Evidence Based Practice

Re Evaluating Stretching for Contracture Management

December 04, 2012 by Elena Noble, MPT

Current evidence is challenging our traditional approaches to contracture management in children with cerebral palsy. Following is a brief review of the literature.

Passive stretching, performed manually or with serial casting and positioning techniques, has long been the traditional approach to contracture management in children with cerebral palsy (CP). Behind this approach is the belief that stretching increases the length of a muscle through the addition of sarcomeres in series within that muscle. Increasing muscle length would have positive effects on the surrounding joints. But this has so far only been confirmed in animal studies done in the 1970s. Tabary et al placed the soleus muscles of cats and rodents in shortened and elongated positions and over time observed a corresponding decrease or increase in the number of in-series sarcomeres in these muscles.1 As good and as reasonable as this explanation sounds, it simply has not been shown yet that human muscles respond in this manner to the same stimuli. Perhaps this explains why studies evaluating the effects of passive stretching on improving joint range of motion at this point remain inconclusive.2,3,4

Katalinic et al in their 2011 systematic review effectively sum up the current state of the evidence on stretching for contracture prevention in a population with neurological deficits. Twenty-five studies were evaluated and included forms of stretching done manually, in splints, by serial casting, and positioning. Their findings showed moderate-quality evidence for small and immediate effects of stretching. But the authors attribute this to viscous deformation of the muscle which is only temporary in its effects and therefore not significant. More significantly, high-quality evidence showed that passive stretching has little or no effect, short-term or long-term, on joint range of motion. And of additional interest, an expansion of this same study showed similar results in performing stretches in a population without neurological deficits.4

Next, we look at  a study by Shortland et al in regards to stretching for contracture management in children with cerebral palsy. Although there is conflicting evidence on this topic,5,6 Shortland’s study certainly helps us look beyond traditional approaches that are so far ineffective. In assessing the gastrocnemius muscles of children with spastic diplegia, Schematic drawings of the gastrocnemius muscleShortland et al determined that the fascicle lengths of the muscles were no different from those of typically developing peers.6 This indicates that fixed shortness of the gastrocnemius may not be due to muscle fiber length. Rather, it could be caused by a smaller muscle fiber diameter secondary to muscular atrophy often seen in this population.7 Smaller muscle fiber diameters would take up less space on the aponeurosis of the pennate gastrocnemius, thus reducing the overall length of the muscle belly. If this is the case, then muscle length could be affected through strengthening interventions rather than stretching.

And clearly, strengthening, at least in the population of children with cerebral palsy, is showing positive effects. Strengthening, as once thought, does not increase spasticity of a muscle in these children,8,9  but on the contrary improves muscular performance with tie-overs to functional activities.10,11,12,13

We should also consider what the International Classification of Functioning, Disability and Health has to say on this topic. Briefly, the ICF as the newest health classification system, broadens the definition of disability. It emphasizes activities and participation both as the optimal intervention and as the best measure of treatment outcome.  Disability is evaluated in the context of every-day functioning. It shifts away from impairment-focused interventions and rather seeks to enable an individual to perform activities that have purpose in their life and within the community. Stretching for contracture management is a passive intervention, and gaining one or two degrees of joint range of motion probably will not have much functional value in the long run. Lesley Wiart, MScPT explains it further:

“From this perspective, the emphasis on joint range of motion changes to a focus on encouraging movement opportunities that enable children with CP to experience a repertoire of movement experiences and participate in enjoyable activities while enhancing their physical fitness. Therapists may want to consider activities such as yoga, Tai Chi, horseback riding, ballet, and swimming programs that allow children to stretch and move within a functional, participatory context. Through such programs, children with CP could become active participants in fitness programs that encourage flexibility instead of passive recipients of therapeutic stretching routines.3

I couldn’t have said it better.

If you have clinical experience that sheds light on this topic please share it here.

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References

1. Tabary JC, Tabary C, Tarieu C, et al. Physiological and structural changes in the cat’s soleus muscle due to immobilization at different lengths by plaster cast. J Physiol. 1972;224(1):231-44.

2. Pin T, Dyke P, Chan M. The effectiveness of passive stretching in children with cerebral palsy. Dev Med Child Neurol. 2006;48:855-62.

3. Wiart L, Darra J, Kembhavi G. Stretching with children with cerebral palsy: what do we know and where are we going? Pediatr Phys Ther. 2008;20:173-78.

4. Katalinic O, Harvey L, Herbert R. Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review. Phys Ther. 2011;91(1):11-24.

5. Mohagheghi A, Khan T, Meadows T, et al. Differences in gastrocnemius muscle architecture between the paretic and non-paretic legs in children with hemiplegic cerebral palsy. Clin Biomech. 2007:718-24.

6. Shortland A, Harris C, Gough M, et al. Architecture of the medial gastrocnemius in children with spastic diplegia. Dev Med Child Neurol. 2002;44:158-63.

7. Mockford M, Caulton JM. The pathophysiological basis of weakness in children with cerebral palsy. Pediatr Phys Ther. 2010;22(2):222-33.

8. Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil. 2002;83:1157-64.

9. Fowler EG, Ho TW, Nwigwe AI, et al. The effects of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy. Phys Ther. 2001;81(6):1215-23.

10. Damiano DL, Abel MF. Functional outcomes of strength training in spastic cerebral palsy. Arch Phys Med Rehabil. 1998;79:119-25.

11. Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young people with cerebral palsy. Dev Med Child Neurol. 2003;45:652-57.

12. Fowler EG, Knutson LM, DeMuth SK, et al. Pediatric endurance and limb strengthening (PEDALS) for children with cerebral palsy using stationary cycling: a randomized controlled trial. Phys Ther. 2010;90(3):367-81.

13. Mockford M, Caulton JM. Systematic review of progressive strength training in children and adolescents with cerebral palsy who are ambulatory. Pediatr Phys Ther. 2008;20:318-33.

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Reply by Margaret@YourTherapySource on January 15, 2012 at 1:10 PM

Excellent update on the recent research. If the child is able, I tend to focus on active exercises that encourage muscle lengthening in a functional manner ie sit to stand transfers and vice versa with a focus on standing tall. Interesting new information to me regarding the smaller muscle fiber diameter that perhaps may influence muscle length. Forms another question for me – If that is the case, how does the use of AFO’s effect muscle length then when the gastroc is not activiated to strengthen?

Reply by Donna on January 15, 2013 at 6:39 PM

Great information to share! Thank you for posting this, we need to share this as way too many therapists continue to rely on passive stretching. On that same note, regarding Margarets excellent question posted here, we need to think very carefully before subjecting patients to the disuse atrophy that accompanies solid ankle AFOs. AFOs can facilitate wonderful functional changes in certain situations and so are easily over recommended. It is important to carefully weigh the benefit / risk ratio. I doubt that a solid ankle AFO has any effect on muscle length, beyond maintaining it, despite the loss of activation, but a literature search would be great! Many of the functional benefits can still be realized with the newer hinged AFOs, which still impact muscle use (loss) and imbalance, but without wiping out all activity at the ankle. Thanks again for sharing this important information!

Reply by Aram@ucpla.org on January 16, 2013 at 12:30 PM

This is terrific information that definitely turns our previous notion of ROM on its head.

My question is; what do I do with clients that function at a very low cognitive level or have very little AROM? These clients cannot/will not perform functional tasks or strengthening exercises. How can I maintain their ROM without PROM or resting night splints which are currently the only way I can have them move through their full ROM?

Reply by Erna Albertz on January 16, 2013 at 4:53 AM

Are there any therapist readers who can share insights regarding Aram’s question about clients that function at a lower cognitive level or have very little AROM?

Reply by Barbara on January 24, 2013 at 12:17 PM

I have had very positive results using the Total Gym apparatus with this population. It provides the immediate feedback of movement through space with any muscle activation and it is very easy to start with active assisted. I use the leg press exercise with a number of students with severe cognitive disabilities.

Reply by Addie on January 03, 2014 at 7:56 AM
As a parent I would love to see this information spread liberally. Furthers my belief in preference of happiness via experience rather than suffering via body. Many of us suffer from significant guilt because we are unwilling to torment our kids with PROM, AFO's, etc, but have had therapists tell us we are doing our children harm by omitting these. I also wonder what other alternative there could be though for a child like mine who has next to no ability to move purposefully (zero possibility of things like ballet, yoga, etc).
Reply by Sue on January 03, 2014 at 4:17 PM
Our daughter had SDR 18 months ago and now has next to no spasticity in her legs. She is 8 and has mild quadriplegia, could not even stand unsupported but now can walk and steer with a standing frame and is able to balance with crutches and in an unsupported high kneel. We stretched her for 15 minutes morning and night for a year and then took her back for percutaneous lengthening. She'd gained range in ankles, hamstrings and adductors gradually over the course of a year through a mixture of stretches and strengthening work. I am completely convinced that this extra range was a result of BOTH stretching and dynamic strengthening. She had gained 20 degrees on her adductor angle, big improvements in hamstrings and so much improvement in her ankles that only one needed a minor lengthening. Her whole lower body is a totally different shape now and her legs have muscles that look rather knee like her friends. If stretches don't increase range of movement how do gymnasts and dancers get to do the splits?
Reply by Elena on January 04, 2014 at 9:21 AM
Hi Sue, Good question. I like to look at it like this: dancers and gymnists certainly stretch, but then they continue to perform their splits and ROM activities throughout their entire day. The kiddos with disabilities on the other hand, may only get stretching as you say 2x/day for 15 minutes at a time. After that, they are pretty sedentary and inactive, so the gains they may have made during that period are often lost. This has been shown pretty clearly in the literature that "traditional" stretching (not including serial casting, tendon lengthenings etc) for this population is ineffective in the long run. I'm sure there are exceptions, but I mainly posted this article as a "thought-provoker." That if stetching appears to be for the most part ineffective, then why not try strengthening and increased physical activity in addition or as an alternative to improve functional ROM. Elena
Reply by Sue on January 03, 2014 at 4:24 PM
I should add that she wore shoe inserts only for most of the first year and now has flexible ankle splints that allow free movement of her ankles but support her foot. We resisted using long AFOs in order to allow her muscles to flex and strengthen. Sorry, I'm not a Physio, but I just wanted to tell you all we reduced fixed contractures over the course of a year through stretches and strengthening together.
Reply by Mike on January 04, 2014 at 6:56 PM
I have a therapy centre in Perth scotland and we specialise in strength and conditioning for pre / post and athletes we have been doing this type of training for years. We do a lot of strengthening with our clients we stretch the muscle with dynamic movement and by contracting the opposing muscles. We train all out clients to try and get intergration into activities such as swimming, martialarts, gymnastic and horse riding. Strength and conditioning work, and movement work also builds bone density . We spend a lot of time working out the right plans for each client. But our main aim is intergration so your training for sport not a disability that way your more likely to keep it up in later life . We also have to remember that stretching also refuses contraction if your about to go into a phase if fast muscle contraction or your wanting to work on hypertrophy, so we always suggest no stretching 1-2 hours before a training session.