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ABR -- Heresy in Physical Rehabilitation???
Welcome everybody,
My
name is Leonid Blyum – you can see it in small print on the slide – and I
happen to be the founder of the hands-on physical rehabilitation approach named
Advanced Biomechanical Rehabilitation (ABR), which I am going to briefly
introduce to your attention today.
The
talk is titled somewhat provocatively “ABR – Heresy In Physical Rehabilitation???”
– drawing the attention to many of the novel and, at first glance, paradoxical,
if not to say “strange” aspects of ABR.
Why
“Heresy”? I think a few remarks about that will help to establish the context
and the meaning.
We're
just coming off this 4-day International
Cerebral Palsy Conference 2009 at Sydney, which was held on Feb 18-21 and
this title ‘a heresy’, that I’ve
chosen several weeks ago, resonates even stronger now, – after attending this
major event.
There
were probably no less than 300 speakers at that conference from all over the
world. One would expect these thought leaders to cover the really broad range
of issues related to the cerebral palsy, and indeed the scope was broad BUT… Surprisingly, no one, not a single
presenter used the keywords like the “upper body stability”
or the “core trunk strength”… Neither did anyone
address the matters of the ‘head control’ with any deliberate focus.
Well,
there was a casual lip service, an occasional remark here and there … but that
was all… No specifics, no dedicated reports, no discussion about the new
approaches and methods, no workshops – nothing… At the same time every single
conference day there was an endless list of presentations about the hip
“enlocations” and Botox injections…
Frankly,
I was quite amazed. I knew from experience these problems were under-served in
everyday practice but I did not really expect such a complete neglect of the
trunk and neck core stability roles by the academic elite… This profound
disregard of the real-life challenges of a severe CP child who struggles to
keep the head up, folds in sitting, drops without any counterbalancing etc. is
really quite disturbing.
It
makes one think that if there was an imaginary Martian who’d descend on Earth J
and would just listen to the Conference presentations, he’d probably think
that a CP child is an ethereal creation that consists of the distorted arms and
legs with nothing else in between (but a vague ether). Isn’t that odd?
What
about improving the upper body strength?
What about improving the trunk and head control?
Cerebral
Palsy is defined as a disorder of a posture and movement – it seems
self-evident that neck and trunk stability are at least no less important than
the role of extremities!?
Yet
nobody spoke about it as if those issues were of no importance and
relevance.
That’s why in
today’s landscape where the periphery of the musculoskeletal system (the legs
and the hands) are deemed as the only worthy targets by the world’s thought
leaders on Cerebral Palsy matters, ABR
indeed sounds like a heresy since it has exactly the opposite perspective – focus on the core not on the
periphery.
In
today’s talk I intend to give you a brief overview of ABR approach. And
hopefully I’ll manage to demonstrate that strengthening the real deep core of
the upper body is not a heresy after all … but carries a lot of potential for
improving the quality of life for children and adults affected by Cerebral
Palsy by improving posture, weight-bearing and balance.
In
a full form ABR stands for ‘Advanced Biomechanical Rehabilitation’.
The
word “Advanced” is self-proclaimed conveying the assumption that this method is innovative and brings some extras to the
classic model.
“Biomechanical” highlights the fact that ABR focuses
on biomechanical aspects as opposed to the neurological, biochemical, genetics,
and psychological considerations.
IS THERE A NEED??
Does
the world really need yet another method for Cerebral Palsy rehabilitation when
there is no shortage of various tools designed to improve the posture and
movement for brain injured children and adults?
True,
there are a lot of Cerebral Palsy rehabilitation methods but how well do they
actually work?
In the past
the answer to that question was quite blurred – many methods and professionals
have claimed various degrees of success making an individual parent really
confused and baffled with a conundrum of options and promises.
However,
this confusion about the expected
outcomes should really be the thing of the past – at least for the
healthcare professionals who keep themselves up-to-date.
Within the last few years the medical community has
arrived to the consensus about the limitations of efficiency of the mainstream
rehabilitation tools for Cerebral Palsy in the form of the GMFCS curves.
I
am sure you are well aware of those but let me re-iterate shortly.
GMFCS
– Gross Motor Function Classification System based on GMFM (Gross Motor
Function Measurement) divides the entire Cerebral Palsy population in 5 groups
according to the severity of motor function deficit.
Level
I being the best (minimal deficit) and Levels IV,V being the most challenging,
electric wheel-chair bound cases, where at a Level V an affected person lacks
even a minimal head control.
[The
classification and the descriptions are available in detail on www.canchild.ca
– the website of the research group that pioneered GMFCS following the massive
multi-year follow-up of the children with Cerebral Palsy born in the province
of Ontario, Canada in 1991-1992. The project was financed by US NIH.
Everyone
had access to the full scope of up-to-date mainstream treatments for Cerebral
Palsy but at the same time some children had a lot less of treatments and some
of them had none for various reasons. It wasn’t an intentional “test” by
specifically denying these kids of therapies but it reflected different family
circumstances.
You’ll
find the GMFCS profile descriptions in Appendix 1 at the end of this document.
This
is how the results worked out:
·
Even
Level I children reach a plateau quite early – around the age of 6, and do not
progress any further in their key motor functions regardless of the therapies
continued
·
Level
IV and V children reach their plateau
very early – not much progress to be expected for them after around the age of
3!
And after the age of 6-7 they are only expected to deteriorate going down
from the quality of movement they had when younger.
· !!?? The results [Motor Function maximum] had little to do with what treatments did the children have or whether they had them at all. !?
· The
outcome for all the following years of life is defined by whatever GMFCS Level
a child was at by the age of 1.5-2.5 years old regardless of what classic treatments
were done for years after that.
.
·
Translation:
the maximum
motor function potential is seen as being “pre-destined” very early in life of a child with Cerebral Palsy regardless
of further treatments and efforts …
In
other words, GMFCS
curves leave little to imagination – clearly pointing
out that an entire
variety of existent mainstream
therapies for Cerebral Palsy (PT, OT, Botox,
surgery etc.) does nothing for improvement and enhancement of motor functions
beyond “pre-destined” Levels
“One
cannot beat the curve…”
– that’s the new mantra of the world thought leaders on Cerebral Palsy. It was
heard over and over during the worldwide conference on CP that just ended here
in Sydney 3 days ago.
The
things are especially challenging for the children/ adults of Levels IV and V.
GMFCS
Level IV and V children make up over 35% of the total number of the Cerebral
Palsy cases and their situation is the most perilous.
Let’s
look at the examples.
This
is the slide “GMFCS V – Optimal management” taken from the lecture delivered
three days ago at the International Cerebral Palsy Conference. This presentation by world authority in orthopedic surgery describes the best possible
outcome for the Level V girl of about 15 years of age as being fused in the motorized wheelchair.
I
think this review of existent options and “achievements” of mainstream
therapies is really important in finding an answer to this fundamental question
that I asked earlier: Is there a need for something new in such a
field as rehabilitation of children with Cerebral Palsy? – Especially
if we talk about the ones who are affected severely?
The
entire package of treatment procedures include feeding tube, botox injections
in the adductor muscles, and all these other surgeries such as
- VDROs – varus derotational
osteotomy, i.e. major bone cutting surgeries – done on both sides
- Spine – spinal fusion with a rod
insertion from T3 to L4
- Feet – subtalar fusion -- fusing together the bones of the anterior foot and ankle
- ITB – Intrathecal Baclofen pump
(a metal ‘puck’ inserted into the abdominal space with a drip to the
spine)
And further ….
- STRs – soft tissue releases
- Botox
- LLD, PO, recurrent hip
subluxation – Leg Lengthening + osteotomy (leg bones being cut, turned,
fused and few more pieces of metal inserted in each of the legs),
The
end result of all of these heavily intrusive procedures is having a girl whose
body is being pretty much fused into a mold that fits a power wheelchair.
Frankly
– that’s hardly exciting for a parent of 2-3 year old GMFCS Level V child to
learn that things are pre-destined and the “Optimum Management” translates as a
molding of a child into a wheelchair by endless surgeries.
That’s
a tough prospect to “sell” mainstream therapies to a sensible parent with such
an outcome being celebrated.
As
a result, the orthopedic surgeons who now tighten their grip on the reins of
decision-making power tend to employ the scare tactics in order to push this
“Optimum Management” through.
The
following is the example taken from the same presentation intended to
demonstrate that if a parent chooses not to adopt the entire package of
surgical treatment procedures offered, the consequence would be as
follows.
These
are the pictures of a completely fused distorted child who has never seen the
surgeon had no Botox, or any other injections ….
Well,
sure, these are some bone-chilling pictures…
BUT:
First,
as it is officially mentioned in GMFCS research, the average -- statistically verifiable -- outcomes in motor functions are
similar in children with/ without the treatments so this presentation wasn’t
exactly ‘fair play’. The key word in GMFCS being “on average” – of course,
there are extreme cases that open the way for biased presentations selectively
attributing progress purely to surgical “optimum management”…
And
then, second, – the main and larger question:
Are our options really so
limited that we only have a choice between a complete collapse vs. a surgical
creation of a ‘bionic’ person who is fused and metalized from the inside all
the way through and molded into the wheelchair?
Parents and
‘non-invasive’ professionals are told and made to believe that the only 2
alternatives existing are:
:
- “very
bad” alternative
- Complete surgical overhaul fusing a GMFCS Levels IV and V child and
molding into a wheelchair presented as “Optimum Management”
- “extremely
bad” alternative
- Complete collapse and extreme distortions threatening the very existence
of a GMFCS Levels IV and V child if a family opts out of profound surgical
intervention
Is there a room for any
non-invasive avenues that could improve on both of the gloomy scenarios?
So that's THE
essential question, which brings us on the doorstep of ABR.
The scientific
community assumes that the proof is always on the shoulders of the newcomer,
but to a certain extent I believe that when the field like Cerebral Palsy rehabilitation
today can only offer these kind of outcomes – “a very bad” vs. “an extremely
bad”, any new ideas should be welcomed and even if there is only limited grain
of truth to them, they should be given serious considerations.
This is the summary of the most important GMFM testing and GMFCS stratification related files:
I have put them here for your download but I invite you to visit the original www.CanChild.ca website for the most up-to-date info.
P.S. These are just first 9 pages from the enhanced transcript of that lecture on ABR for the medical professionals in Sydney.
Please let me know if you are interested in having more excerpts from that lecture -- please let me know.