The clearest means of describing the connection between structural deficiencies and functional limitations is through an understanding of the ABR based concept described as: “Wrong place, Wrong movement “ .
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.