Therapist´s Manifesto: Salutogenesis and Broader Perspectives

The motivations for this post are numerous, however there is a singularity in it´s relevance. It effectively summarizes what I have come to believe is a fundamental understanding within the domain of rehabilitation.  In truth, it is a much broader understanding that extends into medicine itself...and even into our daily lives, I dare say.

Although this central philosophy has always been understood intrinsically, I was never completely sure of what to make of it or how to verbalize it. 

There is a well-established, well-entrenched dichotomy between health and illness that essentially dilutes the potential reach and effectiveness of the healthcare provider.  Moreover, this dichotomy extends into the very mind of the healthSEEKER!  Health and illness (or health and disease, to be precise) are seen as two completely distinct states and therefore exist in their own reality.  This is an intuitive understanding...however, when you examine this from a broader perspective, they are manifestations of a singular state.  It is a continuum which is characterized, at one extreme, by perfect health and at the other extreme by disease. Therefore it can even be considered, not as a ¨health-disease¨ dichotomy, rather varying states of health.  This is likely to resonate to some as simple semantics, but the general philosophy was termed Salutogenesis by sociologist Aaron Antonovsky.  The term describes an approach focusing on factors that support human health and well-being, rather than on factors that cause disease.  The most popular and intuitive Pathogenetic approach is the most familiar...the focused efforts on disease-fighting.

Although this general central philosophy is not difficult to understand, it is a rarity within the healthcare system...in fact, it is sometimes viewed as ¨alternative¨.  But the unfortunate reality is that we have been conditioned to exist within the pathogenetic paradigm...where health needs to deteriorate to a preset level before it is ¨worthy¨ of being labelled as an illness and therefore worthy of intervention.  This is observed in respect to all of the so-called ¨health standards¨...blood pressure, weight, cholesterol levels, etc.  They are all considered ok until they reach a critical level...at which time they morph into a specific pathology and so begins a Pathogenetic intervention.

The Salutogenetic approach does not dismiss or conflict with the Pathogenetic one...it effectively BONDS with it and forms a much larger singularity.  Within this singularity, both exist as equally powerful and valid factors that work to contribute to systemic homeostasis.  Therefore, one does not need to ¨wait¨ for a specific pathology or condition to appear.  Whether in times of health or illness, a focus on salutory factors always contributes to the establishment and maintenance of a homeostatic state.

If I extend this general philosophy to a more specific narrative (CP, MS, Fibromyalgia, Autism, etc...), the overall understanding and framework hold up quite nicely.  With respect to the conditions listed above, the physical, environmental, chemical, and psychological stressors are amplified to various degrees compared to the healthy population.  The critical factor for consideration, when approached from the Salutogenetic perspective, is whether these stresses are received by the system as pathogenic, neutral, or salutory.  This is determined by what Antonovsky termed as Generalized Resistance Resources (GRR´s).  Therefore, the more GGR´s available to the system, the better chance the varying stressors will manifest as neutral or salutory.  In the CP, MS, FMS, etc...community, these GRR´s are characterized by respiratory mechanics, immune system function, lymphatic competence, interstitial fluid flow, and others.

Therefore we arrive to the overall message and intention of this post: The most fundamental, successful, and reliable therapeutic interventions are the Salutogenetic ones.  Even within specific, well-identified diseased states, the salutory stresses serve to develop and support progress and improvement.  Not only does it contribute to a homeostatic state, it effectively defines the ability to adapt to additional stressors by the building up of GRR´s.   The most glaring example of the salutogenetic approach is massage therapy...it is essentially effective for EVERYONE and EVERYTHING.  Why?...because it is a Salutogenetic stimulus (hypothalamic tuning results in automatic muscular relaxation, improving interstitial fluid flow increases fluid drainage and lymphatic performance, improved circulation contributes to better O2 delivery and metabolic performance, etc..)

In summary, the broader perspective does not suggest a continued ¨cleaving¨and ¨compartmentalization¨ for the sake of ease.  Although from a macro level (State, Provincial, Institutional) this may serve a greater good, the micro management (care-seeker to care-giver) should always consider the systemic singularity of the person and implement the appropriate balance of salutogenetic and pathogenetic strategies. 

Immediate versus Long-Term Response

It has been quite a long "layoff" over the holidays, which has allowed for more time to generate new thoughts and formulations...both a blessing and a curse given that time and energy are sometimes in short supply.  However, I thought I would begin the 2013 "season" with a shorter and more "global" rant that centers around perspective...which has often been explicitly explored in this blog, but has always been a consistent undercurrent throughout.  Achieving a proper perspective is a difficult task and is arguably very subjective...based on your own value system, environment, and personal "prism" you may have an approach or attitude that varies greatly from others.  However, if things are expressed conceptually, then the eventual outcome will always be the correct one for you.  Concepts (or frameworks) are effectively neutral and therefore should fit universally across most philosophies. 

A fundamental understanding that needs to be established (whether a care-PROVIDER or care-SEEKER) isthe distinction between Immediate response and Long-Term response.  This will ultimately help in being able to effectively identify what is really happening and what specific intervention is the source of the progress.  Given that most people attempt to combine or "marry" multiple interventions together (in the hopes of somehow extracting all the good from each), it is an intelligent strategy to at least have an understanding of how your system will respond to either or all of the specific interventions. 

In order to project this concept more effectively, I will use a familiar therapeutic example to illustrate the paradoxical behaviour that some interventions may exhibit.  I sue the term "paradoxical" because the general conception is that once a specific therapy is implemented, the response will be immediate and manifest in the same way throughout...but this is relatively simplistic and, more importantly, deceptive.

Trans-Fascial Viscoelastic Stimulation

The adjacent photo represents an example of Trans-Fascial Viscoelastic Stimulation (TFVES).  I have detailed the specifics of the technique in this blog before, but it is essentially a manual massage technique that generates many systemic and mechanical benefit and improvement. 

This technique can be implemented across a braod and diverse range of conditions, pathologies, and considerations. If we use the example of a healthy individual complaining of generalized upper back pain and muscular tension, there are indeed a wide range of treatment options...but the understanding of how the body will respond will ultimately guide the care-seeker towards the most realistic and convenient option.  Further, it provides the professional will much more information from which to formulate a treatment strategy.  Using TFVES (this can also be exported to most forms of manual massage), the immediate response is one of reduction in localized muscular tension and a generalizing decrease in pain.  This is a result of an autonomic response from the hypothalamus as well as a mechanical "pumping" of the interstitial fluid that increases lymphatic drainage and a recycling of metabolic waste.  Therefore, the immediate benefit is release.  This essential phenomenon will continue in the initial stages of treatment and will effectively extend throughout the first few weeks of application.  Once this stimulus has been applied consistently for a longer period of time, it will accumulate and solicit mechanical and structural changes within the connective tissue / fascial network.  Through the process of mechanotransduction, the connective tissue (architectural "scaffolding" of the body) will essentially strengthen.  In other words, the architectural / fascial "sub-failure" that resulted in the initial pain and muscualr tension will have been resolved. 

Sensory stimulation, promotion of interstitial fluid flow, and increase circulation generate the immediate response of releasing muscualr tension and alleviating some general discomfort whereas the long term response is characterized by a strengthening of the structural architecture which contributes to reduction of injury recurrence and a more stable mechanical system.

This brief rant is, of course, a general overview of a much more complex systemic mechanism...but it should provide some insight into the multiple considerations that need to be examined when seeking / formulating treatment.  Although it can be overwhelming when examined to the extreme, once the general concept has been integrated it is actually quite elegantly simple.  As I have recently read and posted in the blog Facebook page: "Simplicity is the ultimate spohistication".  A well-delivered stimulus that is properly and consistently applied will be sufficient to generate a global systemic response from the body and ultimately contribute to it's development and improvement. 

Cheers and Happy 2013! =)

The Human "Hybrid" Skeleton

What in the world are you talking about?!  This is the likely question.  The obvious understanding of human anatomy is that we are effectively characterized by an endoskeleton...or "bony structure lies underneath soft tissue" .  Well...although these familiar labels are quite convenient, they are equally simplistic.  My intention is to use this relatively "light" discussion as an introduction to my upcoming (and comparatively "heavy") post on what true posture really is (title yet to be assigned).

The definition of endoskeleton has already been given, and as the cartoon post image demonstrates, creatures with an exoskeleton are characterized by an external skeleton while the soft tissue remains contained within.  If the question were to be asked "are humans endo or exo?", the odds are that 99.9% would say ENDO.  Therefore, am I suggesting that we are EXO?  As with all biological organisms, humans are a mixture of both.

Why?
This is an intuitive question, but requires some extensive leaps into evolution and the process by which man moved from water to land...which I will save for another time.  However, it should be understood that because of the realities of entropy, we are engineered in the most efficient manner...therefore there must be an architectural reason for the development of a "hybrid skeleton".  I will follow with a more detailed explanation of what i refer to as a hybrid skeleton, but i wanted to convey a fundamental message beforehand:  the realities of moving within a gravitational field have resulted in an efficient blend of compressional and tensional properties (biotensegral properties) that allow for some of the most fluid and precise movements on the planet.  

What?
The Hybrid skeleton is characterized by an exoskeletal "core" and an endoskeletal "periphery".   The core is defined by the thorax, abdomen, and pelvis...while the periphery are the limbs (including the neck).

Thorax 

The above image illustrates the exoskeletal characteristics of the core.  The thorax is amazingly removed from the vertebral column and, given that the arms interact with the shoulder blade, the entire portion can be removed like a "coat".  Therefore this is essentially the representation of an exoskeleton...the superficial muscles (pectoralis, latissimus dorsi, subscapularis, etc...) essentially serve dynamic function and therefore are excluded from the exoskeleton definition.

Soft visceral core

What remains is demonstrated above...a soft tissue "hydraulic" core that is characterized by the lungs, abdominal and pelvic contents, as well as the fascial "wrapping" that encompasses them.  I will exhance this concept in greater detail in the upcoming postural post, however the visceral core of the body is what provides us with postural competence (or postural ability).  The architectural qualities of the exoskeleton provide the most efficient mechanism to provide compressional (postural) strength under a gravitational field.

Visceral core within thoracic cage and pelvic girdle

Above is a demonstration of the soft tissue core "in situ" within the thorax and pelvis.  This informative image gives tremendous perspective into how the deep visceral core (true core) drives the developmental growth of the pelvis and thorax...and therefore the legs and arms.

Tensional characteristics of the arms

The arms and legs therefore exhibit the endoskeletal characteristics dues to the fact that the tensional properties are required for human locomotion.  Effectively the muscles effect tensional force on top of compressional integrity to facilitate movement...hence the concept of biotensegrity.  A fundamental understanding:  tensional force cannot be generated without a competent compressional component.
This last stement will be the key focus of the "true posture" post to follow.

Again, credit to Richard Paletta for formalizing the visceral core concept with the images within this post.  Further credit goes to the works of Frederick Woods Jones who makes some rather startling comparisons between the human organism and our sea-dwelling creatures.

Stay tuned for what will hopefully be an insightful formalization of an interesting concept of posture...more importantly how it fits onto the complex and comprehensive world of movement disorders.

Cheers!

Botox and Cerebral Palsy: Is it for me?

I am not quite sure why it has taken so long to write about this subject, given that it is definitely within the top 3 topics that come up in my discussions with parents of children with Cerebral Palsy (CP) and other disorders of movement and posture.  At any rate, I will step into this popular intervention with definite interest and plenty of debate experience behind me.

In order to properly frame this rant, I will need to provide some initial feedback on my own personal and professional perspective on the matter.  I do not make any claims that this drug is either good or bad, nor do I have any invested interest in it's use or "non-use".  The consistent mandate of this blog is to provide extra insight and some additional perspective so that the decision as to "is this right for my child" can be made with as much conviction and confidence as possible.  Although my general feeling on the issue may be obvious, the relevant message is not to fall into a overly simplistic "good or bad" mentality.  Many spend more time and effort researching a home mortgage or reviewing their stock portfolio than they do researching an injectable drug.  Again, the appropriate question isn't "is Botox good or bad?"...rather, "is it the right thing for my child and my family".  Once this fundamental question has been asked, then the resultant answer is irrelevant...it has been put through the internal "prism" of the family unit and the appropriate answer has come out of the other side.

Perhaps the most "diplomatic" and productive way to engage in this discussion is to simply convey the fundamental issues that I typically put forth to any and all families that ask me about Botox.  Although there are many different debates that can take place regarding its merit, the main goal of this post is to shed light as opposed to polarize.

1. Botox Defined: 

--- a neurotoxin (trade name Botox) that is used clinically in small quantities to treat strabismus and facial spasms and other neurological disorders characterized by abnormal muscle contractions; is also used by cosmetic surgeons to smooth frown lines temporarily. ---

During many of my discussions with parents, when the generic name for Botox (Botulinum Toxin Type A, for example) is actually spoken out in the open, it generates an initial sense of apprehension.  It should not be forgotten that this particular drug is indeed a toxin (or as the definition explains, a neurotoxin).  Therefore it is important to always keep this fundamental understanding in mind.

2. Big Pharma:

I certainly would not be characterized as an activist...however, the unfortunate reality in todays medical system is that "Big Pharma" are an extremely powerful and influencial group.  This idea is not new and, paradoxically, well understood and accepted.  It is also well known that a large number of the studies on the use of Botox are actually funded by the same pahrmaceutical companies that produce it.  Therefore, it is in the best interest of the pharmaceutical industry to have Botox dispensed as much as possible...which inevitably leaves room for misuse and irresponsible behaviour.

If these first two phases are understood, then the path becomes relatively more straightforward. Any use of prescription drug comes with its own set of risks, therefore full disclosure of the risks involved always create a clearer path.  In 2009, the FDA ruled to include boxed warnings on Botox products:

FDA NOTE TO CORRESPONDENTS

For Immediate Release: August 3, 2009
Media Inquiries: Sandy Walsh, 301-796-4669; sandy.walsh@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA

FDA Gives Update on Botulinum Toxin Safety Warnings; Established Names of Drugs Changed

The U.S. Food and Drug Administration today announced an update to a previous safety alert on four botulinum toxin drug products, noting that all of them now have boxed warnings on their labels and have developed Medication Guides for patients, as directed by the agency in April 2009.

The boxed warning cautions that the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism. Those symptoms include potentially life-threatening swallowing and breathing difficulties and even death.

These symptoms have mostly been reported in children with cerebral palsy being treated with botulinum toxin for muscle spasticity, a use of the drugs that has not been approved by FDA. Symptoms have also been reported in adults treated both for approved and unapproved uses.
The affected products are:

- Botox (new established name: onabotulinumtoxinA)
- Botox Cosmetic (new established name: onabotulinumtoxinA)
- Myobloc (new established name: rimabotulinumtoxinB)
- Dysport (abobotulinumtoxinA) was approved in April 2009 with the boxed warning and is not making any name or label changes at this time.

No definitive serious adverse event reports of distant spread of toxin effect have been associated with dermatologic use of Botox/Botox Cosmetic at the recommended doses (for frown lines between the eyebrows or severe underarm sweating). As well, no definitive serious adverse event reports of distant spread of toxin effect have been associated with Botox when used at approved doses for eyelid twitches or for crossed eyes.

The revised labels also emphasize that the different botulinum toxin products are not interchangeable, because the units used to measure the products are different. To help reduce the potential for dosing errors, the botulinum toxin products have changed their established drug names (often referred to as the drug’s “generic” name). Neither the brand names nor the formulations of the products have changed.

The portion in red is understandibly quite alarming...however, it is not intended as a "scare tactic".  As mentioned before, full disclosure of the potential risk is the responsible path which has lead to the boxed warnings and the further clarification by the FDA that Botox has not been approved for the use of muscle spasticity.  

3.  "Relaxation" VS "Paralysis" 

I have often heard the use of Botox described as something that will "induce relaxation of muscles".  Although it could be argued that this is an accurate statement, it is undeniably misleading.  The reality is that it essentially paralizes the tissue at the injection site...which could be equated with "relaxation" but that would be an gross over-simplification.  I agree that both terms tend to elicit two different extremes (one being very pleasant and the other more frightening), but the reality is none-the-less present.

4. Local VS Systemic:

As mentioned in the FDA report, the effect of Botox is not only local but systemic.  The overwhelming assumption that the drug "only goes where it is needed"...as if it were a "smart drug"...but it is only a simple liquid, therefore it will behave like any other liquid that is injected into the body.  It will leech into adjacent tissues (muscles) and will also enter the bloodstream.  It has been said that the amount that actually enters the bloodstream is negligible, but the reality is that there is no conclusive evidence that supports this.  The effects of free flowing Botox through the heart, lungs, and brain have yet to be determined.

5. Practical solutions to the overwhelming reality:

Having been fortunate enough to interact with a large number of families and family units, I am very much aware that parents are consistently under the heavy burden of information overload and the fundamental challenges that come from competing philosophies and schools of thought.  All of this information may potentially serve only to confuse and frustrate even more.  Therefore it is important to boil everything down into something that is more practical, productive, and user-friendly.

The use of Botox (and other interventions) cannot be given a simplistic "good or bad" designation. Their role is completely determined by the circumstances present within the individual and the undividual family unit.  There are some cases where spasticity is so profound that it generates considerable pain and discomfort which inevitably contributes tremendous stress to the childs quality of life and therefore extends into the well-being of the parents.  In this situation, Botox is an understandable (and likely the most recommendable) tactical solution.  To be precise, the overwhelming priority of comfort and well-being outweigh the underlying risks.

Outside of these extreme cases, a fundamental examination needs to take place.  It is important to remember that muscle spasticity is symptomatic...it is a reflection of the underlying biomechanical / architectural weaknesses.  Therefore addressing the symptomatic manifestations is a productive short-term strategy, the long term strategy requires some focused attention as well.  The typical scenario is that spasticity increases as the child grows and is characterized by progressive muscular tension and imbalance.  This is analogous to a growing tree whose limbs continue to grow while the trunk remains relatively small...the mechanical stress will inevitably contribute to distortions within the trunk which only serves to perpetuate a vicious cycle of degeneration.

In summary, there is no intended condemnation of the use of Botox, rather a presentation of what I consider to be very relevant points of consideration.  They are not subjective statements...they are objective realities.  Therefore it should be considered in the same "vein" as food labelling:  knowing "whats in it" contributes a great deal as to whether or not you choose to buy it".  If, after "reading the labelled ingredients" it is decided that it fits within the value system of a particular family, then it is most certainly the right choice for them.

To conclude, I fully agree with the availability of this option...but it requires a higher level of responsibility and accountability on the part of Big Pharma as well as an acceptable level of formulation and consideration from individual families.

Cheers!



  

Future Technology: Nanotech Yarn behaves like Super-Strong Muscle

I must say that upon reading this article, I was both amazed and excited.  I can't remember reading something that has such profound potential implications within the rhealm of artificial tissue.  Although it is quite early and perhaps too premature to extrapolate future breakthroughs, this is unquestionably a very powerful discovery. 

I had initially tried to condense the information into a specific post, however it is difficult to express this information better than was already done in the original article...therefore I have decided to insert only a few comments and simply attach a link to the article itself.  Given copyright procedure, it is not possible to re-print the article directly here therefore I encourage anyone reading to click the link and have a look...it is quite astounding! 

Although from a non-scientific perspective, it is likely to be interesting...it is probably more exciting to the slightly more "nerdy" enthusiasts.  I make this comment for the following reasons:

1)  The elemental component of Biotensegrity within the carbon nanotubes
The carbon nanotubes mentioned in the article (and illustrated in the video) essentially demonstrate the elemental architecture based on biotensegrity (the combination of tension and compression to form a stable structure).  The fact that the fundamental framework of biotensegrity is found at the microscopic level lends further evidence to the fact that biotensegrity is the "true" biomechanics  from which the human organism is derived. 

2) The passive 4-Bar Mechanics concept
I had recently been sent a video of a lecture given by Dr. Steven M. Levin who described the concept of human locomotion as being a derivative of 4-Bar Mechanics.  I would not be able to do credit to 4-Bar Mechanics within the construct of this post, but I encourage all of the "nerds" to look it up and review it.  The contraction / expansion characteristic demonstrated by the carbon nanotube is remarkably similar to this 4-BAr mechanism.  Given that it is an off-shoot of the biotensegrity concept (Dr. Levin is the creator of the biotensegrity concept), it is further demonstration of the implications of the biotensegrity concept within the context of human functional anatomy

3) Further indications of the importance of structural architecture in human movement
I think this is perhpas the most profound "piece" I take from this article.  It is quite well understood that the majority of focus and study is placed squarely on the neurological / electrical contributions to human movement and rehabilitation.  Although it deserves exhaustive study and attention, the actual amount is disproportionate to the amount of study placed on the architecture itself. To put it simply, it isn't simply about getting the right signal to the muscle...the fundamentals of how the architecture is arranged plays an equal (if not more) important role.

In summary, I hope that this information receives the attention it deserves.  Historically, the more technical (or "nerdy") these posts are, the less they are read...but it IS definitely a potential ground-breaker in my view.  The direct implications are enormous in their own right, but the potential off-shoots of study that will be derived from this could be extraordinary. 

I will attach some useful links to the end of this post that should serve as useful references for this article.   Please click the link to view the article...and enjoy!

Nanotech yarn behaves like super-strong muscle

Cheers!

See relevant links below:

http://en.wikipedia.org/wiki/Four-bar_linkage

http://www.biotensegrity.com/

Beware of the "Quick Fix"

This will be a straight off rant...there are no two ways about it.  The all-familiar "Beware of Dog" sign should spring to mind...something that has been caricaturized in cartoons and comedies many times over.  The literal understanding has always been that beyond the sign lies something that will indeed do you harm.  However, the true meaning is "enter at your own risk".

Tying this into the rehabilitative context should be quite easy to manage...and as the title suggests:  beware of anything that claims to be a quick fix.  Whether the claim is deliberate or lies within a deeper rhetoric, you (care-seeker or care-provider) should stop to carefully process what you are about to engage in.  This statement is quite intuitive and logical...but for some reason when it comes to physical therapy, medicine, or rehabilitation...this logic goes completely out the window.  Building wealth takes time...building wisdom takes time...relationships need time to build...but the rehab world is filled with "quick fix merchants" and "quick fix shoppers" who are all crammed into some figurative Mall with the merchants all putting signs in their windows and the shoppers engage in frantic window shopping.

Steering this rant more towards a specific point, I will refer to a recent quote I found which is quite insightful: Adopt the pace of Nature. Her secret is patience.  Although this quote could arguably be considered just "fluff", it couldnt be more accurate.

 In the adjacent image, there is a tree seemingly "growing through the street".  The more important thing to take away is that slow, gradual, and progressive increments show the most potential and therefore yield the best results.  Through patient, gradual, and deliberate stimulus, the roots have adapted to the environment and have adapted to the architecture of the sidewalk.  Fundamental question..."can this be achieved in a quick fix?"...most defintely not.

The examples of how biological organisms respond and exist are abundant and explicit.  The fundamental understanding that remains to be effectively integrated is that the human organism is not immune to this reality...and any attempts to circumvent or bypass are at best ineffective, if not useless. 

In defense of all of the quick fix merchants and shoppers...not all "beware" signs signal inevitable dangers.  There are indeed some occasions where the Beware of Dog sign is visible, but the dog is nowhere to be seen...allowing you to peacefully slip by.  Therefore, this is not an attempt to dismiss the quick-fix...nor is it an attempt to classify the quick fix merchant.  Rather to highlight the reality that we exist within certain physical realities...and any attempts to deviate are consistently unproductive and "quick to lose".  The idea of "simple" fits well into todays fast-paced world and is likely the most attractive, but the human organism is exponentially more complex...and therefore deserves more intelligent consideration. 

Autism: Connective Tissue Links

The connective tissue "trail" seems to be long and well-entwined beyond most perception.  I have recently read some short articles that propose that fascia/connective tissue enthusiasts are far too "energized" about the topic...which in fact is actually relatively accurate...however, when you stop and take a true inventory of each specific pathology (MS, Cerebral Palsy, EDS, Fibromylagia, Cancer, Lymphedema, etc...) you will almost inevitably find some relevant links that point to connective tissue as a relevant source of potential improvement.  With this reality in mind (and in-hand), I wouldn't characterize enthusiasts as fanatical...rather, they are expressing the physiological "high" from experiencing some intellectual enlightenment.  This enlightenment unearths many "archeological understanding" that brings an inevitable sense of excitement.  This may simply be a fancy way of describing a fanatic...but I think that the main message is that the ethusiasm is well grounded in science rather than some intangible belief or philosophy.

I have recently done some preliminary "excavation" into the world of Autism and have found that there exists a probable connective tissue link there as well.  The intuitive reaction from most would be "how does addressing connective tissue cure Autism"...but this is an altogether wrong question.  The more accurate question should be: "how does this understanding of the role of connective tissue within the autistic person impact my ability to manage and improve their everyday lives".  I do not pretend to think that people with autism do not lead productive and rewarding lives...rather, they are exposed to certain diffculties (whether mild or extreme) with respect to communication, emotional responses, and sensory dysfunction.  Therefore ANY strategy that would directly (or indirectly) contribute to the salutogenetic (promotion of health) approach to life management would be relevant.

This initial "dive" into Autism is quite early...and therefore I lack the necessary knowledge to go into great detail or physiological analysis.  However, I came across an article from the Southwest Autism Research and Resource Center (SARRC) that presented some interesting information on "Physical Findings in Autistic Disorder".  You can refer to the article yourself, however it reports that the most frequent findings among the study group (113) demonstrated hypotonia (47.8%) and connective tissue anomalies (41.6%) such as joint laxity, velvety skin, pes planus (flat feet), and prominent fingertip pads.

Although this hardly represents true, hard, scientific evidence...it does at least suggest some potential connective tissue links (more specifically, connective tissue weakness) to some of the sensory dysfunction that is characteristic of the condition.  It is well understood that connective tissue is, not only a powerful sensory mechanism in its own right, but the architectural "mortar" that supports the central and peripheral nervous system.  To be precise, it has an extensive role in the mechanical AND systemic support of sensory competence. 

Although far from a paradigm shifting revolution, it is a personal "Ah-Hah" moment that deserves some more "digging".  Hopefully the "intellectual archeology" bug does its work!

Cheers!

Neurotrauma: Where is the Starting Line and where is the Finish Line.

This will most certainly qualify as a simple "rant".  I do not have anything particularly scientific to deliver, nor am I likely to mention anything that many haven;t likely already pondered...however, putting pen to paper (or "finger to keyboard", in this case) has always been consistently reliable in helping me to integrate and internalize certain ideas and concepts.  So perhaps this brief post is more "therapeutic" as opposed to enlightening.

Over the last 6-7 years within the CP / Neurotrauma landscape, I have had the privelege of engaging in hundreds of discussions and consultations with families from all over the world regarding the very specific and ultimately unique experience of having a child with some form of neurotrauma.  At face value, it would seem that this exposure and experience would yield some relative sense of "confidence" in being able to accurately identify and effect positive changes in the overall mindset of these families and their extended family unit.  However, the more this experience grows, the more my understanding grows as to how unimaginably complex this world is.  To be precise, it is a tangled web of fear, doubt, worry, stress, and potentially some guilt.  Within all of this mix of emotions, the concept of "where do I start" and "when will I be finished" is often contemplated...but is seldom answered.  Further, there is the additional stress of "what is the right path between start and finish"...which is often clouded and muddied by the background "noise" of competing rehabilitative philosophies and schools of thought.

In many circumstances, I have found that my efforts to "enlighten" and "educate" only served to contribute to the amount of "noise" these families were experiencing.  Although most professionals have genuine good intentions, the reality is that there is no real true concensus among neurotrauma professionals as to the best course of action...even to the extent where there are competing diagnostic definitions!  Therefore I was required to take a step back and search for a more "user-friendly" approach...which couldnt have been more intuitive.

Help to filter out the noise.  Before anyone can understand you, they must first be able to "hear" you.  Therefore, your first attempt should not be to "re-train" or "reprogram"...rather to provide some form of noise-cancelling support so that the family unit is more able to concentrate and think with more clarity and efficiency.  This involves some discussion / exxplanation / "de-briefing" on their experiences to date...how are those x-rays evaluated...what are the systemic considerations of such procedures...what is/are the general perspectives of the medical community, etc.  I equate this to the experience of trying to watch a televison show on an old black and white TV...with white noise and static buzzing on the screen, other channels popping in and out, and sometimes the signal going out completely for a time.  In this sense, my honest and transparent efforts would be the equivalent of the neighbour dropping in to play with the rabbit ears...it is likely appreciated, but often times just as distracting.  Providing some insight into the more global considerations of the specific condition will ultimately generate some overall understanding and therefore result in the establishment of an intrinsic "filter" which contributes to clarity of thought. 

This establishes a relatively reliable "starting line".  Although many wait anxiously for diagnosis, the realities of the journey are still the same...it isn't always necessary to defer your strategy until that point.  With respect to the obvious second question "where is the finish line"...the answer is generally not the most popular.  In truth, no one can responsibly provide the answer that so many people are looking for.  With all honesty and respect, this is a fundamentally wrong question to ask.  Even if someone could magically glance through a crystal ball and provide you with THE ultimate answer...would this determine whether it is "worth it or not"?  This is analogous to a young child setting a lifetime goal of achieving a gold medal in the Olympics and asking "is that possible".  Further, if that goal was never to be achieved, would all of his/her efforts have been in vain?  I recently heard a very insightful and powerful statement from a collegue: families spend so much energy trying to prove to the outside world that their child has value and that they are worth it.  This mindset ultimately contributes to the "white noise" that surrounds them...by establishing "pre-set" standards of achievement and often times unrealistic measurement tools.  The finish line should therefore be honestly and responsibly defined as "unset and undetermined".

Instill an understanding of the "Happiness Quotient".  I will outline the genesis of the Happiness Quotient (HQ) in an upcoming post, but it's beauty lies in its simplicity.  Although it can be expanded in many different ways, it is essentially a balance between a number of oppsing metrics:  Pain/Pleasure, Joy/Fear, Achievement/Failure, Relaxation/Tension, and Satisfaction/Frustration.  Within the everyday life of a child with CP or neurotrauma, there are far too many events that contribute to the negative metrics of this equation.  There is always some consistent muscular tension which may induce some pain as well...inability to effectively communicate to loved ones breeds frustration and anxiety...in many cases, positional changes generate periods of fear, etc, etc.  Therefore, the role of the family (and extended family) partly becomes a source of contribution to the positive metrics.  Establishing those activities that create some form of joy...therapeutic interventions (regardless of their overall philosophy) that generate definite periods of relaxation...and even frequent physical contact.  Hugs ARE therapy...therefore they should be considered as fundamental tools in establishing some equilibrium in the HQ.

Definitely a rant...possibly too "fluffy"...but hopefully somewhat stimulating!

Cheers!

Does Fascia Matter?...Yes, it does!

I would consider this more of an "op-ed" piece rather than a true scientific discussion. Although op-ed pieces are authors who are non-affiliated with the "editorial board", I like the idea that the genesis for this post came from a slightly critical source. 

I should point out that this criticism wasn't levelled at me personally, rather on the growing enthusiasm for fascia and fascia science.  Further, I see it not as a negative manifestation but a positive one.  As per the image at the start of this post clearly says:  question everything!  This is the only way that "normal science" evolves...current paradigms are challenged, and if the paradigm still holds, it remains the viable construct. 

I recently read a very insightful article titled "Does Fascia Matter?"  and it was somewhat of an "eye-opener".  It presented a very intelligent and sage commentary on what can realistically be called "fascia fanaticism".  Although I wouldn't go as far as to suggest that there is anything fanatical about the current surge in interest, it is a very interesting perspective.  Further, it stimulates some introspection and generates some level of self-evaluation (and evaluation of a closely-held belief).  For this reason, I feel that this is perhaps one of the most refreshing articles I have read in quite awhile.  I actually contacted the author with some brief questions, but he "graciously" informed me that his email volume is staggering and that he only had time for "the interesting 20%".   Although I fully understand the busy nature of most professionals, however when it comes to the exchange of knowledge and concept, a few sentences or words are the hallmarks of a genuine quest for knowledge.  In a previous post, I reported that renowned author Leon Chaitow even took some time to send me a few words in feedback...which he regularly does on his social media sites.  My initial reaction was slight disappointment, but that quickly faded and I chalked it up as a learning experience to integrate into my working "harddrive".  More importantly, it gave birth to the (re)evaluation of a central-belief system that I have been championing for awhile now...and the end result is refreshing.  Without going into a "critique" per se, I will simply carve out some of the legitimate talking points from the article and address them individually: 

The author of the "Does Fascia Matter" article states that fascia enthusiasts routinely denounce his article.  I personally applaud it...for the simple reason that it does precisely what every intelligent article should do:  push the boundaries of our perception and question our own philosophy.  If someone is truly serious about their craft, this article will only serve to either re-inforce or re-evaluate the pillars of ones perspective...either way, they will come out more enlightened in the end. 

1)  Fascia is biologically interesting, but is it clinical relevant?

I found this to be a very, very good question.  Indeed, it is easy to get consumed by the elegance of fascia, but it is logical to step back and examine whether it has any clinical relevance.  I think that there is no real need to expand into any great physiological explanation, rather simply to identify the fundamentals of the human organism.  The term "clinically relevant", as I perceive it, refers to whether or not it is something that is either (a) adaptive and therefore able to undergo some change, and/or (b)  something that we can actually realistically target.  The very fact that it exists in such abundance indicates it is highly relevance to the establishment of systemic and biomechanical homeostasis.  Further, it has already been established that it is packed with sensory receptors (Ruffini, Golgi Tendon Organs, Pacini, Interstitial Receptors) therefore it serves as a fundamental source of mechanical information to the brain.  Perhaps the most important reality is that fascia is a subset of a much larger consideration:  Connective Tissue.  It belongs to the connective tissue "family", therefore it has equal relevance as every other tissue in the body.  When you consider the other "members" of the connective tissue family, this point becomes relatively clear. 

The above chart provides an elegant perspective on connective tissue.  It is essentially composed of two elements (cells and a matrix) and from there it differentiates quite significantly.  The relevance to fascia is derived from the matrix branch, which is clearly identified as being composed of a base ground substance and protein fibers.  The protein fibers demonstrate the mechanical contribution, while the diverse ground substance manifestations essentially describe the relevance within the human organism.  Mineralized ground substance is manifest as bone...which responds and adapts through cellular mechanotransduction.  The gelatinous/syrupy ground substance is what is widely considered as "fascia"...and it also responds through mechanotransduction. 

Therefore the question of clinical relevance is indeed logical...however, relevance is largely subjective and can only be evaluated through specific "prisms".  I have had the luxury of working exclusively over the last 6-7 years with severely affected children with Cerebral Palsy...who can realistically be categorized as some of the most profoundly weak individuals.  The most efficient, reliable, measureable, and permanent  way to improve their condition is the focused emphasis on the extended connective tissue system! As the chart describes, the connective tissue is a large contributor to biomechanical competence therefore if manual intervention is applied with very specific loading properties and using specific stress transfer mediums, the connective tissue will respond through the process of mechanotransduction.  Perhaps more importantly, the movement of interstitial fluid through the extracellular matrix (via specialized manual applications) contributes to the improvement in lymphatic drainage, nutrient transport, and the removal of metabolic by-product.  This is seen quite clearly in these profoundly weak individuals...and is somewhat "blurred" when you are working within the "healthy" community.  Is fascia/connective tissue relevant?  WITHOUT QUESTION.  

2) Fascia is not exotic and "too tight to release"

This is perhaps the most critical error that is made by the vast majority...including the author.  He states that there are essentially two simplistic rationales that fascia "enthusiasts" cling to that explain why fascia is important:  Its everywhere and connects everything, and it gets tight.  This statement is actually largely accurate...this is indeed a widely accepted "mantra" for most.  The author is correct in suggesting that this is a primitive perspective...however he simply points out this fact without going into any further "sophisticated" enhancement.  This statement, at best, only describes 50% of the reality...and I will explain why.  Further, this explanation will in fact demonstrate that fascia/connective tissue is indeed exotic!  The common conceptual "trap" is to consider connective tissue within its "connective" physiological appearance ONLY.  Although it is intuitive, it is extremely primitive and quite mis-leading.  The exotic nature of connective tissue is that is has a paradoxical physiological function of DIS-CONNECTING as well!  Loose connective tissue (what is largely thought of when thinking of fascia) serves the role of separating specific muscle groups and bundles as well as synthesizing lubricant to allow for un-interrupted sliding between muscle groups.   This mechanism is in place to increase force transmission efficiency...without which, movement and function would be significantly disturbed.  In essence, the exotic nature lies in this paradoxical dual purpose.

The other notion that fascia is too strong to be released is not anything that I have a particular comment on.  Rather, it is the idea that fascia/connective tissue ONLY gets tight...or is only somehow "overstrong".  This is the most unproductive mindset I can think of.  In reality, "tightness" is a relative expression, NOT an absolute one.  To be specific, it is always assumed that one "sheet" is too tight and needs to be released. The overwhelming failure lies in the fact that this perceived tightness is in relation to the adjacent sheet...is it really tight, or are both of them weak with one of them being "less weak?".  Therefore, with respect to the absolute true status of the fascial band, if you disregard the potential that it may in fact be weak...you have effectively reduced your chances of success by a minimum of 50%.  It is already widely known (and researched) that a spastic muscle is approximately 4 times stronger than a healthy muscle...but the connective tissue matrix is 30-40 times weaker!  Therefore, it may in fact be true that healthy fascia need not be released...it may even be a viable extrapolation to claim that it CAN'T be released...however, this paradigm excludes the reality that connective tissue can indeed manifest weakness and that this weakness can contribute to an alteration of the biotensegral homeostasis of the human organism (both mechanically and systemically). 

In summary, the author is right in the claim that physically changing fascia by force would be "medievil"...however this falls squarely within the "tight-only" paradigm.  Weak connective tissue systems can be gradually strengthened over time with appropriate loading properties and adequate stress transfer mediums. 

3) Does it matter that fascia contains muscle cells?

The simple reality is that the human organism is the most efficiently constructed "machine" on the planet.  In essence, if it exists, it matters!  It is true that, when compared to actual muscle tissue, its contractile potential is significantly less...but muscle tissue has the singular purpose of contraction!  It is a specialized tissue that does nothing else but contract and relax.  Conversely, connective tissue (fascia) has diverse and widespread physiological roles.  Therefore if you gauge connective tissue solely on contractile potential...it will obviously fall very short.  The fact that it extends throughout the entire organism from top to bottom, inside and out reflects the significant impact it has even with limited contractile potential...in other words, its effect on the organism is cummulative.  If the entire connective tissue network were to contract, it would generate significant force...which is quite regularly manifest in the "fight or flight" response where individuals are reported to perform feats of "superhuman strength".  This is the automatic recruitment of the contractile properties of conenctive tissue. 

4) What does Dr. Schleip think?

For those who are unfamiliar with Dr. Schleip, he is widely considered as one of the leading experts in fascia research.  The author makes a point to mention that he has forwarded his position to Dr. Schleip (which is a noble and respectable gesture) for his feedback.  According to the article, Schleip shares the authors reserved attitude in making any "God particle" claims with respect to fascia...additionally, that there are some people making some claims that are made from no facts, extrapolation of fact, or theory regarding fascia.  However, the mere fact that Dr. Schleip exists...and that he has been sought out for comment by the author...indicates that fascia IS important.  The reality is that there have been no real advances in physical therapy since the invention of the EMG.  The current "muscular" paradigm we currently follow is based on the idea that anything important must generate an electrical signal...if not, it isnt important.  The consideration of fascia/connective tissue as active "players" is a relative "stretch" within this paradigm.  Therefore, I can confidently say that the current environment is consistent with what Kuhn calls a "Model Crisis".  A Model Crisis is when there are accumulating anomalies that the current paradigm cannot explain.

Kuhn Cycle for Scientific Revolutions

  
This inevitably leads to a model revolution and a subsequent paradigm shift.  The typical crisis stage is characterized by a polarization of philosophy and perspective with those resisting the "revolution" and those who are attempting to drive the paradigm shift forward.  It is my personal belief that the current fascia science is stimulating and perpetuating this cycle through the most sensitive (and challenging) phase.  The ultimate result is a likely paradigm shift that reconfigures the working mindset and will therefore re-shape the manner in which "normal science" is done how research methods are approached.

Fascia matters.  Case closed.

Cheers!
 

 

Cerebral Palsy Guidebook: Symptomatic or Problematic?

The two previous "Guidebook" post on the blog have received quite a few reads...just over 1000 reads in about 3 weeks.  I have decided to add an "insert" here on the Facebook page as a complement to the first "Developmental VS Choronological" entry.  The essential framework of this note is identical...presenting a given perspective on the daily challenges associated with CP and how they impact the fundamental decision making process within the family unit.

 Although they may seem mutually exclusive, the reality is that symptomatic and problematic are intimately related.  Within the CP landscape, they are essentially "blurred" together and it seems that everything is defined as problematic.  It is important to make very clear distinctions between them, however...because this distinction will ultimately have a direct impact on how these challenges are received (anxiety, panic, worry) and, more importantly, how they are addressed.  In order to make this distinction, I have chosen an analogy that is likely to be the most "universal"...the famous "Check Engine" light.

As simple as it sounds, the check engine light is an indicator of more profound problems within the engine itself.  Even if the engine seems to be running smoothly, the "check engine" light may blink on to signal that some intervention is needed in the immediate future and that some form of assessment is required.  As many of you have already experienced, as soon as this light comes on, you immediately get a typical "what now?"  reaction (which may have a few expletives added to the front).  In alot of cases, myself included, the light itself becomes a nuisance...and therefore the immediate problem.  The reality is that it can be realistically considered as a "symptom" of the internal engine problem...therefore, the immediate (and instinctive) reaction is often directed at the symptomatic manifestation as opposed to the more fundamental under-lying issue.

This analogy translates quite effectively into the CP landscape.  There are multiple "check engine" lights going on and off (muscular tension, seizure activity, digestive dysfunction, joint dysfunction, immune system deficit, etc..) that instinctively grab almost 100% of the attention.  All of these challenges are indeed difficult in their own right...this is not to say that they are any less important or challenging.  The main message of this note is to understand the relationship between symptomatic and problematic.  To be precise, the alarming majority of strategies are centered purely on symptomatic resolution.  Using our analogy, this is the equivalent of "turning the check engine lights off".  Having had this discussion many times in the past, I am acutely aware that this distinction may still be somewhat elusive...therefore I will be more explicit:

1.  Symptoms are typically the most visible...Problems are essentially "hidden".  This is an important fundamental understanding to integrate.  The most immediate, obvious, and intuitive challenges are typically those that are easy to spot and identify (chaotic movement, convulsions, fever, feeding dysfunction, spastic muscles, etc.).  Although often quite difficult and challenging to manage, they stem from a general subset of systemic problems that "lie underneath the surface".

2. Symptoms have the potential for some immediate short-term relief, while Problems require a more comprehensive and long-term strategy.  Another important reality is that the symptomatic challenges have a relatively well-established list of tools for their immediate resolve.  Whether it is in the form of pharmaceuticals, manual techniques, or nutrition...the current "menu" is quite extensive.  In addition, the itemson this "symptomatic menu" have the most appeal: "immediate relief of...."   The resolution "menu" is relatively non-existent and falls short of any true appeal simply due to the idea that it is long-term and the progress is evaluated over months and years as opposed to days and weeks.

3.  Problematic issues are the most detrimental to overall health, systemic homeostasis, and general quality of life.  Although this statement could realistically be debated, when you accurately identify the problematic issues it becomes somewhat less obscure as to the true root of most challenges.  They can be outlined in this general format:

a. Profound deficiency in the connective tissue quality and integrity----- leading to joint dysfunction and irregular muscular activation
b. Reduction in the quality of interstitial fluid flow----leading to immune system dysfunction, poor tissue (skin) quality, and spastic conditions
c. Insufficient lymphatic function ---- leading to higher systemic sensitivity and susceptibility to viral / bacterial infection
d. Profound insufficiency in CSF flow --- leading to reduction in brain metabolism, poor processing potential of the brain, poor nutritional maintenance of the spinal cord, electrolyte dysfunction within the brain, convulsions

This of a basic description, of course...the list is actually alot more comprehensive and complex.  However the main message should be quite obvious.  The underlying, hidden, and fundamental problems are the true source of the more obvious and external symptomatic manifestations. 

In summary, the most successful rehabilitative strategies take both  into consideration and designate selective interventions to address the entire organism.  Refering back to the original analogy, there is a fundamental understanding that should be well integrated into youe mental "hard-drive":  There is no need to WAIT until the check engine light comes on before you act".  The unfortunate reality is that most are not given this option...nor is it generally even considered.  This is a result of the Pathogenetic paradigm that currently overwhelms the thought process and therefore manifests in most treatment strategies.  The pathogenetic paradigm is also considered as the "disease fighting"  paradigm and can be equated with the idea of waiting until the engine light comes on.  This is quite common and has become almost expected as standard operating procedure:  "the x-ray shows the hip is at 20 degrees, but when/if it gets to 30 we will have to consider surgery...the spine is curved now at 33 degrees, but when it gets to 43 degress, you will need a corset...the EEG shows some irregular activity, but it isnt too bad at the moment."  Although the pathogenetic approach is an essential component of any successful strategy, it shouldnt be the singular focus.  There is also a Salutogenetic Paradigm that exists as well...which essentially is the promotion of health and maintenance of systemic homeostasis.  In other words, during periods of relative health and stability there should be some active intervention in place to address the underlying systemic deficits...or "implementing a regular maintenance program so that the engine light doesnt come on at all".  As with the car analogy, the human organism is dependant an adequate fluid flow, efficient thermoregulation, and regular structural assessment and evaluation.

Although the human organism is exponentially more complex, the general philosophy and mindset applies for both.  The symptomatic challenges are addressed within the pathogenetic paradigm for immediate resolve, while the consistent implementation of salutogenetic strategies address the underlying problematic roots.  The most recent research and investigation demonstrates undeniable and significant positive results in progress when salutogenetic interventions are adopted...and therefore should become an integrated part of the rehabilitative protocol.

Cheers!

Connective Tissue: Finding the Beauty in Disconnection

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!

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!

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!