Flexibility and Stretching

• Stretching is a therapeutic approach used to increase the extensibility of soft tissue.
• A comprehensive evaluation is required to identify structures limiting a patient's functional mobility.
• Stretching aims to lengthen both contractile and non-contractile components of the musculotendinous unit, along with periarticular structures.

Flexibility

• Dynamic flexibility describes the active range of motion.
• Active mobility, or AROM, indicates how far an active muscle contraction can move a body segment through a joint's available range.
• Passive flexibility relates to the passive range of motion.
• Passive mobility, or PROM, is how far a joint can be moved passively through its available range.
• Passive flexibility doesn't guarantee active flexibility.
• Muscle length, joint integrity, and the extensibility of soft tissues all influence flexibility.
• Dynamic flexibility indicates the degree to which an active muscle contraction moves a body segment through the available joint ROM.
• Passive flexibility indicates the extent to which a joint can be passively moved through the available ROM
• Passive flexibility does not guarantee active flexibility.

Hypomobility

• Hypomobility is decreased mobility or restricted motion in a joint or series of joints.
• Pathological processes and various factors can cause hypomobility.
• Contractile, non-contractile, and connective tissues can shorten, contributing to hypomobility.
• Shortened soft tissues contributing to hypomobility include tendons, ligaments, joint capsules, fascia, skin and muscle.

Factors Contributing to Hypomobility

• Extrinsic factors leading to prolonged immobilization include casts, orthotics, and skeletal traction.
• Intrinsic factors leading to prolonged immobilization include pain, joint inflammation/effusion, or muscle/tendon/fascial disorders.
• Additional intrinsic factors are skin disorders, bony blocks, and vascular disorders.
• Lifestyle and habitual activities like confinement to bed/wheelchair and prolonged positioning related to occupation/sports can cause hypomobility.
• Paralysis, tonal abnormalities, and muscle imbalances, like CNS/PNS dysfunction, can contribute to hypomobility.
• Congenital or acquired postural malalignment like scoliosis or kyphosis can result in hypomobility.
• Additional examples of factors contributing to hypomobility are fractures, soft tissue trauma/repair, microtrauma/macrotrauma, degenerative joint diseases, joint traumas, myositis, tendonitis, fasciitis, burns, skin grafts, peripheral lymphedema, osteophytes, ankylosis, and surgical fusion.

Immobility

• Prolonged immobility leads to decreased contractile protein, muscle fiber diameter, number of myofibrils, and intramuscular capillary density.
• Immobility results in muscle atrophy and weakness, along with increased fibrous and fatty tissue, decreasing overall extensibility.

Contracture

• Contracture describes adaptive shortening of the muscle-tendon unit and surrounding soft tissues.
• Contractures result in limited passive or active stretch and decreased range of motion.
• Tissues losing elasticity due to prolonged joint positioning can lead to contractures.
• Contractures are long-term impairments that significantly compromise functional abilities.

Types of Contractures

• Myostatic contractures occur when the musculotendinous unit shortens without muscle pathology, like gastroc/soleus shortening from wearing high heels.
• Pseudomyostatic contractures result from hypertonicity related to CNS lesions.
• Arthrogenic/periarticular contractures involve intra-articular pathology, such as effusion or osteophytes, impairing movement.
• Fibrotic contractures involve changes in the connective tissue of muscle/periarticular fibers, creating adhesions between tissues (scar tissue).

Indications for Stretching

• Stretching is recommended when ROM is limited due to loss of soft tissue extensibility from adhesions, contractures, and scar tissue, causing activity limitations.
• Restricted motion may lead to preventable structural deformities, indicating a need for stretching.
• Muscle weakness and shortening of opposing tissues leading to limited ROM indicate stretching.
• Stretching is helpful as part of fitness or conditioning programs to prevent musculoskeletal injuries.
• A warm-up or cool-down routine before and after exercise is an appropriate time for stretching
• Improved symptoms of tightness and perception can also be improved by stretching.

Contraindications to Stretching

• Bony blocks limiting motion are a contraindication for stretching.
• Recent fractures or insufficient bone union contraindicate stretching.
• Acute inflammatory or infectious processes that involve heat and swelling are also contraindications.
• Stretching should be avoided if it disrupts the early healing process.
• Sharp, acute pain on joint movement or muscle elongation contraindicates stretching.
• Hematoma or other indications of tissue trauma are contraindications for stretching.
• Hypermobility is a contraindication for stretching.
• Stretching is contraindicated when shortened soft tissues provide joint stability in the presence of abnormal structures or lack of neuromuscular control.
• Do not stretch if shortened soft tissues allow a patient with paralysis or severe muscle weakness to perform specific functional skills.

Stretching: Theories & Anatomy Review

• Goals of the lecture are to explain musculoskeletal and neuromuscular adaptation to flexibility exercise.
• Variables of flexibility exercise include, type, duration of holds, dynamic/static, velocity, load, and ROM
• Goals are to select appropriate exercise based on limitations
• Describe Selecting Flexibility Exercises
• Manipulate Flexibility Exercise Prescription
• FITT-VP guideline application to improve performance

Non-Contractile Tissue: Mechanical Properties

• Endomysium, perimysium, and epimysium are non-contractile tissues.
• Connective tissue consists of collagen fibers, elastin fibers, reticulin fibers, and ground substance.

Mechanical Properties of Contractile Tissue

• Myofibrils are contractile tissues
• Sarcomeres are contractile tissues
• Myofilaments are contractile tissues

Stress/Strain Curve Review

• Elasticity describes a material's ability to return to its original shape after deformation.
• Plasticity describes the material's state

Neurophysiological properties

• GTO
• Muscle Spindle

Theories to explain muscle extensibility

• Viscoelastic deformation
• Plastic deformation
• Increased sarcomeres in series
• Neuromuscular relaxation
• These mechanical and sensory principles affect muscle extensibility

Modes of Stretching

• Therapeutic maneuvers that promote the extensibility of soft tissue.
• Evaluate any limits to the functions mobility
• Elongation should be applied to both musculotendinous and periarticular components.

Stretching Includes

• "Hands on" activities
• Joint mobilization
• Mechanical Self

Methods of Stretching

• Manual stretching involves an external force applied by a PT or caregiver with controlled alignment and stabilization.
• Self-stretching involves activity from the patient or client. Provide education and cues to avoid compensation.
• Mechanical stretching includes low load intensity. A brace, cuff etc. are examples

Proprioceptive Neuromuscular Facilitation (PNF)

• Hold relax (contract relax)
• Agonist contract
• Hold relax (contract relax) with agonist contraction

Implementation of Stretching: Mode

• Manual
• Mechanical
• Self-Stretching
• Passive
• Assisted
• Active

Implementation of Stretching: Intensity of the stretch

• Low intensity and load
• Avoid voluntary and non-voluntary guarding
• Decreases risk of injury
• More effective to elongate tissue

Implementation of Stretching: Speed

• Speed should be slow
• Encourages relaxation
• Prevents Injury
• More control for both patient and practitioner

Implementation of Stretching: Duration

• Static stretch shows improvement in ROM in 4-26 weeks
• Minimum 5 minutes per muscle per week.
• Static
• Static Progressive
• Cyclic Intermittent
• Must consider changes in tissue

Implementation of Stretching: Frequency

• Frequency is number of bouts each day/week
• Depends on tissue quality of patient
• 5 days static stretch shows increased ROM
• Allow sessions for healing
• Use clinical judgement on patient

Implementation of Stretching: Direction

• Stretch opposite the muscle's action
• When Hamstrings or knee flexors are shortened, apply knee extension
• When Elbow Extensors are shortened, apply Elbow Flexion
• Single muscles must cross the joint
• Movement across joint muscles can include passive insufficiencies.

FITT-VP in Stretching

• Type- Passive Stretching of Hamstrings
• Time- 3 sets for 30 seconds and rest
• Intensity- To end range and no pain
• Frequency- 3X per day
• Volume- 2 sets a day for 5 day/week
• Progression- should work on self stretching

Precautions

• Osteoporosis
• Post- Imbolization
• Elderly
• Edema
• Look for soreness

Contraindications

• New fractures
• Inflammation
• Acute pain
• Harmotoma
• Stabilize as needed.

Pre Stretch Considerations

• Provide patient education
• Check the environment
• Check how cold/hot/active they are

Post Stretch Considerations

• Look for how strengthening the area feels

Joint Adjuncts to Stretching

• Tai Chi
• Yoga
• Pilates
• Heat
• Massage
• Exercise
• Function