to medical professionals by L. Blyum, the founder of ABR at University of
Sydney, Holme Building, on Feb 24th, 2009.
ABR -- Heresy in Physical Rehabilitation???
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’.
word “Advanced” is self-proclaimed conveying the assumption that this method is innovative and brings some extras to the
“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
IV and V children reach their plateau
very early – not much progress to be expected for them after around the age of
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. !?
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?
walk through that “Optimum Management” example further:
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
- 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.
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.