STRETCHING

WHAT IS STRETCHING???

 It is a therapeutic maneuver designed to

increase the extensibility of soft tissues,
thereby improving flexibility by elongating
structures that have adaptively shortened and
have become hypo mobile over time.
 FLEXIBILITY
 HYPOMOBILITY
 CONTRACTURE
 TYPES OF CONTRACTURE
 FLEXIBILITY

Is the ability to move a single joint or series of

joints smoothly and easily through an
unrestricted pain free ROM
 Flexibility depends of joint integrity and

extensibility of periarticular soft tissues

 Hypomobility
 Decreased mobility or restricted motion
Causes For Hypomobility

 Prolonged immobilization
 Sedentary life style
 Postural malalignment
 Tissue trauma
 Congenital or acquired deformities
 Contracture
 It 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.
Last class??
 Stretching definition
 FLEXIBILITY
 HYPOMOBILITY
 CONTRACTURE
 TYPES OF CONTRACTURE
 Learning objectives

 Types of contractures
 Indications
 Contra-indications
Types of Contracture

 Myostatic contracture
 Pseudomyostatic contracture
 Arthrogenic contracture
 Periarticular contractures
 Fibrotic and irreversible contracture
 Myostatic contracture

 Musculotendinous unit has adaptively

shortened
 Significant loss of ROM
 There is no specific muscle pathology present
 Reduction in the number of sarcomere units
 No decrease in individual sarcomere length
 Can be resolved in short time with stretching

exercises
Pseudomyostatic Contracture

 Impaired mobility and limited ROM

 Caused by hyper tonicity
 Central nervous system lesion such as

cerebral vascular accidents, spinal cord

injury, traumatic brain injury
 Muscle spasm, or guarding and pain
 Involved muscles appear to be in a constant

state of contraction
 Which leads to excessive resistance to passive
stretch
 Inhibitory techniques are used to reduce

muscle tension
Arthrogenic and periarticular
contractures

 Is the result of intra-articular pathology

 Adhesions
 Synovial proliferation
 Joint effusion
 Irregularities in articular cartilage
 Osteophyte formation
 Tight capsule
Fibrotic and Irreversible Contracture

 Fibrous changes in the connective tissue of

the muscle and periarticulalr structures
 Normal muscle tissue replaced with a large

amount of relatively non extensible , fibrotic

adhesions and scar tissue or heterotopic
bone
 These changes occur after long periods of

immobilization of tissues in shortened

positioned
Indications
 Rom is limited by adhesions, contractures
and scar tissue
 Restricted motion may lead to structural

deformities
 Muscle weakness
 For total fitness program to prevent

musculoskeletal injuries
 May be used prior to and after vigorous

exercise to prevent post exercise muscle

soreness
Contraindications to Stretching
 A bony block limits joint motion
 Recent fracture
 Unhealed fracture
 Evidence of acute inflammatory or infection
 Sharp, acute pain with joint movement or muscle
elongation
 A hematoma
 Hyper mobility
 Shortened soft tissues provide necessary joint
stability
 Shortened soft tissues enable a patient to perform
specific functional skills
 Summary

 Types of contractures??
 Indications ??
 Contra-indications??
Interventions to increase Mobility of
Soft Tissues

 Manual or mechanical / passive or assisted

stretching
 Self-stretching
 PNF
 Muscle energy techniques
 Joint mobilization/manipulation
 Soft tissue mobilization and manipulation
 Neural tissue mobilization
Properties of Soft Tissue
Response to Immobilization and Stretch

 Muscle – contractile and non contractile

elements
 Contractile elements of muscle
 Sarcomeres
 Non contractile connective tissue of muscle
 Ednomysium
 Perimysium
 epimysium
 Connective tissues

 Tendons
 Ligaments
 Joint capsules
 Fascia
 skin
Response to Stretch

 Elastic change
 Viscoelastic change
 Plastic change
 contractile and non contractile – elastic and

plastic qualities
 Only connective tissue have – viscoelastic

properties
Elasticity
 is the ability of soft tissue to return to its

pre-stretch resting length directly after a

short-duration stretch force has been
removed.
 Viscoelasticity
is a time-dependent property of soft tissue
that initially resists deformation, such as a
change in length, of the tissue when a stretch
force is first applied.
 If a stretch force is sustained, viscoelasticity

allows a change in the length of the tissue

and then enables the tissue to return
gradually to its pre-stretch state after the
stretch force has been removed.
Plasticity
 is the tendency of soft tissue to assume a

new and greater length after the stretch force

has been removed.
 Mechanical Response of the
Contractile Unit to Stretch and
Immobilization
RESOPONSE TO STRETCH

 Stretch force is transmitted to the muscle

fibers via connective tissue
 Longitudinal and lateral force transduction

occurs
 Mechanical disruption of the cross bridges
 Which leads to abrupt lengthening of the

sarcomeres
 When stretch force is released, individual

sarcomeres return to their resting length

RESPONSE TO IMMOBILIZATION

 Physical stress is decreased on the muscle

 Decay of the contractile protein
 Decrease in muscle fiber diameter
 Decrease in the number of myofibrils
 Decrease in intramuscular capillary density
 Above all leads to muscle atrophy
 Increase in fibrous and fatty tissue in muscle
IMMOBILIZAION IN A SHORTENED POSITION

 Reduction in the length of the muscle

 Reduction in the number of sarcomeres
 Sarcomere absorption
 Decrease in the overall length of the muscle

fibers
 Muscle atrophy and muscle weakness
 Decrease in force production capacity
 More fibrous tissue and subcutaneous fat in

the muscle
IMMOBILIZATION IN A LEGNTHENED POSIOTION

 MYOFIBRILOGENESIS
 ( increasing the number of sarcomeres )
 This leads plastic changes in muscle
lengthening
Neurophysiological Properties of
Contractile Tissue

 Two sensory organs of muscle-tendon units

 Muscle spindle
 Golgi tendon organ
MUSCLE SPINDLE
The muscle spindle is the major sensory
organ of muscle and is sensitive to quick and
sustained (tonic) stretch .
 The main function of muscle spindles is to

receive and convey information about

changes in the length of a muscle and the
velocity of the length changes.
 Golgi Tendon Organ

The Golgi tendon organ (GTO) is a sensory

organ located near the musculotendinous
junctions of extrafusal muscle fibers.
 The function of a GTO is to monitor changes

in tension of muscle-tendon units.

 Neurophysiological Response of Muscle to
Stretch ??????????

 STRETCH REFLEX
Mechanical Properties of
Noncontractile Soft Tissue
Mechanical properties of non-
contractile soft tissue

 Composition of connective tissue

 Collagen
 Elastin
 Reticulin
 Nonfibrous ground substance
Collagen fibers

 Responsible for the strength and stiffness of

the tissue
 Resist tensile deformation
 Ligaments and tendons – type 1 collagen
 Which is highly resistant to tension
 Tissues with a greater proportion of collagen

provides greater stability

Elastin fibers

 Elastin fibers provide extensibility

 They show a great deal of elongation with

small loads
 Fail abruptly without deformation at higher

loads
 Tissues with greater amounts of elastin have

greater flexibility
Reticulin fibers

 Reticulin fibers provide tissue with bulk

Ground sunstance
 Made up of proteoglycans and glycoproteins

 Functions of PG

 Hydrate the matrix

 Stabilize the collagen networks
 Resist compressive forces
 Cartilage and discs
 Glycoprotein's
 Provide linkage between the matrix

components and between the cells

 It contains water
 Reduces friction between fibers
 Transports nutrients and metabolites
 May prevent excessive cross-linking between

the fibers by maintaining space between

fibers
Mechanical behavior of
noncontractile tissue

 The proportion of collagen and elastin fibers

 The structural orientation of the fibers
 Proportion of proteoglycans
The Stress-Strain Curve

 Stress-strain curve illustrates

 The strength properties,
 Stiffness,
 And amount of energy the material can store

before failure of the structure.

 And is used to interpret what is happening
 to connective tissue under stress loads
Stress-strain curve

 Stress:
 Stress is force per unit area.
 Mechanical stress is the internal reaction or

resistance to an external load

Types of stress
 Tension

 A force applied perpendicular to the cross-

sectional area of the tissue in a direction
away from the tissue.

 A stretching force is a tension stress

 Compression:

 A force applied perpendicular to the cross-

sectional area of the tissue in a direction
toward the tissue

 Eg: muscle contraction and loading of joint

during weight bearing
 Shear:
 A force applied parallel to the cross-sectional

area of the tissue

 Strain:

 The amount of deformation or lengthening

that occurs when a load or stretch force is
applied
The Stress-Strain Curve
Connective Tissue Response to
Loads

 Creep
 Stress-relaxation
creep

 When load applied for an extended period of

time , the tissue elongates resulting in
permanent deformation
Stress-Relaxation

 When a force is applied to stretch a tissue

and the length of the tissue is kept constant
after the initial creep there is a decrease in
the force required to maintain that length and
the tension in the tissue decreases
Summary of Mechanical Principles
for Stretching Connective Tissue

 Connective tissue deformation (stretch)

occurs to different degrees at different
intensities of force and at different rates
of application

 It requires breaking of collagen bonds and

realignment of the fibers for there to be
permanent elongation or increased flexibility
 Failure of tissue begins as microfailure of
fibrils and fibers before complete failure of
the tissue occurs.

 Microfailure (needed for permanent

lengthening) also occurs with creep, stress-
relaxation, and controlled cyclic loading
 Healing and adaptive remodeling capabilities
allow the tissue to respond to repetitive and
sustained loads if time is allowed between
bouts.
 This is important for increasing both

flexibility and tensile strength of the tissue

 If healing and remodeling time is not allowed,

a breakdown of tissue (failure) occurs as in

overuse syndromes and stress fractures
 Intensive stretching is usually not done every
day in order to allow time for healing.

 If the inflammation from the micro ruptures is

excessive, additional scar tissue, which could
become more restrictive

 It is imperative that the individual use any

newly gained range to allow the remodeling of
tissue and to train the muscle to control the
new range
Factors

 Immobilization
 Inactivity
 Age
 Corticosteroids
 Injury
 Nutritional deficiencies
 hormonal imbalances
 and dialysis
Determinants of stretching

 Alignment
 Stabilization
 Intensity
 Duration
 Speed
 Frequency
 mode
Alingment and Stabilization
Alignment:
positioning a limb or the body
 Stabilization:

 fixation of one site of attachment of the

muscle as the stretch force is applied to the
other bony attachment
 Intensity:

 Low intensity by low load

 Low intensity coupled with long duration
 Effective for dense connective tissue
 Less soft tissue damage
 Less post-exercise soreness
 Duration:? ?

 The duration of stretch refers to the period of

time a stretch force is applied and shortened
tissues are held in a lengthened position
 Long duration stretch

 Static stretching
 Static progressive stretching

 Short duration stretch

 Cyclic stretching
 intermittent,
 or ballistic
 Speed :

 Speed of stretch should be slow

 The stretch force should be applied and

released gradually
 Slow stretch decrease stress on connective

tissue
 Decrease stretch reflex
 Ballistic stretching:

 A rapid forceful intermittent stretch- high –

speed and high intensity stretch
 It is characterized by the use of quick,

bouncing movements that create momentum

to carry the body segments through the ROM
to stretch shortened structures.
 For whom????

 Highly trained athletes

 Gymnastics
 Young active patient in final phase of

rehabilitation
 Frequency:
 Number of bouts or sessions per day or per
week a patient carries out a stretching program
 It is based on
 Underlying cause and quality and level of
healing of tissues
 And severity of a contracture
 Age
 Use of corticosteroids
 Previous response to stretching
 On weekly basis : Two to Five sessions
 Rest between sessions for tissue healing and

to minimize post exercise soreness

 Mode of stretch:
 The form of stretch or the manner in which

stretching exercise are carried out.

 Who or what is applying stretch force

 Manual stretching
 Mechanical stretching
 Self stretching or active stretching
 PNF stretching
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.
MANUAL STRETCHING
 Therapist
 Trained practitioner
 Caregiver
 Move the extremity slowly through the free

range to the point of tissue restriction.

 Grasp the areas proximal and distal to the

joint in which motion is to occur.

 The grasp should be firm but not

uncomfortable for the patient.

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.
Mechanical Strething
PNF STRETCHING ????
 Active stretching
 Facilitative stretching
 Integrates active muscle contractions into
stretching maneuvers
 It require normal innervation
 voluntary control of either shortened muscle or
muscle opposite side of the joint
 PNF techniques are designed to affect the
contractile elements of muscle
 It is very effective when muscle spasm limits motion
 Less appropriate for stretching fibrotic contractures
TYPES OF PNF STRETCHING

 HOLD-RELAX (HR) OR CONTRACT-RELAX(CR)

 AGONIST CONTRACTION ( AC )
 HOLD – RELAX WITH AGONIST CONTRACTION
HOLD-RELAX

 The range limiting muscle is first lengthened

 Patient performs prestretch, end range

isometric contraction for 5-10 seconds

 Followed by voluntary relaxation of the tight

muscle
 The limb then passively moved into new

range
 ????????
AGONIST CONTRACTION
 Agonist = the muscle opposite the range
limiting muscle
 Active stretching
 DROM dynamic range of motion
 Patient concentrically contracts the muscle
opposite the range limiting muscle
 And then holds the end range position for
several seconds
 The movement of the limb is independently
controlled by the patient
 ??????????
 AC technique is effective in muscle guarding
 Less effective in reducing chronic

contractures
 This technique is useful when HR is not

possible
 It is also useful for initiating neuromuscular

control
 It is least effective if patient has close to

normal flexibility
 HR WITH AC
Precautions for Stretching
 Do not passively force a joint beyond its
normal ROM
 Osteoporosis
 Prolonged bed rest
 Prolonged use of steroids
 Avoid vigorous stretching after prolonged

immobilization
 Progress the dosage of stretching gradually
 Avoid stretching edematous tissue
 Avoid overstretching on weak muscles
ADJUNCTS TO STRETCHING
INTEVENTIONS

 REALAXAION TRAINING
 HEAT
 MASSAGE
 BIOFEEDBACK
 JOINT TRACTION OR OSCILLATION