Stretching Exercises PDF

Faculty of Physical Therapy Stretching exercise BY Prof. Dr. Ahmed Elerian Dean and Professor of Physical Therapy Objectives Following completion of this topic, the student will be able to: Define the term of stretching Distinguish between different impo...

Faculty of Physical Therapy Stretching exercise BY Prof. Dr. Ahmed Elerian Dean and Professor of Physical Therapy Objectives Following completion of this topic, the student will be able to: Define the term of stretching Distinguish between different important terms (flexibility- hypo mobility- contracture- contraction –shorting) explain the effect of stretch on muscular units discuss types of stretching techniques enumerate the basic knowledge for stretching (indications- contraindications- principles – precautions) Apply different types of stretching techniques Stretching Exercise : is therapeutic techniques designed to lengthen (elongate) pathologically shortened soft tissue at the musculotendinous units to facilitate an increase in Range of Motion (ROM). It's an essential part of physical therapy programs for both rehabilitation and injury prevention Physiological Benefits of stretching Flexibility and ROM: it improves the extensibility of the muscles and surrounding soft tissues, and increase joint ROM. Muscle Performance: By increasing flexibility, it optimizes muscle function, reduces stiffness, and enhances movement. Injury Prevention: it can prevent acute injuries (like strains) and chronic overuse injuries by increasing tissue tolerance. Circulation Improvement: it increases blood flow to muscles, which is especially important during rehabilitation and post- injury recovery.  Basic Anatomy and Physiology of Stretching Muscle Fibers: Muscles are made of contractile fibers that stretch when lengthened and contract when shortened. Stretching helps align these fibers, improving flexibility. Connective Tissues: Ligaments, tendons, and fascia support muscle and joint movement. Stretching these tissues helps maintain their elasticity and flexibility. Stretch Reflex: When a muscle is stretched too far, the body responds with a reflex contraction to prevent overstretching. The muscle spindle and Golgi tendon organ are key sensors in this process.  Important terms 1-Flexibility : The flexibility has been defined as the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM. Muscle length in conjunction with joint integrity and the extensibility of periarticular soft tissues determine flexibility.. Types of flexibility: A-Dynamic flexibility. Active mobility or active ROM. is the degree to which an active muscle contraction moves a body segment through the available ROM of a joint. It is dependent on ❑ The force of contracted muscle. ❑ The extensibility of antagonist muscle. B-Passive flexibility. Or passive ROM is the degree to which a joint can be passively moved through the available ROM It is dependents on ❑ Extensibility of muscles and connective tissues that cross and surround a joint. ❑ Joint integrity. Passive flexibility is a prerequisite for but does not ensure dynamic flexibility. Factors affecting flexibility 2-Hypomobility: Hypo mobility refers to decreased mobility or restricted motion. Restricted motion can range from mild muscle shortening to irreversible contractures 3-Contracture Contracture 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, and it may compromise functional abilities. Contracture is defined as an almost complete loss of motion.  Contracture Shortness Contracture is defined as ❑ Shortness is used to an almost complete loss denote partial loss of of motion. motion. Elbow flexion contracture.  Muscle tightness Restricted motion due to adaptive shortening Muscle tightness is of soft tissue (mild adaptive shortening of muscle shortening). the contractile and noncontractile elements of muscle ?  Contracture Versus Contraction Contraction is the process of tension developing in a muscle during shortening or lengthening).  Types of Contracture Myostatic contracture. ❑ A reduction in the number of sarcomere units in series. ❑ No decrease in individual sarcomere length. ❑ A significant loss of ROM Pseudomyostatic contracture. ❑ Resulted from a constant state of contraction, giving rise to excessive resistance to passive stretch. (Hypertonicity (i.e., spasticity or rigidity) , Muscle spasm or guarding and pain. ❑ full, passive elongation of the apparently shortened muscle is possible. Arthrogenic and periarticular contracture ❑ Is the result of intra-articular pathology. (adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation). Fibrotic contracture and irreversible contracture ❑Permanent loss of extensibility of soft tissues (normal muscle tissue and organized connective tissue are replaced with a large amount of relatively non extensible, fibrotic adhesions and scar tissue or even heterotopic bone) cannot be reversed by nonsurgical intervention Selective Stretching ❑ Is a process whereby the overall function of a patient may be improved by applying stretching techniques selectively to some muscles and joints but allowing limitation of motion to develop in other muscles or joints. Overstretching and Hypermobility is a stretch beyond the normal length of muscle and ROM of a joint and the surrounding soft tissues , resulting in hypermobility (excessive mobility). Used with certain healthy athletic individuals with normal strength and stability. Creates joint instability when the supporting structures of a joint and the strength of the muscles around a joint are insufficient. Instability of a joint often causes pain and may predispose a person to musculoskeletal injury.  Response to Immobilization Decreased physical stresses on the muscle. Increase in fibrous Decay of contractile and fatty tissue protein muscle atrophy and Decrease in the weakness number of myofibrils Decreased intramuscular capillary density  more quickly and more extensively in tonic (slow-twitch) begin within as little Atrophy as a few days to a week. motor unit recruitment reduction reflected by electromyographic (EMG) activity  Immobilization in a shortened position ❖ Length of the muscle and its fibers. ❖ Number of sarcomeres in series within myofibrils. ❖ Muscle atrophy and weakness. ❖ Proportion of fibrous tissue and subcutaneous fat in muscle. ❖ Extensibility of the shortened muscle. RESPONSE TO STRETCH  Composition of Connective Tissue Collagen Elastin Strength Elasticity Ground substance Reticulin BULK ( proteoglycans (PGs) and glycoproteins) reduces friction transports nutrients prevent excessive cross-linking between fibers ❖ In tendons, collagen fibers are parallel and can resist the greatest tensile load. They transmit forces to the bone created by the muscle. ❖ In skin, collagen fibers are random and weakest in resisting tension. ❖ In ligaments, joint capsules, and fasciae, the collagen fibers vary between the two extremes, and they resist multidirectional forces. Ligaments that resist major joint stresses have a more parallel orientation of collagen fibers and a larger cross-sectional area  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. Muscle contraction and loading of a joint during weight bearing cause compression stresses in joints. Shear—a force applied parallel to the cross-sectional area of the tissue.  The Stress-Strain Curve The stress-strain curve illustrates the mechanical strength of structures and is used to interpret what is happening to connective tissue under stress loads. ❑Stress is force (or load) per unit area. Mechanical stress is the internal reaction or resistance to an external load. ❑ Strain is the amount of deformation or lengthening that occurs when a load (or stretch force ) is applied Regions of the Stress-Strain Curve  Regions of the Stress-Strain Curve Toe region. in which there is considerable deformation without the use of much force. In which most functional activity normally occurs. Elastic range/linear phase. when tissue is taken to the end of its ROM, and gentle stretch is applied. In this phase there are some microfailure between the collagen bonds begins. There is complete recovery from this deformation, and the tissue returns to its original size and shape when the load is released if the stress is not maintained for any length of time.  Elastic limit. beyond which the tissue does not return to its original shape and size is the elastic limit. Plastic range. The range beyond the elastic limit extending to the point of rupture is the plastic range. in this range tissues has permanent deformation when the stress is released. Ultimate strength. The greatest load the tissue can sustain Once this load is reached, there is increased strain (deformation) without an increase in stress required (macrofailure). ❑ The region of necking is reached in which there is considerable weakening of the tissue, and it rapidly fails. ❑ The therapist must be cognizant of the tissue feel when stretching because as the tissue begins necking, if the stress is maintained, there could be complete tearing of the tissue. ❑ Failure. Rupture of the integrity of the tissue. ❑ Structural stiffness: The slope of the linear portion of the curve (elastic range) is known as Young’s modulus or modulus of elasticity and represents the stiffness of the tissue. ❑ Tissues with greater stiffness have a higher slope in the elastic region of the curve, and there is less elastic deformation (elongation) under stress. ❑ Contractures and scar tissue have greater stiffness, probably because of a greater degree of bonding between collagen fibers and their surrounding matrix. ❑ Tissues with less stiffness demonstrate greater elongation under similar loads.  The grades of ligament injuries (strains) can be related to the stress-strain curve. Grade I—Microfailure: rupture of a few fibers in the lower part of the plastic range. Grade II—Macrofailure: rupture of a greater number of fibers resulting in partial tear further into the plastic range. Grade III—Complete rupture or tissue failure Creep. When a load is applied for an extended period, the tissue elongates, and does not return to its original length Stress-relaxation. When a force (load) 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. Elastic, Viscoelastic, or Plastic changes occur. Both contractile and noncontractile tissues have elastic and plastic qualities; however, only noncontractile connective tissues, 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. Plasticity, or plastic deformation, is the tendency of soft tissue to assume a new and greater length after the stretch force has been removed Viscoelasticity, or viscoelastic deformation, 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. Effect of stretch on muscular units Stretching has an impact on both contractile and non-contractile soft tissues. Passive stretching to the elastic limit can allow these tissues to resume the original resting length. Passive stretching beyond the elastic limit into plasticity will lead to a greater soft tissue length compared to the original resting length when the stretch is removed. Prolonged lengthening of the contractile units of muscle, into the plastic ROM progressively leads to increased soft tissue length due to an increased number of sarcomeres in series. Non-contractile units of muscle are ligaments, joint capsule, and fascia which all consist of collagen and elastin fibers. Prolonged lengthening of collagen up to its yield point leads to tissue lengthening due to permanent tissue deformation. Elastin fails without deformation with high loads. The more elastin the tissues contain, the more flexible the tissues. To avoid damaging soft tissues, healing and remodeling time must be allowed between periods of stretching. Neurophysiological Response to Stretch Two sensory organs of muscle-tendon units, the muscle spindle and the Golgi tendon organ, are mechanoreceptors that convey information to the central nervous system about what is occurring in a muscle-tendon unit and affect a muscle’s response to stretch. Muscle Spindle is the major sensory organ of muscle and is sensitive to quick and sustained (tonic) stretch. Golgi Tendon Organ 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. Indication of stretching 1. Restricted ROM -Post-traumatic stiffness 2. Post-immobilization stiffness -Spasticity. 3. Congenital or acquired bony deformity 4. Joint pathology resulting in soft tissue stiffness 5. Soft tissue pathology leading to relative soft tissue stiffness 6. Healed burn scars -Fear of pain spasm 7. Adhesion formation over soft tissue 8. Contracture of the joint and soft tissue - Muscle spasm Contraindications -Synovial effusion -Recent fracture -Sharp pain while doing stretch -Bony block limiting joint motion -Infection over tight tissue -Immediately after dislocation -Edema -Osteoporosis -Hemarthrosis -Malignant tumors -Flail joint -After joint arthroplasty -Unhealed scars -Sever muscle weakness or paralysis -Unhealed burns -Chronic rheumatoid arthritis. -Within the first 24 to72 hours of muscular or tendinous trauma. -Following muscle strain or ligament sprain.  Relative contraindications ▪ Sever muscle weakness or paralysis. ▪ Osteoporosis. ▪ Within the first 24 to72 hours of muscular or tendinous trauma. ▪ Following muscle strain or ligament sprain. ▪ Edema. Goals of stretching exercises: 1- The overall goals are to regain or re-establish the ROM of the joint and mobility of the tissues that surround a joint. 2- Prevent irreversible contractures. 3- Increase the general flexibility before vigorous activities. 4- Prevent or minimize the risk of musculotendinous injures. PROCEDURAL GUIDELINES FOR APPLICATION OF STRETCHING INTERVENTIONS Preparation for Stretching 1. Review the goals and desired outcomes of the stretching program with the patient. 2. Obtain the patient’s consent to initiate treatment. 2. Select the stretching techniques. 3. Warm up the soft tissues to be stretched. 4. Have the patient assume a comfortable, stable position. 6. Explain the procedure to the patient and be certain he or she understands. 7. Free the area to be stretched of any restrictive clothing, bandages, or splints. 8. Explain to the patient that it is important to be as relaxed as possible or assist when requested. Also explain that the stretching procedures are geared to his or her tolerance level. Types of Stretching: there are many ways to stretch. Each type has its own advantages and disadvantages, and the key to getting the most out of stretching lies in being able to match the right type of stretching to the purpose, or goal trying to be achieved. For example; PNF and passive stretching are great for creating permanent improvements in flexibility, but they are not very useful for warming up or preparing tile body for activity. On the other hand, dynamic stretching is great for warming up but can be dangerous if used in the initial stages of injury rehabilitation. Although there are many ways to stretch, they can all be grouped into one of four categories: 1-Static stretch (static position- passive stretch which divided in to (manual passive stretch, mechanical passive stretch ) 2- Dynamic stretch (ballistic stretch) 3-Self stretch 4-Proprioceptive neuromuscular facilitation (PNF stretch) 1-Static Stretching the term static stretches refers to stretching exercises that are performed without movement. Divided in to: A-static or position stretch ❑ Static stretching is performed by placing the body into a position whereby the muscle to be stretched is under tension. ❑ Both the antagonist and agonist or muscles to be stretched are relaxed. Then slowly and cautiously the body is moved to increase the tension on the stretched muscle (or group of muscles). ❑ At this point, the position is held to allow the muscles to relax and lengthen. ❑ Static or position stretch is a very safe and effective in stretching with a limited f injury. ❑ It is a good choice for beginners and sedentary individuals.  B- Passive stretching It involves a partner or special equipment that carefully moves the joints through their ROM without contribution of the patient, this type of stretching is commonly used during rehabilitation program. Passive stretching exercises can be manual or mechanical. 1- Manual passive stretch The therapist applies the external force and controls the direction, speed, intensity and duration of the stretching force. The patient must be as relaxed as possible. The stretching force is usually applied at least 30 second and repeated for several times. 2. Mechanical passive stretch A low intensity external force is applied to shortened tissue over a prolonged period with the mechanical equipment. It may be maintained for 20 to 30 minutes Dynamic Stretching : refers to stretching exercises that are performed with movement. In other words, the individual uses a swinging or bouncing movement to extend their range of motion and flexibility. Ballistic Stretching : refers to A rapid, forceful intermittent stretch that is, a high-speed and high-intensity stretch. It is characterized using quick, bouncing movements that create momentum to carry the body segment through the ROM to stretch shortened structures. The main disadvantages including: 1. Muscle soreness in the following days 2. Activate muscle spindle which creating opposing force that may cause soft tissue injury 3. It does not promote tissue adaptation,, so ballistic stretching does not allow for lengthened position of the fascia The main example of ballistic stretching is the sitting toe touch. The individual sits on the ground with the leg straight out in front and reaches the hands forward as far down the legs as possible. This movement is repeated 10 to 15 times. 3- Self stretching It is a type of flexibility exercises where the patient carries out himself that can be done by using his body weight as a stretching force. All the procedures are the same as in passive stretching exercises. This form of stretching is often an integral component of a home exercise program and is necessary for long-term self-management of many musculoskeletal and neuromuscular disorders. 4-Proprioceptive neuromuscular facilitation (PNF stretch) PNF stretching (Proprioceptive neuromuscular Facilitation), sometimes referred to as Facilitated Stretching, is a more advanced form of flexibility training that involves both the stretching and contracting of the muscle group being targeted. It is also excellent for targeting specific muscle groups. And as well as increasing flexibility, it also improves muscular strength. Types of PNF Stretching 1. Hold–relax (HR) 2. Contract- relax(CR) 3. Slow reversal hold relax (agonist contraction). Autogenic and reciprocal inhibition both occur when certain muscles are inhibited from contracting due to the activation of the Golgi tendon organ (GTO) and the muscle spindles. The GTO, located between the muscle belly and its tendon, senses increased tension when the muscle contracts or stretches. When the muscle contracts, the GTO is activated and responds by inhibiting this contraction (reflex inhibition) and contracting the opposing (antagonist) muscle group. This process is known as autogenic inhibition. When the GTO inhibits the (agonist) muscle’s contraction and allows the antagonist muscle to contract more readily, the muscle can be stretched further and easier. Autogenic inhibition is often seen during static stretching, such as during a low-force, long-duration stretch. After 7 to 10 seconds, muscle tension increases and activates the GTO response, causing the muscle spindle in the stretched muscle to be inhibited temporarily, which makes it possible to stretch the muscle further. The muscle spindle is located within the muscle belly and stretches along with the muscle itself. When this occurs, the muscle spindle is activated and causes a reflexive contraction in the agonist muscle (known as the stretch reflex) and relaxation in the antagonist muscle. This process is known as reciprocal inhibition. 1-Hold–Relax (HR): The patient performs an isometric contraction of the tight muscle before it passively lengthened.( autogenic inhibition) The Golgi tendon organ was stimulated and inhibits tension in this muscle, so that it can be more easily too lengthened. A B Note: It is not necessary for the patient to perform a maximal isometric contraction of the tight muscle prior to stretch. Could result in an acute increase in arterial blood pressure, most notably after the third repetition. To minimize the adverse effects of the Valsalva maneuver (elevation in blood pressure), have the patient breathe regularly while performing submaximal (low-intensity) isometric contractions held for 5 to 10 seconds with each repetition of the stretching procedure. A submaximal contraction is also easier for the therapist to control if the patient is strong 2-Contract–Relax (CR): A variation of contract relax technique is contraction of the tight muscle and relaxation of tight muscle followed by concentric contraction of the opposite the tight muscle as the muscle opposite to tight muscle shortens, the tight muscle lengthens. 3-Slow Reversal Hold Relax (agonist contraction): the tight muscle is the antagonist , the opposite is the agonist ❑ Dynamic range of motion (DROM) and active stretching , are other terms that have been used to describe the AC procedure. ❑ The patient concentrically contracts (shortens) the muscle opposite the range-limiting muscle ❑ Then holds the end-range position for at least several seconds. ❑ The movement of the limb is controlled independently by the patient and is deliberate and slow, not ballistic. For example, if the hip flexors are the range-limiting target muscle group, the patient performs end-range, prone leg lifts by contracting the hip extensors concentrically; the end-range contraction of the hip extensors is held for several seconds. After a brief rest period, the patient repeats the procedure. Increased muscle length and joint ROM using the AC procedure have been reported 1- age-related changes in flexibility: don’t passively exceed the ROM suddenly 2-Patients with known or suspected osteoporosis due to disease, prolonged bed rest, age, or prolonged use of steroids. 3- newly united fractures: apply appropriate stabilization 4-Avoid vigorous stretching especially with long period immobilized patients. High-intensity short-duration stretching procedures tend to cause more trauma and resulting weakness of soft tissues than low-intensity, long-duration stretch. 5. Progress the dosage (intensity, duration, and frequency) of stretching interventions gradually to minimize soft tissue trauma and post exercise muscle soreness. Warm-up prior to stretching ❑ This helps to make the muscles loose, supple and pliable, and is essential to ensure the maximum benefits are gained from stretching. ❑ A correct warm up also has the effect of increasing both heart rate and respiratory rate. ❑ This increases blood flow, which in turn increases the delivery of oxygen and nutrients to the working muscles. ❑ All this helps to prepare the muscles for stretching. Stretch before the exercise ❑ help prevent injury by lengthening the muscles and associated soft tissues , this in turn increases range of motion. Stretching after exercise has a very different role. ❑ aid in the repair and recovery of the muscles and associated soft tissues by lengthening the muscles. ❑ prevent developing tight muscles and delayed onset muscle soreness (DOMS) that sometimes accompanies strenuous exercise. ❑ After exercise stretching should be done as part of a cool down. The cool- down will vary depending on the duration and intensity of exercise undertaken, it consists of five to ten minutes of very light physical activity and be followed by five to ten minutes of static stretching exercises. To: ❑ Remove waste products from the muscles: ❑ Prevent blood pooling: and promote the delivery of oxygen and nutrients to the muscles. ❑ All this helps to return the body to a pre-exercise level, thus aiding the recovery process. Designing Stretching Programs Individualized Approach: Programs should consider patient’s injury, age, and functional goals. FITT Principle: o Frequency: Stretch at least 2-3 times per week. o Intensity: Stretch to the point of mild discomfort, not pain. o Time: Hold stretches for 15-30 seconds. o Type: Include a variety of stretching types (static, dynamic, PNF) based on the patient’s needs. Case Study 1: Lower Back Pain Case Study 2: Post-ACL Reconstruction  1. Many patients with lower back pain have tight hip flexors and hamstrings, which contribute to lumbar strain. Example Stretching Program: Focus on hip flexor stretches (lunges), hamstring stretches, and core stability exercises. 2. Initially focus on regaining knee extension with passive stretching, progressing to active quadriceps and hamstring stretches as healing progresses. 1.……… is defined as an almost complete loss of motion a. contracture b. shortness c. tightness d. none of the above 2. …………….resulted from a constant state of contraction, giving rise to excessive resistance to passive stretch a. Pseudomyostatic contracture b. myostatic contracture c. Arthrogenic and periarticular contracture d. Fibrotic contracture 3. If a muscle is immobilized for a prolonged period of time , all the following is true except a. Decrease in the number of myofibrils. b. Decay of contractile protein. c. Decreases in muscle fiber diameter , d. Decrease in in fibrous and fatty tissue in muscle 4. collagen fibres are parallel and can resist the greatest tensile load a. in ligament b. in tendon c. in skin d. joint capsule 5. in ………..the muscle will stretch too fast and too far that activate muscle spindle which creating opposing force that may cause soft tissue injury. a. mechanical stretching b. Ballistic stretch c. passive stretching d. PNF stretching. 6. collagen fibres provide tissues extensibility, while Reticulin fibers provide tissue with bulk. ( True or false ) Thank you