No strong conclusions about the effects of passive stretching, active stretching, or therapeutic positioning on joint range of motion in individuals with CP can be reached from this body of research. As Pin et al17 reported, the research in this area is weak because of methodological issues, small sample sizes, and the existence of only a small number of studies. In addition, there has been little attention in the research literature to the evaluation of active stretching with children with CP as demonstrated by the one study in our review that evaluated active stretching.22
We invited 46 Canadian rehabilitation centers to respond to a survey to identify stretching practices with children with CP; 26 sites responded (response rate 56.5%). The survey included questions about the prevalence of passive, active, and therapeutic positioning strategies used by therapists at each centre, the stretching parameters typically used (duration and frequency of stretches), specific muscle groups targeted, and the therapists’ goals for stretching. The therapists at each site completed the survey collaboratively, resulting in one completed survey from each participating centre.
Sites reported that therapists spend approximately 10% (median) of their time (range 5%–33%) performing stretching techniques and 15% (median) of their time (range 1%–25%) teaching children, parents, and caregivers how to stretch. Therapists select specific stretching techniques (passive, active, or positioning) by considering a variety of factors including age of the child, severity of spasticity and contracture, perceived compliance of child and/or caregiver, tolerance and/or motivation for stretching, cognitive level of the child, functional abilities of the child as rated by the Gross Motor Function Classification System,26 and the child’s environment.
Therapeutic positioning and active stretching are frequently used for the hip flexors, hip adductors, knee flexors, and ankle plantarflexors. Passive stretching was reported as a prevalent management strategy for all muscle groups, particularly the hip flexors, hip adductors, knee flexors, and ankle plantar flexors. Choice of stretching approach did not vary with age of the child. The parameters for stretching intervention varied considerably across the reporting sites. The number of repetitions for passive stretching ranged from 1 to 10 (median = 4), the length of time to hold the stretch varied from 15 to 90 seconds (median = 30). Parameters for active stretching ranged from 1 to 10 repetitions (median = 4) and 15 to 90 seconds duration (median = 21). The reasons for using stretching techniques were to (1) maintain current range of motion (all sites); (2) increase range of motion for functional tasks (all sites); (3) defer or avoid surgery (12 of 26 sites); and (4) attain full range of motion (11 of 26 sites). This small survey suggests a lack of standardization of stretching techniques. The common assumption across all sites is that stretching will maintain range of motion and may positively affect functional abilities. Many of the sites also assumed that stretching may delay or avoid surgical intervention for muscle contractures. Research studies have not confirmed these assumptions and therefore it is evident that a significant gap exists between clinical rationale for stretching and research evidence.
Our understanding of the mechanisms of contractures in spastic muscles is rudimentary. Ideally our clinical decisions should be guided by good scientific inquiry.27 There is a need for laboratory research into the mechanisms of muscle contracture to provide additional information about the theoretical assumptions that guide physical therapy interventions for children with CP.
Clinical evaluation of the effects of stretching techniques is also needed because existing research evidence is not adequate to support or refute the effectiveness of stretching as a management strategy. Pediatric physical therapists have an essential role to play in this area of evaluation. The primary outcome evaluated in studies examining the effects of passive stretching in individuals with CP has been joint range of motion. Goniometric measurements are appropriate because the primary outcome expected with stretching is a change in muscle length and joint range of motion. Therapists use stretching interventions for children with CP with the assumption that the stretching program will not only assist with maintenance of joint range of motion, but positively impact the functional abilities of the child. Many therapists also use stretching to avoid or delay the development of secondary complications. The current body of research on stretching does not include any investigation of the relationship between changes of joint range of motion and changes in functional abilities or need for surgery. The International Classification of Functioning, Disability and Health (ICF)28 explicitly cautions against assuming a direct relationship between factors at the component of body function and structure (eg, range of motion, spasticity) and changes at the component of activity (eg, dressing or riding a bike) and participation (e.g. integration in classroom activities). For example, maintaining a child’s hamstring length may not make it any easier for him to get on and off the school bus (activity) or to participate in gym class at school (participation). A recent study evaluated the interrelationships among muscle tone, passive range of motion, selective motor control, and gross motor function in a group of children with CP and reported only a modest relationship between motor impairments and participation in everyday activities.29 It is essential that future research includes the evaluation of the relationships among outcomes representing body functions and structures, activity and participation to determine both the physiological and functional outcomes of stretching programs, particularly because enhancing functional abilities is one of the reasons why therapists use stretching as a clinical intervention.
Another reason to consider alternative outcomes is the documented measurement error of goniometry with children with a diagnosis of CP. McDowell et al30 reported significant variability with measurements errors as high as 14° for 3 of the 6 range of motion measurements with 12 children with spastic diplegia. Other researchers have also reported significant measurement error using goniometry to measure joint range of motion with children with CP.31–33 Researchers need to consider more precise ways of measuring joint range of motion and the use of different outcome measures to document changes in children’s functioning.
Passive stretching is, by its very nature, a “passive” technique that is done without the child’s participation. Isolated active stretching and positioning practices such as prone lying and stretching hamstrings in long sitting are also not particularly fun for the child or family. Parents may be hesitant to use traditional stretching techniques as they may be uncomfortable for their children34 and they may already be overwhelmed by a number of other interventions their children require. Contemporary approaches to rehabilitation for children with CP are changing to include community participation, fitness, and functional goals35–37 and therapists are challenged to explore innovative management approaches that reflect these values. Perhaps the focus on maintaining joint range of motion needs to change to an emphasis on maintaining flexibility and encouraging the exploration and maintenance of a variety of movement options. All children, including children with physical disabilities, need to have opportunities to engage in physical activities that will enhance their levels of physical fitness. They also need opportunities to participate in fun activities with other children. 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. Therapists can use their expertise to identify innovative flexibility options that are enjoyable for everyone and will lead to life long fitness opportunities for the child.38
Physical therapists possess the knowledge of development, movement, and CP to assist children and adolescents with CP to participate in community fitness programs. Therapists can play an important role in the development of transitional programs in rehabilitation centers, in which typical fitness programs are adapted to meet individual movement abilities. Therapists can also help families to identify community programs and provide support for the transition to these programs. Therapists can work with families and community fitness facilities to encourage children and adolescents with CP to integrate flexibility exercises into their regular fitness routines and to modify program content so that children and youth with motor disabilities can participate effectively and safely. Our experience with a community-based fitness program for children and adolescents with CP21 convinced us that community fitness programs are a viable alternative to medically oriented therapy programs. It is an exciting time in pediatric rehabilitation and an ideal time for therapists to use their creativity, knowledge, and skills to develop innovative and fun strategies to integrate therapy with fun physical activities and to contribute to the rigorous evaluation of stretching strategies used in pediatric rehabilitation.
The authors express their appreciation to Monica Gorassini, PhD, and the two anonymous reviewers for their valuable suggestions that improved this manuscript.
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