To be able to answer this question, we first have to agree on a certain realisation. For many years, the condition of the children with neurological disorders has been explained through a concept which took into account the damage of nervous system structures (the neurological part of the equation) and how those damaged neurological structures influence and interact with muscles and bones (the muscle-skeletal part of the equation). Further, how they influence the motor functioning of the children and their everyday activities. Classical rehabilitation approach and all of its tools, instruments, and procedures are built based on that understanding and knowledge. It is very important to note this fact. This was before we acquired extensive knowledge about the roles of connective tissue in the human body.
To put it simply, there was no understanding of fascial tissues as an important and integral part of human biomechanics. As a parent of a child with special needs, you will even notice that in the classical approach of rehabilitation there is not much mentioning of the connective tissue. Maybe, not at all. You will notice also a strong focus on the muscle-skeletal system. That is also the reason why in the classical rehabilitation approach, recommendations will revolve around the importance of stretching of shortened, spastic muscles, without paying any special attention to how that may affect the connective tissues in the long term.
In my experience, even though the new knowledge on connective tissue is emerging, the same procedures, same tools, same instruments keep being recommended for solving the problems of the children with neurological disorders in the classical rehabilitation paradigm. Inside of that system, work simply continues based on the principles of the classical approach of rehabilitation as if nothing has really changed. Business as usual. From the point of information, there may be some discussion about connective tissues, but from the point of rehabilitation, the same way of thinking is still present: going from the level of the classical understanding of the muscle-skeletal system. This situation resembles two separate worlds that still didn’t merge into one meaningful entirety.
Yes, connective tissue does really exist and it is proven that it has important roles in the human body and clinical relevance in the rehabilitation process. In this article, I will not give an in-depth explanation of each of these connective tissue functions. Instead, my intention is to explain why we should observe the old rehabilitation procedures with a fresh pair of eyes. Why new understanding simply forces us to re-examine the previously established points of view.
One of the most important roles of connective tissue is to provide support, connection, and separation between the human body parts. Imagine building a house from different kinds of materials and parts, like bricks, lumber, and elements like doors, windows, and roof. All those materials have to be attached if we expect to have a stable house in the long run. Imagine that instead of connecting all those elements, you simply lay bricks on top of each other. You decide to support windows, doors, and roof simply with lumber. With just a slight breeze, the entire structure would fall apart. That is why there is the cement between the bricks and other parts that are also attached to the frame made of brick and cement or another material so that the house can stay stable for a long time.
If we apply the same idea to the human body, we can see that all the parts of the body do not simply sit on top of each other loosely. The connective tissue network holds the human body together; this network enables interconnectedness of bones, muscles, nerves, blood vessels, and internal organs. The connective tissue maintains the shape and proportion of the human body. Before having the knowledge of the connective tissue, we thought that only muscles and bones support the human body, and now we know that this is not the case. It is the connective tissue that holds it all together. We used to think before that only muscles and bones are involved in the generation of movement, but now we know that the connective tissue plays a huge role in it. It actually governs the quality of muscle action by enhancing or decreasing it. In the 2012 international Fascia Research Congress, fascia is described as: ‘fibrous collagenous tissues which are part of a body wide tensional force transmission system’. (Schleip R, Findley T, Chaitow L Huijijng P 2012b Fascia: the tensional network of the human body. Churchill Livingstone Elsevier, pp 44-48).
I would like to keep it simple. If you observe the picture, you can see the cross-section of the muscle which, on the one end, is connected to the bone with a tendon. Going from the smallest towards the largest structure, we can see the following: microfilaments are grouping and forming myofibrils. Myofibrils are grouping to form muscle fibre. Muscle fibres are grouping to form muscle fibre bundles. Grouped muscle fibre bundles form a muscle. But as you see in the picture, the connective tissue is between all those structures, and binds and holds them together, maintaining the structural integrity. It provides form and shape on all levels of muscle structure from the smallest to the largest elements. Why am I pointing this out so much? How is this fact linked to passive stretching?
When a muscle is being stretched, not only muscle tissue is being affected. As you can see, it is impossible to separate muscles and connective tissues in the human body. Together, they form one inseparable structure. Note that the muscle tissue is inside the connective tissue which envelops it. It is impossible to stretch the muscles and not affect the connective tissue. That is my point. As a parent of children with special needs, you need to be aware of that. Maybe you think that you are stretching muscles, but in fact, you are stretching all of it!
A further point is that in the classical approach there is a lot of talk about the stretching of the muscles, but there is no mentioning of how it affects the already weak and bad quality of connective tissue of the children. To me as a professional, who has been working in this field for 11 years, this does not seem right. How is it possible that in the classical rehabilitation system, the discussion is focused only on muscles and the effects of stretching on them, and the connective tissue is completely being ignored, if one knows how intimately they are connected to each other? That does not fit reality. Here’s my opinion: that is an artificial separation of the two different entities that, in the anatomical and functional perspective, form one structure; when it comes to rehabilitation strategies of the children with neurological disorders, they should be observed and analysed in such a way.
Let me try to make it clearer. Imagine that you would like to understand the total costs of running your household for a month. You include your electricity bill, water expense, cable TV and internet costs in your cost calculation, and based on that, you plan a certain amount of expenses. As each month passes by, you realise that the costs are much higher then you expected. One would expect that you would, of course, start thinking that you have forgotten to include some other expenses (for example, food costs and taxes). You would re-examine your first calculation, so that the numbers which you are getting at the end of each month can be closer to reality. You would adapt your way of thinking. You wouldn’t repeat the same calculation over and over again and expect a different result? Wouldn’t you?
Well, the situation with the passive stretching and muscle concept is the same. A logical question is: why is the thought process adaptation so slow? Probably, because we are dealing with a complex concept, and mistakes in the thinking process are far less obvious and much harder to detect. Logically, as a consequence, the understanding that something needs to be changed in the classical rehabilitation paradigm is not so obvious.
My key point for parents of children with special needs is that we shouldn’t think only about the stretching of the muscles. Connective tissues should be included in the equation, as we are now aware of their existence and functions. Then, with the new concept, we should re-examine all the procedures of rehabilitation including passive stretching and see what is going to come out as a conclusion from all of that.
