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 Medical Massage & Rehabilitation

Active Isolated Stretching and Strengthening:
Injury Rehabilitation, Part 1

essential skills

By Ben E. Benjamin and Jeffrey P. Haggquist

Originally published in Massage & Bodywork magazine, May/June 2010. Associated Bodywork and Massage Professionals. All rights reserved.

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.
Active Isolated Stretching and Strengthening: Injury Rehabilitation, Part 2

In Part 1 of this article (May/June 2010, page 88), we talked about the various roles that Active Isolated Stretching and Strengthening (AIS) can play in rehabilitating an injury. We introduced the five steps of the rehabilitation process and gave a detailed explanation of the first three: addressing the pain, restoring the full range of motion, and neuromuscular reeducation.

In Part 2, we conclude by discussing steps four and five-- rebuilding strength and restoring full function--and various ways in which we can personalize this process so our clients heal as effectively and efficiently as possible.

4. Rebuilding Strength
While restoring mobility and flexibility is an important step forward, we must be careful not to stop there. Increasing the range of motion without developing strength in that range makes a client more susceptible to injuries and joint dysfunction. Only by actively building strength can balance and resilience be achieved.

There are several principles to keep in mind when working to rebuild strength. First, you want to make sure that a person's strength extends beyond the demands of his or her normal activities. Most people are strong enough to meet the basic demands of daily life, but don't have reserves of strength. Therefore, in an unusually challenging situation (such as lifting a particularly heavy object or slipping on ice and using their arms to catch themselves), they may easily get injured. This means that it's important both to develop each muscle more fully and to develop a wider range of muscle groups. AIS protocols incorporate the full spectrum of muscles in a particular area--including those responsible for rotating, bending, extending, and flexing--so you don't focus solely on the most frequently used structures.

Another source of risk is having uneven levels of strength in a given muscle. Generally, a muscle is much weaker and more vulnerable at the end of its range of motion. As a result, a sudden or strong exertion from a position of full stretch (e.g., getting up suddenly from a lunge or starting to use a pectoral weight machine from the most stretched position) can result in injury. AIS exercises limit this risk by working each muscle throughout its full range of motion, starting with very light weights.

Along the same lines, you want to be sure that the person has adequate strength in eccentric contraction, not just concentric contraction. In concentric contraction, the muscle shortens while it contracts, as when you lift a weight in a biceps curl. Slowly releasing from a biceps curl involves eccentric contraction, in which the muscle is simultaneously contracting and lengthening. As we mentioned in Part 1, some individuals experience difficulty with eccentric contraction following an injury. AIS places a strong emphasis on eccentric contraction, which actually builds strength 30-40 percent more efficiently than concentric contraction. In many cases, we use manual resistance (resisting the client's motion with our own strength, rather than a weight), which enables us to directly feel where the muscles are weaker and then adjust the exercise regimen accordingly. Because AIS is so specific, we can make targeted adjustments that isolate the precise areas that need the most work.

One final consideration is the need to combine strength with endurance. It's possible to be strong enough to lift a relatively large amount of weight, but lack the endurance to carry it for any length of time. In AIS, we simultaneously build endurance and strength by performing many repetitions of an exercise, very slowly, with a relatively low weight. The gentle, repetitive motion enhances metabolism within the soft tissues, improving nutrient delivery and the circulation of blood and lymph.

5. Restoring Full Function
All the work we do in the first four stages lays the groundwork to prepare clients for whatever training is necessary to resume their normal level of activity, which will be somewhat different for each individual. At this point, a lot of the progress may be made outside the treatment room, sometimes with the help of a physical therapist, personal trainer, or coach. For instance, in working with a runner, we'd get that person ready to go back to track practice. We can provide some guidance on how to proceed (e.g., starting slowly and building up gradually), and then it's the process of actually running and doing training drills that will ultimately restore full function. In other cases, an individual may need help in preparing to return to a physically challenging job. Physical therapy clinics have special sections devoted to "work hardening," using real or simulated work activities to mimic the demands of various types of jobs--from driving to custodial duties to heavy manual labor.

Back in the treatment room, we can play an important role in this stage of rehabilitation by tracking clients' progress and helping to ensure that they don't reinjure themselves by doing too much too quickly. As people resume more strenuous activities, they may develop new accommodation patterns (using stronger muscles to compensate for the ones that have just recently healed) or fall back into old, unconstructive ways of moving that contributed to their injury in the first place. If any setbacks do occur, we can facilitate healing and help prevent minor strains from developing into larger, chronic problems.

A Personalized Process
While the five guidelines we've discussed provide a good general outline of the rehabilitation process, the details will vary depending on each person's individual needs. That process won't necessarily be linear, you might find yourself circling back to earlier steps, particularly if the client incurs any new injuries or has other setbacks in the healing process. At times, it may also make sense to change the order of the steps. For instance, with a person who is hypermobile (excessively flexible), you typically want to introduce strengthening early on in the rehabilitation protocol. A hypermobile joint is less stable and more vulnerable to injury, so it's important for the surrounding musculature to be strong.

The time needed for recovery will also vary from person to person, depending in part on the individual's overall health and fitness. A client whose body is relatively strong, flexible, and healthy (apart from the injury) will tend to heal much more quickly than someone who is in generally poor shape. Healing time is also highly dependent on the nature and severity of the injury and/or accompanying disease conditions. While some clients take months or years to regain functionality, others recover very quickly once they receive the appropriate treatment.

In the interviews we conducted for this article, several practitioners reported that it was witnessing or experiencing one of those rapid recoveries that first got them excited about AIS. Paul John Elliott says he was inspired by observing Aaron Mattes (the creator of this system) as he worked with a woman who had severe scoliosis. When she first came in, her torso was rotated about 20 degrees and bent about 20 degrees to the left. Over the course of several days, she straightened out dramatically. (This practitioner now sees that same woman as a client, the bend in her spine has been reduced to roughly 4 degrees, and the rotation is virtually gone.) Another practitioner, Kathy Shadrick, was impressed by the healing of her own injury. Her carpal tunnel pain had become so intense that it was waking her up in the middle of the night, and she had begun to worry that she'd have to give up doing massage. She attended a five-day AIS workshop, and Mattes treated her at his clinic, between clients. By the end of the workshop, her pain was gone.

Of course, most musculoskeletal problems will not resolve quite so rapidly. It's important for clients to keep doing AIS work regularly until the healing is complete. However, once they have received instruction from a skilled therapist, they can often do much of this work on their own. This is particularly beneficial for individuals who cannot afford to come for frequent sessions. So long as they are compliant--consistently doing the stretches and strengthening exercises they've been taught--they can go a long way toward healing themselves. In our minds, the ability to empower clients in this way is one of the greatest assets of AIS. Other practitioners we spoke with feel the same way. In Shadrick's words: "It proves it's not about me as a therapist, it's about the work. It's AIS, not me. That keeps me humble."

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 extensively across the country on topics including orthopedic massage, Active Isolated Stretching and Strengthening, SAVI 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.

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.