Intelligence vs. Literacy.
Difficult to describe it in words…

On ‘Hawks’ in Disguise

Just recently I came across one quite important insight considering overt and covert ‘hawkish’ approaches that I want to share with you.

This is an e-mail that I received recently from one of the parents:


“Hi Leonid. 

I just came across this non-invasive procedure by Dr. Nuzzo in New Jersey called PERCS or SPML.  I believe you are aware of this because another ABR family has done that http://www.pediatric-orthopedics.com/Treatments/Muscle_Surgery/Perc_Lengthening/perc_lengthening.html

Do you think this surgery will help J.? 

 I know straight legs don't mean good functions. But since it's done by lengthening the fascia, is it in a sense doing exactly what we are doing but through surgical means? I can see the benefit being faster and low risk because it's done percutaneously.

 Of course, I know this is not the magical solution but more therapy is required after the surgery. Please  share with me your thought as my husband is really eager to do this for J. (It may even be covered by insurance).”

 

This is my answer:

 Dear …,

I want  to emphasize two important distinctions:

1.     “Nothing forceful” true ‘Peacenick’ approach of ABR vs. hawkish paradigm/ mindset/ approach.

2.     Fundamental difference between milder children with cerebral palsy (GMFCS II-I – mild hemiplegic or diplegic cases) and more severe cases (GMFCS III-V – mainly quadriplegics, and some more severe cases of diplegia and hemiplegia)

 

1. True ‘Peacenick’– ‘Nothing Forceful’– vs."non-invasive" surgery

What is meant by "non-invasive" surgery? – ‘Non-invasive’ surgery assumes that there is a lot less of COLLATERAL DAMAGE than in "traditional" surgery.

Reduction of collateral damage is most welcome … but  the "hawkish" approach with "non-invasive" surgery is still there as strong as ever! It is still the same  "war" against the "tight/ spastic muscles". The only thing different is the use of a “Delta Force assassination squad” instead of the “carpet bombing” of traditional surgery.  

The use of a Delta Force commandos doesn’t turn a ‘hawk’ into a ‘dove’.

ABR message is different – we talk about fundamental difference between 'dove' -- nothing forceful and 'hawkish' -- "wrestle the muscles into submission"  -- approaches.

What is the essence of ABR’s ‘peacenick’ mindset? – We emphasize the fact that spastic muscles are weak muscles. Yes, spastic muscle are “too strong” in force, but more importantly they are too weak in fascial matrix composition.

See: "INFERIOR MECHANICAL PROPERTIES OF SPASTIC  muscle DUE TO COMPROMISED EXTRACELLULAR MATRIX MATERIAL"

RICHARD L. LIEBER, PhD,1 EVA RUNESSON, PhD,2 FREDRIK EINARSSON, MD,2 JAN FRIDE´ N, MD, PhD2

1 Departments of Orthopaedics and Bioengineering, University of California and Veterans Administration

Medical Centers, 3350 La Jolla Village Drive, San Diego, California 92161, USA

2 Departments of Hand Surgery and Orthopaedics, Sahlgrenska University Hospital, Go¨teborg, Sweden

 Spasticity is just another of manifestation of fascial weakness.

We believe that the right focus for children with cerebral palsy is the one on the strengthening of fascia matrix throughout the entire musculoskeletal system – from core levels (deep  fascia layers of trunk, neck etc.) to superficial/ peripheral ones (skeletal muscles of the arms and legs).

Does non-invasive" surgery contribute to strengthening? – Most definitely not. It’s another form of weakening – same as stretching, casting, Botox injections etc.

 

My goal – is to make sure that you really understand the difference and have a proper perspective .You are the boss -- you are the ones who makes decisions -- I only share a different perspective with you.

 

2. Quadriplegic child is in a different league of complexity

This is my plea to parents of a QUADRIPLEGUC child -- please do not fall for the illusion that 'non-forceful' "needs to be assisted" by forceful “help”.

I remind that the spastic muscle -- is WEAK muscle. Any type of forceful intervention and any sort of cutting makes it weaker, period.


However, when it comes to milder children with cerebral palsy things are completely different.

There are cases when I do not have any objections to forceful intervention at a clearly selected target  -- actually in the case you are referring to I was a proponent for that surgery.

Now you might ask: “How come? Aren’t you contradicting yourself, Mr. Blyum?”– Not at all. I still maintain that any surgical intervention, no matter how small and/or local and/or ‘non-invasive’, carries nothing but weakening. Surgery imposes what I call a “biomechanical tax”.

a) However, for a milder child we have to apply a larger perspective and weigh this ‘biomechanical tax’ against the ‘personality development’ tax.

So that’s the first reason when I could be a proponent of a surgical release (below the knee level) –  a case when psychological cost of missing years of interaction with his peers is much greater than biomechanical imperfections.

b) The surgery below the knee became feasible only once the knee stabilized.

That’s my other principal point: any surgery at the knee level or above (hip, pelvis etc.) – is completely unpredictable – it interferes into the muscular balance that is too complex. I have never seen a precedent of success for such surgeries. Biomechanical tax is too great even for milder cases.

However, once the knee has been stabilized via ABR work – a child is in a different league.

Basically the remaining question is – “Do we want to rebuild a true complexity of a human foot or – are we alright with settling for a ‘paw’? ”

Since calf muscles are dense and have different pennation angles from the muscles above the knee – their transformation and then the development of proper segmentation of  a 20+ bone-foot – is a multi-year project and for all these years a child has to get around with his heel being up.

If a child 7-8 years old and older – it makes sense to assess the personality development tax caused by feeling handicapped and unable to be fully engaged in games and social activities with his peers.

In such a case my advice is – go for a surgery and try to choose least invasive one.

That’s exactly how it worked for a case that you are referring to – the ‘PERC’ surgery was done after having the knee stabilized via ABR. As a result -- the release of the calf m/fascia through weakening -- did not cause any major deterioration above the knee.

 

However, for a quadriplegic child (GMFCS  III– IV -V) – and even a hemiplegic or diplegic child of GMFCS III – the reasoning is completely different.

Any ‘cut’ -- even done below the knee level is still going to weaken further a fascial matrix in the upper parts of the body  via long kinematic chains.

2 reasons:

a)     The knee itself is too weak to stop the distorted ascending long kinematic chains stemming from the calf

b)    Any muscle release at the knee or hip level is useless because the only gain is short-lived cosmetic visual ‘pleasure’ of parent who for a few months observes “straighter leg” , however, from a practical standpoint – those cuts just weaken the fascial matrix and aggravate the inability for true load transfer and weight-bearing.

In other words – “release” or “straightening” surgeries made to quadriplegic children have no practical value. As a parent you then trade few months of ‘cosmetic surgery’ – visual pleasure of observing ‘a straighter leg’ for major long –term damage and further weakening of fascial matrix. It was extremely weak before surgery and becomes even weaker after it.

 I hope I made my point clear. Any release for J. is purely cosmetic and has zero benefits  -- in fact there are only long-term negatives.


However, – this is nothing more than my biased and unqualified opinion…

 The choice is yours The decision is yours.

Sincerely,

L. Blyum”

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 That’s all – I hope that this insight helps and clarifies some points that otherwise were somewhat vague…

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