Chapter 14

Summary

What is Therapeutic Stretching?

 Stretching is the behaviour a person adopts to recover, increase or maintain their range of movement (ROM)

 Therapeutic stretching is the process used to recover or improve ROM

 ROM challenges are the different techniques and methods used to achieve ROM change

What Model is Used for Therapeutic Stretching?

 The therapeutic stretching promoted in this book uses a functional model for ROM rehabilitation

 A functional approach aims to employ the patient’s own movement repertoire to facilitate ROM recovery

 It is based on the principles of recovery behaviour. It is the behaviour a person adopts to recover their functionality after injury or immobility

 The recovery behaviour contains three traits that are important for ROM recovery: specificity, overloading and repetition

 Specificity is how closely the ROM challenge resembles the affected functional movement. Overloading is the progressive increase in physical demands on the affected movement, and repetition is the overall exposure to the challenge

 ROM recovery is associated with three recuperative processes in the body: repair, adaptation and symptomatic relief; processes that encompass the tissue, neurological and psychological–behavioural dimensions

 ROM rehabilitation aims to engage the patient in behaviour that facilitates these recuperative processes

 ROM recovery is a multidimensional process intrinsic to the individual but also highly influenced by their environment. Hence, in functional rehabilitation we aim to co-create with the patient environments that challenge their ROM losses

How are Therapeutic Stretching Techniques Classified?

 ROM challenges can be either functional or extra-functional

 Functional challenges are active approaches that resemble daily movement patterns. Extra-functional challenges are dissimilar to normal daily patterns

 The functional approach contains managed and assisted recovery behaviour

 In managed recovery behaviour the therapist helps the patient to develop a self-care daily programme using specificity, overloading and repetition components of the recovery behaviour

 In assisted recovery behaviour, the therapist provides physical assistance during functional tasks

 All traditional stretching methods, whether active or passive, are extra-functional

Why do We Need a Functional Approach?

 A functional approach is needed because traditional stretching approaches have been shown to be ineffective for recovering ROM in many musculoskeletal conditions

 Functional ROM challenges, including managed and assisted approaches, all contain the effective ingredients necessary for engaging the recuperative processes (repair, adaptation and modulation of symptoms)

 Extra-functional ROM challenges, including all traditional passive and active stretching approaches, provide only a few or none of the effective ingredients necessary for repair, functional adaptation and long-term management of pain

When do We Use a Functional Approach or Traditional Stretching?

 ROM rehabilitation should strive to be functional at a level that matches the individual’s movement capacity

 Regressing to a lower level, below the patient’s current capacity, is likely to reduce effectiveness and may prolong recovery

 If the patient is able to perform functional tasks, avoid extra-functional challenges, i.e. traditional methods

 Extra-functional challenges can be used if the patient is unable to perform functional tasks

 Extra-functional passive challenges can be used if the patient is unable to perform active movements

 A functional approach does not exclude the use of extra-functional exercise or stretching techniques

What Defines End-range?

 ROM contains active and passive components set within variable and (often) ill-defined end-ranges

 In healthy individuals active ROM is often determined by the capacity of agonist muscles to overcome antagonistic tissue tension

 Passive ROM is determined by tissue resistance. This will influence the angle at which the person will experience pain and discomfort. How far a person will stretch beyond that point will depend on their pain tolerance

 Most daily activities are performed within a small percentage of the full active ROM

When is Movement Considered Functional (Normal) or Dysfunctional (Abnormal)?

 Functional movement is the unique movement repertoire of an individual

 Functional movement contains shared activities which are universal to all and special activities which are unique to each individual

 Functional ROM is defined as the ROM required to perform functional activities effectively, efficiently and comfortably

 Dysfunctional ROM is defined as the ROM limitation that impedes the ability to perform functional movement

 Clinical-anatomical ROM ideals strive for anatomical ROM perfection

 Functional ROM is a patient-centred goal associated with recovering functionality

 Functional ROM goals are often more important than clinical ones. Most individuals judge their improvement by their ability to carry out daily activities.

What Causes ROM Loss?

 ROM loss in often the outcome/symptom of a condition

 Loss is often multidimensional with changes seen in the tissue, neurological and psychological dimensions

 In the tissue dimension ROM losses can be due to adaptive tissue changes and mechanical and chemical irritation

 In the neurological dimension, it can be due to loss of motor control and nociceptive processes such as sensitization

 In the psychological dimension, movement-related anxieties may also contribute to ROM loss

What is the Potential for ROM Recovery?

 The potential for ROM recovery is dependent on the prognostic nature of the causative condition and the body’s recuperative processes of repair, adaptation and modulation of symptoms

 The conditions that cause ROM loss can be classified as self-limiting, persistent or progressive

 ROM recovery is more likely in self-limiting conditions in which the recuperative processes are saved

 ROM rehabilitation will have a diminishing effect in persistent and progressive conditions, in particular if the adaptive or reparative capacity of the affected tissue is reduced, or when symptoms cannot be alleviated

What Happens in Adaptive ROM Loss and Recovery?

 The musculoskeletal system has the capacity to adapt to the physical environment

 Tissue adaptation is associated with mechanotransduction: a process by which the myocytes and fibroblasts convert mechanical signals into biological processes

 In immobilization and remobilization, adaptive processes can be seen in all musculoskeletal tissue

 Adaptive ROM loss is associated with shortening and stiffening of connective tissue, adhesion and muscle shortening and atrophy

 During ROM recovery the deleterious effects of immobilization are reversed and normalized

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Stretch-tolerance Model Functional and Dysfunctional ROM Exposure and Scheduling the ROM Challenge The Overloading Condition for Recovery Pain Management and ROM Desensitization Demonstration of Functional Approach in ROM Rehabilitation

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