Active Isolated Stretching and Strengthening (AIS) is a uniquely effective exercise system developed by Aaron Mattes. In recent articles [“Active Isolated Stretching” Parts 1 and 2, November/December 2009 and January/February 2010, pages 100 and 88], we gave a general introduction to the stretching component of AIS, explaining the physiological principles underlying the techniques and the various ways in which this modality can benefit our clients.
In this two-part article, we’re going to discuss the ways in which AIS (including both stretching and strengthening) can play a role in injury rehabilitation—therapy aimed at restoring function that has been lost through physical trauma or other types of soft-tissue damage. A large proportion of our clients require some degree of rehabilitative work, and since we began using AIS, our effectiveness in helping them has increased greatly. In speaking with various AIS practitioners and their clients, we have also collected many other reports of restored neuromuscular functioning. We’ll incorporate some of their stories throughout the article as well.
Specialists in the field recognize five key components in the rehabilitation process:
1. Addressing the pain.
2. Restoring the full range of motion.
3. Neuromuscular reeducation.
4. Rebuilding strength.
5. Restoring full function.
We’ll address each of these, one at
a time.
1. Addressing the Pain
The first step in rehabilitation is to relieve whatever pain the client feels. This makes intuitive sense—you can’t effectively stretch or strengthen an injured structure until it stops hurting. Among other problems, pain usually causes a protective contracture, which ultimately increases the problem rather than solves it. To help resolve the pain, you need to determine what the cause is. We separate three kinds of causes: precipitating event, direct cause, and indirect cause.
Suppose a person begins experiencing shoulder pain when lifting a suitcase after returning from vacation. Lifting a suitcase uses a small, fairly weak muscle called the supraspinatus, which sits on top of the shoulder beneath the trapezius muscle (Image 1). An average person can lift about 10–15 pounds using this muscle. When we go on vacation, our suitcases usually weigh a good deal more (often 30–40 pounds). It is likely that dealing with the suitcase—lifting it, carrying it around, putting it into the trunk of a car, lifting it up to place it in the plane’s overhead bin, etc.—was the precipitating event that led directly to the injury. What is causing the pain now (the direct cause) is the result of that event: tears in the supraspinatus muscle and/or tendon and the resulting adhesive scarring. There may also be additional factors that predisposed this person to injury, such as a lack of strength or flexibility, muscle tension, or poor body alignment. These are indirect causes.
Whether or not you can identify a specific precipitating event, it is important to resolve the direct cause of the pain. The necessary treatment may range from hands-on work to exercise therapy to injections to surgery, depending on the nature and severity of the injury. While AIS does not work in every case, it is a good place to start. AIS is noninvasive, and for some mild to moderate cases, it may be the only form of therapy required. Gentle, progressive stretching and strengthening exercises in the AIS protocols can help modify adhesive scar tissue and restore pain-free movement.
In treating the supraspinatus muscle-tendon unit, the process includes a series of stretches referred to as hyperextension of the shoulder. In these stretches, the AIS practitioner assists the client to extend the arm straight back with the arm rotated in four different positions (Image 2). The strengthening component starts with a standing abduction exercise (moving the arm away from the body sideways, using a light weight), and then progresses to the same movement done side-lying, which is much more challenging (Image 3).
By starting to improve flexibility and strength, such AIS techniques may begin to resolve the indirect causes of injury and help prevent future damage from occurring. Ongoing stretching and strengthening work, in stages 2 through 5 of rehabilitation, will also be beneficial in this regard.
2. Restoring the Full Range of Motion
After you have addressed the client’s pain, the next challenge is to restore the full range of motion in the muscles, fascia, and joint structures. This includes not just the immediate site of injury, but also other structures that may have been affected. When people are injured, they tend to compensate with other parts of the body, which can decrease the range of motion in these areas. For instance, a person who has an injury in her foot may compensate by walking in an unbalanced way, leading to pain and loss of mobility in her hip. The structures most likely to be affected are those in the same kinetic chain as the injured tissues. For example, if someone has a shoulder injury, both the neck and the elbow will likely be affected as well.
Often, it’s necessary to work on other parts of the kinetic chain before we can improve the range of motion in the injured area. This relates back to the idea of indirect causes. A client with a knee injury may have an underlying problem with one of his arches collapsing and placing strain on both the hip and the knee on that side. In that case, before you can truly correct the knee dysfunction, you’ll need to first strengthen and restore functional integrity to the foot. It’s also possible to have a kinetic chain dysfunction in the hip that causes an uneven distribution of weight through the knee, leading to knee injury and pain. Whenever you don’t get results from working directly on an injured area, try looking elsewhere to see what other factors may be preventing a full recovery.
In order to test for any limitations in mobility, you need to know the normal range of motion for the joint you’re testing (see Normal Range of Motion in the Hip, page 94, for examples). It’s also important to consider the client’s performance goals. For instance, an elite swimmer or baseball player may require a greater capacity for internal rotation of the shoulder than the average individual.
Once you’ve identified the area(s) where range of motion needs to be restored, there are various methods of stretching you can use. As discussed in previous articles, AIS is a highly efficient approach; it develops maximum flexibility in the shortest amount of time by taking into account key principles of human physiology.
One advantage of AIS is its specificity, isolating individual muscles and ensuring that each one is stretched in the correct functional position and plane of movement. For example, to stretch the hamstring muscles by lifting the leg straight up, you need to stay on the mid-sagittal plane (keep the legs parallel). If the leg rotates out to the side, you lose much of the hamstring stretch and start affecting other muscles instead. The same is true with stretching the rectus femoris in the anterior thigh; once you move off the mid-sagittal plane, you may lose the stretch in that muscle and begin to stretch the lateral quadriceps (vastus lateralis) instead. AIS techniques clearly specify these positions and also differentiate between different fibers of specific muscle groups. You can pinpoint restrictions very precisely, in the proximal or distal portion of a given muscle, and then focus your stretching on whichever area is most limited. For instance, one stretch of the hamstring works the distal half (from mid-thigh to the knee) and another works the proximal half (between the back of the hip to the middle of the thigh) (Image 4 and 5, page 95).
3. Neuromuscular Reeducation
The next step is to reestablish normal communication between the muscles and the brain. After a prolonged period of disuse following an injury, you may see various signs of decreased neuromuscular control. For instance, the client may exhibit co-contraction (when one muscle contracts, the opposing muscle also contracts at the same time) or a muscle may shake or tremble on eccentric contraction (muscle contraction that occurs while the muscle is lengthening). Restoring normal functioning may require activating tissues and neural pathways that have remained latent for some time, establishing new pathways, and/or stimulating neurogenesis (the creation of brand new nerve tissues). There are three basic guidelines for facilitating neuromuscular reeducation, based on constructivist learning theory. Each is supported by AIS practices.
Using Active, Rather Than Passive, Motion
Throughout an AIS session, the client actively initiates each movement and maintains continuous focus on performing the movement.
Going Slightly Beyond the Comfort Range
The practitioner increases the range of motion at the end of each stretch with a gentle assist, so the muscles are continually moving into novel territory.
Repeating the Process
By repeating every movement six to eight times, we reinforce the neural pathways and solidify the learning in the nervous system.
Conclusion
Stay tuned for Part 2 of this article, where we’ll explain the final two steps in the rehabilitation process—rebuilding strength and restoring full function—and discuss how you can personalize this process for your clients to help optimize their healing.
Ben E. Benjamin, PhD, holds a doctorate in education and sports medicine. He is founder of the Muscular Therapy Institute. Benjamin has been in private practice for more than 45 years and has taught communication skills as a trainer and coach for more than 25 years. He teaches courses across the country on topics including Active Isolated Stretching and Strengthening, orthopedic massage, communications, and ethics, and is the author of Listen to Your Pain, Are You Tense? and Exercise Without Injury, and coauthor of The Ethics of Touch. He can be contacted at 4bz@mtti.com or on Facebook at facebook.com/DrBenBenjamin.
Jeffrey P. Haggquist, DO, is an osteopath who specializes in physiatry, a branch of medicine focused on restoring optimal functioning and quality of life to people with physical impairments or disabilities. Haggquist completed his residency training in physical medicine and rehabilitation at Temple University Hospital in Philadelphia, his osteopathic internship at the University of Medicine and Dentistry of New Jersey, and his medical education at Kansas City University of Medicine and Biosciences. He teaches widely on flexibility and neuromuscular reeducation, and is a national specialist on Active Isolated Stretching. He has trained elite athletes and is the medical director of the Flexibility, Sports, and Rehabilitation Clinic in Washington, D.C. Prior to his medical training, he practiced as a neuromuscular massage therapist for more than two decades.
Editor’s note: Massage & Bodywork is dedicated to educating readers within the scope of practice for massage therapy. Essential Skills is based on author Ben E. Benjamin’s years of experience and education. The column is meant to add to readers’ knowledge, not to dictate their treatment protocols.