Stretching Flashcards
Indications for Stretching
ROM is limited by:
Adhesions
Contractures
Scar tissue formation
Prevention of possible structural deformities
Muscle weakness in antagonist muscles
Reduce post exercise muscle soreness
Fitness or sport specific exercise program
Contraindications
Bony block limiting ROM (End feel)
Recent fracture
Evidence of acute inflammation, infection
Sharp, acute pain with movement or muscle elongation
Hematoma or other indications of trauma
Contracture improves joint stability, function that otherwise would limit activity or participation functions
Neurophysiology of Stretching: Stretch Reflex
Stimulation of mechanoreceptors to CNS which provide information on muscle length and tension
Mechanoreceptors: Muscle Spindle and GTO’s
Protect muscle from becoming injured during stretching
A quick stretch will facilitate a reflex contraction
Muscle Spindle
Respond to changes in length and velocity of the length change
Stretch occurs
Impulse goes to brain telling it the amount of stretch
Impulse returns to muscle spindle from spinal cord to cause a reflexive contraction of the muscle
Especially sensitive to rapid changes such as what occurs with ballistic stretching
GTO’s
Located in the musculotendinous junction
Respond to muscle length and muscle tension
Detects increase in tension
Sends message to CNS to cause reflexive relation of muscle tissue
Stretch > 8 seconds overrides muscle spindle and will get relaxation of the muscle being stretched
Autogenic inhibition
Effects of Stretching
Short Term
Muscle relaxation
Elongation of elastic components
Long Term
Plastic deformation
Addition of sarcomeres
Failure
Stretched beyond limits
Fibers become brittle and rupture
Changes in Collagen Affecting the Stress-Strain Curve: Immobilization
Weak tissue
Weak bonding of new tissue
Adhesion formation
Changes in Collagen Affecting the Stress-Strain Curve: Inactivity
Decrease in size and amount of collagen fibers
Weak tissue
Increase in elastin fibers
Changes in Collagen Affecting the Stress-Strain Curve: Age
Decrease in tensile strength Decrease in elastin Rate of adaptation to stress is slower Increase in overuse syndromes Tears and fatigue failure
Changes in Collagen Affecting the Stress-Strain Curve: Corticosteroids
Decrease in tensile strength
Fibrocyte death next to injection site
Changes in Collagen Affecting the Stress-Strain Curve: Injury
Follows predictable pattern if fibers have been disrupted
Changes in Collagen Affecting the Stress-Strain Curve: Other Co-morbidities
Nutritional deficits
Diabetes
Hormonal imbalances - thyroid
Good Stretching Fundamentals
Alignment
Stabilization
Alignment
positioning of the limb or body in such a way as to direct the force of the stretch to the appropriate muscle
Stabilization
obtain proper fixation of one side of the joint/muscle while applying an appropriate stretch on the other side
Influences on Elastic or Plastic Deformation: Intensity
Low-Load
Decreased muscle guarding
Patient relaxes more
High-Load
More painful
May cause tissue failure
Influences on Elastic or Plastic Deformation: Duration
Shorter the duration the greater number of reps are needed.
Lack of agreement of the ideal combo of duration and reps.
Common prescription 3 x 30 seconds
Up to 1-2 minutes
Optimal rate of improving ROM
Low-load with long-duration
Long Duration
Long duration stretch 5 seconds to 5 minutes to hours/days
Joint mobilizations, sustained
Short Duration
Cyclic stretching Repeated and gradually applied Low velocity, low intensity Stretch cycle is 5-10 seconds Joint mobilizations, oscillations
Influences on Elastic or Plastic Deformation: Velocity
Slow speed to minimize risk to tissue and DOMS
Not just on application but with release as well
Slow decreases activation of stretch reflex
Influences on Elastic or Plastic Deformation: Frequency
Based on…
Underlying cause of the impaired mobility
Quality and level of healing tissues
Chronicity and severity of the contracture
Age
Corticosteroid use
Previous response to stretch
Modes/Types of Stretching
Static Stretching Cyclic/Intermittent Stretching Ballistic Stretching PNF Stretching Manual Stretching Mechanical Stretching Self-Stretching Active/Dynamic Stretching
Static Stretch
“Low-Load Long Duration”
Typically the most common type you’ll see in the clinic
Cyclic / Intermittent Stretch
Short-duration that is repeated and gradually applied, released, and then reapplied.
Multiple repetitions
Duration not clearly defined
Some literature 5-10 seconds
Some literature states 5-10 seconds is static
Ballistic Stretching
High speed
High intensity
Not recommended for elderly or sedentary patients
Avoid in most cases
If used, rapid, low intensity stretches should occur
PNF Stretching
Hold-Relax
Contract-Relax
Agonist Contraction
Combination of these
Manual Stretching
Therapist controls... Site of stabilization Direction Speed Intensity Duration of stretch
Mechanical Stretching
Device applies a stretching force typically at home
Dynasplint
Low load long duration
Hours
ERMI (End Range Motion Improvement)
High load short duration
Used from 10-15 minutes
Can use free weights in clinic
Self-Stretching
Patient performs independent of therapy site
Can use surfaces to help support during the stretch
Can use towels, belts, cane’s etc to help with the stretch
HEP
Active/Dynamic Stretching
Different than ballistic stretching
Momentum from static-active stretching
Doesn’t exceed the static-passive stretching ability
Commonly used prior to athletic events
Teaching Self-Stretching Exercises
Teach all elements of a stretch Alignment Stabilization Intensity Duration Frequency
Utilize an appropriate surface for the stretch
Ensure the patient can perform the stretch at home
Watch the patient perform the exercise and make corrections
Warming up tissue prior to stretching
Written instructions with pictures
Review it with patient at next visit
Different Dynamic Stretches
Knee to Chests Straight Leg Kicks Straight Leg Kick Cross-Overs Bottom Kicks Lunges Side Lunges Karaoke
UE too!
Stretching Considerations
Avoid poor / dangerous spinal and extremity positions
Keep in mind unnecessary tension on…
Peripheral nerves
Articular cartilage
Intervertebral discs
Protect the smaller joints
Protect the pathological joints
Don’t stretch beyond normal ROM
Should only feel it where it’s supposed to be felt
ASK! – not just if they feel it but where!
Progress dosage
If pain/soreness > 24 hours after stretching, then too much force
Inflammatory response=increased scar tissue formation
Avoid overstretching weak muscles
Effects of Modalities on Stretching
Superficial Heat
Deep Heat
Cryotherapy
Primarily heat / cool small areas…
Individual joints
Muscle groups
Tendons
Cryotherapy
Applied only with muscle guarding or muscle spasms
Decreases tone
Less sensitive to stretch
After healing and scar formation begin
Less extensibility
More susceptible to microtrauma
Spray and Stretch
Applies cold spray with static stretching at the same time
Flouri-methane or ethyl chloride sprays produce the cold
Decreased patient discomfort
Trigger Point technique
Thermotherapy
Increases tissue extensibility
Stretching window: about 3.3 minutes following removal of deep heat, may be shorter with superficial heat
Heating combined with stretch more beneficial than heat alone
Deep heat more effective than superficial heat
Thermo- vs Cryo-therapy
Research does support either – chronic issues
General Rules for Acute Injury…
Ice for 1st 24-48 hours post injury to minimize edema, muscle spasm, and pain
At this time stretching is contraindicated
After inflammation subsides, warming prior or during stretching is effective
Can apply cold to the soft tissues held in the lengthened position
Minimizes soreness
Promote longer-lasting gains in ROM
Active Warm-Up
Low-intensity active exercises that the patient does prior to stretching
Increases tissue temperatures Core and circulation Allows for plastic change to occur Muscle spindle activity is decreased Golgi tendon organ activity is stimulated
It is recommended that an active warm-up for be performed for at least 10-15 minutes prior to stretching
