, and automatically reduces itself to a minimum. Tensegrity structures make possible an infinite variety of stable shapes through changes in the lengths of their compression members, and changes in those shapes that require very little control energy. As each component influences all the others, stresses distribute throughout the system, creating a structure that can react to external forces from any direction without collapsing.6,7,51 An organism utilizing such a system would be able to move with the minimum of energy expenditure without losing stiffness or stability.6,7,51 Because tension and compressional forces are separated, the material properties of components can be optimized, and in biological systems this typically occurs through hierarchies. Tensegrity hierarchies achieve a significant reduction in mass,6,7 and provide a functional connection at every level, from the simplest to the most complex, with the entire system acting as a unit.5,51,76
4.1 The tensegrity helix
Considering the six struts in different groups of three, joined on the surface by ‘tension triangles’ (fig. 6c), shows that each strut within the group is oriented at 90o to the others, and together they create a chiral twist. On the other side of the structure is a similar group with a twist in the opposite direction, which means that a tensegrity icosahedron already contains helical precursors of both chiralities.
5 THE HELICAL-TENSEGRITY BODY
The cellular cytoskeleton is described as a multi-functional tensegrity structure that influences cell shape, and activates multiple intra-cellular signalling pathways.5 Helical microfilaments of actin and microtubules of tubulin are the tension and compression elements, respectively (fig. 1a,b); while spectrin fibres and actin bundles may have similar roles within the cell cortex (Figs. 1c).81,82Tensioned intermediate filaments link everything together, from the nucleus to the cell membrane.83
Tension is generated through the action of actomyosin motors and polymerization of microtubules, and any change in force at one part of the structure causes the cytoskeleton to alter overall cell shape.5 Many enzymes and substrates are situated on the cytoskeletal lattice, and changes in its configuration alter their activity, leading to a switch between different functional states such as growth, differentiation or apoptosis.5
The cytoskeleton connects to the matrix and other cells through transmembrane proteins, such as integrins and cadherins, respectively. These create a mechanical coupling that transfers tension, generated within the cytoskeleton, to the matrix and adjacent cells. A prestressed state of isometric tension thus exists between them, so that a change in matrix tension causes a realignment of structures within the cytoplasm, and a change in cell function. This reciprocal transfer of mechanical forces is likely to orchestrate cellular growth and expansion, allowing the emergence of complex multi-cellular tissue patterns, based on the same principles.5,84,85
5.1 Helical tubes
The capacity for fluid flow through a tube depends, in part, on the porosity of the tube wall. The helical tensegrity ‘wall’ in figure 8 has many gaps, but if the struts were expanded into plates that just touched each other, they could be made to ‘seal’ the internal space. This compares with the selective barrier of endothelial cells that allows vascular contents to pass out between capillary walls. The internal cellular cytoskeleton determines cell shape and orientation, through tensegrity;5 is affected by signalling mechanisms and variations in fluid flow; and alters the tension between cells through adherens junctions,88 ultimately affecting tube permeability.89,90
In tensegrity terms, there is no specific need for a compressional element within the tube wall if this is provided by outward pushing radial pressure, although arterial walls are pre-stressed even when load free. It is likely that wall components under tension are linked to other structures under compression at different hierarchical levels; Fuller (1975) emphasized that tension and compression must always coexist.50 Collagen type I fibrils are the predominant tensors, and are virtually inextensible under tension (<5%);30 but the mechanical properties of more than twenty other types are poorly understood. Proteoglycans and glycosaminoglycans tend to increase in tissues under compression. Combining these and other components into tissue specific matrices contributes to huge histological variation. Confirmation that they are tensegrity configurations, however, will depend on analysis of their physical interactions.
Undoubtedly, the fibre angle within any particular tissue depends on the functional context. The model in figure 8 shows struts arranged in a self-similar array and tension cables with differing orientations. Previous descriptions of “random” collagen orientations may have misinterpreted what were actually functionally ordered tensegrity alignments,91 and the sensitivity of newer imaging techniques and their analysis may resolve this.92,93
5.2 Helixes within helixes
The intervertebral disc contains collagen arranged in concentric lamellae, with opposing orientations in alternate helical layers that provide tensile reinforcement.29 Whether this is a tensegrity configuration is yet to be assessed; but the widespread view that discs provide resistance to spinal compression as a prime function is probably too simplistic, and the whole spine has been looked at from a tensegrity perspective.51 Although disc failure usually occurs in tension,94 this is usually due to abnormal loading.
The negative Poisson ratio may also have relevance to the helical dynamics of the heart and has been described with the tensegrity ‘jitterbug’ mechanism. When any two tension triangles of a tensegrity ‘icosahedron’ are pushed together or pulled apart (Fig. 6c), the entire structure contracts and expands, respectively. 1,50,51,95
5.3 PUTTING THIS ALL TOGETHER
51,74,76 Helical ‘tubes within tubes’ mean that fascial compartments of the trunk and limbs can be considered in the same way. Objections that fascia is too flexible to contain compression struts can be overcome by considering the diameter of muscle, and its increase during contraction, as such struts. This would undoubtedly alter the tension pattern of surrounding fascia, which has itself been shown to influence the force appearing at tendons.39,40 In a tensegrity sense, fascia is the bodies main component of tension suspended between bones under compression, with smaller compartments taking origin from larger ones. Muscle fibres can then be considered as mere motors.
Helical and tensegrity structural systems complement each other, and are based on the fundamental properties of the tetrahedron and icosahedron. A chain of tensegrity icosahedra simply contains the crossed-helical fibres of a tube. Putting all this together from a helical-tensegrity perspective necessitates a reappraisal of structural biology and manual therapeutic techniques in terms of fundamental geometry.
6 CONCLUSION
Molecules assemble spontaneously and automatically balance the attraction and repulsion of their constituent atoms in a state of minimal-energy.24,79 The helix forms because of the same ‘platonic’ rules, those of organic chemistry and the dynamic nature of biological systems. The tetrahelix and its geometry then describe the helical hierarchies of protein structures and DNA.
Concurrent with the molecular helix is the principle of tensegrity. Tension and compression (attraction and repulsion); geodesic geometry and minimal-energy; and the inherent ability to form hierarchies are characteristics of both these structures. At the cellular level, the tensegrity principle describes the mechanical behaviour of the cytoskeleton, being a semi-autonomous system amenable to such analysis because of its size.5 As a structural mechanism, tensegrity depends on the integration of every part, and it has been proposed that this includes the whole body from molecules, cells, extra-cellular and fascial matrix to the entire musculo-skeletal system.1,4,5,74-76 Although it has been described at higher levels of anatomy, detailed multi-scale syntheses of its components are few. The helix, however, is a readily observable pattern at many different levels and may be inseparable from tensegrity, but there is a caveat.
If the structure of the human body is considered as a vast hierarchy of interacting sub-tensegrities, structurally and functionally, the examination of any part in isolation can be misleading, as it is inevitably incomplete.39-41 The possibilities for enquiry become virtually endless and make it unlikely that ‘bio-tensegrity’51 could ever be proved. However, if it describes biological systems more thoroughly, it is only a matter of time before this becomes the standard approach to biomechanics.
Human anatomy and physiology have been described in terms of tensegrity, and the volume of supporting evidence is steadily increasing. The helix is a well-known structural motif in biology. The fundamental links between tensegrity, the helix and platonic solids support a comprehensive view of human anatomy that is best appreciated as a complex interaction of natural physical forces.
Sunday, August 19, 2012
Interstitial Fluid and Multiple Sclerosis: Conductor of the Homeostatic Orchestra
As part of the continuing series on systemic homeostasis, I have decided to deliver a post that has both a global application as well as a focused and specific target audience. Although seemingly contradictory, the main message to take away from this post is that the overall implications of the contribution of interstitial fluid are universal and can be applied to any condition (acute or chronic) or pathology.
The choice of the term "conductor" was made intentionally to convey a fundamental understanding that can be imported from our intuitive notion of conductor into the general "biological" perspective: Despite the presence of finely tuned intruments and classically trained musicians, it is the conductor that mediates the activities of the orchestra with the end objective of achieving pleasant, seemless, and integrated sound. Therefore without the "physiological conductor", the biological orchestra is reduced to a conglomerate of subsystems that ultimately underperform and actually contribute to the overall deterioration of the architectural integrity of the Supersystem (human organism). More importantly, the role of homeostatic "catalyst" indicates that strategic focus in improving the flow of interstitial fluid will have a significant impact on improving the intrinsic physiological environment and health. I will refer to specific non-invasive strategies for systemic enhancement through the promotion of interstitial fluid flow in the follow-up post...but in order to fully grasp the practical aspects, there needs to be a fundamental understanding of the theoretical and conceptual ideas.
Interstitial Fluid:
Interstitial fluid is defined as the fluid found in the intercellular spaces composed of water, amino acids, sugars, fatty acids, coenzymes, hormones, neurotransmitters, salts, and cellular products. It bathes and surrounds the cells of the body, and provides a means of delivering materials to the cells, intercellular communication, and removal of metabolic waste. In addition to these essential systemic functions, the interstitial fluid also transports nutrients to all of the tissues in the body and has a critical role in tissue maintenance. It has also been shown that interstitial fluid flows have a role in tissue morphogenesis, tissue remodelling, inflammation, morphoregulation, and immune cell trafficking (1).
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| Interstitial flows and their corresponding microenvironments |
![]() | |
| Interstitial flow through the ECM |
Importance of Interstitial Flow Rate:
Relevance to Multiple Sclerosis:
The individual with Multiple Sclerosis manifests a very diverse range of symptomatic challenges which ultimately stress the ability to establish and maintain systemic homeostasis. Regardless of the specific neurological genesis, the biomechanical manifestations are significant and demonstrate progressive deterioration over time. They can be demonstrated in the more intuitive fashion such as gait difficulties and dysfunction, postural dysfunction, and spasticity...however, the long-term consequences are more profound. The select muscular dysfunction ultimately leads to fibrotic conditions brought on and exacerbated by irregular muscular activation, chronic overuse syndromes, and gradual deterioration of the entire extended fascial (connective tissue) system. This can also be described as a loss of the visco-elastic properties of the fascia, connective tissue, and ECM. This loss of viscoelasticity in the ECM will ultimately reduce interstitial fluid flow similar to the way (to use an analogy) a hair mat would block the flow of water through a drain. The denser the hair mat, the more resistance to flow is present. This flow reduction will ultimately results in metabolic waste build-up and inefficient delivery of nutrients to the tissues. When this is allowed to persist, it will inevitably accumulate and tax an already sensitive system which contribute to a degenerative "spiral" (reduced systemic competence---reduced muscular performance---irregular muscle activation and force transfer---increased fibrotic environments---further reduced systemic competence---further reduced muscular performance, etc...). The profound muscular consequences are a result of the reduced viscolelastic properties of the deep fascia and the secretion hyaluronic fluid which permits the efficient "sliding" of muscle bundles (as well as capillaries) between each other. When this is deficient, the result is poor muscle function and force transmission through the mechanical chain as well as to adjacent synergists.
In summary, when the accurate "biophysical" reality is examined and explored, it exposes some fundamental concerns regarding the "Big Pharma" philosophy of treatment of pathology. Indeed, when a specific "diseased state" exists a mechanistic (disease fighting) strategy should be considered...however, the over-looked and under-appreciated reality is that there exists a profound organic (promotion of health) opportunity that shows equally (or greater) potential to contribute to a homeostatic state.
Practical Strategies:
The follow-up to this post will focus on the strategic implementation of practical (non-invasive) interventions designed to contribute to the improvement of interstitial fluid flow. As a result, there will be a "flush" of stagnant interstitial fluid and a subsequent "drag" of fresh and nutrient rich fluid. In addition, the mechanical stimulus will contribute to the healthy remodelling of weak and dysfunctional tissues and therefore reduce any muscular imbalances that exist.
Using the pre-established analogy: this paradigm serves to contribute to the potential and performance of the "conductor" of the orchestra. Even with sub-standard "instruments" and musicians, the overall effect on the "music" will be far greater.
Cheers!
---Gavin---
Sunday, August 12, 2012
Implications of Cervical-Cranial Instability in MS: Links to Cerebral Palsy
I have recently been enlightened as to the many challenges associated with Multiple Sclerosis (MS) as well as to the very complex and diverse manifestations. Although my professional experience and expertise is more deeply rooted in Cerebral Palsy (CP) and general movement dysfunction, my recent investigations and research over the last few months has resulted in some rather interesting links between CP and MS. These links are note intuitive and have required some analysis to arrive to, however I feel that they are valid concepts to investigate and examine further.
These links are very specific in nature and center around Chronic Cerebrospinal Venous Insufficiency (CCSVI) as well as the presence of cervical-cranial instability (Atlas instability). My investigation is on-going and therefore relatively "young", however my understadning of this phenomenon is that this Atlas instability (misalignment) transmits compressive forces to the brainstem which in turn may produce venous occlusion resulting in chord ischemia. This particular manifestation (cervical-cranial instability / misalignment) is quite common and characteristic in individuals with CP. They manifest profound connective tissue (fascial) weakness that is global in nature...therefore this weakness in the neck is manifest by significant cranial-cervical connections which are typically characterized by complete loss of head control. In addition to this, CP is also characterized by developmental dysfunction...more specifically disrupted establishment of proper bony alignment of the cranium. This results in sutural deformities and altered bony alignment. The skeletal distortions contribute to a profound muscular imbalance which further exacerbates the manifestations of the cervical-cranial weakness.
The most interesting finding in my work in CP is that while the structural defficiency remains in place, motor intelligence is still quite actively engaged. Therefore, there are a number of "intrinsic compensations" that take place. To use a term from CP expert, Leonid Blyum: "The instability at this level can be considered as an intrinsic de-capitation". One of these compansations is the active engagement of the mouth...more specifically the opening of the mouth. It is very common to observe CP children with their mouth consistently open. While there are mal-occlusion issues also involved, the most interesting phenomenon occurs when they actively want to stabilize their head or engage in some dynamic performance: They open their mouth very wide and keep it open. This can be considered as a mechanical "bypass" through which head stability is achieved. By contracting certain muscles in the jaw, they can artificially stabilize the head and therefore be able to achieve a "quasi-stable" head position which then allows them to improve tracking and proprioceptive performance. This stability is derived from the activation of muscles on the anterior surface of the face /neck to mechanically lock the posterior neck. In CP, this compensation is also demonstrated by intermitent tongue-thrusting. This phenomenon draws very interesting links to MS and the focus on dental dysfunction. My investigation has also revealed that clenching of the jaw is a common occurence that contributes to constant headache and potentially sleep disturbances. These are physiological stressors that contribute to further exacerbation of the symptomatic challenges in MS. Although in MS the jaws are clenched and in CP the jaw is held open, it indicates a very tangible link between the cranial-cervical instability and performance of the jaw. The specific interventions to improve the stability of the cervical-cranial connection in CP has yielded very tangible and measurable reduction in the compensatory actions of the jaw.
In summary, I am aware that my formulations are quite "raw" and my understanding still needs to be populated by more investigation and discussion with experts in the field...however, there is significant precedent to suggest that a focused approach to the cervical cranial instability (without the use of aggressive / invasive procedures) can have very profound positive contribution to improving venous flow, reduction of prevalence of dental dysfunction and associated challenges, and ultimately contribute to a more stable and manageable condition. I would like to thank my good friend, Jamie Chalmers for introducing me to the MS world with such drive and passion...and I encourage any and all comments and feedback that will help to contribute to the formulation of non-invasive interventions that can be immediately available for the MS community. I will be continuing my raw investigations and hopefully will be able to share some productive information / demonstration in the very near future! Best regards, Gavin.
Systemic Homeostasis And Cerebral Palsy
This is the beginning if what is likely to be a relatively long series of posts...therefore I will make every attempt to keep it as "digestible" as possible.
The stimulus for this particular focus and direction was derived from two sources: 1) my recent trip to Chile to work with another amazing group of CP children and their (always entertaining) parents and extended family, and 2) a very informative piece of writing I just read (see the One Giant Leap Facebook page for the article on Pain and Stress) that set in motion a train of thought that can only be integrated by writing it down. Given that this topic is quite comprehensive, it will be more productive to consider this as a general introductory entry into more detailed discussion and explanation. More importantly, a clear and concise explanation of the overall context will help to solidify the main message of this post. My thoughts are still relatively "all over the page" at the moment, but my most productive posts historically come from this type of chaotic beginnings.
The stimulus for this particular focus and direction was derived from two sources: 1) my recent trip to Chile to work with another amazing group of CP children and their (always entertaining) parents and extended family, and 2) a very informative piece of writing I just read (see the One Giant Leap Facebook page for the article on Pain and Stress) that set in motion a train of thought that can only be integrated by writing it down. Given that this topic is quite comprehensive, it will be more productive to consider this as a general introductory entry into more detailed discussion and explanation. More importantly, a clear and concise explanation of the overall context will help to solidify the main message of this post. My thoughts are still relatively "all over the page" at the moment, but my most productive posts historically come from this type of chaotic beginnings.
The following is a very insightful and accurate definition of Homeostasis: Although the term homeostasis
commonly connotes adjustment to achieve balance, McEwen asserts that
homeostasis strictly applies to a limited set of systems concerned with
maintaining the essentials of the internal milieu.
The maintenance of homeostasis is the control of internal processes
truly necessary for life such as thermoregulation, blood gases, acid
base, fluid levels, metabolite levels, and blood pressure. McEwen’s
strict distinction means that homeostasis does not contribute to
adaptation; rather, adaptation protects homeostasis.
This is quite informative when placed within the context of Cerebral Palsy (CP). Although the statement may seem intuitive, as with many other things in the CP world it gets lost in the myriad of challenges of everyday life (the CP family) and in the dissected, compartmentalized, and (sometimes) overly simplistic "protocols" provided by some health care systems. The reality is that addressing the needs of the entire organism is logistically impossible to do with any degree of efficiency. To be precise, the only way a responsible health care delivery system can work (and thrive) is to provide interventions that address the most common denominator...standardization over customization. This is not a condemnation of the system itself, rather a comment of the necessary reality...it can only be delivered to large numbers of people in this manner. However, this does not mean that each individual person in "lost"...it simply dictates that each individual CP family unit needs to acquire a fundamental understanding of the conceptual and theoretical realities of CP. In other words, the more enlightened and informed the CP unit is, the better they are at navigating the multiple theories, philosophies, and interventions and formulating the most effective rehabilitation strategy possible for them.
"Failure to sustain homeostasis is fatal. Generic threats to
homeostasis include environmental extremes, extreme physical exertion,
depletion of essential resources, abnormal feedback processes, aging and
disease. Environmental perturbations can threaten homeostatic
regulation at any time. The stress response exists to sustain
homeostasis."
When you consider this very accurate statement, the relevance and importance of systemic homeostasis becomes amplified. The CP individual is continually under excessive physical exertion (excessive muscular activation), experiences abnormal feedback responses (irregular ground force transmission, proprioceptive dysfunction), and in more severe cases is extremely sensitive to temperature change. Further, this inability to properly adapt to these challenges creates further complication and barriers to improvement. Therefore the logical rehabilitative strategy should be driven by comprehensive and progressive development / enhancement of systemic homeostasis. The overwhelming focus and attention in placed squarely on the "biomechanical manifestations" or in some cases on the (relatively unimportant) "cosmetic / aesthetic" presentations. Although these concerns are indeed a part of the larger picture, they serve no strategic purpose if systemic homeostasis is allowed to deteriorate. As presented in the article, there are 3 interdependant systems that contribute to the preservation of homeostasis: neural, endocrine, and immune systems. Further, "the term for the physiological protective, coordinated, adaptive reaction in the service of homeostasis is allostasis. Allostasis insures that the processes sustaining homeostasis stay within normal range".
To summarize this brief introduction, the overall philosophy emerges quite clearly with respect to the formulation of effective, permanent, and progressive rehabilitation strategies: The development, enhancement, and protection of systemic homeostasis is the overwhelming priority in the CP individual. Again, the biomechanical role is significant...most specifically in it's implications in social and cognitive development (see my previous post on the relationship between physical, social, and cognitive development) but it's relevance is dependant on a relatively stable systemic competence. Further expansion on this subject will explain the various nuances and specifics of homeostasis in the CP individual and then will examine the various strategies to improve and maintain it.
Cheers!
Monday, August 6, 2012
One Giant Leap on Facebook
The last few months have shown a very exciting and welcomed jump in "readership" of the One Gian Leap blog...which has generated a different set of challenges and "probelms"...how do I get all of the relevant information out without putting the audience to sleep?
Therefore, the OGL Facebook page has emerged as a more broader and diverse extension of the blog that covers more topics and also links to other valuable sources of information and knowledge. It allows for the more efficient "day-to-day" exchange of information and education while keeping the format relatively informal, quick, and digestible. The OGL blog can be considered as the resource for more in-depth, comprehensive, and detailed explanation and formulation.
However, each source will compliment the other and therefore contribute to the more efficicent delivery of the overall OGL message. I would encourage anyone and everyone who has read material here on the blog to visit the One Giant Leap Facebook page and "browse" all of the additional information from multiple and diverse sources.
Part of the central mandate of this blog is to deliver intelligent and well-formulated concepts, theories, and practices...and the reality is that these are found in a great many places and come from a great many people...therefore the Facebook format is the most efficient and effective way to deliver them to you and provide you with productive links to informative and productive resources.
If this blog has provided some valuable information, then the Facebook presence will certainly continue the process. Once there, click LIKE as it provides useful information on the most popular subjects and helps to define the subjects and issues that resonate most.
Cheers and happy reading!
Therefore, the OGL Facebook page has emerged as a more broader and diverse extension of the blog that covers more topics and also links to other valuable sources of information and knowledge. It allows for the more efficient "day-to-day" exchange of information and education while keeping the format relatively informal, quick, and digestible. The OGL blog can be considered as the resource for more in-depth, comprehensive, and detailed explanation and formulation.
However, each source will compliment the other and therefore contribute to the more efficicent delivery of the overall OGL message. I would encourage anyone and everyone who has read material here on the blog to visit the One Giant Leap Facebook page and "browse" all of the additional information from multiple and diverse sources.
Part of the central mandate of this blog is to deliver intelligent and well-formulated concepts, theories, and practices...and the reality is that these are found in a great many places and come from a great many people...therefore the Facebook format is the most efficient and effective way to deliver them to you and provide you with productive links to informative and productive resources.
If this blog has provided some valuable information, then the Facebook presence will certainly continue the process. Once there, click LIKE as it provides useful information on the most popular subjects and helps to define the subjects and issues that resonate most.
Cheers and happy reading!
Friday, July 27, 2012
Fascia Therapy --- Sports Injury and Rehabilitation: Acute or Chronic Swelling
This post is intended to complement my earlier post on Multiple Sclerosis (MS) and the multi-modal approach of the Fascia Therapy (formerly the Activ8 System) to address the common symptomatic challenge of lymphedema and chronic inflammation in the lower leg as well as swelling and edema as a result of sports injury. The multi-modal approach is designed to integrate complimentary interventions in an effort to maximize the potential impact as well as allow for customized modification and adjustment to ever-changing systemic and mechanical environments.
Lymphedema is a chronic condition that is characterized by the inability for the lymphatic system to remove fluid from the lower extremities in conditions such as MS and can also be the result of acute injury which results in a level of edema accumulating that the lymph system is unable to remove efficiently. In chronic conditions such as MS, this symptom can be uncomfortable and even incapacitating...therefore focused intervention is not only a productive long-term objective, but it may also be a very real and critical short-term goal as well. With respect to sports / acute injury (ankle sprain, calf muscle strain, etc...) swelling is a normal part of the healing process, however it is essentially a "supercompensatory" mechanism where there is often times and inordinate amount of fluid that is drawn to the area (capillary flow, osmosis, etc..). This can sometimes create additional levels of pain and, more importantly, affect the ability to implement more aggressive rehabilitative protocols. Further, the large amount of local fluid draw can also leave the surrounding tissue in some level of nutritional and oxygen deficit which lead to secondary challenges.
The specific multi-modal approach used to address inflammation in the
Fascia Therapy concept is the combination of therapeutic taping (Kinesiotaping) and Trans-Fascial Viscoelastic Stimulation (TFVES). Using various stress-transfer mediums, the practitioner is able to access the connective tissue / fascia at all levels including the very deepest visceral / core level. TFVES is a very comprehensive set of skills, applications, guidelines, and targets that require an extensive process of learning and development...however the overwhelming scientific and clinical evidence shows that is produces extraordinary benefit and contribution to the improvement of connective tissue strength, health, integrity, and homeostasis...therefore reducing fascial dysfunction and the reduction of abnormal pain signalling. In addition to the enormous systemic benefit, there is also a very significant improvement in the overall health, strength, and integrity of the connective tissue system which contributes to structural integrity and therefore improves functional performance and the reduction in rate of re-injury. More importantly, and most relevant to this specific application, TFVES is a very effective tool for the manual movement of fluid. In other words, the very specific loading properties (guidelines) and the specific viscoelastic characteristics of the stress stransfer medium enable the practitioner to access fluids at the deepest level...which are typically unaccessible using the hands alone. This powerful tool facilitates very rapid and effective movement of the interstitial fluid through the lymphatic system and therefore replenishes the entire system by flushing stagnant fluid and stimulating return of new nutrient rich fluid.
Kinesiotaping is a specifc technique that has been widely used since the early 1970's in the rehabilitation setting in Japan but since the 80's has risen to become relatively mainstream. Its function / implementation serves 2 essential purposes: 1) facilitate movement performance, 2) facilitate fluid flow and systemic homeostasis. For this particular post, it is being implemented as a facilitator of lymphatic drainage and interstitial flow. It is applied using the lymphatic correction technique (Kase) and is channelled to another part of the system that is functioning properly...therefore application location is highly variable depending on the individual case. In combination with the TFVES technique, fluid flow is effectively channelled away and therefore facilitating the return of nutrients back into the system as well as the proper elimination of waste and toxic by-product. I recommend that you refer to my two previous posts that outline the diverse potential of the systemic implications of the use of Kinesiotape.
Inflammation of the Lower Leg:
TFVES application with Kinesiotape:
As previously mentioned, the TFVES technique has very specific guidelines and movement / loading properties that require some expanded and enhanced demonstration and training in order for it to be effective (SEE FASCIA THERAPY Sports Injury Protocols and Courses). However, I will provide a demonstration that is to serve for illustration purposes only.
The same guidelines should be applied along the entire length of the lower leg in separate sections (mid-calf, proximal calf) until the proximal end of the application is reached.
In summary, this particular multi-modal intervention has shown significant results in our MS patients as well as the treatment in the healthy individual / athlete. Not only is there a visible and tangible improvement, the patients report overall relaxation and a slight increase in function and performance. These initial reports conclude that further implementation of the multi-modal approach is indicated. Future posts will demonstrate the diversity of this intervention over a wide spectrum of acute and chronic conditions. In addition, the Fascia Therapy Sports Injury and Rehabilitation protocols will further consilidate and formalize specific taping applications and the respective Fascia Therapy techniques.
Cheers!
Lymphedema is a chronic condition that is characterized by the inability for the lymphatic system to remove fluid from the lower extremities in conditions such as MS and can also be the result of acute injury which results in a level of edema accumulating that the lymph system is unable to remove efficiently. In chronic conditions such as MS, this symptom can be uncomfortable and even incapacitating...therefore focused intervention is not only a productive long-term objective, but it may also be a very real and critical short-term goal as well. With respect to sports / acute injury (ankle sprain, calf muscle strain, etc...) swelling is a normal part of the healing process, however it is essentially a "supercompensatory" mechanism where there is often times and inordinate amount of fluid that is drawn to the area (capillary flow, osmosis, etc..). This can sometimes create additional levels of pain and, more importantly, affect the ability to implement more aggressive rehabilitative protocols. Further, the large amount of local fluid draw can also leave the surrounding tissue in some level of nutritional and oxygen deficit which lead to secondary challenges.
The specific multi-modal approach used to address inflammation in the
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| Silicone Stress Transfer Mediums |
Kinesiotaping is a specifc technique that has been widely used since the early 1970's in the rehabilitation setting in Japan but since the 80's has risen to become relatively mainstream. Its function / implementation serves 2 essential purposes: 1) facilitate movement performance, 2) facilitate fluid flow and systemic homeostasis. For this particular post, it is being implemented as a facilitator of lymphatic drainage and interstitial flow. It is applied using the lymphatic correction technique (Kase) and is channelled to another part of the system that is functioning properly...therefore application location is highly variable depending on the individual case. In combination with the TFVES technique, fluid flow is effectively channelled away and therefore facilitating the return of nutrients back into the system as well as the proper elimination of waste and toxic by-product. I recommend that you refer to my two previous posts that outline the diverse potential of the systemic implications of the use of Kinesiotape.
Inflammation of the Lower Leg:
| 1 |
Patient is positioned with the knee in extension and the foot in dorsiflexion.
| 2 |
Working from proximal to distal, the first fan tape is placed on the posterior medial aspect of the knee.
| 3 |
Lay down the strips over the area of edema with approximately 25% tension. The last 2 inches of the strip should be laid down without any tension.
| 4 |
The second fan tape is placed just superior to the first (or depending on the specific case, can be placed on the lateral aspect of the knee).
| 5 |
Angle the strips inferiorly and form a criss-cross pattern over the area of edema.
| 6 |
Initiate glue activation by rubbing the entire application vigorously (but carefully). Glue activation should be done before any movement is initiated.
| Completed Application |
TFVES application with Kinesiotape:
As previously mentioned, the TFVES technique has very specific guidelines and movement / loading properties that require some expanded and enhanced demonstration and training in order for it to be effective (SEE FASCIA THERAPY Sports Injury Protocols and Courses). However, I will provide a demonstration that is to serve for illustration purposes only.
| 1 |
Starting distally, the stress transfer medium is slowly loaded (pressed) into the posterior leg.
| 2 |
| 3 |
The cylinder is then rolled until it reaches the mid-palm. The pressure is released slightly, and the action begins again from the starting position.
The same guidelines should be applied along the entire length of the lower leg in separate sections (mid-calf, proximal calf) until the proximal end of the application is reached.
In summary, this particular multi-modal intervention has shown significant results in our MS patients as well as the treatment in the healthy individual / athlete. Not only is there a visible and tangible improvement, the patients report overall relaxation and a slight increase in function and performance. These initial reports conclude that further implementation of the multi-modal approach is indicated. Future posts will demonstrate the diversity of this intervention over a wide spectrum of acute and chronic conditions. In addition, the Fascia Therapy Sports Injury and Rehabilitation protocols will further consilidate and formalize specific taping applications and the respective Fascia Therapy techniques.
Cheers!
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