Physical Therapy: Congenital Talepes Equinovarus (CTEV)/Clubfoot

Congenital Talepes Equinovarus

What is it?: Congenital Talepes Equinovarus or more commonly known as Clubfoot is a congenital disorder that affects normal structural positioning of the ankle or both ankles in infants. Infants with the disability will demonstrate an inversion at the talus and calcaneus joint, adduction of the talus and navicular bone, and equinus (or an upward bend) at the ankle joint. It occurs in males more so than females by a 2:1 ratio and if it occurs there's a 50% chance that it will be unilateral vs bilateral.

How does it occur?: There are several theories on the development of the disorder. Structural TEV can be attributed to a trisomy 18. Another common theory is that the deformity is caused by mechanical factors in the womb (mid trimester). There is also a theory that a primary plasma germ defect results in the talus bone being shortened and the anterior portion being rotated medially and plantarly.

How is it treated?: The Ponsetti method is the most popular method of correcting the deformity. Essentially a doctor or therapist will manipulate the feet towards the correct positioning and cast the feet in that new fixed position over the course of four weeks until the limb is properly aligned. Afterward, an achilles tenotomy, or division of the achilles tendon is performed to help lengthen the tendon and increase range of motion and flexibility of dorsi flexion and plantar flexion of the foot. A brace must then be worn for the next four years by the child to prevent possible relapses. This treatment claims an absurd success rate (95%). Invasive surgery is rarely necessary in the treatment of the deformity.

Physical Therapy: Myofascial Release Technique

Myofascial Release Technique

What is it?: A physical therapy technique that targets the soft connective tissue (myofascia) of irritated and inflamed muscle groups accomplished by relaxing contracted muscles, increasing circulation, increasing venous and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia.

What does it treat?: Irritation of fascia or muscles results in local edema, when this edema becomes chronic the connective tissue thickens (fibrosis), which in turn causes more pain and swelling as well as a reflexive increase of muscle tension which completes the positive feedback loop of edema and somatic dysfunction. Ischemia, or restriction of the blood vessels is also a possible outcome if the edema is not treated.

How it's done: There are two common approaches to myofascial release: direct and indirect. The direct approach is essentially deep massage that directly attacks the restricted layers of myofascia and stretches them out. The indirect approach takes a more gentle and sustained stretching/massaging technique and applies it over time, stimulating blood flow and letting the fascia unwind itself.

Criticism:  John Barnes who is one of the most outspoken members in the field sounds like the Ultimate Warrior during his promos and one of those motivational speakers. He talks about "Ancient Warrior" speaking through him and how everyone is unique and the challenges we face. Of course JFB-MFR as his particular extreme view of the field is called claims they can stretch out repressed memories in the myofascia, help the verbal and intellectual functioning of autistic children, contacting the dead (!?), and treating past trauma occurred while in the womb as a fetus (!?) among other outlandish claims. Moreover, there has yet to be very much scientific evidence to prove myofascial release therapy actually works.

Verdict: It's new science but it seems to work. Getting repeatable evidence in the field of physical therapy seems to be difficult. Barnes is kind of a nutcase though.

Physical Therapy: Muscle Energy Techniques (MET) and Craniosacral therapy

Craniosacral therapy

What is it?: Craniosacral therapy is the alternative and holistic system that utilizes palpatation to "listen" (literally, some therapists claim to be able to hear the CSF flow with their hands) to the rhythmic pulse and tide of cerebral spinal fluid (CSF) throughout the brain and spine. Restrictions in the movement of the cranial sutures cause abnormalities in the CSF flow which in turn leads to disease.

What does it cure: Craniosacral therapy claims to ameliorate the following symptoms: headaches, migraines, neck and back pain, motor coordination and CNS difficulties, Temporamandibular joint (TMJ) dsyfunction, autism (!?), chronic fatigue, depression, attention deficit disorder (ADD), and many others.

How it works: Light palpations and massage of the cranium along cranial sutures to release restrictions in the in the CSF flow.

Verdict: Absolute nonsense. Anatomy 101 teaches that the cranial bones fuse together at the end of adolescence. While there is evidence that the CSF does exhibit a rhythm, no significant causal relationship has been proven between it and a person's health. The claims of listening to the CSF rhythm through gentle palpations border on the absurd, in one instance suggesting the ability to discuss with what one proponent of the treatment calls the "inner physician" which seems more akin to spiritual rather than scientific medicine. Studies have shown that measurements of CSF rhythmic rates are significantly inconsistent among therapists. Moreover, some of the dysfunctions that Craniosacral therapy claims to heal are spurious, autism for instance is still a mystery as far as causes and cures go. I suppose there may be some value in the massage techniques utilized in the system but not for the reasons Craniosacral osteopaths claim. There's always a possible psychological placebo affect that could occur as well. Otherwise, the therapy is completely sketchy. It is the physical therapy and osteopathy equivalent to psychology's phrenology.

Muscle Energy Techniques

What is it: Muscle Energy technique is a method of phsical therapy that utilizes joint manipulation and isometric contractions to address decreased range of motion and muscular hypertonicity caused by injury.

What does it cure: Joint pain, musclular hypertonicity, and decreased range of motion.

How does it work:  MET is a direct and active therapy system, meaning it attacks the barriers of movement directly and require active participation on the part of the patient. The therapist manipulates the joints to the evaluate the extent of the patient's decreased range of motion, then places the joint at the barrier of movement and the patient participates in isometric contractions. The isometric conctractions take advantage of reflexive reciprocal inhibition, essentially when the antagonist of a joint is contracted, the agonist is inhibited and relaxed allowing further mobility of the impaired joint. The therapist then continues to further push the restricted movement until range of motion is recovered.

Verdict: MET is a functional and scientific approach to treating decreased range of motion in patients. The technique is similar to propioception neuromuscular facilitation (PNF) stretching.

Long Division

  "His head was a city of paper buildings
And the echoes that remained
Of old friends and lovers
Their features bleeding together in his brain
Once it started it's harder to tell them apart

He was always distracted
By the very mention of an open door
Because he had sworn not to be what he'd been before

To be a remain, remain, remain, remainder" - Long Division, Death Cab for Cutie

I never did feel comfortable in that white plastic folding chair. Its left arm rest had broken on one end and collapsed under the slightest weight, the back legs of the chair were positioned on an unsteady gravel pit that felt as if it would tip over with the slightest shift of backwards momentum. There was no cushion for the chair other than its hard plastic frame that which creaked with every nervous maneuver. I sat among strangers and makeshift friends, all aligned in a circumference in similar makeshift furniture. In the center stood a table, the top of which was obscured by a forest of empty brown beer bottles and cans. I had been welcomed openly into a tightly knit group of pleasant and jovial people despite my presence being foreign and anomalous. I had been given a window seat into the casual weekend night of a group of peers still residing in the college town I had not so long ago called my home. They offered me an invitation to the drinking, games and festivities but I politely declined, content to quietly watch from the sidelines. Or rather was I just too shy too interact? That plastic lawn chair became my fortress and from where I perched I viewed the drunken revelry, grinning in envious approval of my new friends bohemian like energy. I even mouthed the words to the songs they sung, that which secretly I knew most by heart. I sat back in that plastic chair, keeping my feet anchored to the ground, clasped my hands behind my head and stared into the darkness of the night sky. I had been accepted and yet I could not shake the feeling of disconnection, the sense of being out of place and out of touch with what was taking place in front of me. Why the hell was I so goddamn uncomfortable?

I had came up to visit a friend who was soon to be saying her goodbyes. Having known her for some time, it was regrettable that we were not closer friends. She was always someone I admired and her presence was always something I was conscious and aware of. Yet despite occasional run ins on campus we never really connected, somehow time just passed by and what seemed like introductions yesterday soon were to be farewell. An effort no matter how late was still an effort and when I reflect upon all the bridges burned behind me and all the faces I never had the opportunity to formally bid adieu, I was more than enthused to interrupt the boring hum drum grind that my life had become since college and revisit the city town once more to visit her and send her off once more.

Perhaps I shouldn't have gone back with her to meet her friends, maybe I should have said my goodbyes then and there. I was hesitant to go back when she invited me to stay and hang out, knowing full well how shy I can be in unfamiliar group settings. I had came to spend time with her before she left and for a few hours I had enjoyed her company for a Shakespearian play, that was more than I could ask for. Perhaps a finale at that point would have been more poignant and appropriately timed yet I didn't want to seem rude and turn down her offer, this was the girl who single handedly got me to attend math club in high school after all. Or maybe I just wanted to prolong the night for as long as possible, fully aware of the finite time I had available to me.

I never did feel comfortable in that white plastic folding chair but it was not the fault of the chair itself. My new acquaintances never put me in an awkward situation or did anything that would place me at unease. The scorching heat of the day had receded into a cool pleasant breeze and I was in delightful enough company. I mean no ill words of ungratefulness and now that I recollect, I was rather fortunate to have such an enjoyable night. And it was, it was genuinely a fun and entertaining reprieve from the life I had taken up since leaving college and reminded me of how much I missed and loved this college town. In fact I curse my own meekness and inability to overcome my introversion, how easily I was overwhelmed by the group atmosphere and wish I had volunteered more actively. So why was I so uncomfortable then? Why do I sound like I'm in denial and that I'm reassuring myself? Why did I feel like I was invisible, on the outside looking in?

It's a bittersweet epiphany to realize the life you're missing out on with the people you miss. Despite all the accommodations, something deep down inside me knew that I would never truly fit in with these people and that I would always feel uncomfortable sitting in the white plastic lawn chair. They were not my friends but hers and with an almost jealous longing I watched as she interacted with them with such ease. With my head in my hands I recalled the last time I had felt so relaxed around those I had called my closest friends. The memory seemed so old that the details and features seemed to bleed together in my brain. There was no way for me to participate because I was never truly there to begin with, I was instead lost in my own memories. These people were actors putting on a surreal play that recalled echoes of my own Saturday nights of my own past and I a passive audience. As the night dragged on and the fatigue set in, it became increasingly difficult to subdue and keep clandestine the swelling of conflicting emotions inside me. Joy mixed with bitter envy for what was and no longer is and the pervasive loneliness that such feelings yielded, I began even to hate this city that I had once considered a sanctuary. So many people in my life have moved on and here I was witnessing yet another friend leaving me, no longer would I likely run into her on campus as I no longer run into the many faces that have left me behind. I was disconnected from these people not by place but by time, for them they lived in the moment yet for me I remained in the past.

I will miss her as I miss all my friends that have passed me by. Sometimes it seems like you're never really ready to move on and say goodbye, until life has already passed you by.