Short term vs. long term and Level 5 against Level 1 and 2. This is the question we often receive from parents. It is a good opportunity to explain fine details that parents often are not aware of when they observe the changes acquired by passive stretching.
What are the results that parents usually want to achieve with passive stretching? The reduction of muscle and soft tissue stiffness, elongation of shortened tendons and ligaments, improved range of motion and prevention of contractures in the cases where they haven’t developed yet.
To be able to debunk the question about the results of passive stretching, I would like to make three important points:
- Short-term changes vs. Long-term changes.
- Understanding the difference between the strategic and tactical reasoning in relation to the rehabilitation process.
- Level four and level five vs. level three, two and one on Gross Motor Function Classification System (GMFCS).
- Connective tissue remodelling prospective.
I.
Firstly, I would like to state an obvious thing: when passive stretching is applied to certain shortened and spastic structures (muscles, tendons, ligaments) immediate changes follow. Stiffness reduces, muscles get more relaxed, tendons, ligaments and other soft tissues get more elastic. Even the range of motion increases. This is what parents usually perceive as a result and I agree that to some extent that is the case. But, numerous times, parents themselves report that after the passive stretching is applied, the result diminishes in a matter of a few hours or one day.
They often ask why the results do not stick.
- Short-term changes. They emerge because passive stretching increases the friction between the fibres and sheets of soft tissues, consequently the temperature inside of the tissue rises which initiates immediate changes in Extracellular matrix (ECM). ECM becomes loose and more fluid. In return, that increases the lubrication inside of the tissues. Soft tissues become softer, more pliable, and elastic. That is why the stiffness reduces, the range of motion increases. But when the stretching stops, ECM soon returns into the more solid state and positive changes are gone.
- Long-term changes. In the previous articles, I wrote and showed that if passive stretching is done for a long time and in a manner that is not precise, it can bring negative changes such as adhesions, fibrosis, and scarring of the soft tissues. The point is that even though in the short-term we can observe some changes which really are beneficial, it is more likely that in the long run we will damage tissues and cause the mentioned negative changes.
To summarize in simple words: short-term effects are welcome, but if stretching is used very often it will bring damage to the tissues which in the long run will bring fibrosis and scarring.
II.
When we talk about the strategy and tactics, one would connect these terms with military or war.
You are not far from the truth. But, to be able to explain my point, we need to differentiate between the following two:
- The strategy is the big, overall, long-term plan on how to achieve a certain aim – how to achieve some big goal, sitting for example.
- The tactics are practical planning of each individual step and action to fulfil the actual goal which will bring us closer in achieving our strategic aim – plan of the actions on how to achieve for example 1-2h of BDA daily.
Why am I explaining something which at first glance does not have any connection to the topic of passive stretching? Well, actually it does.
In my practice, I often see that parents are assessing the success of the rehabilitation process based on the tactical reasoning instead of strategic and are confusing those two. This is where most of the disappointment comes from.
When you set the strategy, everything that you do in the tactical/everyday level should be in line with the strategy and not against it. This is where I think that many parents stumble. Strategically, they have an idea and a plan, but on a practical level, sometimes it happens that they are doing actions which drive them away from the strategic aim. This usually happens because they mix short-term benefits for a long-term achievement!
Now, when I wrote this, I want to be clear that I do not imply that you should never do passive stretching. It only means that you need to differentiate in your head that passive stretching can be a useful tactical tool when you use it just from time to time to reduce stiffness, pain, increase the range of motion of joints and increase comfort.
But, do not expect that passive stretching will give strategic results. It does not have that power and it should not be used regularly, because in that case it brings damage and works against your long-term strategy.
Do not expect that stretching will bring long-term benefits, and if you are clear with that and you start using it with that mindset – then you are safe.
Different tactical things which can contribute toward overall improvement and work in the positive direction are all non-invasive procedures and treatments which help the child to relax, regenerate:
spending time in the pool, warm baths, soft massage, osteopathy treatment, hippo-therapy, etc.
Surely, there are exceptions because children with cerebral palsy and other neurological conditions and diseases can be very specific.
III.
There are children with neurological conditions and diseases with different levels of severity in relation to motor functions. Gross Motor Function Classification System (GMFCS) classifies them in five levels.
The first two are the easiest and fourth and fifth levels are most severe. It is no surprise, to assume that the first two levels are, from the point of body structure, most preserved and that fourth and fifth levels are the weakest. Their structure is more damaged, more fibrotic, more dried out.
It is also not hard to conclude that parents of the children in a less severe condition will report more short term benefits and less long term adverse effects, while the parents of the children belonging to more severe levels will report less short term benefits and more long term benefits. Always have in mind who you are talking to. Whether you are talking to a parent of the first level or fifth level child.
IV.
Why am I so cautious about passive stretching again?
From the point of connective tissue remodelling, it can go in a positive direction and support the healing process and strengthening, or it can go in the negative direction and go toward pathology, fibrosis, and scarring.
The way we mechanically treat the body is what makes the difference !
Connective tissue is sensitive to mechanical loading, mechanical force, whatever you want to call it. Don’t forget that research showed that stretching of the collagen fibre of 4% of its length brings healing and positive remodelling cycles. But stretching of the collagen fibre of 8% of its length brings pathology and negative remodelling cycles. (Boris Hinz, Sem H. Phan, Victor J. Thannickal, Marco Prunotto, Alexis Desmoulière, John Varga, Olivier De Wever, Marc Mareel, Giulio Gabbiani, 2012)
During normal tissue repair, such as skin wound healing, the controlled and transient activation of myofibroblasts contributes to the restoration of tissue integrity by forming a mechanically sound scar. For example, scars stabilize the heart muscle after myocardial infarction and tendon, bone, and cartilage after fracture or rupture. However, when myofibroblast activities become excessive and persist, beneficial tissue repair turns into the detrimental tissue deformities characteristic of organ fibrosis.
From this being said, we can see how small the difference between the healing process and damage and chronic inflammation which can bring the opposite effects.
Passive stretching has the potential to damage tissue in the long run, while soft tissue stimulation which we promote so much in BDA, has potential to repair and build connective tissues which in the long run will bring more benefits. Not right away, because the connective tissue remodelling is the process in which the body needs one year to replace one half of old collagen with a new one.
There is one more study which talks about soft tissue manipulation as a potential tool for the reduction of inflammatory processes, the processes of adhesions, fibrosis and scaring and the promotion of positive connective tissue remodelling cycles which in return will push forward a child’s development.
Loghmani MT, Whitted M (2016)
This short review provides an important perspective on soft tissue manipulation/mobilization (STM) as a powerful and direct form of mechanotherapy, which has significant implications in physical rehabilitation, disease prevention and health promotions. STM, e.g. therapeutic massage, whether administered by hand alone or with a rigid device, is a type of manual therapy frequently used by clinicians worldwide to address common musculoskeletal pain disorders. It is a type of mechanotherapy that applies non-invasive mechanical stimuli to the surface of the body to influence molecular, cell and tissue structure and function via mechanotransduction, ultimately leading to improved clinical outcomes. A brief overview of mechanotransduction is provided, with a focus on the ECM integrin-cytoskeleton pathway, and the impact of STM mechanical stimulus on different tissue types are considered in this article. On-going research is suggested to further validate STM as a viable, cost-effective treatment option in an aging population and the clinical relevance of STM is discussed. STM intervention should be approached as a prescription, a targeted and precise form of mechanotherapy in which optimal dose pressures and frequencies are delivered to achieve desired outcomes and advance the field of soft tissue manual therapies.
