In many countries New Year is the time when people throw away everything old and useless that accumulated in a house with the idea of having a fresh start and letting the new things in.
I admire the tradition and decided to follow suite – the first post of 2011 is about flushing down the drain the outdated neurological dogmas that paralyze and lead astray professionals and parents of kids with Cerebral Palsy alike.
Disclaimer – big and bold: everything you are going to read is my own extremely biased opinion that is most unlikely to be supported by qualified medical professionals.
I’d actually go even further and say this – to leave no doubts about my extreme biasness:
In my opinion, “brain-based” approach to Cerebral Palsy that treats ‘brain injury’, i.e. damage to a part of the brain, and ‘Cerebral Palsy’ – disorder of posture and movement/failure in reaching biomechanical developmental milestones -- as the interchangeable synonyms – is the most important obstacle that stifles the progress of physical rehabilitation and freezes current abysmal status quo.
In other words, a neurological paradigm is: a blindfold over your eyes; sticky glue, quicksand and rocky terrain underneath your feet; iron gloves over your hands; plugs in your years and shackles around your feet – all of these in a single nasty package… So you are welcome to figure your chances of success if you are ever lured by
In Part 2, I am going to go over 16 most obvious reasons why neurology leads you astray and why the guidance by neurologists who define the discourse of today’s interpretation and approach to Cerebral Palsy is the worst and most unproductive thing that is responsible for astonishing lack of progress in Cerebral Palsy therapies over the last 100 years.
I’ve been thinking about these flaws for years and collected quite a pile – but in order to spare you from a nearly endless list – I gave myself a time line: I put the kitchen timer on 10 minutes and proceeded to write down as many stubs exposing the fundamental flaws of neurology and brain-centered paradigm for Cerebral Palsy as possible.
By the moment the timer went “Bzzz” – I was on reason # 16.
Well, If I were to give myself ½ hour – I’d probably come up with a list that would have been three times as long– but I think even a basic version will do to begin with.
However, before proceeding to Part 2 – the actual list – I wanted to immerse you in the context of the case – I hope that’ll give you an improved perspective.
I do not know whether it’s my nerdy self but I find this picture incredibly funny and strangely appealing.
This is the cover of Harper’s Magazine and it has been on my office’s kitchen table since October but every time I walk past it – I can’t help smiling… The white-haired man with the badge: “Hello my name is Sigmund”, who is being kicked out from a gathering as an unwelcome trespasser by a muscle-bound security, is obviously Dr. Sigmund Freud.
The cover of the magazine refers to the featured article inside: “The War on Unhappiness” – ‘Goodbye Freud, Hello Positive Thinking’; which reports from the all-American gathering of the psychotherapists which pledged allegiance to positive thinking and happiness promotion instead of a classic Freudian psychoanalysis that studies trauma and misery – all the way from the analyzed person’s early childhood.
I must say that the article is quite interesting and thought-provoking in itself but what gave me the most inspiration is the picture.
You see – when it comes to Cerebral Palsy – pretty much the same has to be done with these two distinguished gentlemen:
Who are these people? What do they have to do with my child’s chances for better function and quality of life?
What influence do they have on Cerebral Palsy / brain injury rehabilitation?
They seem to be intelligent and nice people – why do you want to give them a boot, Mr. Blyum?
These gentlemen are: Sir Charles Scott Sherrington (left) and Ivan Petrovich Pavlov (right) – they lived at the same time as Freud (late 19th-first half of 20th century) and they are of equal stature if not more influential than him for medicine and related practices until these days.
Sherrington and Pavlov are the founding fathers of neurology, both are the Nobel Prize winners, and clearly both were remarkably intelligent people whose profound and influential books shaped the course of their discipline for years to come…
However, these towering figures are the ones inadvertently responsible for the mind-boggling stagnation in the field of Cerebral Palsy where the outcomes have not improved by any sizeable margin for the entire 20th century.
The unfortunate reality in the field of movement disorders is the astonishing lack of progress – your child with Cerebral Palsy today has very little gain in terms of tangible improvements to structure and function comparing to a child who was born 100+ years ago.
There wasn’t a lack of trying – hundreds of thousands of doctors tried their best and billions of research dollars went down the drain – but all with very little to show for the massive investment of resources.
What is the official explanation? – More funds and new technological breakthroughs needed… The standard mantra…
My humble opinion? – If the wrong path is chosen at the start of the journey –then no matter how much investment and effort is poured in – wrong path always leads to a wrong place…and what initially is seen as perseverance then becomes stubbornness and eventually turns into hopeless dogmatism… That’s where the “Cerebral Palsy science” is today.
So-called scientific conferences in Cerebral Palsy became pitch festivals for brutal and toxic interventions – major surgery, Botox and baclofen…
Who is ultimately responsible for the wrong choice of the path? – These two distinguished gentlemen that you see on those portraits.
Drs Sherrington and Pavlov are the ones who had established the fundamental paradigms of neurology that until these days define where and how the answers are being searched for debilitating conditions related to profound impairments of posture and movement.
They are the ones who came up with definitions of “reflexes” and outlined the main bioelectric “control paths”. Of course, there were quite a few others – but of much lesser stature than these two Nobel Prize winners. They had the fame – so, they should get the blame as well, right?
The essence of neurology is the bio-electric approach – the study of signals: where they originate from, where they go to, and what effects are observed once the signal arrives. Neurology approaches the body with a perspective of a bioelectric nervous system being the puppet master that plays the script via all other organs of the body. The body itself is seen very much both as a medium and a stage for that play. The ultimate control is with CNS (central nervous system) – essentially ‘the brain’ – that has different areas and compartments each of them being “responsible”/ “in charge” of its own domain of subordinates – organs and functional systems of the body. CNS is akin to the ‘ever-seeing eye of the Beholder’ being in control of everything from tissues and individual organs to the organismic functional system.
There is a also an added touch of drama that every schoolchild knows: the nerve cells do not re-generate. Whenever they die – there is no way back by growing the new ones. Respectively the understanding goes that with a loss of neurons in the brain some areas of control are being lost forever. As a result the body structures that lost bio-electrical guidance become unruly, cause mayhem and disobedience that translates into deteriorating functional performance.
In general, ‘the loss of bio-electric guidance’ is the principle framework that neurology has for any disease or chronic condition. There could be plenty of specific ways of how and why such a ‘loss of guidance’ occurs – but the essence is always the same..
Of course, this is just a sketch and an outline of what neurology is – there are plenty of disclaimers, refinements and sub-clauses that were accumulated over the years – however, all those are for the insiders only and do not change the neurological paradigm itself.
The outside product of neurology is what I described – bioelectric paradigm with the brain as the main switchboard that controls everything via signals.
In order to understand the deep appeal of neurology and how did it manage to get a stranglehold on all the other competing lines of thought so quickly and so powerfully – one needs to see a historical context.
I mean, personally the very premise of neurology struck me as fundamentally flawed very early on. In fact, the first 2 books that I ever read on the subject of therapies for Cerebral Palsy were the ones by Bertha Bobath and her husband, Karel Bobath. She was the one who invented the exercises known as Bobath Method for the last 50 years, but actually he – the neurophysiologist – was the mastermind behind it who gave all the explanations and reasoning via neurological descriptions.
I couldn’t really digest the mismatch – how on Earth can one seriously try to justify and develop specific biomechanical interventions, i.e. exercises and therapeutic movements, – which are tangible acts of force transfers characterized by ranges, pivots, distribution of loads, recoils, accelerations and decelerations, velocity within short and long kinematic chains that are hierarchically related to one another etc. – via bioelectrical reasoning that has no built-in sensitivity to these biomechanical parameters at all??…
Imagine an actor expected to perform Shakespeare from stage in English is given the works of Confucius in Chinese as the script he has to learn from… It’s an absolute nonsense. But somehow everyone seemed to be quite contempt with it.
Unfortunately, the more I read the more I saw that no one cared about this mismatch between the biomechanical reality of physical rehabilitation and treatments for Cerebral Palsy versus the bio-electrical reasoning that all the books took for granted .
So I’ve been thinking about the nature of this mass delusion and obsession with electrics for a long while collecting blunders, paradoxes and oxymorons but still I remained puzzled.
The realization came to me couple of years ago while visiting science and transportation museums in England with my son in the summer of 2009. We’ve been to London, Oxford and Manchester visiting technically oriented museums.
All of us today – children of the 20th century living in the 21st take a lot of surrounding civilization for granted. Electricity has always been a huge underlying part of our everyday life that penetrates absolutely everything we use and do that it is difficult to visualize life in the pre-electricity era.
(2 weeks in a summer cottage on the remote lake– do not count. That’s a voluntary temporary escape from pressures of city life – but it doesn’t change your civilizational experiences. )
I do not think we can fully realize the breakthrough that the city life took in a span of merely 20-30 years at the turn of the 19-20th century and the emotional effect of fascination and awe that it had.
Electricity absolutely transformed the everyday landscape and environment – city lights, home lights, telephone, cinema, radio, electric railcars all that together with the installation of new sewage and water supply systems – made a dramatic change in everyone’s life.
Yes, today we live in the age of computer and the Internet and mobile phones etc. – but these are merely upgrades of the original electrical revolution. All the changes that we have faced personally as the 20th century was turning into 21st – they absolutely pale in comparison with what took place 100 years before that. Today our cities , electric grids, transportation means are fundamentally the same as they were 30-40 years back (Just watch the movies… ) 100 years ago the perceivable change of everyday city life within the same span of time was many times greater.
Plus we got so used to the technological advances that we pretty much have lost the ability to be amazed by them – they do not capture imaginations anymore.
To really get the feel of how drastic was the change I strongly recommend to visit relevant museums – pretty much any large city museum will do. You’ll see through the artifacts and reconstruction of the scenes of city life how dramatic was the change of everyday environment at the end of 19th-early 20th century.
This summer our tour of science and transport museums went through Germany – and it’s the same thing: whether it’s Munich or Berlin – the end of 19th century was clearly the time of engineering triumph with electricity at the helm of change and innovation…
Why am I telling all this? – Simple reason – it’s exactly the same time when the founding fathers of neurology worked and that was a public sentiment of the day.
The soil was fertile – everyone believed that electricity is “the thing”. Imagine a person who has just experienced the awe and magic of talking to someone distantly via the phone operated via a huge switchboard being presented a similar idea but in respect to the human body? – Obviously, it strikes the cord.
And once the Pavlov’s experiments with the dogs and salivation were made famous – the deal was sealed.
Neurology received the key to the medical kingdom on a silver plate.
Add to this the insatiable desire of a humankind for the ‘magic key’ – where one single switch of a selector into a “right” position is capable of solving a galore of related problems – and voila the neurological quest has been born…
Neurology ran this wave of early promises for several next decades firmly establishing itself as a leading paradigm in medical science until seemingly coming out of breath by late 40s where it seemed that everything that could have been studied by rather crude electrical devices of the day had already been explored without giving much of truly effective clinical answers … but then the technology came to the rescue once again.
First, it was the mass-production of a transistor – as a result all sorts of new devices like EMG, EEG etc. became available with tons of new electrical phenomena to be measured and classified. So no one bothered with re-evaluation of paradigms but jumped on a bandwagon of even more measurements and detection of even finer bioelectrical phenomena in the human body.
Second, soon after, the electronic microscope provided another boost – now it became possible to dig even further into the microstructures that compose the pathways of bio-electric signals – huge new fields opened up for studies… Who’d silly enough to bother with the issues of integration of ever-growing pile of microfacts and re-evaluation of underlying paradigm when there were so many geese to chase?
Meanwhile, the 60s came in – and the computers started to appear. So there was a new powerful way of doing more computations around all these micro-facts.
And then 70s – the MRI – now it became possible to observe the actual nerves as such with unprecedented clarity.
80s – computers got even smaller yet much stronger – so there were more facts to detect and databases to plough…
At the same time emergence of the computer as a driving force of progress at the last decades of 20th century added an extra conceptual boost to neurology and bio-electrical paradigm.
What was previously perceived as a more or less simple switchboard now evolved into a readily available upgrade: the brain as a supercomputer.
But wait … there is more – computer science brought in the concepts of networks and complex integration of those – so there was even more room to squeeze creative juices from the neurological paradigm.
Until today technology and ever-growing proliferation of computers continues to give the life-saving shots to the old neurological horse that refuses to die…
It all seems so excited and complicated and promising and absolutely impenetrable for the mere mortals BUT … as they say in the movies …– “Show me the goods..”
Well, and that’s the simple question that pierces the armor like a knife through a melted butter…
There are none … Nothing to brag about…
Botox? – a locally applied toxin that brings extra paralysis but short-lived one.
Splints? – Err, aren’t those the same things that we see on the 18th century pictures. That’s what – nearly 300 years ago
Surgeries? – They keep becoming more and more invasive..
Physical rehabilitation and training? – Clearly unable neither to beat the GMFCS curve in comparison to spontaneous development, i.e. “doing nothing”, nor to prevent the surgical invasions.
Stretching? – Until today nobody knows for sure for how long and how exactly and where at one needs to stretch
What is the highly lauded “greatest achievement in Cerebral Palsy science over the last 50 years” – GMFCS curves…
Wow!? But what are these curves? – GMFCS ‘curves’ are the official statistical recognition of the fact that all the efforts aimed at improving the functional performance of children with Cerebral Palsy bring , well, –nothing, when compared to “doing nothing” and quantifying the exact extent of these failures… That’s optimistic, isn’t it?!
So, my basic message is simple – with all due respect to Drs. Sherrington and Pavlov – they need to be treated the same way as Dr. Freud on the opening picture:
Of course, these gentlemen deserve respect and they have earned their place in the history books and museums – but for all their brilliance and intelligence they were the products of their times and the path that they have chosen is a flawed one. Whether it’s their fault or the fault of the followers who did not have the same caliber of thinking and preferred to swim with the current – I do not really know or care.
I am looking towards the future… and it’s a collective responsibility of medical science to kids with Cerebral Palsy to perform better than it did over the last 100+ years under the guidance of bio-electrical ideas.
Of course, by today – those are the dogmas and the untouchable idols on the pedestal.
Frankly, I shiver when I think about the dominance of bioelectrical paradigm as today’s chosen basis for treatments and interventions into the musculoskeletal disorders and movement impairments, especially for Cerebral Palsy.
I ask myself a simple question: Do I want to live in a house designed by an electrician? – No roof, no walls, no heating, no sewage, open to the elements but the mesh of wires being lovingly encased… Well, maybe I’ll be able to watch a plugged TV magically floating in thin air but all that is only going to last until the first rain.
So, my answer is a resounding: “No”.
I want the walls and the roof first. Lighting is a nice upgrade but shelter me from elements to begin with.
Now, as the parents of kids with Cerebral Palsy – you are the obvious victims of this bio-electrical paradigm.
Reality bites – whether one chooses to acknowledge or ignore it.
Exercises and therapeutic movements, – which are tangible acts of force transfers characterized by ranges, pivots, distribution of loads, recoils, accelerations and decelerations, velocity within short and long kinematic chains that are hierarchically related to one another etc. – via bioelectrical reasoning that has no built-in sensitivity to these biomechanical parameters at all.
When you put your child to stand – you better know what biomechanical environment you subject him to. When you grab a the leg and decide to “stretch” – you need to be aware of the joint stability, exact distribution of miofascial stiffnesses, safe and damaging ranges, accelerations, loads etc.
If you force a child to crawl utilizing the cheats like inclined plane or plain push at the legs coupled with drag of the arms – you need to be realize what structures are put to work and how and whether your well-intended ‘signals’ are going to come from the right places or from the wrong ones...
The list is long and requires investment on your behalf in studying what biomechanical factors are at play and how to control them.
Arrange them mechanical stimulation correctly and you are able to start building a virtuous cycle of developmental progress.
Screw the mechanical impacts up by loading the wrong structures or by working in a wrong mode – and all your hard work is going to result in nothing else but further aggravation of the vicious cycle that leads to further deterioration…
These are the stakes at play and I hope that you are going to choose wisely….
P.S. A little laugh ...