One Giant Leap: The Science of Physical RehabilitationA blog dedicated to present, discuss, and debate scientific concepts in the field of physical rehabilitation, structural integration, and high performance training.
It has been quite awhile since the posting of part 1 and part 2, however there has been a recent ¨spike¨ in reads for both parts (currently rank #2 and #9 in the top 10 reads) therefore I think it is an appropriate time to complete the trilogy. As per part 1 and 2, a radical alteration of conceptual understanding of joints must take place in order to fully grasp (and appreciate) the complexity of human movement. I read a book called The Structure of Scientific Revolutions that effectively demonstrates a ¨fatal¨ flaw in the evolution of science...most (if not all) of the new ¨scientific discoveries¨ are derived from already established paradigms. To be specific, research into human movement and (bio)mechanics assumes that the traditional mathematical model (single pivotal movement) is the ¨law¨...therefore every hypothesis, design, conclusion is derived from this ¨fact¨. Common sense dictates that, if the overriding paradigm is flawed (or otherwise over-simplified), then the results / conclusions will also be so. Although over-simplification has some merit in making treatment protocols easier to ¨digest¨and conform to current health care delivery methods, it does not mean than more precise and effective understanding should be ignored. In fact, deeper understanding does not disregard the current formula...rather it ABSORBS IT. In order to fully appreciate part 3, I suggest a read (or re-read) of parts 1 and 2. However, to summarize the main message: The true definition of a joint must be expanded into a broader understanding that it is the linear or angular displacement between separate biological elements. Therefore, simple pivotal movement is only a fraction of the equation. There are 2 fundamental realities that also exist alongside of the classical mathematical model: 1) Fascial Articulations: This term defines the very real movement potential between the individual fascial layers that exist from the surface of the skin to the periosteum of the bone (and indeed even deeper into the very cell itself). The above image illustrates an example of the fascial relationship between muscle/tendon and adjacent structures. Effective movement requires, not only proper ¨connective¨ elements, but selective ¨DISCONNECTIVE¨ properties. In other words, the ¨sliding¨ (hence articulation) of fascial layers between each other is essential. By definition, this constitutes a joint...without these characteristics, movement potential is significantly altered leading to movement dysfunction, irregualr load bearing and stress distribution, and ultimately deterioration. 2) Movement is more precisely ¨Gear-like¨: This is perhaps confusing and counter-intuitive, however it is none-the-less a reality. The pivotal model suggests that movement is a summation of single pivots moving at the same time. Once again, this is a serious over-simplification. True function is achieved through a complex of gear-like movements that are NOT the sum of individual movements rather a single unified systemic response. The image to the left clearly illustrates that single pivotal movement (hip joint) is effectively a small contributor to the performance of a straight leg raise (hip flexion). This movement is defined by gear-like movement between the individual vertebrae of the lumbar spine, the pelvis, and the hip. In addition, this requires proper fascial articulation (sliding) of the fascial layers of the posterior leg. It is precisely these realities that highlight some of the current flaws in assessment and evaluation protocols. The fundamental question remmains: how can an effective treatment protocol be formulated when only one third of the mechanism is observed and identified??! At best, these types of approaches will be successful only 33% of the time and/or resolve only 33% of the initial problem. The concept of re-defining the definition of a joint only serves to enhance understanding and by default result in more effective interventions. The switch from pivotal understanding to the ¨gear ratio¨ perspective will provide some valuable insight and clarity into the amazing movement potential of the human body. I am reminded of an ¨Old School¨ kids game called Spirograph. My brother and I played with this quite alot, but it has its merits from a conceptual perspective. It involved placing variuos small gear-like tools into the center of a larger circle with gear teeth. You would then insert pencils of different colour into the smaller gear and spin it around the outer circle. The result was a myriad of amazing shapes and images. Although it is a simplistic analogy, it reveals the sophistication and complexity that exists in this model...whch is reflected in the everyday marvel of human movement. I hope this trilogy has been both informative and insightful. If nothing else, it serves as an example of the need to reach beyond current accepted paradigms in an effort to evolve your understanding. Cheers.
This post might seem as a departure from matters of Cerebral Palsy – but it is definitely – not.
On opposite, I hope that you can see this as the opportunity to understand the fundamentals of rehabilitation domain much better once you have the exposure to the other side of the spectrum – how the surgery and physical therapy handle ‘regular’ fractured bones.
It is really important for you to keep in mind that – all the concepts, diagnostic criteria, best practices and tools of both orthopedic surgery and physical rehabilitation were forged and tested in the field of dealing with fractures, bone and joint displacements, muscle tears etc.
For instance I mentioned a number of times before – that deeply ingrained belief of physical therapy in the benefits of stretching and in the ability of a therapist to restore the proper mobility via stretching – stems from the practices of dealing with muscle contractures that follow the immobilization.
That’s where stretching works the best and every experienced physical therapist has an entire collection of ‘victories’ over contractures behind his or her belt. They witnessed with their own eyes how a severely restricted leg mobility consistently gets improved via stretching until full recovery within weeks.
That’s the experience and the expectation they transfer into the Cerebral Palsy field including quadriplegic Cerebral Palsy. What happens then? – First, they see some 10-15-20% of range increase – they celebrate it and reinforce their believe in being on the right course. Second, when the range increase comes to a halt – they start blaming it on the spasticity and brain injury.
Therefore, when a friend of my son had his lower leg bones fractured in the go-cart accident – I waited for few weeks until he got out of pains and decided to seize this opportunity to illustrate the essential differences between the orthopedic handling, physical therapy, rehabilitation and recovery of a healthy person after a typical injury to a musculoskeletal system – in contrast to the most important specifics of the challenges experienced by Cerebral Palsy kids especially in quadriplegic condition.
I hope that you are going to find this being a valuable perspective that will improve your understanding of the priorities for your own child and have a clearer focus of where you need to put the most of your efforts.
P.S. As always – please let me know what you think and whether this perspective is helpful. Don’t forget the ‘Like’ button as well.
What is the best birthday present a person can get? – Well, there are many facets to that, right?
First of all – I want to thank all of you – my Facebook page and e-mail were full of birthday wishes and cards. I really appreciate that and it means a lot to me…
But today I wanted to talk about a different and very special present. Finally I know the answer to what really is an incredible birthday present :-)
Obviously I can only speak from my own weirdo perspective – but this year I have really got treated to an amazing birthday present… a 2-day long 1-on-1 meeting with a person I consider a bona fide genius – Dr. Jaap Van der Wal.
His insights lifted me out of one of my deepest and longest standing frustrations (obviously without knowing it – I was just one of 100s of people in the audience when he talked from the stage).
What frustration am I talking about? – well, the one that is central to the entire medical and biological discourse of today.
You see, there are two camps out there and the rift between them is of a Grand Canyon size.
Happy New Year. I wish you all the best in 2012,and looking forwards for your kids achievements. The 2011 brought significant improvements to the ABR techniques boosting effectiveness to the new level thanks to improved Super-Soft Ball Rolling Technique and the 'eggs' ... officially labeled as Trans-Fascial Viscoelastic Stimulation Technique (TFVES) ... so I am really eagerly anticipating a major boost in the developmental progress of your kids ...
Most importantly in the New Year I wish you inner strength -- spiritual, mental, emotional, physical -- you name it ... Being a Pro Parent to a child with Cerebral Palsy is not an easy place to be -- but on the other hand it has the potential to be truly rewarding in many instances. After all -- the tougher the challenge the more appreciated is every single achievement.
However, on your journey to super-achievement for your kids -- there are plenty of dangerous rocks, many of which unfortunately come from those who by right should be helping you -- the orthopedic profession.
Today's video is about this -- How to keep your cool and vigilance and not to fall for the dangerous mistakes that the limitations of the surgical mindset creates when looking at the X-Rays of the hips and pelvis. We talked about those limitations before -- keyhole vision and the knife-centered evaluation of options.
The following video is going to walk you through two incredibly dangerous interpretation mistakes that orthopedic surgeons are extremeley likely to fall for everywhere -- from America to Australia.
Keep you cool and never fall for those...
Writing for this blog always puts me in a real dilemma – on the one hand, there are lots of things I really want to share with you because I believe that you are missing so much of important knowledge about Cerebral Palsy and on rights and wrongs in dealing with it; but on the other hand –I have to switch on the internal censor and ask a simple question: “With what I am eager to share –am I going to help and improve clarity for the families or is it going to add to the information overload?”
In other words – by pouring down all that information on you – am I doing you a service by giving clarity and making your life easier or am I doing you a disservice by adding to overwhelm and exposing you to more concerns and worries?
These internal dilemmas really bugged me for the things that I have been busy with for the last couple of months. In the preparations to BioTensegrity meeting that took place in Munich few weeks ago – I made a dive into the engineering books on Tensegrity and the original works of Buckminster Fuller (the famous engineer-architect who coined the term “Tensegrity”) and found myself at awe with the depth of his insight… It is really amazing for the person who never really came close to the human body in any tangible sense to have so many remarkable foresights that really lay a perfect framework for the correct interpretation of the Fascia Man…
The Bio-Tensegrity perspective alone is enough to come up with hours and hours of exciting stuff – of how it all ties in and gives a much deeper understanding of Cerebral Palsy and stages of progress and transformation… but then again? – Do you really have time and sufficient interest for all that? …
I must admit that this weighing of the pros and contras turned out into the period of the relatively prolonged silence – it’s 2 months since I made the last post in this blog… So after a lot of such internal discussions – I decided to curb my enthusiasm for all things new and to try to focus on the ideas with greatest “de-clogging” value.
So I am going to try to stick to the more earthly matters and self-censor along the lines of what I think matters the most to you and how I can help you in reducing the information overload rather than adding to it...
I can’t promise that the text is going to be simple – but it is definitely going to be de-clogging: if you work your way through this – then you are really going to know what is your starting point in the quest of maximizing your child’s developmental potential.
So here it is –the question that has absolutely the greatest value and that defines the choice of a path: Cerebral Palsy – reverse or re-arrange?
This question is so essential that it deserves some extra clarification.
Today I am going to touch a very sensitive subject – the issue of Stem Cell treatments for Cerebral Palsy.
Obviously, I am being asked about it frequently nonetheless, for a long period of time I preferred to keep very neutral – sticking to the explanations about ABR itself leaving it up to the parent to make a decision.
However, recently couple of parents came up with a different perspective – pointing out that this “diplomatic” stance is being of a disservice to the parents because whenever there is an expectation of miracle – it is very difficult to keep a cool head and most of the parents of special needs children vote with their heart only.
Unfortunately, voting with the heart is the sure path to extremely poor decision-making when it comes to Cerebral Palsy.
The most difficult thing for you is to step back far enough and to get a full bird’s eye perspective of what are the fundamentals behind a certain advertised “therapy for Cerebral Palsy”, how exactly does it fit into a larger picture of your child’s long-term developmental progress as well as the context of your resources.
If you limit yourself to the question “Is it a good therapy for Cerebral Palsy?” – if you start your reasoning from such a point – you are guaranteed to be steered away from solid decision-making.
You really need to start much earlier and truly understand the fundamentals in order to judge a Cerebral Palsy “therapy” correctly.
That’s why this video stretched into 3 parts – first 2 cover the starting points of your decision-making and due diligence, which are applicable not only to the “stem cell” issue but to pretty much any therapy for Cerebral Palsy that you might come across.
Only the 3rd part addresses the “Stem cells for Cerebral Palsy” issue specifically.
I realize that often enough parents tend to be impatient and have this background voice that is saying: “C’mon Mr. Blyum, let’s not stretch the philosophical part too far – give me the specific answer…” – at the expense of sounding boring, paternalistic and even offensive – I’d put it bluntly:
There are 2 strategies that you can take as a parent:
- 1. Being smart and trying to educate yourself getting a better vantage point and seeing the big picture
- 2. Being a smartass – fast forwarding through the big strategic matters and skipping them in order to get to the tactical ‘substance’ faster.
I leave the choice to you – that’s why even though I initially wanted to merge the 3 parts into a single video – I am leaving them separate and letting you decide whichever route you’d want to take.
Obviously, comments and feedback an heated discussions are more than welcome. There is nothing worse than silence. This blog’s intent is to discuss important, complicated and controversial matters, which have far more than a single perspective at them.
I do not fool myself on being so explicitly clear and convincing that there are no questions left afterwards – on opposite, if anything – this blog is an invitation to the conversation, to the opening of the ‘brackets’ and to the exposure of dangerous myths.
P.S. On behalf of all of you I want to thank the family who asked me the ‘stem cell’ question this time and was happy to share some of the personal matters to the benefit of the fellow special parents.
“Analytical review. Cerebral Palsy and forceful devices- orthoses, splints, braces”
Introduction of the tactical information into our communication.
After some intro of a larger scale concepts – such as the key division of all therapies of Cerebral Palsy into the clusters it is time to get more tactical and tackle the smaller issues.
Paradoxically enough, I reckon that these smaller “day-to-day” things are what you are looking for – a lot more eagerly than for a larger scale concepts.
I say paradoxical because obviously everything “day-to-day” tactical – like the subject of today’s post – “Analytical review. Cerebral Palsy and forceful devices- orthoses, splints, braces” – are entirely defined by what the root concepts are. So if the concepts – seemingly abstract and removed far from everyday practice – are flawed then the flaw passes down all the way to the tactical everyday decisions, getting worse with every step. And the opposite is true – the new methods can only be considered truly new when they bring different claims at the level of concepts. Otherwise – the new method are just a different remix of the same old song.
The knowledge descent hierarchy is well-known and goes like this:
- Concepts (defines the field, the fundamental criteria for defining directions)– descend into
- Principles (Why thing Work one way or another – introducing the idea of “wrong” and “right”) – descend into
- Processes (how to make it work the “right”) – descend into
- Procedures (exact implementation – what model of a splint to use and how to put it on and how long to wear).
Fact is – in your experience you are used to the fact that the PTs and OTs always talk to you at the level of ‘Procedures’. Rarely they bother to present a mini explanation dumbed-down from the “Process” level – and when it comes to Principles – their reply is one and only “Brain injury is at fault”.
This is the typical style of interaction of the Pros (Professionals) to the Amateurs – crumbs of information: “Just do as you are told”…
Well, another fact is that most of the local level therapists that you face in your school and treatments encounters where you live– are the ones that have very vague idea of Principles – they covered a couple of textbooks on those Principles during their studies – but all that is a long gone history. They are the Process people.
The key feature of the process people is expediting obedience – they are the Sergeants and you are the grunts. Why do you have to do certain things with your kids? – Because he/she, the Sergeant told you so. Why? – Don’t ask – just do what you are told. The Officer (who are supposed to be in touch with the “Principles”) knows and that is enough.
I think that you have noticed that very often when you try to move out of this mold – and start questioning what the therapists – especially the ones who practice in schools – do to your child… they become really irritated and often quite nasty and vicious.
Don’t be surprised – medical system is modeled after the army (in fact the current roles were carved into it during the war times ) – imagine what happens in the army if the ‘grunt’ (rookie soldier of the lowest rank) starts asking questions that go to the Officer level?! Chaos and disorder! – That can’t be tolerated by Sergeants – that’s their job description to handle the grunts and to let the Officers be free of menial tasks.
You equally shouldn’t be surprised when you find out that a Doctor is often no different – that’s the Officer who has been so used to copy-paste quotes from textbooks that he grew into those quotes as dogmas without ever asking deeper “Why” question that belongs to level of Concepts.
Ask any doctor – does he see any flaws with the way the Cobb angle represents scoliosis and whether the concept of “scoliosis” accurately represents the 3D deformity of the child’s spine? Ask a doctor – does he see any problems with the way that so-called “hip subluxation” represents the 3D deformity of the pelvis? – He’ll be puzzled and outraged at the same time.
Puzzled – because he never thinks that way – his reasoning ends with the labels “scoliosis” & “hip subluxation” – he never ever questioned the way these labels came to being.
But even more likely he wouldn’t even get to the point of being puzzled – because he is going to be outranged – how could a person with no official qualifications, a grunt – you – dare to question the engraved “Principles”…
What I am trying to do when communicating with you – is to talk to you at the level of ‘Concepts’ – the really big questions that precede the definition of the “wrong” and “right” by setting the reference system.
So effectively I am elevating our conversation to the level of a “General”. Well – often you might feel somewhat lost – because for your entire “service” of being the parent of a child with special needs – you’ve been dealing with Sergeants in a status of a lowly grunt.
Why do I feel that is really important to talk directly to you at the ‘Concepts’ level? – 2 main reasons:
a) I see you as a primary guardian of your child and a primary therapist – so for me you are colleague of an equal statute – a key person. I assume the role of your mentor – but I am definitely not a Sergeant or an Officer.
b) The existent system is logical. It is flawed at the level of the Concepts – if you try to change it at the level of Procedure or Processes or even Principles – things are consistent from one level to another. Wrong principles define the horrid and inefficient Procedures.
But the change has to start all the way from the very origin – the Concepts
But at the same time I understand that often times you might find difficult to see how new Concepts (what I share with you) relate to the outdated Procedures (realities of your everyday interactions with Sergeants) and what do you actually need to do in the situations when you are under pressure.
So, I think that the best course of action for me is to do the mix – I will continue share the new Concepts related to Cerebral Palsy with you – but I will also start doing more of the “Response to Outdated Procedure” level explanations.
Probably it is going to take a certain time for me to find the right format – but I am looking forwards for your replies:
a) Am I reading the social dynamics of your everyday situation correctly;
b) How accessible are my Tactical level explanations – what you’d want to get explained – Clearer? Simpler? Broader?
Well, dear friends, the summer is almost over – and it is time to get back to the ABR matters.
I didn’t bug you during the last few weeks with ABR-related food for thought – as parents you deserve some vacation as much as your kids… without me bugging you with large chunks of information to process.
Historically ABR calendar follows the division into the academic/ shool years rather than the calendar ones – so I guess I need to congratulate you with the beginning of the new school year.
More studies are coming your way!... I hope that makes you excited rather than grumpy… :-)
Usually I am quite reserved in progress descriptions that kids achieve with ABR – trying to avoid the hype and over-expectations. Typically I am more keen on outlining the specifics of the challenges that lie ahead rather than celebrating the achievements already made. And often enough parents find this style not the most motivating … but that’s the way I see the world: whatever has been achieved as of today is already part of the past – so, let’s try to focus on the next step forwards…
By telling you this I just want to draw a bit of extra attention to what I am about to share with you today… because this time it is different… and even I cannot contain emotions … because it is indeed – a mind-blowing freaking unbelievable miracle!
Well, I hope that I have your attention now :-)
… and probably you think that I am going to demonstrate a quadriplegic child who miraculously went from horizontal incapacitation to running around and jumping on a single leg? – Sorry, not this time…
This type of stuff – “a developmental airlift “, or a “developmental helicopter ride”, that allows to skip phases of development – is cut of heavenly cloth. I am much more earth-bound.
Nonetheless the transformation that I am about to share with you counts on a scale of miracle as long as we stay earth-bound and realistic.
What I am going to demonstrate is an exceptionally rapid structural transformation of a classic distorted and merged quadriplegic pelvis following the “egg” work…
Let’s proceed to the video to have the entire case well illustrated…
I hope that I have managed to get you excited enough to sit through a 35 minute video…
First I wanted to charge straight through to the comparison of before and after – but afterwards decided that it is going to be of greater educational value for you to have it done in 3 parts:
- Normal pelvis structure and X-ray
- Typical pelvis of a child with quadriplegic Cerebral Palsy that ends up under the knife of an orthopedic surgeon with a massive intervention (bone cutting, metal screws insertion etc.)
- The “mind blowing freaking miracle” – amazing transformation of the pelvic structure in a severe spastic quadriplegic child following the “egg” rolling work delivered by the ABR superstar man – Alexander “The Great “from Greece :-)
And all that leads to a not so subtle hint – your child’s future is in YOUR HANDS – but these hands have to be skillful to extract the full potential that ABR work has for your child… – so you need to study and practice and pay attention to detail without rushing to “I got it –can I go home earlier?”
P.S. I am going to add a couple of final episodes to the previous video – “Cerebral Palsy and fascia science in a tea cup” – and I hope are going to appreciate the connection that my tea cup simple example of the relationship between a dense film-like membrane and porous underlying gel has with the specifics of skeletal transformations in Cerebral Palsy pelvis…
P.P.S. Comments and likes are most appreciated.
This is a mini-post that illustrates that sometimes valuable insights into the fundamentals of what’s happening to fascia and musculoskeletal structures as a result of challenges associated with cerebral palsy could be gained from most mundane everyday experience – from observations of what’s happening in a tea cup –literally…
Anyone who had a training by me knows that: 1) I am a tea fan; 2) that I have a tendency to leave cups with unfinished tea everywhere opting for the new cup of a fresh tea instead..
Well, I’ve been criticized for this untidy habit more time that I can remember – to no avail I must admit… However, sometimes there are some unforeseen bonuses that come out of it…
For the recent weeks I’ve been thinking a lot of how to visualize for parents the effects of fascia layers adhesion in case where the flow of the interstitial fluid is affected and how we can restore their proper division by means of Thermoplastic elastomers (TPE) as the Force Transfer Medium [well that’s the official title of “egg rolling” :-)]
So couple of days ago I looked at one of my cups with the tea leftovers from a previous day … and found and excellent illustration ..
I hope you are going to find that metaphor/ spatial homology useful and insightful
As usual Facebook likes and comments are most appreciated