Stretching | Physiosimplified

STRETCHING

Definition:
Stretching is a general term used to describe any 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.

Precautions:

Do not passively force a joint beyond its normal ROM.
Give a low intensity stretching in patients with known osteoporosis due to disease, prolonged bed rest, age, or prolonged use of steroids.
Protect newly united fractures; be certain there is appropriate stabilization between the fracture site and the joint in which the motion takes place.
Avoid vigorous stretching of muscles and connective tissues that have been immobilized for an extended period of time.
Progress the dosage (intensity, duration, and frequency) of stretching interventions gradually to minimize soft tissue trauma and post exercise muscle soreness.
Avoid stretching edematous tissue, as it is more susceptible to injury than normal tissue.
Avoid overstretching weak muscles, particularly those that support body structures in relation to gravity.

Preparation for Stretching:

Obtain the patient’s consent to initiate treatment.
Select the stretching techniques that will be most effective and efficient.
Warm up the soft tissues to be stretched by the application of local heat or by active, low-intensity exercises.
Warming up tight structures may increase their extensibility and may decrease the risk of injury from stretching.
Have the patient assume a comfortable, stable position that allows the correct plane of motion for the stretching procedure.
The direction of stretch is exactly opposite the direction of the joint or muscle restriction.
Free the area to be stretched of any restrictive clothing, bandages, or splints.
Explain to the patient that it is important to be as relaxed as possible or assist when requested.

Indications:

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.
May be used as part of a total fitness program designed to prevent musculoskeletal injuries
May be used prior to and after vigorous exercise potentially to minimize postexercise muscle soreness.

Contraindications:

A bony block limits joint motion.
A recent fracture, and bony union is incomplete.
There is sharp, acute pain with joint movement or muscle elongation
Acute inflammation of joint.
A hematoma or other indication of tissue trauma is observed.
Hypermobility already exists.

Determinants of Stretching:

Alignment: positioning a limb or the body such that the stretch force is directed to the appropriate muscle group
Stabilization: fixation of one site of attachment of the muscle as the stretch force is applied to the other bony attachment
Intensity of stretch: magnitude of the stretch force applied
Duration of stretch: length of time the stretch force is applied during a stretch cycle
Speed of stretch: speed of initial application of the stretch force
Frequency of stretch: number of stretching sessions per day or per week
Mode of stretch: form or manner in which the stretch force is applied (static, ballistic, cyclic); degree of patient participation (passive, assisted, active); or the source of the stretch force (manual, mechanical, self)

Types of Stretching:

Static stretching
Cyclic/intermittent stretching
Ballistic stretching
Proprioceptive neuromuscular facilitation stretching procedures (PNF stretching)
Manual stretching
Mechanical stretching
Self-stretching
Passive stretching
Active stretching

Static Stretching

Static stretching is a commonly used method of stretching in which soft tissues are elongated just past the point of tissue resistance and then held in the lengthened position with a sustained stretch force over a period of time.

Cyclic (Intermittent) Stretching

A relatively short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied is described as a cyclic (intermittent) stretch. Cyclic stretching each cycle of stretch is held between 5 to 10 seconds.

Manual Stretching

During manual stretching a therapist or other trained practitioner or caregiver applies an external force to move the involved body segment slightly beyond the point of tissue resistance and available ROM. The therapist manually controls the site of stabilization as well as the direction, speed, intensity, and duration of stretch. Manual stretching each cycle of stretch is held between 15 and 60 seconds.

Self-Stretching

Self-stretching (also referred to as flexibility exercises or active stretching) is a type of stretching procedure a patient carries out independently after careful instruction and supervised practice. This form of stretching is often an integral component of a home exercise program and is necessary for long-term self-management of many musculoskeletal and neuromuscular disorders. Self stretching each cycle of stretch is held between 15 and 60 seconds.

Mechanical Stretching

There are many ways to use equipment to stretch shortened tissues and increase ROM. The equipment can be as simple as a cuff weight or weight-pulley system or as sophisticated as some adjustable orthoses or automated stretching machines.
Mechanical stretching involves a substantially longer overall duration of stretch than is practical with manual stretching or self-stretching exercises. The duration of mechanical stretch reported in the literature ranges from 15 to 30 minutes.

Proprioceptive Neuromuscular Facilitation Stretching Techniques

Proprioceptive neuromuscular facilitation techniques used for stretching (PNF stretching) also referred to as active stretching or facilitative stretching, integrate active muscle contractions into stretching to facilitate or inhibit muscle activation and to increase the muscle to be lengthened remains as relaxed as possible as it is stretched.

Types of PNF Stretching

Hold–relax (HR) or contract–relax (CR)
Agonist contraction (AC)
Hold–relax with agonist contraction (HR-AC)

1.Hold–Relax and Contract–Relax

With the hold–relax (HR) procedure the range limiting muscle is first lengthened to the point of limitation or to the extent that is comfortable for the patient. The patient then performs a pre stretch, end-range, isometric contraction (for 5 to 10 seconds) followed by voluntary relaxation of the tight muscle. The limb is then passively moved into the new range as the range-limiting muscle is elongated. A sequence for using the HR technique to stretch shortened pectoralis major muscles bilaterally and Increase horizontal abduction of the shoulders.

2.Agonist Contraction
Agonist contraction (AC) stretching patient concentrically contracts (shortens) the muscle opposite the range limiting muscle and then holds the end-range position for at least several seconds. The movement of the limb is independently controlled by the patient. E.g: if the hip flexors are tight, the patient can perform end-rage, prone leg lifts by contracting the hip extensors concentrically; the end-range contraction is held for a number of seconds.

3.Hold–Relax with Agonist Contraction
The HR-AC stretching technique is a combination of the HR and AC. The HR-AC technique is also referred to as the slow reversal hold–relax technique. To perform the HR-AC move the limb to the point that tissue resistance is felt in the tight (range-limiting) muscle; then have the patient perform a resisted, pre stretch isometric contraction of the range-limiting muscle followed by relaxation of that muscle and an immediate concentric contraction of the muscle opposite the tight muscle.
E.g : to stretch knee flexors, extend the patient’s knee to a comfortable position and then have the patient perform an isometric contraction of the knee flexors against resistance for 5 to 10 seconds. Tell the patient to relax the knee flexors and then actively extend the knee as far as possible, holding the newly gained range for several seconds.

Ballistic Stretching

A rapid, forceful intermittent stretch with a high-speed and intensity is known as ballistic stretching. It is characterized by the use of quick, bouncing movements that create momentum to carry the body segment through the ROM to stretch shortened structures. It is not recommended for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures due to tissues, weakened by immobilization or disuse, are easily injured.

REFERENCES

Kisner Carolyn & Lynn Alley Colby, Therapeutic exercise foundation and techniques PG NO. 636 sixth edition
Decoster, LC, Cleland, J, Altieri, C, Russell, P: The effect of hamstring stretching on range of motion: a systematic literature review. J Orthop Sports Phys Ther 35:377–387, 2005.
De Weiger, VC, Gorniak, GC, Shamus, E: The effect of static stretch and warm-up exercise on hamstring length over the course of 24 hours. J Orthop Sports Phys Ther 33(12):727–732, 2003.
Pope, RP, Herbert, RD, Kirwan, JD, Graham, BJ: A randomized trial of pre-exercise stretching for prevention of lower limb injury. Med Sci Sports Exerc 32:271–277, 2000