Tuesday, May 22, 2012

Stretching and Cerebral Palsy: What you should know.

This is something I would most certainly define as a ¨hot button topic¨. Although most would consider it a relatively straightforward issue, the reality is that there are many schools of thought on this particular issue...all of which typically claim to have the ¨correct¨ perspective on the subject. It has been my experience that most take an all-or-nothing approach...black or white...do or don´t...stretching in Cerebral Palsy (CP) is good / stretching in CP is bad. I certainly have a specific position in the matter, however I think it is more productive to for people (both professional and health care seeker) to arrive to their own conclusions and convictions. This relatively trivial and non-sensical debate becomes completely irrelevant once the reality of the CP condition is analyzed in any decent way. I don´t think that there is any requirement to go into detail about the implied rationale for stretching...this is something that, to say the least, is well understood. However, a broad look into ¨what is stretching¨ will help to frame the overall message of this post.

 Stretching is most commonly performed to achieve a specific end result: elongation of a particular muscle or group of muscles. This seems relatively intuitive and would make sense to any lay person. The part that is not so intuitive is that the muscles themselves are embedded within a connective tissue matrix...which is in turn blended with other differentiated connective tissue (tendon) that is continuous with the outer layer (periosteum) of the bone. From there, the periosteum continues and eventually blends once again and the kinematic chain continues.
Therefore it becomes quite clear that it is next to impossible to selectively isolate muscle tissue from the connective tissue matrix / system it exists with..in fact, they are inseperable and synonymous with each other. In other words, ¨stretching the muscle¨ effectively results in applying tensional force throughout the entire system (muscle, epimysium, perimysium, fascia, tendon, ligament, periosteum, etc...). In order to further decontruct the entire stretching concept, the terms muscle and connective tissue need to be further defined.

Muscle is defined as a tissue composed of bundles of elongated cells capable of contraction and relaxation to produce movement. Connective Tissue can be descried as a tissue developed from the embryonic mesoderm that consists of collagen or elastic fibres, fibroblasts, fatty cells, etc., within a jelly-like extracellular matrix. It supports organs, fills the spaces between them, and forms tendons and ligaments. Knowing these basic facts and definitions, their respective functional appearances within the normal muscle and the spastic muscle (CP) need to be defined. They should be the same, right? This couldnt be further from the truth. This is what the current (and most popular)approach assumes...that muscle is muscle and fascia is fascia. I have attached a very interesting and informative study that was performed to identify the similarities / differences between spastic and normal muscle tissue, spastic and normal extracellular matrix, as well as the differences between individual cells and collective bundles of cells for both. I recommend that you take the time to read it, but I will summarize its contents here in an effort to expediate my point (it´s effectively the abstract of the article): 1) The difference between bundles and single cells was much greater in normal muscle tissue (16 times stronger) than in spastic muscle (2 times stronger). 2) Actual muscle fiber strength is greater in spastic muscle than in normal muscle. However..... 3) Extracellular matrix strength / Connective Tissue strength is 43.5 times weaker!! Therefore, the ¨inconvenient truth¨ is exposed and a fundamental question is raised: if the spastic muscle itself is stronger than normal muscle, and the connective tissue attachments are 43 times WEAKER...what is really happening when you attempt to stretch that particular muscle(s)? In my professional opinion, it seems only logical that the likely result is further weakening and de-stabilization of an already weak connective tissue system...however, I am more than willing to set that staunch opinion aside if ever there was a way to guarantee this wouldn´t happen. The current reality is that, at best, there is no definite way to determine if the attempts to relax spastic muscles via stretching will not potentially be of some detriment. Indeed, there are some cases where some relief has been attributed to active stretching...however, these responses are transient and were most likely done in a very mild form.

 The article goes into more important details (muscle fiber size and area is smaller in spastic muscle, for example), so I will leave those for the more curious to digest. In summary, I do not belong to the extreme end of the continuum in saying that ¨all stretching is bad¨ and that it absolutely shouldnt be done. My main message is that proper consideration be made to the actual mechanical and physiological benefits / consequences of ANY therapeutic intervention. If, through careful thought, consideration, and analysis, stretching is indicated...then it is obviously worthy of implementation. The harsh reality is that many forms of stretching are dispensed without any constructive analysis...which is fundamentally dangerous. To put a final point on this topic...forget about absolute ¨black and white¨solutions. There is a whole lot of grey to choose from! Cheers! Inferior Mechanical Properties of Spastic Muscles Due to Compromised Extra Cellular Matrix Material

10 comments:

  1. I wish this information was known 14 years ago. My son, Adam, was subjected to PT induced stretching and even worse "stretching and serial casting with botox". It made his contractures and level of spasticity worse. It's my belief that with ABR we are still undoing the damage of the first three years of forced stretching. Many beliefs and hypotheses of traditional PT have not changed in decades. Thanks for sharing this insight and explanation.....

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  2. Great summary, Gavin. And - perfect timing, as I am trying to explain to all the professionals in our lives (especially the nurses that help us care for Abbie), that the only "stretching" we will be doing will be for comfort, if at all...instructing them instead to do light lymphatic drainage massage on the limbs when they feel overcome with the need to "so something."

    Thanks for giving us tools to help tease out decisions we must make in the grayness of this life.

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  3. Thanks Gavin, very informative and enlightening article! I am a massage therapist in Michigan, and I am always trying to learn. It sounds like the fascia in a spastic muscle is in some ways like a tendon in an overuse injury -- the muscle is hypertrophic from constant contraction, but the fascia is worn and stressed from the same, and has no time to rest and rebuild.

    My wife has had rheumatoid arthritis since childhood, and has stories about barbaric PT practices. In my massage practice I have not had a client with CP, but I would never try to fight with a contracted muscle, certainly not with a spastic one. I wonder if recruiting reciprocal inhibition or some other reflex might give enough relief for some motion to be possible. But if it can't be done gently, I wouldn't do it.

    Do any of you have some good resources on bodywork for people with CP?

    Rich Bartlett, NCTMB

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    1. Hello Rich. First of all, thank you for taking the time to leave a comment on what you read. Although readership is high, actual comments are few and far between...and I am glad to get them. Your observation that the fascia in spastic muscle is similar to an overuse injury is inuitive, however the reality is somewhat more complex. In general, the weakened tissue in overuse injuries is the result of a reduction in the viscoelastic properties over time due to chronic inflammation and scar tissue (adhesion) buildup. In the CP person/child, the weakness is significantly more profound and systemic.

      Regarding resources on bodywork for people with CP, I have been working exclusively with CP for the last 6 years in Argentina, Chile, Colombia, Canada, US, France, Mexico, and Singapore...and I have quite a plethora of resources accumulated! As per the mandate of this blog, I am more than happy to exchange information, feedback, and resources on any topic...so please feel free to communicate with me more either here or on the One Giant Leap Facebook page. Again, I appreciate your time in reading this particular post and am very glad you found it worth your while. All the best! Gavin

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  4. I found your article, studies, and onservations highly interesting. As an aging CP person I find less and less resources to address CP issues. I am not wheelchair bound or in need of a walker, though I do use a cane on occassion. As a child I had surgery wich legthened my archelis tenden to straighen my gaunt. My excercise routine has always included massive amounts of strecting as learned during childhood. Though I really have never found it highly effective besides just a good mornng stretch. As I age (45 year old now) systoms that never bothered me before have occured and are becoming more pronuonced by the day. Some of these systoms are joint and muscular pain along with decreasing balance issues. I have sought out physical therapists but again the only expertise seem to be geared toward children and somewhat preventive measures that rely highy on stretching. How would your method benfit me as a adult and how would I go about finding a therapist knoeledgeable in this technique?

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    1. GavinJune 30, 2012 10:47 PM

      Hello LeAnne! I had written a reply earlier, but I think it got deleted somehow. It was rather lengthy and I almost hit the ceiling when it didnt appear here. On that note, I will try to be a little more brief in my response, but please feel free to communicate with me again if you requrie more enhancement. Your observations are essentially right on point regarding most of the information and resources aimed at children and young adults. However, the techniques mentioned in my blog most certainly apply to adults as well. The reason that most emphasis is placed on younger people is that it is the point in time when you get the most return on your rehabilitative ¨investment¨. Meaning, progress is more labour-intensive and time-intensive when you are an adult...but that is simply a reality...there should still be a focused effort to improve the adult life as well.

      In response to your specific question ¨how would it benefit you¨, the answer is relatively straightforward. The fascial / connective tissue system in your body is still much weaker than a non-affected person, therefore the joints themselves, joint capsules, muscular attachments fail quite regularly and are under significantly more stress. This is precisely why you are experiencing the aches and pians in the joints as you enter middle-age. The specific fascial strengthening techniques mentioned here are specifically geared to improve connective tissue health and integrity and therefore improve performance as well as reduce instability and hence reduce pain and discomfort.

      The mechanism is indeed more complicated than that, but this is just a very simple overview. If you refer to one of my earlier posts ¨The Role of Fascia in Cerebral Palsy¨, you will see the signficant potential for stengthening..and in another post titled ¨Spastic Muscles: Victim or Perpetrator¨, you will see an example of the potential for overall reduction in muscular tension.

      With respect to finding a therapist with knowledge in this technique, I am one of only about 3 or 4. If you require any more information or need some specific feedback, I am more than happy to provide you with some support. you can simply email me at gavinbroomes@hotmail.com and I will refer back to you right away. If you are interested in a more formal exchange, these techniques are essentially designed for home-based implementation...therefore the online / video / audio protocols set up through the blog will be able to provide you with the support and help you need.

      I hope this has been helpful...and please do not hesitate to communicate with me further. I am always very willing to share any information that is of use. All the best, and thanks for reading! I hope you keep coming back! Cheers.

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  5. Your opinions are quite interesting, I enjoy reading what you write. Hope to hear more from you. You have been Subscribed.
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    1. Many thank, Brian! Although the topics are diverse, my hope is that the overall perception and philosophy resonates with as many people as possible. Thanks for reading and feel free to send me your feedback as well...any information is good information! Cheers!

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  6. HI Gavin,
    I'm new to blogging and was just writing about this very topic http://wiredondevelopment.blogspot.co.nz/2013/06/stretching-and-cerebral-palsy.html
    I like the way you approached it and as it is as you say a "hot topic" it's always good to have a BIG think about what we are doing. It was really helpful being able to read the full article you were referring to.
    Just a few thoughts from me:-
    As noted by the researchers, there is a large difference in age between the controls and the subjects. Children's muscles are fundamentally different to adults and I would be very cautious about drawing to close a comparison.
    Secondly - all the children in the study were undergoing surgery for muscles which were already contracted. Again, there is a very big difference in function and structure of a contracted muscle and a normal length/strength muscle.
    Not all muscles with spasticity are necessarily contracted - I wonder what the properties of these normal length spastic muscles look like?
    The research does lend weight to the clinical pearl of not trying to stretch out a contracted muscle - but how about we keep those little muscles flexible as they grow? There is a lot of evidence for this and I have certainly seen the benefits of a good stretching routine for kids with cerebral palsy compared to those that have not done it. Stretching to maintain flexibility is still essential - I would hate for parents of littlies to think that it was bad from the discussions around you article. Traditional stretching through tears is archaic, but stretching can be done through games and movement so that it is fun and part of a good routine. It should involve functional movement patterns and should not cause distress, but it should still be done!
    I have seen more than a few older kids who haven't maintained their flexibility and are past the point of return - it is ugly, painful and difficult to manage - and almost impossible to correct.

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    1. Some great feedback there...and you are definitely correct in your assertion that we should be careful not to make any snap judgements. The main objective of the post was to shine some light on the complexity of the CP individual...whether child or adult...and that complex systems require more complex analysis. The unfortunate reality is that stretching (as defined as the typical "athletic type" stretching) is widely considered as a "must do" and is something that is dispensed without much analysis. Therefore it is sometimes necessary to demonstrate physical realities in a more explicit sense in order for people to more towards the "shades of grey" and away from black or white. Of course, there are many modes of stretching that are most certainly productive...however most parents do not associate movement (as such) with stretching...this is an advanced concept and much be taught. Further, "flexibility" is essentially over-simplified. As a biotensegral system, flexibility needs to be well-defined as either muscular flexibility, tissue extensibility, etc...

      In addition to this, each muscle is in fact part of a much larger kinematic chain...therefore the presence of "super weak" tensional elements (such as connective tissue, tendons, insertions, etc...) implies that implying tensional stress to this kinematic chain be re-evaluated. Not in the sense of "do or dont do"...rather in the more appropriate sense of "HOW should we be imposing this stretch". As an appendix to this much larger discussion, there is a "monopoly" of sorts by the neuromuscular paradigm with respect to rehabilitation...meaning that the nerves and muscles are given paramount attention, responsibility, and focus while the remaining tissue is essentially disgarded or disREgarded as unimportant to the kinematic chain. Force transmission, force distribution, and reaction force are heavily dependant on the tensional competence of connective tissue...therefore they need to be put back into the "movement equation".

      Again, I think your feedback is quite intelligent and astute...and I appreciate your perspective on this important topic. Although we may have some differences in general philosophy, I think our overall objectives converge quite well onto the point that each case needs to receive its own special consideration.

      Thanks again!

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