I would like to address the topic of passive stretching procedure in children with cerebral palsy and other neurological conditions that involve increased muscle tone. I find this topic to be a multi-layered and complex one, and that is the reason why it needs to be analyzed from more than one perspective.
This is the question most frequently asked by parents: should we do the stretching or not?
I believe that before explaining the effects of passive stretching on spastic muscles, to be able to put the things in the right order, we should focus our attention on another important question. From our extensive experience in the field of rehabilitation of children with these conditions, we can see that parents ask themselves one more question, which bewilders them even more: why do we keep getting contradictory recommendations from different specialists in the field?
I believe that this question should be answered first for one to be able to navigate through the topic and sort out the confusion.
I would like to point out that today there are no modern therapies/approaches of rehabilitation that use classic passive stretching as a procedure to achieve the reduction of spasticity and muscle stiffness.
They rather use other modalities to achieve these results. Only classic physiotherapy and rehabilitation use passive stretching. First, we need to understand where those contradictory opinions and recommendations come from. What is their source?
As a procedure, passive stretching was present long before we acquired such extensive knowledge about the connective tissue (fascia) importance and roles in the human body. It can be concluded from all these facts that the recommendations of the BDA team are based on those new findings and knowledge.
Just like other modern rehabilitation approaches, BDA tries to explore and integrate connective tissue knowledge in practice
In the classical rehabilitation paradigm, this is simply not done yet. It is not the topic fully present in the curricula of classical medical high schools, colleges and universities. Because of that, logically, we do not have generations of medical workers who already gained in schools the knowledge on connective tissue. On the contrary, they gained classical knowledge about human biomechanics, the classical image of the muscle-skeletal system and its workings. At the same time as this is happening in the standard educational system, new findings, new data, and a new understanding of human anatomy and human biomechanics, slowly but steadily, emerge in scientific circles.
Those two processes are happening at the same time, but what is the result?
On the one hand, we have medical workers who come out from medical schools without having the extensive knowledge on connective tissue and repercussions caused by the lack of knowledge that affects the understanding of human body workings. On the other hand, all new knowledge of connective tissue is factual! There is so much new information on connective tissue out there that they are even becoming aware of this in the classical rehabilitation approach. It is impossible to ignore it. Over the last 20 years, a lot of research has been done, scientific publications have been made, books have been written, and congresses have been held. Many things about the human body physiology, anatomy and biomechanics have been explained in a way that is different than before.
Thus we have a paradoxical situation that the information and concepts which are already factual in the real world are not learned in schools.
You may ask yourself – why is the situation like that? I can’t say that I know that for sure, but I guess that we are witnessing the inertness of the large systems, such as educational and public healthcare system. They are usually slow, not willing to change easily because every change is hard. It pushes people inside of that system out of their comfort zone. State-owned systems usually do not have much motivation to change. They are burdened by bureaucratic overregulation.
Also, I believe that there is a long way from scientific research and scientific community to education and schools. This is also being changed, I must say. Slowly though, but the changes happen.
In 2008, when I started to learn about connective tissue, not many professionals in the rehabilitation field talked about it. Now, you can hear about fascia from many colleagues, but it will take time for these new facts to be embraced by the classical system of education and rehabilitation.
Understanding that new findings about fascia/connective tissues in the field of rehabilitation of children with neurological disorders are not learned in medical schools and that they are not automatically included in any official curriculum is an important realization.
This brings us to the logical conclusion: the amount of knowledge that any specialist or therapist is ready to acquire about this topic, depends only on him or her! It depends on individual desire and motivation to get additional education and to devote time and energy to thoroughly understand this topic. It is a long process.
Also, I would like to be very clear: I am not advocating the position that all colleagues who acquired a deeper knowledge of the workings of connective tissue will never recommend the use of passive stretching as one of the options; but I am more than certain that it will give them a possibility to see the bigger picture and think of tools to achieve better results by using other means.
At least, they won’t be so explicit and rigid regarding their opinion on whether passive stretching has to be done or claiming that it is the only way to fight muscle spasticity and contractures.
From my point of view, in the field of rehabilitation of children with neurological disorders, the types of therapists are as follows:
- The ones who haven’t heard about fascia/connective tissue and consequently do not know anything about it, and work and think in the way that the generations of therapists have been working and thinking before them. They think that rehabilitation modality is simply passed from generation to generation by experience.
- Also, some therapists are totally reluctant to re-examine their point of view.
- Those who have heard about it and are aware of its existence, but never really tried to understand it on a deeper level or to understand how the new findings change our perception about the rehabilitation of children with neurological disorders. As a consequence, they keep doing the same good old stuff they got used to.
- The ones who understood the importance of this new research and information, and have accepted the challenge of constant learning. Those people invest their time and energy to understand the new data presented to them; they try to explore them, try them out in practice and integrate them into their work.
Basically, what happens to parents when they come for advice to different specialists is that they witness a collision of two worlds, two concepts of knowledge and rehabilitation, as I previously explained.
I think those are the main reasons why parents of children with neurological disorders get contradictory recommendations from different specialists in the field.
Finally, I would like to say that no one holds a monopoly on the ultimate and absolute truth on these matters. It is our professional duty to educate ourselves constantly, to be open for new findings and information, to be ready to adopt them and change. Time will show if everything we know is just 50% correct – maybe less or even more. Yet, I believe it would also be irresponsible to ignore that the paradigm shift in the rehabilitation of children with neurological disorders is emerging.
