Can we prevent contractures by Stretch Interventions?

of course not

One of the primary goals of physiotherapy is to prevent the reduction of patients' joint range of motion (ROM). In exercise therapy, a significant focus is on passive ROM exercises. For patients with conditions such as cerebral palsy or those recovering from a stroke, much of the therapy time is dedicated to performing passive movements and passive stretching.

The rationale behind this approach is that maintaining range of motion is essential for producing “normal movement.” This is evident in various activities: for instance, reduced ROM in the ankle joint can impair walking, stair climbing, rising from a chair, and more. Tight hip adductors can cause the limb to adduct during walking, while tight hip flexors can prevent taking longer steps.

So, we stretch and stretch. seems fair.

There are 2 issues to we need to be contemplate while thinking about reduction in ROM- due to contracture of the soft tissues.

1. why does the muscle and soft tissue go into contracture

2. can we prevent it? if so whats are the best methods to do so?

Why does the muscle and soft tissue become shorter?

The straightforward answer is that as the movements are difficuit to do in case of UMN lessions- dysfunctioning connections between the upper motor neurons and lower motor neurons or pain as in case of muskuloskeletal diseases and conditions. however, for this discussion we will stick on to upper motor lessions. In UMN lessions shorthening and contracture get worse with time as the functional movements gets lesser or disuse.

Keeping that in mind we want to prevent contractures from happening we want to prevent that from hapening.

So we stretch and stetch.

Does streching and other passive ROM exercises prevent contractures?

of course no!

The integrity and physiology of muscles depend on their ability to function throughout their entire range of motion in the Cartesian space, not on external forces pulling them apart. Additionally, any muscle lengthening achieved through stretching is only temporary and insufficient for long-term benefits. Even if we could lengthen the muscles, it is unlikely this would translate into improved functional activity. Muscle activity is driven by necessity and context, making it improbable that stretching alone would result in increased functional activities, such as longer steps or faster walking, without abnormalites etc.

In conditions like cerebral palsy, as the child grows, the entire architecture of the bones and, consequently, the muscles change. Therefore, merely stretching the muscles to a certain range will hardly be effective.

can we prevent it? if so whats are the best methods to do so?

It seems preventing contractures is hard, especially when the ability of the patient to do activity. That is severe the patient more likely he or she is going to get contractures as time progess. It is nearly inevitable. at the same time if the patient is unable to do any activity whats the point of just maintaining the lenght of the muscles?

So what should we do?

The same principle always applies: encourage your patients to perform active functional movements. The more they move, the better the chances of maintaining muscle length and joint range of motion. For instance, stretching the posterior leg muscles can be naturally achieved through activities such as walking up a ramp or standing up from a low stool. These movements challenge muscle length while engaging in functional activities.

Maintaining upper limb muscle length and range of motion is much more challenging, even when functional activities are available. This difficulty can arise from various factors, including limited variability in functional exercises and limited variability of movements due to the lession.

So what should i do if there is poor functional activity in my patients?

Patients with severe stroke or those at levels IV and V on the GMFCS are prone to developing contractures. Unfortunately, our options to prevent this or enhance their functional ability are limited. Therefore, we need to concentrate on rehabilitation, the subject we are all familiar with- rehabilitation (the whole of BPT).

We also need to move away from reductinistic thinking like reducing spasticity, increase ROM and other impairments and concentrate on global outcome like meanigful activites.

Note: Issues with Passive Stretching:

1. Patient Discomfort: Passive stretching can cause discomfort or pain, which may reduce patient compliance.

2. no or limited value- for the discomfort it produces the value is misicule. it is mostly used because we are not taught proper rehablitation techniques.

3. The changes in the lenght you feel or observe is better tolerance for stretch or change in thershold for activation of stretch reflex and many not be changes in the actual lenght of the muscle.

4. it does not lead to sacrogensis, muscle fascicles lenght and other changes in muscle properties like thixotropy, hence limited long term changes or leading to improvement in functional activities.

5. we cant stretch the muscle leave alone fascia- so if someone says they are distoring the fascia or use jargons like fascia train, piezo electric effect and others, run, run like hell- there stupidity is contagious.

6. stop wasting time on ROM and stretching and do real rehabilitation.

7. if someone say the patients asks for stretching- well enable them by education.

8. I want a round 10 so blah blah blah

9. blah blah

10. blah

with so much love

Hariohm

Reference:
1. Stretch for the treatment and prevention of contractures

2. Effectiveness of Stretch Interventions for Children With Neuromuscular Disabilities: Evidence-Based Recommendations