Stretching PPT PDF - PHT 1217 Principles and Procedures Spring 2025

STRETCHING PHT 1217—Principles and Procedures Spring, 2025 Rebecca Overdorf, PT, DPT  IMMOBILIZATION Prolonged immobilization can result in decreased ROM in soft tissue and joints Immobilization can be related to inactivity, pain, or post-injury/post-...

STRETCHING PHT 1217—Principles and Procedures Spring, 2025 Rebecca Overdorf, PT, DPT  IMMOBILIZATION Prolonged immobilization can result in decreased ROM in soft tissue and joints Immobilization can be related to inactivity, pain, or post-injury/post- surgical protocols (e.g., immobilization after fracture) Inactivity is the leading cause of decreased ROM and contractures EXTRINSIC FACTORS THAT LIMIT RANGE OF MOTION Casts/orthotics/external fixators Skeletal traction  INTRINSIC FACTORS THAT LIMIT ROM Pain Bony/mechanical blocks (e.g., Inflammation (systemic or local) osteophytes, spinal disk herniation) Joint effusion Vascular disorders Muscle/tendon/fascial disorders (e.g., Contracture adhesions, tendonitis) Vascular disorders Skin disorders (e.g., burns, scleroderma)  OTHER FACTORS THAT LIMIT ROM Muscle weakness Psychological factors (e.g., kinesiophobia) Sedentary lifestyle/inactivity Tone abnormalities/muscle imbalances (e.g., spasticity, muscle weakness) Postural misalignment (e.g., scoliosis, kyphosis) INTERVENTIONS TO IMPROVE MOBILITY STRECTHING PROM/AAROM/AROM SURGERY  ROLE OF PHYSICAL AGENTS Can increase soft tissue extensibility Can help control inflammation Can help limit formation of adhesions Can help control pain/discomfort during stretching Can help facilitate motion  FLEXIBILITY ABILITY TO MOVE A JOINT (OR SERIES OF JOINTS) SMOOTHLY THROUGH AN UNRESTRICTED, PAIN-FREE RANGE OF MOTION CAPSULAR VS. NON-CAPSULAR RESTRICTION CAPSULAR→ Joint capsule is limiting movement NON-CAPSULAR→ Factors unrelated to joint capsule are limiting movement  CAPSULAR RESTRICTION Capsule surrounding a synovial joint has become tight, restricted, or adhered Motions are restricted in multiple planes PROM of joint is limited in a specific capsular pattern Each synovial joint has a unique capsular pattern characterized by a specific combination of restricted motions Movements have firm, capsular end-feel  CAPSULAR RESTRICTION (Contd.) POTENTIAL CAUSES: Prolonged immobilization Joint effusion Tissue fibrosis Local or systemic inflammation (e.g., DJD, RA, OA, acute trauma)  NONCAPSULAR RESTRICTION Motion loss that is not related directly to the joint capsule or follow a specific pattern POTENTIAL CAUSES: Ligamentous adhesion Internal joint derangement Extra-articular lesion  SPEED OF STRETCH SLOW STRETCH IS SAFER THAN HIGH-VELOCITY STRETCH Slow stretch reduces risk of tissue injury and post-stretch soreness Slow stretch is less likely to increase stress on connective tissues Slow stretch is less likely to active stretch reflex (muscle spindle) Slow stretch is more compatible with viscoelastic properties of connective tissues Slow stretch is easier for therapist or patient to control  MODES OF STRETCHING Static/static progressive Mechanical Cyclic/intermittent Self-stretching Ballistic Passive Proprioceptive neuromuscular facilitation (PNF) Active Manual  MODES OF STRETCHING: PASSIVE Patient is as relaxed as possible during the stretch Can be applied manually or mechanically  MODES OF STRETCHING: STATIC/STATIC-PROGRESSIVE STATIC Soft tissues are lengthened and held in sustained position just beyond point of tissue resistance Stretch is held for a period of time and then removed Duration of stretch can vary depending on patient tolerance and response to stretch Can be applied manually or mechanically  MODES OF STRETCHING: STATIC/STATIC PROGRESSIVE (Contd.) STATIC PROGRESSIVE Shortened tissues are held in comfortably elongated position until relaxation of tissues is felt Shortened tissues are then incrementally lengthened further into range and held in each new end-range position for duration of time Static stretching is most effective method of static stretching  MODES OF STRETCHING: CYCLIC/INTERMITTENT Short-duration stretch force is gradually applied, released, and reapplied repeatedly for multiple repetitions End-range stretch is applied at slow velocity, in a controlled manner, with relatively low intensity → Is not the same as ballistic stretching Duration of stretch and number of repetitions is determined by patient tolerance/response  MODES OF STRETCHING: BALLISTIC High-velocity, high-intensity stretch Characterized by fast joint movement that quickly elongates the targeted soft tissues Is appropriate for some individuals (e.g., highly trained athletes, young active patients wanting to return to high-demand recreational or sport activities) Is not recommended for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures Is thought to cause greater trauma to stretched tissues and greater residual muscle soreness than static stretching  MODES OF STRETCHING: MANUAL / MECHANICAL MANUAL MECHANICAL Clinician or patient applies stretch to Stretching is applied using external the target tissue beyond the point of mechanical device tissue resistance Very low-intensity constant stretch Clinician or patient manually controls applied for long duration stabilization, direction, speed, Goal is to produce plastic changes intensity, and duration of stretch over time Can be performed passively or with Examples: Cuff weights, weighted assistance from the patient pulley systems, Flexionator ® or Extensionator ®  MODES OF STRETCHING: SELF-STRETCHING Stretching is done independently by the patient after careful instruction and supervised practice Enables patient to maintain or increase extensibility Is often an integral component of a home exercise program Is necessary for long-term self-management NEUROMUSCULAR FACILITATION/INHIBITION TECHNIQUES Founded on the concept of reflexively decreasing tension in shortened muscles before or during stretch Has commonly become known as PNF (proprioceptive neuromuscular facilitation) stretching Examples: Hold-relax (contract-relax), agonist contraction, hold-relax with agonist contraction  HOLD RELAX / CONTRACT RELAX Uses autogenic inhibition to relax target muscle and allow for further elongation Tight target muscle is lengthened to the point of tissue resistance or patient comfort level Patient actively performs end-range isometric contraction of the target muscle against resistance (manual or external) This contraction is held for about 5 seconds, followed by voluntary relaxation of the target muscle The limb is then passively moved further into the range and stretch is held several more seconds See figure 4.14 A-B (pg. 108) and 17.31 A (pg. 621)  ACTIVE INHIBITION Uses reciprocal inhibition to temporarily relax target muscle to allow for greater elongation Tight muscle is passively stretched to point of resistance or limit of patient comfort Patient performs end-range isometric contraction of opposite muscle and holds for approximately 5 seconds Patient relaxes and target muscle is passively stretched into new range Stretch is held for several seconds and procedure is repeated  AGONIST CONTRACTION Also uses reciprocal inhibition “Agonist” in this case refers to the muscle opposite the target muscle, while the “antagonist” refers to the tight (target) muscle Patient concentrically contracts the muscle opposite the target muscle and holds the end-range position for several seconds Concentric contraction is usually performed without resistance Patient performs technique independently Movement is deliberate and slow, not ballistic Patient rests briefly then repeats the procedure  SELECTIVE STRETCHING APPLICATION OF STRETCHING TECHNIQUES TO ONLY CERTAIN MUSCLES AND JOINTS TO HELP IMPROVE FUNCTION Stretching is applied to some muscles while flexibility in other muscles is allowed to remain restricted  OVERSTRETCHING Lengthening muscle and other joint soft tissues well beyond their normal length Exceeds the normal ROM of a joint Results in hypermobility Hypermobility causes joint instability that can interfere with functional activities  CONTRACTURE Adaptive shortening of muscle-tendon unit and other soft tissues surrounding a joint Results in significant resistance to passive or active movement and limited ROM Is named for the side of the joint that has tissue tightness CAN BE CAUSED BY: Disuse/prolonged immobilization/prolonged immobility (most common cause) Spasticity/hypertonia Disease  TYPES OF CONTRACTURE MYOSTATIC → No specific muscle pathology is present Can be resolved in a short period of time with stretching PSEUDOMYOSTATIC → Results from muscle being in a constant state of contraction due to hypertonicity or spasm/guarding Can possibly be resolved using neuromuscular inhibition techniques to reduce muscle tension  TYPES OF CONTRACTURE (Contd.) ARTHROGENIC / PERIARTICULAR Arthrogenic: Caused by intra-articular pathology (e.g., adhesions, joint effusion, articular cartilage damage, osteophytes) Periarticular: Caused by tightness in connective tissues that cross or attach to a joint or joint capsule  TYPES OF CONTRACTURE (Contd.) FIBROTIC / IRREVERSIBLE Fibrotic: Caused by fibrous changes in the connective tissue of muscle and periarticular tissues Increased ROM is possible with stretching, but optimal tissue length is unlikely to return Irreversible: Permanent loss of tissue extensibility that cannot be resolved without surgical intervention Is due to extensive fibrosis or heterotopic bone formation Can be caused by long periods of immobilization or by inflammatory response related to tissue trauma  Soft Tissue Extensibility Several factors can affect soft tissue’s ability to regain extensibility after period of immobilization: Tissue type → Each type of tissue has unique qualities that affect its extensibility Velocity, intensity, duration of stretch force Temperature of the soft tissue at time of stretch Contractile vs. noncontractile tissue  Soft Tissue Properties Elasticity → Soft tissue returns to its pre-stretch position after stretch force is removed Viscoelasticity → Tissue is initially resistant to stretch but will slowly lengthen with sustained stretch force Is time-dependent → Tissue must be given time to lengthen during stretch Viscoelastic tissue will gradually return to pre-stretch position after stretch force is removed Plasticity → Ability of soft tissue to retain new and greater length after force stretch is removed Is the result of prolonged period of progressive stretching  Soft Tissue Properties (Contd.) Plastic and elastic properties → Both contractile and non-contractile tissues Viscoelastic properties → Only non-contractile tissues CONTRACTILE SOFT TISSUE (SKELETAL MUSCLE) Mechanical properties that influence muscle’s response to stretch: Elasticity Contractility Extensibility CONTRACTILE SOFT TISSUE / SKELETAL MUSCLE (Contd.) Neurophysiological properties that influence muscle’s response to stretch: Muscle spindle (intrafusal fibers) Golgi tendon organ (GTO)  CONNECTIVE (NONCONTRACTILE) SOFT TISSUE Can include ligaments, tendons, joint capsules, fascia, noncontractile tissue found in muscles, skin Responds to stretch differently → Tissue must be remodeled in order to effectively increase extensibility  COMPOSITION OF CONNECTIVE TISSUE Collagen fibers Are responsible for the strength and stiffness of tissue Resist stretch / tension Elastin fibers → provide extensibility Reticulin fibers → provide tissue bulk Ground substance → Organic gel made up of water and proteoglycans Reduces friction between fibers Transports nutrients and metabolites within the tissue Maintains space between fibers to help prevent excessive cross-linking between them  CONNECTIVE TISSUE: MECHANICAL BEHAVIOR CONNECTIVE TISSUES HAVE VARIED ABILITIES TO WITHSTAND TENSION Tendons Ligaments, joint capsules, and fascia Collagen fibers are parallel Collagen fiber alignment varies → These Can resist the greatest amount of tension tissues can better resist multidirectional forces Skin Expect gain of 5° per week when Collagen fibers have random orientation stretching capsular adhesions Limited ability to resist higher levels of Ligaments with more parallel fiber tension arrangement and larger cross-sectional area can resist high levels of stress STRESS-STRAIN CURVE  STRETCHING: GOALS Prevent irreversible contracture Increase general flexibility of a body part prior to strengthening exercises Prevent or minimize the risk of musculotendinous injuries related to specific physical activities and sports OVERALL GOAL → Regain or achieve flexibility and ROM necessary for functional activities  STRETCHING: INDICATIONS Limited ROM due to decreased tissue extensibility Decreased ROM that may lead to preventable structural deformities (e.g., contracture) Decreased ROM due to agonist weakness and shortening of antagonists Prevention of musculoskeletal injury when engaging in fitness or sports conditioning programs Warm-up or cool-down before and after vigorous exercise  STRETCHING: CONTRAINDICATIONS Joint motion limited by a bony Joint hypermobility block Hematoma or other signs of tissue Recent fracture with incomplete trauma bony union Shortened tissues provide Signs of acute inflammatory or compensatory joint stability or infectious process (e.g., heat, support for functional activities redness, swelling) See Box 4.2 on page 90 Tissue healing could be disrupted by stretching  STRETCHING: PRECAUTIONS Do not passively force a joint beyond its normal ROM Stabilize newly united fracture sites between fracture site and joint being mobilized Patients with osteoporosis → Use caution Do not vigorously stretch soft tissues that have been immobilized for prolonged period of time Pain or soreness lasting more than 24 hours after stretching → Indicates that too much stretch force has resulted in inflammatory response Do not stretch edematous tissue Do not overstretch weak muscles → Especially those that provide stabilization against gravity  STRETCH WEAKNESS AND TIGHT WEAKNESS Stretch weakness → Muscles habitually kept in a stretched position tend to be weaker because of a shift in the length-tension curve Tight weakness → Muscles habitually kept in a shortened position tend to lose their elasticity These muscles are strong only in the shortened position and become weak as they are lengthened Example: Prolonged exaggeration of spinal curves Causes postural impairments, muscle strength and flexibility imbalances, and other soft tissue restrictions or hypermobility See Kisner and Colby chapter 14  PROCEDURE: HAMSTRING STRETCH Patient position: Supine with both knees extended Stabilization: Anterior aspect of opposite thigh using hand or towel/belt (prevents posterior pelvic tilt) Hand placement: Support patient’s lower leg with arm or shoulder Stretch direction: Hip flexion (keep knee at 0 ° extension)  PROCEDURE: END-RANGE KNEE EXTENSION Patient position: Supine with small towel roll under knee Stabilization: Anterior thigh (prevents hip flexion) Hand placement: Posterior aspect of distal tibia Stretch direction: Knee extension  PROCEDURE: GASTROCNEMIUS Patient position: Supine, knee extended Stabilization: Anterior aspect of tibia Hand placement: Posterior calcaneus (subtalar joint in neutral) with forearm along plantar surface of foot Stretch direction: Dorsiflexion To stretch soleus: Same procedure with small towel roll under knee PRECAUTION: Avoid placing too much pressure against metatarsal heads and stretching the long arch of the foot  GASTROCNEMIUS/SOLEUS: STANDING Using a slant board for standing dorsiflexion stretch protects long arch of the foot Is safest and most effective way to perform standing dorsiflexion stretch  PROCEDURE: SHOULDER FLEXION Patient position: Supine Stabilization: Axillary border of scapula (teres major) or lateral thorax/pelvic crest (latissimus dorsi) Hand placement: Posterior aspect of distal humerus, proximal to elbow Stretch direction: Shoulder flexion  PROCEDURE: WRIST EXTENSION Patient position: Seated with pronated forearm on table Stabilization: Dorsal aspect of distal forearm, just proximal to wrist Hand placement: Palmar aspect of patient’s hand Stretch direction: Wrist extension, allow fingers to flex