Poop Hips

Poop? Seriously? That’s the name of this book?

Yeah..yeah.. I know. Gross.

But, are you aware of how close the phrase “potty mouth” comes to being real in our more involved kids with neurological injury? And why is there such underwhelming interest? It gets the General Custer treatment. Doctors looking at hip x-rays look right past a cause of many big surgeries that these kids come to as well as it being a source of grief and woe. Do you know what’s neat about being an anesthesiologist? Where others only get to SAY “Up your nose with a rubber hose!” anesthesiologists get to do it every day, often to those undergoing big surgeries that could have been prevented. Poop matters. It matters in situations most don’t even suspect. This book has only one main goal. To get this detail to be taken seriously: Most of the hip dislocations operated on in CP are preventable and caused or contributed to by BOWEL malfunction. BOWEL ! Especially when paired with dystonic reactivity.

Deaths are caused by BOWEL; from chronic bowel obstruction getting dismissal as commonplace & OK. If a big fast asteroid strikes Earth and billions die, is it OK as death would be common? Let’s start at the very beginning, in a loose sketchy way for the obvious underpinnings we all kind of know about but maybe in differing contexts. There are bacteria. They count, but, we’ll set them aside for later. A long time ago, plants got quite diversely complex. They gave and still give us oxygen. Nice. No drum to beat there. Then came the early weird animalish things. Eventually, one of them got itself up onto land – perhaps to escape others who wanted to do what all of them did and still do… engulf. Engulf food. Back then anything “not me” was probably food. An animal, basically, a tube. Engulf and digest. If it is too big to engulf, then use something sharp to engulf a piece of it and then digest that. So we wind up with a tube. Whatever, goes in gets digested. Whatever won’t digest either gets ejected the way it came in (primitive tubes were open on one end only), or more efficiently passed on through and out the other end – if it fit. If digestion is too complex, perhaps due to a limited available food source, then help is allowed ( BACTERIA ETC.) which contribute to the digestion and thus nutritional bounty is shared. But many bacteria also make waste which is outright toxic – so – some

arrangements are required for speed of transit and functional shields from toxins and for limitation of the volume of bacteria. Some tubes are really great at capturing stuff to engulf and digest. Sharks in the water, big snakes on land. In => digest => out=> poop. Simple. But what if you block the ‘out’ part? Those tubes go primitive… They go in reverse. Or die. The reverse tube mechanism is very primitive and pretty much intact as higher levels evolved. Some eating tubes are just tubes… snakes. Some eating tubes have fins. Some have LEGS! Legs are nice to have. Four legged eating tubes or two legged eating tubes roam around devouring plants and other tubes … and pooping. Some even have strong opinions about what they allow themselves to devour such as only plants. Where we are going with this? Reverse mechanisms are very strong and waiting to be called upon in need. Primitive and essential: FLOW & CONTENT of that FLOW

Let’s discuss the anatomy of bacteria as as bacteria are a threat to us or a solution for us to handle what we cannot digest without help. The central most important anatomical feature of bacteria is that they have no teeth. They can’t chew nor bite off workable hunks. Their intake isn’t a continuous tube. They must digest nutrients to the simplest form before those are absorbed. Toothless, they must create – on the fly – a stomach. Their environment must become that stomach as a digestion mechanism. A deep wound that traps fluid makes a PERFECT stomach for bacteria. Wide open wounds that have FLOW defeat bacteria. That flow also washes away overt bacterial toxins and digestive enzymes. SOAP denatures the

bacterial enzymes that do the digesting as well as washing away bacterial nasty molecules. It starves the buggers. No immunity to soap. Wounds closed without regard to this will bring on serious damage. Wounds and infections are now to be set aside. Here we begin our topic. How does poop dislocate hips and kill kids with CP?

Our tube is quite long and has different properties from teeth to hemorrhoids. To fit it all in, it gets folded & twists around. Each segment has a different look and differing supportive things that serve that phase of passage (when flow is forward).

Very regionally close to the small and large intestines are the iliopsoas muscles which supply more than 90% of the energy of walking and which have multiple large segmental blood vessels. Just as hearts may project ill sensation into the arm or jaw, these large structures, when troubled, may manifest as asymmetrical leg tension. “Wind swept hips” become hurricane swept. Gut distention feedback may well stay local amplifying regional reflexes and dystonic responses while not making it to pain perception level. Consider it painless pain as the conscious part is blocked.

Look at the wrist/hand posture. Obvious dystonia. A rubber feeding tube and a ‘plication’ (tightening loop) at the lower esophagus were placed to prevent “THE BACK FLOW”. “THE BACK FLOW?” Why is there back flow?

A dystonic posture, the very strong aBduction of the left hip is in combination with very strong and unremitting right hip aDuction skewing both legs to the same side (‘windswept’ left in this case). Abduction tends to protect that side whereas adduction pushes the soft posterior hip socket edge backward until so flat that the hip ball simply and quietly dislocates. It happens with nothing that anybody notices. Braces which spread the legs” actually interCONNECT the legs such that the abducting side makes the adducting side even worse. Just because you want that right hip abducted does not mean that an “ abduction brace” will abduct – at all. Usually not. The legs apart braces we call “hip positioning braces” so as to not linguistically poison perception of what is otherwise obvious to the eye. To put the hip ‘ back in ’ is a delusion as the hip socket is partly gone. Why would it do any better when what was once normal was destroyed by these forces that are still active. Just putting it back in is like resetting a crossbow while pulling the trigger continuously.

Teeth are up here ^

This way is nutrition going in...

This way left overs go out...

So we begin with input too big to swallow. Teeth & chewing also fold in some enzymes from saliva that get a head start breaking down large complex food substances. Much of that substance is, at the molecular level, made of long strings of repeating units. Some are like pearl necklaces of main units connected by links. Most are more like strings of close line clips clipped head to tail in long sequences. Some of those protein and starchy connections are disconnected by the salivary enzymes. Many are burst by the stomach hydrochloric acid. Nasty stuff. That section of the long tube called the ‘stomach’ doesn’t just hold chewed food. It does the bulk of acid type molecule disconnection. It requires an inner surface structure with processes to not dissolve itself. A valve-like stomach entry prevents this acid from touching the less protected tube from teeth to stomach. The tube section going from mouth to the stomach is the esophagus ( Greek: to carry to the gut [phagus = to eat]). A valve at the far side of the stomach helps retain the food in the acid bath long enough to be effective. There is a serious complexity en route to the stomach. These “valves” are rings of muscle that simply squeeze the tube tight in specific places. They must – quickly – respond so as to not block entry into the stomach nor loosen too much and thus allow acid to go into the less protected intestinal regions faster than that section can buffer the acid. When acid flows into esophagus, it burns. There are names of postures that are seen and noted to tell us when a nonverbal person has such burning of the esophagus.

Hmm – low tech – how to confirm? Swallow a pill which has a nontoxic dye or use a plastic tube to place that dye into the stomach. Wait. Does the tongue start to discolor from dye coming back up? Faster high tech? Use a pH meter in the mouth and measure acid. It does not need to be mystery. Raised & contorted arms in a dystonic patient is semaphore for “Hey! Acid is eating holes in my esophagus.” Other pain sources can do likewise. That message needs attention for another compelling complication… the gut and the lungs share a common entry segment. We do NOT want acid going into the breathing tube that it shares with the mouth & throat.

The diaphragm, which separates chest cavity from abdominal cavity has two big holes of interest here. The open one seen here is where a big artery passes (aorta). The other is seen here allowing the esophagus access to the stomach. The diaphragm muscle can assist the valve that squeezes the stomach entry closed. But – if torn or dilated somehow… the

stomach can herniate (poke through) and go in part (even 100%) into the chest. This upsets the mechanics and guarantees common leakage of stomach acid into the lower esophagus.

This is what we don’t want… back flow from the stomach toward the throat and then into the tubes that bring air to the lungs. Acid going where air should go is deadly and can kill. Hmm, a small leak? That’s a big target for such small leakage. Not small. It is supposed to be flowing toward the colon – in the other direction. What happens when the far end gets slowed or blocked fully or even somewhat? Flow reverses. Oooo. Add things that make stools loose (by

holding water)… ??? An even bigger acid volume results. CP kids are not geezers who need ‘plenty of fiber’… as 90% of their

existence. This is a neurological PARALYTIC failure wherein colons get to do what they are meant to do –but too long and too much. Colons are not about nutrition (that train left the station). The colon is about WATER RETENTION - not wasting water. It dehydrates the stuff coming through. If that stuff lingers too long, it becomes bricks. Some flow will, as pressure builds, leaks around the brick wall that forms giving an illusion of bowel flow. Stool may even be very fluid. A skinny kid with a protruding belly is trouble. What can’t go this way ===> then goes <=== that way…. Call in a plumber! General surgeons are called to cure the leaky esophageal valve problem by making a tight loop around the esophagus near that diaphragm area. A “plication is born”. Feeding tricks evolve but the lower gut distends more & more. We have what, in any other clinical setting, would be called intestinal obstruction and that would be handled accordingly. However, “parallel distended loops of bowel” seen right there as you draw stupid angles on the x-rays of hip bones to impress what is visually obvious about those hips – parallel loops of intestine go unmentioned. “Oh, they all have that.”

Meanwhile anti-proton pump meds (anti mitochondrial mechanism) are prescribed to stop acid formation and also dietary acid sources are restricted. Scurvy? What? Kids are ill as massively distended colon bacterial volumes build and toxins are not passed. Those mega-colons become outright toxic… A condition called ‘toxic mega-colon’ is common but dismissed as common constipation. And just as there are very characteristic arm postures that semaphore esophageal acid, the legs muscles – especially those about the hips – go nuts into dystonic postures of very high and sustained tension. That leg & hip tension breaks down the hip socket walls. When there isn’t enough of the socket intact to keep the ball where it should be we get dislocation. Get a bone surgeon guy here! TOXIC MEGA-COLON

Let’s get deeper into this...

What is dystonia?

This is dystonia… a complex multi joint posturing that has directionality but no purpose. I could imagine a mechanic unscrewing a hard to reach bolt down under the engine block using this shape… mmmmm? Here it has no purpose.

If an Italian gives you this gesture, ho boy! But, otherwise, it is another complex gesture serving no end. These are dystonic broad postures from neurological wells that are leaking activity. Sensory input – of any kind – even loud sound - can make these things come to life. Pain from anything might actually not be felt as pain as the path to pain awareness is not always intact. Even so, the local reflexive reactivity to what would have been pain is intact and it acts to amplify the dystonia.

Brain effects that happen low in the nervous system feel as if it is happening to self. But with those, from the very high centers, abnormality takes on a sense of self. So, high diencephalon injury creates a curved sensation space in which a curved patient feels at rest… and centered in curvature, it feels correct. They will seek the postures that we try to rid them of. Often we hear wailing when merely positioned correctly. THAT is dystonia. These abnormalities come from neural circuits that merely react and so they are not willed into or out of. Primitive centers detecting abnormality (patient aware or not) will drive these reactions.

These abnormal neural driven muscle forces have no upper boundary of application. They are amplified by noxious stimulus and can twist anatomy. So, why this mess? What is the connection? The gut tube has its own (and usually intact) nervous system as well as local chemical signaling mechanisms. Bowel and intestine flow have a unifying spatially coordinating system. The “autonomic” nervous system has two main parts. One is mostly stimulatory while

the other tends to dampen activity is a broad sense. Think of it as a bias to do or a counter bias to do less. The central nervous system can boost either or both. Chemical signaling exists as well; especially upper gut releasing chemical signals to lower gut (get ready for what’s coming).

In the absence of correct control, these mechanisms tend to revert to clock like cyclical function. There are tricks to bowel train people with paralysis so as to make toileting not interfere with daily activities. At the most primitive level peristalsis defaults to moving contents from mouth to anus. How? It is easier to visualize in the large colon. ====> First a bowel region narrows closing the lumen at the constriction.

When the next [lower] segments squeeze, contents must move and can only do so in a down-the-line direction.

If distal obstruction exists then bowel distends – inflates - the way a balloon would. It may even reopen the clamping area such that the existing back pressure causes flow to follow a pressure gradient rather than the

peristalsis direction. As bowel distends more & more the muscle thins more and more. Squeezing propulsion power gets lost.

Also, without a good fully closed location, any squeeze can go in both directions. With enough distension flow reverses. Laxatives will only hasten disaster. Mechanical obstruction is MECHANICAL. Pills won’t do anything good. The stretching bowel, often not perceived as normal sensory paths are damaged, is sending up a neurological howl over the more primitive intestinal pathways which spill into central paths and trigger dystonic response. The hips are victims in this troubled neurologic overflow. So, what is this? . . . . Just 4 dots? ?

The typical dystonic hip dislocation is paired with gastric feeding tubes, plications to try to stem aspiration, severe and highly tonic scoliosis, a general malnutrition, and overall unrecognized toxicity from the massive unvented bacterial overload in the colon.

What is sad is that right after the stomach, the duodenum normally gets a load of stuff from the pancreas which neutralizes the acid in the small intestine – especially closer to the stomach. This area absorbs the bulk of what is needed. With toxic mega colon we have those pancreas enzymes pushed upstream into the acid bath. Oy. Malnutrition?

Following the ram’s horns development of the higher brain we can trace the ventricles which are bounded by our culprit brain structures whose damage gets us here. Lots of images are in the Brain books. In spastic diplegia these structures are usually OK. But if the near ventricle injury (periventricular) widens we may tickle these same structures and then see some minimal dystonic qualities in (especially) the hands. The low incidence of lower limb derived periventricular tracts would account for the very much lower issue of both gastrointestinal and dystonia (thus hip joint) problems.

Watch for parallel loops of bowel (small bowel especially) as a clear indicator of intestinal obstruction. Beware of General Custer

remarks from health ‘maintenance’ people.

GI doctors – especially those who care for spina bifida – will know what to do. This is not something for the uninitiated to self treat.