Back to School: Part 2A School-Based Physical Therapy

    

     Many children who have severe special needs and attend public schools will receive a "related service" called Physical Therapy through their IEP.  In many cases, these children are neurologically affected because of a brain insult, i.e. stroke, cerebral palsy, traumatic brain injury, muscular dystrophy, genetic mutations, metabolic disorders, etc.  These diagnoses result in movement disorders as a result of spasticity, dystonia, contractures of limbs, scoliosis, hip subluxations and a host of issues which impact a student's ability to progress educationally.
     From my experience as a high school principal for over 30 years, physical therapists and their assistants work with students to overcome these deficits to some degree.  Most of their efforts result in more severe, sustained damage rather than good.  Most IEP's call for 30 minutes of PT about 3 times a week; the equivalent of receiving no service at all.
       A bit of history is required.  Physical therapy is based on a model which has not changed over the past 50 plus years.  This practice is often in direct contradiction to research and science based evidenciary approaches.  I would assert that most school based physical therapists know little about the human body and movement, but they would be insulted.  I do know that the approach in school based special education program does not work, is not scientifically based and is harmful in many cases.
       Adapted physical education is a component of regular physical education...the curse of most students.  It's actually activity which could be directed by any paraprofessional.  Also PT may be beneficial to those students whose muscles may need some strengthening but possess normal tone.    That's where the value stops.
       School based PT's are infamous for intruding into territory where bodies or limbs or spines are spastic, contorted, dystonic, deformed, non-mobile, etc.  Here is the area which abounds with failure and damage because their bag of tricks is rooted in orthopedic modeling.  The bag of tricks includes stretching limbs, rolling spastic bodies on therapy balls and bolsters, standers, gait trainers, etc.  They also frequently recommend AFO's,  DAFO 's, and consults for medicines and surgeries.  So let me take a   look at several tricks which cause damage: stretching spastic muscles, standers, and orthotics.
       STRETCHING:  Well, it's obvious that a brain insult results in a collapse in the fascia.  The musculo-skeletal systems are there, but relatively useless without the support of a network of connective tissue called the myofascia.  Without an intact, seamless, strong fascia where the layers glide seamlessly, the other systems don't work.  An inability to hold one's head upright is not a function of a lack of cervical vertebrae, nor cervical muscles...it a collapsed fascial system.  This is a symplistic explanation of a newer view of a dynamic interaction of systems.

      So, PT's believe that if you stretch spastic muscles or contracted limbs, the muscles will lengthen.  When the muscles lengthen spasticity will decrease and movement is more probable or efficient.  The reality is that the opposite happens .. the more stretching, the more intensity of stretching, the greater the intensity of the spasticity.  This occurs in the context of collapsed fascia.  Despite the research, PT's stretch the shit out of kids' muscles.  It never works but you keep doing the same thing.
       Research references on stretching muscles and spasticity:

•        Inferior Mechanical Properties of Spastic Muscle Bundles Due to Compromised Extracellular Matrix Materials
•        Stretching with Children with Cerebral Palsy: What do we know, Where are  we going?   
•        Stretching with Children with Cerebral Palsy
•        Effectiveness of Stretch for the Treatment and Prevention of  Contractures in people with Neurological Conditions:A Systematic Review
•         Electrical Stimulation in Addition to Passive Stretching Has Small Effect on Spasticity and Contracture in Children with CP
•          Spastic Muscles: Victims or Perpetrators?
•          No Scientific Evidence on Use of Passive Range of Motion on Spasticty and Contracture in Children wit Cerebral Palsy  Best Review of Many Reviewed Studies
•           ABR Position on Stretching Spastic Muscle

       STANDERS:  Here is another very expensive, relatively meaningless piece of PT equipment which after a few months of use ends up sitting around.  There is minimal research concerning the effectiveness of standers.  A PT will say that it allows a disabled kid to appear more "normal" in that he or she can be at eye level with kids and adults.  OK?  The only research that I was able to access was that over a 6 week period of time, standers did temporarily lengthen hamstring muscles ...note for only six weeks.  Anyone know of positive research?

Place this child in a stander with the effects of
gravity and you will amplify the existing curvature

      Of course the negatives are big negatives.  Strap a kid in an upright stander and imagine the strain on the system?  Here is a scenario with my son, Adam, in a stander for one hour a day.  First you have a weak core of fascia which envelopes the trunk.  Oh, the fascia supports the muscles and the vertebral column.  So, a weak support system of fascia leads to uneven support of the spine.  Some muscles pull left, others right, some are weak, others strong....a tug and pull on the spine.  Add an upright stander and add the effect of gravity pulling the cores and the spine downward...the weakness of the fascia provides the ground for an unequal distribution of forces which allow the gravity to pull downward unequally on the spine.  The result is scoliosis.  Once the curve is initiated, the more time in the stander, the greater the curve.  Seems simple.  The cure for the resulting scoliosis is either orthopedic intervention by fusing vertebrae or inserting titanium rods which have snapped due to increasing spasticity. 

Piss poor operation to insert a titanium rod
to solve the problem of scoliosis

This is a high price to pay for eye-level positioning.   And, the surgery further weakens the fascia through scaring and adhesions.   Do no harm?

•        Effects of gravity, etc on Scoliosis 
•        Standers in School Settings and Evidence Based Research
•        Standers Blog Post by Leonid Blyum (ABR)

      Orthotics?  They take the intricate web of bone and assume it's similar to a hoof.  One simple joint at the heel or the ankle.. The purpose?  Dunno!  Can't correct a deformity, can't strengthen the myofascia, can't prevent spasticity or contracture ... do have some mild effects with children who are walkers.  Big money and they hurt!

•    Braces and Orthoses in Cerebral Palsy (YouTube explanation of why they do not work in most cases)  

      For the past 50 years we have considered the same interventions based upon faulty assumptions of how the body works while there is skepticism towards newer approaches which have positive and non-intrusive effects on the body.  But they don't teach these in PT schools which are probably endowed by durable medical suppliers and keep making the same devices without peer-reviewed research as to their effectiveness.  I truly believe that the present system of school based physical therapy is minimally bogus and generally dangerous.
      I could share thoughts and experiences in more depth on orthopedic surgery for scoliosis and various subluxations, on spasticity meds and baclofen pumps, and I will on request in a later blog, but only if there is interest (please comment if you want me to explore interventions of orthopedics or physiatry). 
      The follow up post will focus on promising modalities which work more effectively than the old stretch and pull. There are a number of promising approaches based on scientific evidence that you won't see in school, unless, of course,  you throw a hissy fit as a parent.  Remind PT's "FIRST and Always Do No Harm!"

ABR Egg Rolling on Adam's Back...Fixing Lots of Stuff

       Well, Adam has scoliosis (which has improved dramatically); a depressed vertebral column; insufficient space between the vertebrae, and intercostals which seem to fuse ribs together. Also the illiacs and the sacrum need to be shifted forward. These issues are common to the collapse of the myofascia which often are a result of Traumatic Brain Injury and a near drowning.    
         And so, here is a video in which Leonid explains how to use the egg and the "blob" to roll on Adam's back and extract the dural column and "unglue" the intercostals. The instruments and the technique have been further developed since our last visit six months ago. We expect clearer and deeper respiration and increased flexibility as well a strengthening of the core.

ABR Egg Rolling Demonstration on Adam ..Separating Upper Ribs from the Clavicles

The New, Improved Egg Rolling Exercise...a demonstration of refinements to the egg rolling exercise by Leonid Blyum. This video focuses on selection, hand technique and work on separation of the clavicle from the 1st and 2nd ribs and their connection to the manubrium.  The fusion of the myofascial fibers  result from their collapse during the aftermath of a traumatic brain injury, This separation is vital for the improvement of respiratory processes in the upper thoracic regions of the upper anterior portions of the chest wall.

 

New ABR Exercises . . . Onward and Upward

              Advanced Biomechanical Rehabilitation (ABR) is our primary therapy used in Adam's rehabilitative journey.  It is supported by a host of other complimentary approaches as we we continue on this long journey.  The previous post focused on Adam's evaluation in Montreal which informs the exercises described here.

Intense, super soft ball mini-rolling on Adam's head

     Two full days of training, after a comprehensive evaluation,  provide us with the next six months of body work on Adam.  The theory which underlies ABR continues to unfold, it is never static.  The applications also unfold; there are new techniques and new targets to focus upon.

Application to Adam's ever expanding thighs

      The changes in application are significant as two new theoretical constructs are explained.  We will, of course, continue to support and reinforce Adam's hydraulic structure and numerous applications are targeted at the head because the head is the nexus of the hydraulic system which supports the myofascial layers...strengthening of the layers lead predictably toward mobility and eventually function.  Even in the tiniest embryo, you see a head and a rudimentary structure which develops...the remainder of the body develops from the head in the womb.

Leonid supervising Sharon's back of the head technique

       Two new constructs;  intense ball rolling and super-soft balls.  We learn a targeted ball rolling which is much more intense with a greater manual force exerted .  It goes deeper, it allows a penetration of the stress shielding layers of the body and above all it accelerates the rates of myofacial strengthening and change.  Change actually accelerates.  Super soft balls are actually the same structures which are further deflated and allow for greater coverage of the target areas.  This technique is especially applicable to the head.

Leonid demonstrating the positioning of head applications with the super soft ball

      Again, the applications provide for compression without distortion...intense compression of ball with mini rolls and a solid transfer medium...the energy of the process is transferred while bypassing the stress shielding factors of the outer body.  Strengthening the core ...structural change, mobility and function...a predictable course of change.
       And of course, ABR would not be complete with the more traditional 3-Q technique (quasi-static, quasi-spherical, quasi-isotropic).  We have three new 3-Q applications which target specific areas of the head.  These are targeted applications which are very specific to areas which need to extracted.  We are working on areas below the occiput and on both platforms behind the ears.  Intense ball applications focus on the head (both top and back); three areas along the vertebral column, the sacrum, fifth - eighth vertebrae on the thorax, shoulder apexes,and  both thighs.  We usually work on Adam several hours a day; Maribeth usually does 5 hours of applications every week.  Changes are definitively happening and at an increasing pace and in a very positive direction.

Maribeth employing the 3-Q technique on the lower lateral neck platform

     Oh, yes...Adam also has two ABR machines with 8 bladders inflating throughout the night..sacrum, abdomen, hips, thorax and mid vertebral column...also a set of high quality ear plugs.  He sleeps like a baby.
     Before you feel bad for Adam because of all the ABR, please remember that we usually give him one a week off from all therapies.  Really nice of us, no?

      For my adventurous readers, Leonid will be presenting and doing a live assessment at the Pacific Rim International Conference on Disabilities on April 18 in Hawaii ... still time to sign up...LINK to brochure.   It would make for a nice vacation on short notice!

ABR (Advanced Biomechanical Rehabilitation)...Evaluation: Spring 2011

       ABR is a biomechanical approach to cerebral palsy, brain injury, stroke, near drowning and other brain assaults.  With such an injury, there is a progressive collapse of the myofascia which supports the musculo-skeletal systems.  The myofascia are bands of interconnected tissue which allow systems to function as a whole.  This collapse is evidenced in scoliosis, hip subluxation, spasticity, dystonia, contractures and numerous motor impairments.  ABR believes that parents, with training, can bring back volume to the collapsed structures.  With a functional body hydraulic system, normalization of structure through the strengthening of the myofascia produces mobility and function.  All change is a function of non-invasive procedures: traditional physical therapy, orthopedic procedures and surgeries are avoided, and the use of botox is eschewed.

Adam and Leonid, sitting with some support

       All sessions are preceded by an evaluation of all the structural components of the body.  Skin quality, tone, volume, function, change are considered in the development of individual prescriptions of various activities.  Evaluations usually last one to two hours and are video-taped and photographed so that long range change can be plotted both for personal and science based reasons.  Change is evidenced in photos over the years.
       We have just returned from Adam's evaluation in Montreal by Leonid Blyum, the developer of ABR.  It's important to note that Adam is among the most compromised ABR clients given the extent of his brain assault:  25 minutes under water.  Numerous children and adults have lesser structural issues.

        In the last six months, Leonid noted that the skin quality of Adam's upper arms and volume in his thighs has significantly improved, making room for muscular expansion.  He is eating better as his jaw is more properly aligned.  His thorax is now level (originally the left side was higher and the right sunken). The space between his vertebrae has expanded and the ribs are rotating toward the proper positions.  His spine is gradually straightening and the pelvic floor is moving into a more proper position.  We are very pleased with evaluation, the observations and ongoing predictability of change.

Sharon, Adam, Leonid...thoracic evaluation

        Over the next two days, Leonid introduced parents to further refinements of ABR theory and applications and we were trained in new specific applications to continue the change.  Despite the severity of Adam's injury, his health is superb, spasticity lessening, and his body normalizing.  It's a marathon, over seven years so far, and probably many more.  The change has always been unidirectional and that is in a positive, predictable direction.  The following blog will examine some of the new prescriptions and and areas we will work on for strengthening.  Underneath all spasticity is underlying weakness of the myofascia layers.

Leonid, Gavin, Sharon..examining new folds as they emerge

ABR . . . Returning Home Again

Leonid Blyum, ABR developer

“The soul of man with all the streams of pure living water seems to dwell in the fascia of his body. When you deal with the fascia, you deal and do business with the branch offices of the brain. That is as under the general corporation law, the same as working with the brain itself, so why not treat it with the same degree of respect?”  (Andrew Taylor Still, Founder of Osteopathy, 1899)

     Within the many layers of myofascia, we find the muscular and  the skeletal systems normally supported.  With anoxic brain injury ,CP, stroke, etc., there is a collapse of these layers of supportive tissue wherein the whole no longer functions with integrity and mobility is lost or compromised  Fundamentally, there develops an inherent weakness which lies underneath the spasticity and contortion of the body.  Given the fact that motor neurons do not regenerate, there are alternative pathways to mobility and function.  The ABR techniques (Advanced Biomechanical Rehabilitation) reach into the visceral core and strengthen this tissue layer  which in turn normalize structure and brings mobility and function.  ABR is scientifically researched and supported through the science of tensegrity study.

Rotation of scapula above collarbone, common evidence of collapse  which is treated by ABR   protocol; Adam had a similar rotation which was resolved.

      ABR is not a quick fix, but a long term therapeutic process carried out by parents as a result of regular evaluation of progress and application of new techniques.  It does work and this is scientifically documented and research continues as progress of clients is measured against the expectations of  the GMFCS scale.  We are starting year 8 of Adam's journey in the ABR process.  It has reinforced good health and strengthened respiration (vital in all cases of brain injury), radically changed his thoracic landscape, clearly improved his scoliosis (by expansion of the volume between vertebrae) and reduced his overall spasticity.  Adam is also among the most compromised and complex of the ABR population.  The progress in the normalization of his structure has been marked, and this is a common reflection of many ABR parents. In the past 8 years, there have been no surgeries, no medications of any kind, no orthotics, no hospitalizations, no emergency visits to the doctor.

      It does take commitment, a minimum of 3 hours of manual application per day and can be supplemented by machine applications while children sleep.  Manual applications target specific areas, machine applications are wider and supportive but do not replace the manual.  Each series of exercises are developed and prescribed by Leonid Blyum, the developer, through either a personal evaluation at the center or by video.  In the initial years, four sessions of training are required either in Montreal or satellites across North and South America.  After a number of years, the evaluations are reduced to bi-annual.

Leonid Blyum, hands on evaluation

       We are looking forward to Montreal March 30 to April 3.  Leonid will skillfully point out changes in Adam's structure, he will prescribe a new set of applications for manual and machine work, and the trainers will develop the materials required and provide training in the specifics.  Above all, we look to Leonid to be our cheerleader as he recognizes a predictable pattern of change...change is predictable.  ABR is a backdoor to mobility and function.  It is based upon pure research and science.  This blog contains many links to ABR theory, application and work of the centers around the world.  ABR makes rehabilitation and progress in the area of brain injury possible.  Parent blogs are replete with stories of significant change.

Fehim Medinic, a trainer, observes Sharon's technique on working to  normalize the pelvic floor.

        So, next week marks year 8 and it marks a re-dedication to our commitment.  After the sojourn in the big city, I'll have an update of changes, improvements, new techniques and pictures galore.  While we have tried almost every available realistic therapy, this is the only one which produces positive structural change which is permanent.  ABR eschews any orthopedic surgery, DAFO's, standers, and poisons (botox, intrathecal baclophen pumps), traditional strategies of physical therapy which are all contra-indicated.  Scoliosis, hip subluxation, contractures are non-surgically and non-invasively treated.  It works, it's tough, it's a long commitment, but it's a true expression of love of your child as he/she moves to a normalized structure.

www.blyum.com