Stretch Techniques

Definition of terms related to stretching.

The term mobility (. It is often defined as the ability of structures or segments of the body to move or be moved to allow the presence of range of motion for functional activities (functional ROM).

The flexibility (i.e., extensibility of soft tissues that cross or surround joints—muscles, tendons, fascia, joint capsules, ligaments, nerves, blood vessels, skin), which are necessary for unrestricted, pain-free movements of the body during functional tasks of daily living.

Hypomobility (restricted motion) caused by adaptive shortening of soft tissues can occur as the result of many disorders or situations.

 Factors lead to hypomobility.

·        prolonged immobilization .

·        sedentary lifestyle,

·        postural mal-alignment and muscle imbalances,

·        impaired muscle performance (weakness) associated with an array of musculoskeletal or neuromuscular disorders.

·        tissue trauma resulting in inflammation and pain, and

·        congenital or acquired deformities.

Contracture is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM, and it may compromise functional abilities.

Types:

·        Myostatic Contracture.

1-    In a myostatic (myogenic) contracture, although the musculotendinous unit has adaptively shortened and there is a significant loss of ROM,

2-    there is no specific muscle pathology present.

3-    can be resolved in a relatively short time with stretching exercises.

·        Pseudomyostatic Contracture

The result of hypertonicity (i.e., spasticity or rigidity) associated with a central nervous system lesion such as a cerebral vascular accident, a spinal cord injury,  traumatic brain injury or Muscle spasm

·        Arthrogenic and Periarticular Contractures

An arthrogenic contracture is the result of intra-articular pathology. These changes may include adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation.

·        Fibrotic Contracture

Due to chronic inflammation and fibrotic change of soft tissue – very difficult to reduce.

·        Irreversible contracture

Cannot be released by non surgical treatment .

Interventions to Increase Mobility of Soft Tissues;

Manual or Mechanical/Passive or Assisted Stretching

A sustained or intermittent external, end-range stretch force, applied with overpressure and by manual contact or a mechanical device, elongates a shortened muscle tendon Self-Stretching Any stretching exercise that is carried out independently by a patient after instruction and supervision by a therapist is referred to as self-stretching. The terms self-stretching and flexibility exercises are often used interchangeably.

Neuromuscular Facilitation and Inhibition Techniques

Neuromuscular facilitation and inhibition procedures are purported to relax tension in shortened muscles reflexively prior to or during muscle elongation. Because the use of inhibition techniques to assist with muscle elongation .

Muscle Energy Techniques.

Muscle energy techniques are manipulative procedures that have evolved out of osteopathic medicine and are designed to lengthen muscle and fascia and to mobilize joints. The procedures employ voluntary muscle contractions by the patient in a precisely controlled direction and intensity against a counterforce applied by the practitioner. Because principles of neuromuscular inhibition are incorporated into this approach, another term used to describe these techniques is post Isometric relaxation.

Joint Mobilization/Manipulation.

Joint mobilization/manipulation methods are manual therapy techniques specifically applied to joint structures and are used to stretch capsular restrictions or reposition a subluxed or dislocated joint.  Mobilization with movement techniques for the extremities are described and illustrated throughout the regional chapters (

Soft Tissue Mobilization and Manipulation

Soft tissue mobilization/manipulation techniques are designed to improve muscle extensibility and involve the application of specific and progressive manual forces (e.g., by means of sustained manual pressure or slow, deep stroking) to effect change in the myofascial structures that can bind soft tissues and impair mobility. Techniques, including friction massage, myofascial release, acupressure, and trigger point therapy,97,137,146 are designed to improve tissue mobility by mobilizing and manipulating connective tissue that binds soft tissues. Although they are useful adjuncts to manual stretching procedures, specific techniques are not described in this textbook.

Neural Tissue Mobilization

(Neuromeningeal Mobilization) After trauma or surgical procedures, adhesions or scar tissue may form around the meninges and nerve roots or at the site of injury at the plexus or peripheral nerves. Tension placed on the adhesions or scar tissue leads to pain or neurological symptoms. After tests to determine neural tissue mobility are conducted, the neural pathway is mobilized through selective procedures.

. Stretching therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility by elongating (lengthening) structures that have adaptively shortened and have become hypomobile over time.

Indications for Use of Stretching

• ROM is limited because soft tissues have lost their extensibility as the result of adhesions, contractures, and scar tissue formation, causing functional limitations or disabilities.

• Restricted motion may lead to structural deformities that are otherwise preventable.

• There is muscle weakness and shortening of opposing tissue.

• as part of a total fitness program designed to prevent musculoskeletal injuries.

• prior to and after vigorous exercise potentially to minimize postexercise muscle soreness.

Goals :

1-main goal

(Regain normal ROM)

2- specific goal :

·        prevent irreversible contractures

·         Increase the general flexibility before strengthening.

·        Prevent or minimize the risk of musculotendinous injuries related to specific physical sports.

Contraindications to Stretching

• A bony block limits joint motion.

• There was a recent fracture, and bony union is incomplete.

• There is evidence of an acute inflammatory or infectious process (heat and swelling) or soft tissue healing could be disrupted in the tight tissues and surrounding region.

• There is sharp, acute pain with joint movement or muscle elongation.

• A hematoma or other indication of tissue trauma is observed.

• Hypermobility already exists.

• Shortened soft tissues provide necessary joint stability in lieu of normal structural stability or neuromuscular control.

• Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible.

PRECAUTIONS FOR STRETCHING

1- Do not passively force a joint beyond its normal ROM.

2- patients with known or suspected osteoporosis due to disease, prolonged bed rest, age, or prolonged use of steroids.

3- Newly united fractures.

4- Muscles and connective tissues that have been immobilized for an extended period of time.

5- Progress the dosage (intensity, duration, and frequency) of stretching interventions gradually to minimize soft tissue trauma and postexercise muscle soreness.

6- Joint pain or muscle soreness lasting more than 24 hours.

7- Edematous tissue.

8- Avoid overstretching weak muscle.

Types of stretch:

A- Passive stretching

1-    Manual passive stretching.

2-    Prolonged mechanical.

3-    Cyclic mechanical.

B- Active inhibition.

1-    Contract-Relax.

2-    Contract-Relax-Contract.

3-    Agonist contraction.

C- Self stretch.

D- Ballistic stretch.

E- over stretch.

F- Selective stretch.

A- Passive stretching

   1- Manual passive stretching.

·        The therapist applies external force.

·        The therapist controls the direction, speed, intensity, and duration.

·        Time: 15: 30 seconds and repeated several times.

·        The intensity and duration depend on the patient tolerance and therapist strength and endurance.

·        Make temporary and transient achieve in range (elastic change in sarcomere (actin-myosin overlap).

B- Prolonged mechanical passive stretching:

·        Low-intensity external force (5:15 LB)

·        Applied for prolonged time with mechanical appliance.

·        Applied through (positioning, weight, traction, pully system, dynamic splints)

·        Time: 20:30 minutes or as long as several hours.

·        More effective than manual.

·        More comfortable than manual.

·        Permanent lengthening (plastic changes) in contractile and non contractiltissue.

C- cyclic:

·        Passive stretching using a mechanical device as auto-range.

·        Similar in intensity and duration to manual passive stretching.

B- Active inhibition:

·        The patient reflexively relaxes the muscle to be elongated prior to stretching maneuver.

·        Used to relax only the contractile structures within muscle not connective tissue.

·        Muscle must be normally innervated and under voluntary control (cannot be used in patient with sever muscle weakness spasticity or paralysis).

·        Comfortable form of stretch.

·        Disadvantage: affect only the elastic structures of muscle and produce only temporary increase in muscle length.

Types of active inhibition.

1-    Contract-Relax.

2-    Contract-Relax-Contract.

3-    Agonist contraction.

1-    Contract-Relax (hold-relax).

·        The patient performs isometric contraction of the tight muscle before it is passively lengthened.

·        Depend on ( Autogenic inhibition) ( relaxation of muscle after contraction due to fire of golgi tendon organ that inhibit tension in muscle )

Procedure:

·        Start with the tight muscle in a comfortable lengthened position.

·        Patient make isometric contraction in tight muscle for 5: 10 seconds (until muscle begin to fatigue).

·        Patient relaxes.

·        The patient stretch muscle passively through gained range.

N.B:

·        Isometric contraction should not be painful.

·        Make sub-maximal isometric contraction not maximal contraction due to post contraction sensory discharge ( lingering tension in muscle after the pre-stretch contraction).

2-    Contract-Relax-Contract (hold-relax-contract).

·        Contraction of tight muscle and relaxation of the tight muscle followed by a concentric contraction of the muscle opposite the tight muscle)

·        This technique combines (autogenic inhibition and reciprocal inhibition).

Procedure:

·        Follow the same procedure as contract-relax.

·        After the patient relax the tight muscle, patient perform a concentric contraction of muscle opposite the tight muscle, the patient actively moves his own extremity through the increased range.

3-    Agonist contraction:

·        The agonist refers to the muscle opposite the tight muscle (muscle that will perform the limited range.)

·        Antagonist (tight muscle)

·        Patient dynamically contracts the muscle opposite the tight muscle against resistance.

·        This course reciprocal inhibition of the tight muscle .

Procedure:

·        Passive length the tight muscle to comfortable position.

·        Patient performs a dynamic (shortening) contraction of muscle opposite the tight muscle.

·        Apply mild resistance to the contraction muscle but allow joint movement occure.

N.B:

·        Do not apply excessive resistance to the contracting muscle. This may cause irradiation of tension to the tight muscle rather than relaxation.

Selective Stretching

Selective stretching is a process whereby the overall function of a patient may be improved by applying stretching techniques selectively to some muscles and joints but allowing limitation of motion to develop in other muscles or joints.

·        In a patient with spinal cord injury, stability of the trunk is necessary for independence in sitting. If the hamstrings are routinely stretched to improve or maintain their extensibility and moderate hypomobility is allowed to develop in the extensors of the low back, this enables a patient to lean into the slightly shortened structures and have some trunk stability for long-term sitting.

·        Allowing slight hypomobility to develop in the long flexors of the fingers while maintaining flexibility of the wrist enables the patient with spinal cord injury who lacks innervation of the intrinsic finger muscles to develop grasp ability through a tenodesis action.

 Overstretching and Hypermobility

Stretch well beyond the normal length of muscle and ROM of a joint and the surrounding soft tissues, resulting in hypermobility (excessive mobility).

·        in sports that require extensive flexibility.

·        Overstretching becomes detrimental and creates joint instability when the supporting structures of a joint and the strength of the muscles around a joint are insufficient.

Ballistic Stretching

A rapid, forceful intermittent stretch—that is, a high-speed and high-intensity stretch—is commonly called ballistic. Ballistic stretching is thought to cause greater trauma to stretched tissues and greater residual muscle soreness than static stretching.

High-Velocity Stretching in Conditioning Programs and Advanced-Phase Rehabilitation

there are situations when high-velocity stretching is appropriate for carefully selected individuals. For example, a highly trained athlete involved in a sport such as gymnastics that requires significant dynamic flexibility may need to incorporate high-velocity stretching in a conditioning program. Also, a young, active patient in the final phase of rehabilitation who wishes to return to high-demand, recreational activities after a musculoskeletal injury may need to perform carefully progressed,

Static stretching → Slow, short end-range stretching → Slow, full-range stretching → Fast, short end-range stretching → fast, full-range stretching.

Self-Stretching

 Is a type of stretching procedure a patient carries out independently after careful instruction and supervised practice. Self-stretching enables a patient to maintain or increase the ROM gained as the result of direct intervention by a therapist.