Month: September 2016

 Human movement is dependant upon precise limb/trunk coordination.
Due to the lack of a sufficient intrinsic structural stability of the trunk – most notably in the spine itself – children with special needs lack the spinal strength and mobility necessary for initiating movements from the trunk.

The stiff or immobile spine leads to disrupted limb to trunk coordination, which becomes obvious both when the children attempt to move or when movements are initiated with them from without.

The inhibitions in the sequence of movement between trunk and limbs in a child with special needs leads to the various difficulties the children experience when trying to carry out movement sequences and weight bearing functions. When the child is small it is often possible to attain a functional level through training and exercising, but this level often diminishes when the child grows and the limb trunk proportions change through normal growth.  This deterioration in function is evident in the GMFCS motor score curves seen clearly with the GMFCS Levels III, IV, and V:

Typical of this lack of a sufficient trunk limb coordination is also a tendency to carry out “robotic” movements, to use excessive muscular effort and also to require a high level of  concentration for carrying out movements.

Older and adult individuals on the other hand may have developed some level of gross motor function, but this function can also most frequently be characterized as ”stereotype” or ”robotic” in nature. This robotic function often leads to joint distortions, stiffness, pains and discomforts, etc.

The purpose of ABR exercises is to create the environment and the conditions that support the child or adult to develop and to initiate the undulatory motions of the spine rquired for creating the proper trunk limb coordination. ABR applications achieve this at ages and stages where it is normally no longer possible for the person to establish this coordination themselves. In fact the integration of these primary movements and  stages of movements connected to the spine,  belong to the earliest motor developmental moments of life  – which normally are completed between birth and  six months of age. If this coordination is not already established by then, the child or adult can no longer initiate and establish these intrinsic movements on his own.

ABR Techniques  open a new door of opportunity for such individuals.

The sequences of activation necessary relate not only to the trunk and the limbs in their related coordination, but also correspond to specific muscle fiber types belonging to the trunk and limbs respectively.

The muscle fiber types that react first during normal muscular activation are most highly integrated within the trunk (type one) and those that have a higher reaction threshold (type two) are more highly integrated within the superficial muscle layers  of the limbs.

Whe persons with Cerebral Palsy, or other illnesses affecting the motor skill function go through training or ordinary rehabilitation and other exercises – this out of necessity will tend to initiate an inverted sequence of reaction within this highly organized muscle reaction sequence.

The waking up of and activation of the type one muscle fibers of the trunk belongs intrinsically to ABR work which is designed to install the “baby stages” of deep intrinsic undulatory spine movement in children and adults who have long left the baby age – and also in those children who may be  at this young age and are too weak or too stiff to initiate the proper coordination between the deep intrinsic muscles of the trunk and those of the limbs on their own.

ABR Techniques for the spine and trunk are based upon a re-integration of a proper trunk-limb coordinatinon.  To further support the active integration of these movements we have a variety of specialised techniques:

ABR based active exercises that we call PAVES or “Peri-Articular Visco-Elastic Stimulation”. These exercises work to strengthen the trunk, encourage the development of deep undulatory trunk movement, stabilize the joints, etc. without causing stress to the persons weak structures and without creating a high cost to the individual’s energy household level. These exercises involve the application of specific and well-controlled movements applied : soft gymnastic balls, soft room trampolines and visco elastic pillows and materials.

TheraTogs Usage is in itself a great way to promote a healthy coordination of limbs and trunk.  The TheraTogs is a specialized garment that helps children with special needs to stabilize their trunk.  When trunk stability is present and the child is not so highly dependant upon muscle tension for creating this stability, then the trunk can react in a more appropriate manner and it is possible to establish the proper sequence of activation of the limbs in respect to the trunk.   This garment can easily be integrated into daily routines. It will add a significant advantage to all movements performed by the users. It adds  tensional uniformity and intrinsic pre-stress to the trunk , which in turn allows for a higher freedom of limb activation. At the same time it encourages physiologically sound tissue remodelling – creating a continuously improved intrinsic foundation for movement development.

Diane Vincentz
Director
ABR Denmark Aps

This concept of “Wrong place, wrong movement” allows us to administer a more exact analysis of functional limitations of movement, than the commonly recognized ideas regarding the range of motion, spasticity, etc. These classic concepts fail to recognize obvious structural links within the musculoskeletal system that directly lead to conditions such as: hypotonic cases, cases of fluctuating tonus or even the more classic cases of spasticity. And because they fail to analyse the deficiencies of the musculoskeletal structure, the classical methods of treatment also target false areas of the body for treatment through stretching, training and even surgery.

If we take the example of a classic case of a spastic child with Cerebral Palsy (CP), the most obvious and visible problems would be regarded as limited mobility of the arms and poor alignment – or even deformities – of the shoulder, elbow, wrist and hand. The classic approach of physical therapy in such a case would be to try to force extra mobility, either through stretching or weight bearing – via attempts at crawling, kneeling, etc. However, even when hundreds of hours are invested, such attempts most often fail for the quadriplegic CP child.

Why is this?

The concept of the wrong movement – wrong place helps to illustrate why direct forceful measures fail to succeed in improving the mobility of the arms in such a case. The healthy individual serves as a comparison for wrong place/wrong movement whereby the opposite situation is at hand: right place/right movement.

For the healthy movement of the arm right place/right movement requires two fundamentals:

Stability of the entire shoulder girdle including the shoulder blade, the clavicle, and the connections between them and other neighboring elements.
Mobility at the shoulder joint – which provides the ‘right place’ of movement for the variety of arm performances.

In a typical case of quadriplegic CP, one can see that the primary difference between such a child and a healthy person is the excessive instability of the shoulder girdle. In such children it is not uncommon that the shoulder blade can slide as far as onto the posterior neck. At the same time – due to instability of the joints at the sternum – the clavicle typically collapses into the lateral neck. The limited mobility at the shoulder joint, as well as the poor alignment and distortion of the entire arm, is a secondary consequence – although the easiest to notice. This is exactly the situation described by “wrong place/wrong movement”. This also explains why direct attempts to force improved movement of the arm via stretching, in the end results in increasing the instability of the shoulder girdle – in other words the movement in the “wrong place”. What we actually need to achieve is to increase the stability at the level of the shoulder blade – in the ‘right place’ – instead of promoting the mobility at the “wrong place”. ‘Wrong” mobility of the upper arm then causes the ‘wrong’ movements in the elbow, wrist etc. These ‘wrongs’ accumulate and amplify with each level of the body, and as a result, the hand is usually the most visibly affected area.

In addition, in severe cases the shoulder girdle could easily become so distorted that the ‘wrongs’ compound upon each other: due to the initial instability it could shift its position so badly as to become immobile as well. These are the situations where ‘fixed’ deformities are visible.

Obviously, the same principles are true for the legs as well, where distortions and wrong places of movement at the level of the pelvis, abdomen and lumbar spine cause secondary spasticity and limited movements at the levels of the hip, knee, ankle and foot.

This concept of the right movement in the right place gives us a working roadmap for rehabilitation. Right place, right movement could be seen as an obvious neutral point or “zero” level − as the starting point from which a normal or healthy child begins to develop his motor functions. Depending on the extent of distortion of the musculoskeletal structure and the general depletion of the internal structures, a CP child might have reached a negative level being as low as [-5] or [-6] below the zero level.

This understanding of the zero level as being equivalent to “right movement – right place” is essential for any rehabilitation strategy. Any attempt to teach the child to have some function within the limits given by a structure composed of negative components, can at best be a gamble at best The outcomes are unpredictable and even the achievements are very short-lived. Any extra motor activity based on the “wrong movement – wrong place” achieves functional gains at the expense of further distortions and aggravations of the structural negatives.

The ABR approach is based on a long-term improvement strategy. A child progresses by reducing structural negatives with functional results following spontaneously. Only after arriving at the “zero” level of normalised bodily structure and mobility, can the focus of rehabilitation legitimately shift to true gains in function. First at this level, can a child truly begin to build the strength and coordination necessary for dynamic function.

Hence ABR is often described as the process of the reduction of negatives. It is necessary to significantly reduce the negative structural components before the child can obtain the momentum required to begin achieving functional improvement through increasing motor activity. First then can the child’s own motor activities bring extra strength and improvement of structure at the right places via healthy movements.