THERAPEUTIC EXERCISES

TX1 MOD5: STRETCHING EXERCISE Contracture

Ø Adaptive shortening of the muscle-tendon unit and other soft
Definition of Terms Associated with Mobility and Stretching tissues that cross or surround a joint, resulting in significant
Stretching resistance to passive or active stretch and limited ROM.
Ø Is a general term used to describe any therapeutic maneuver Ø “almost complete loss of motion.”
designed to increase the extensibility of soft tissues.
Ø Has the intent to improve flexibility and ROM by elongating Designation of Contracture by Location
(lengthening) structures that have adaptively shortened and
have become hypomobile. Ø Contractures are described as the side of the joint that has the
tissue tightness or by identifying the action of the shortened
Flexibility muscle.
Ø The ability to move/rotate a single joint or series of joints Ø If the tightness is on the flexion side of the flexion/extension joint
smoothly and easily through an unresisted, pain-free ROM. axis, it is called flexion contraction.
Two types: Ø Ex1: if a patient has shortened elbow flexors and cannot fully
extend elbow = elbow flexion contracture.
Dynamic Flexibility Passive Flexibility
Ø Ex2: When a patient cannot fully abduct the leg because of
• Active mobility or Active • Passive mobility or Passive
shortened adductors of the hip = hip adduction contracture.
ROM ROM
• The degree/extent to which • The degree/extent to which
Types of Contracture:
an active muscle a joint can be passively
1. Myostatic (Myogenic) contracture
contraction moves a body moved through the
Ø No underlying pathology or no specific muscle pathology
segment through the available ROM.
present.
available ROM of a joint. • Depends on extensibility of
Ø Although there may be a reduction in the number of
• Depends on the ability of a soft tissue that cross and
sarcomere units in series, there is no decrease in individual
muscle to contract thru surround joint.
sarcomere length.
ROM and on the degree • A prerequisite for––but
Ø Can be resolved in a relatively short time with stretching
and quality of tissue does not ensure––dynamic
exercises.
extensibility. flexibility.

2. Pseudomyostatic (Apparent) contracture

Hypomobility
Ø Refers to decreased mobility or restricted motion at a single
joint or series of joints.
Ø Reduced functional motion, is often caused by adaptive
shortening or decreased extensibility in soft tissue.
Ø Can occur as the result of many disorders or situations.
Ø Any factor that limits mobility by decreasing the extensibility
of soft tissues may also lead to impaired muscle performance.
Ø Hypomobility can lead to functional limitations and disability in
a person’s life.
Factors for restricted motion:
• Prolonged immobilization of a body segment.
• Sedentary lifestyle.
• Postural malalignment and muscle imbalances.
• Impaired muscle performance.
• Tissue trauma resulting in inflammation and pain.
• Congenital or acquired deformities.
Ø With underlying pathology
Ø Impaired mobility and limited ROM may also be the result of
hypertonicity (i.e., spasticity or rigidity) associated with a
central nervous system lesion, such as a cerebrovascular
accident, a spinal cord injury, or traumatic brain injury. Muscle
spasm or guarding and pain may also cause a
pseudomyostatic contracture.
Ø In both situations, the involved muscles appear to be in a
constant state of contraction, giving rise to excessive
resistance to passive stretch. Hence, the terms
pseudomyostatic contracture or apparent contracture are
used. If neuromuscular inhibition procedures to reduce
muscle tension temporarily are applied, full, passive
elongation of the apparently shortened muscle is then
possible.
3. Arthrogenic and Periarticular contracture
Ø Contractures within the joint
Ø Arthrogenic contracture is the result of intra-articular
pathology. These changes may include adhesions, synovial
proliferation, joint effusion, irregularities in articular cartilage,
or osteophytes formation.
Ø Periarticular contracture develops when connective tissues
that cross or attach to a joint or the joint capsule lose
mobility, restricting normal arthrokinematics motion.

4. Fibrotic and irreversible contracture

Ø Covers connective tissue surrounding the muscles
Ø Fibrous changes in the connective tissue of muscle and
periarticular structures can cause adherence of these tissues
and subsequent development of a fibrotic contracture.

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Ø Although it is possible to stretch a fibrotic contracture and
eventually increase ROM, it is often difficult to re-establish
optimal tissue length.
Ø Permanent loss of soft tissue extensibility that cannot be
reversed by nonsurgical intervention may occur when normal
muscle and organized connective tissue are replaced with a
large amount of relatively non extensible fibrotic adhesions,
scar tissue, or heterotopic bone.
Ø These changes can occur after long periods of immobilization
with tissues in a shortened position or after tissue trauma and
the subsequent inflammatory response.
Ø The longer a fibrotic contracture exists or the more extensive
the tissue replacement, the more difficult it becomes to
regain optimal mobility and the more likely it is that the
contracture will become irreversible.
Stretching: Indications, Contraindications, and Precautions
General Precautions for Stretching
• Use extra caution in patients with known or suspected
osteoporosis.
• Protect newly united fractures; be certain there is appropriate
stabilization between 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)
gradually to minimize soft tissue trauma and post exercise muscle
soreness.
As suggested:
- 15 sec hold x 10 reps x 3 sets
- 30 sec hold x 3 reps x 1 set
• Avoid stretching edematous tissue
• Avoid overstretching weak muscles
Interventions to Increase Mobility of Soft Tissues
1. Manual or Mechanical/Passive or Assisted Stretching
Ø GPS – gentle passive stretching = performs with ranges that
are not painful.
Ø An end-range stretch force will elongate shortened muscle-
tendon units and/or periarticular connective tissues when a
restricted joint is rotated just beyond its available ROM. The
force can be applied by manual contact or a mechanical
device and can be sustained or intermittent. When the
patient is as relaxed as possible during the stretch, it is
called passive stretching. If the patient assists in moving the
joint through a greater range, it is called assisted stretching.
2. Self-Stretching
Ø Can be done actively by the patient
Ø Any stretching exercise that is carried out independently by
a patient after instruction and supervision by a therapist is
referred to as self-stretching. In this case forces are applied
by the patient at the end of available ROM for the purpose
of elongating hypomobile soft tissues. Flexibility exercises
are also performed independently, but this term usually
indicates stretching that is part of a general conditioning
and fitness program by individuals without mobility
impairments.
3. Neuromuscular Facilitation and Inhibition Techniques
Ø Maneuvers to relax the muscle before stretching
Ø Neuromuscular facilitation and inhibition procedures are
founded on the concept of reflexively decreasing tension in
shortened muscles prior to or during the stretch. Because
the use of inhibition or facilitation techniques to assist with
muscle elongation is associated with an approach to
exercise known as proprioceptive neuromuscular facilitation
(PNF), many clinicians and some authors refer to these
procedures as PNF stretching, active inhibition, active
stretching, or facilitated stretching.
4. Muscle Energy Techniques
Ø Tries to fatigue tight muscles
Ø Muscle energy techniques are manipulative procedures that
evolved out of osteopathic medicine 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
postisometric relaxation.
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5. Joint, Soft Tissue, or Neural Tissue Mobilization/Manipulation
Ø Joint manipulative techniques are skilled manual therapy
interventions specifically applied to joint structures by the
clinician to modulate pain and treat joint impairments that
limit ROM.
Ø Soft tissue manipulative techniques are designed to improve
the extensibility of any soft tissue that limits mobility. These
techniques involve the application of specific and progressive
manual forces using sustained manual pressure or slow, deep
stroking. Specially crafted instruments can also be used by
clinicians to apply these forces. Many techniques, including
friction massage, myofascial release, acupressure, and trigger
point therapy are designed to improve tissue mobility by
manipulating connective tissue that binds soft tissues.
Although they are useful adjuncts to manual stretching
procedures.
c. Intensity – magnitude of the stretch force applied. How much
stretch? Low-intensity stretching (coupled with a long duration of
stretch) results in optimal rates of improvement in ROM.
d. Duration – length of time the stretch force is applied during a
stretch cycle. Number of holds (the shorter the duration of a
single stretch cycle, the greater the number of reps applied
during a stretching session).
e. Speed – rate of initial application of the stretch force.
f. Frequency – number of stretching sessions per day or per week
g. Mode – form or manner in which the stretch force is applied
(static, ballistic, or cyclic), degree of patient participation (passive,
active, or assisted), or the source of the stretch force (manual,
mechanical, or self).

Ø Neural mobilization techniques are used to improve or

restore nerve tissue mobility. Neural tissue mobility may
become restricted by tissue adhesions or scar tissue following
trauma or surgical procedures. Increased tension placed on
nerve tissue by these adhesions during joint motion can lead
to pain or neurological symptoms. After specific tests are
conducted to determine neural tissue mobility, the neural
pathway is mobilized through selective procedures.

Selective Stretching

Ø Process whereby the overall function of a patient may be

improved by applying stretching techniques to some muscles
and joints while allowing motion limitations to develop in other
muscles or joints.
Ø When determining which muscles to stretch and which to slightly
shorten, the therapist should keep in mind the functional needs
of the patient and the importance of maintaining a balance
between mobility and stability for maximum functional
performance.
Ø The decision to allow restrictions to develop in selected muscle-
tendon units and joints typically is made in patients with
permanent paralysis. For example: patient with spinal cord injury;
patient with tenodesis effect.
Types of Stretching

Overstretching

Ø Is a stretch well beyond the normal length of muscle and ROM of

a joint and the surrounding soft tissues, resulting in hypermobility
(excessive mobility).
Ø Hypermobility causes instability which increases subluxation
(partial dislocation).
Ø Creating selective hypermobility by overstretching may be
necessary for certain healthy individuals with normal strength and
stability who participate in sports that require extensive flexibility.

Determinants of Stretching Interventions

a. Alignment – positioning a limb or the body such that the stretch
force is directed to the appropriate muscle group. (figure 4.8-9)
b. Stabilization – fixation of a bony segment that has an attachment
of the muscle to be stretched. (figure 4.10)
Static stretching – 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.

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Ballistic stretching – a rapid, forceful intermittent stretch––that is, a The direction of stretch is exactly opposite the direction of the
high-speed and high-intensity stretch. joint or muscle restriction.

Procedural Guidelines for Application of Stretching e. Explain the procedure to the patient and be certain he or she
understands.

I. Examination and Evaluation of the Patient
a. Carefully review the patient’s history and perform a
comprehensive systems review.
b. Select and perform appropriate tests and measurements.
Determine the ROM available in involved and adjacent joints and
assess if active and/or passive mobility is impaired.
III.
c. Determine if hypomobility is related to other impairments of
body structure or function and if it is causing activity limitations or
participation restrictions.
d. Determine if soft tissues are the source of the impaired mobility.
If so, differentiate between joint capsule, periarticular structures,
noncontractile tissue, and muscle length restrictions as the cause
of limited ROM. Be sure to assess joint play and fascial mobility.
e. Evaluate the irritability of the involved tissues and estimate their
stage of healing. When moving the patient’s extremities or spine,
pay close attention to the patient’s reaction to movements. This
not only helps identify the stage of healing of involved tissues; it
also helps determine the probable dosage (such as intensity and
duration) of stretch that stays within the patient’s comfort range.
f. Assess the strength of muscles in which there is motion limitation
and realistically consider the value of stretching the range-
limiting structures. Ideally, an individual should have the
capability of developing adequate strength to control and use
any newly gained ROM safely.
f. Free the area to be stretched of any restrictive clothing,
bandages, or orthotics.
g. Explain to the patient that it is important to be as relaxed as
possible and that the stretching procedures are meant to remain
within his or her tolerance level.
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After Stretching
a. Apply cold to the soft tissues that have been stretched and allow
these structures to cool in a lengthened position. Cold may
minimize poststretch muscle soreness that can occur as the result
of microtrauma during stretching. When soft tissues are cooled in
a lengthened position, increases in ROM are more readily
maintained.
b. Have the patient perform active ROM and strengthening
exercises through the gained range immediately after stretching.
With your supervision and feedback, have the patient use the
gained range by performing simulated functional movement
patterns that are part of daily living, occupational, or recreational
tasks.
c. Strengthen the antagonistic muscles in the newly gained range to
ensure adequate neuromuscular control and stability as flexibility.

g. Consider the outcome goals (i.e., functional improvements) that

the patient hopes to achieve as the result of the intervention
program and determine if those goals are realistic.

h. Analyze the impact of any factors that could adversely affect the
projected outcomes of the stretching program.

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II. Preparation for Stretching

a. Review the goals and desired outcomes of the stretching

program with the patient. Obtain the patient’s consent to initiate
treatment.

b. Select the stretching techniques that will be most effective and

efficient.

c. 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 decrease the risk of
injury from stretching.

d. Have the patient assume a comfortable, stable position that

allows the correct plane of motion for the stretching procedure.

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References: Lecture discussion, PPT, and Kisner Colby & Borstad

(2018) Therapeutic exercise Foundations and Techniques (7e).pdf

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