Stretching

Question 1

Indications for Stretching

Answer 1

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

Question 2

Contraindications

Answer 2

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

Question 3

Neurophysiology of Stretching: Stretch Reflex

Answer 3

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

Question 4

Muscle Spindle

Answer 4

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

Question 5

GTO’s

Answer 5

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

Question 6

Effects of Stretching

Answer 6

Short Term
Muscle relaxation
Elongation of elastic components

Long Term
Plastic deformation
Addition of sarcomeres

Failure
Stretched beyond limits
Fibers become brittle and rupture

Question 7

Changes in Collagen Affecting the Stress-Strain Curve: Immobilization

Answer 7

Weak tissue
Weak bonding of new tissue
Adhesion formation

Question 8

Changes in Collagen Affecting the Stress-Strain Curve: Inactivity

Answer 8

Decrease in size and amount of collagen fibers
Weak tissue
Increase in elastin fibers

Question 9

Changes in Collagen Affecting the Stress-Strain Curve: Age

Answer 9

Decrease in tensile strength
Decrease in elastin
Rate of adaptation to stress is slower
Increase in overuse syndromes
Tears and fatigue failure

Question 10

Changes in Collagen Affecting the Stress-Strain Curve: Corticosteroids

Answer 10

Decrease in tensile strength

Fibrocyte death next to injection site

Question 11

Changes in Collagen Affecting the Stress-Strain Curve: Injury

Answer 11

Follows predictable pattern if fibers have been disrupted

Question 12

Changes in Collagen Affecting the Stress-Strain Curve: Other Co-morbidities

Answer 12

Nutritional deficits
Diabetes
Hormonal imbalances - thyroid

Question 13

Good Stretching Fundamentals

Answer 13

Alignment

Stabilization

Question 14

Alignment

Answer 14

positioning of the limb or body in such a way as to direct the force of the stretch to the appropriate muscle

Question 15

Stabilization

Answer 15

obtain proper fixation of one side of the joint/muscle while applying an appropriate stretch on the other side

Question 16

Influences on Elastic or Plastic Deformation: Intensity

Answer 16

Low-Load
Decreased muscle guarding
Patient relaxes more

High-Load
More painful
May cause tissue failure

Question 17

Influences on Elastic or Plastic Deformation: Duration

Answer 17

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

Question 18

Optimal rate of improving ROM

Answer 18

Low-load with long-duration

Question 19

Long Duration

Answer 19

Long duration stretch 5 seconds to 5 minutes to hours/days

Joint mobilizations, sustained

Question 20

Short Duration

Answer 20

Cyclic stretching
Repeated and gradually applied 
Low velocity, low intensity
Stretch cycle is 5-10 seconds
Joint mobilizations, oscillations

Question 21

Influences on Elastic or Plastic Deformation: Velocity

Answer 21

Slow speed to minimize risk to tissue and DOMS
Not just on application but with release as well
Slow decreases activation of stretch reflex

Question 22

Influences on Elastic or Plastic Deformation: Frequency

Answer 22

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

Question 23

Modes/Types of Stretching

Answer 23

Static Stretching
Cyclic/Intermittent Stretching
Ballistic Stretching
PNF Stretching
Manual Stretching
Mechanical Stretching
Self-Stretching
Active/Dynamic Stretching

Question 24

Static Stretch

Answer 24

“Low-Load Long Duration”

Typically the most common type you’ll see in the clinic

Question 25

Cyclic / Intermittent Stretch

Answer 25

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

Question 26

Ballistic Stretching

Answer 26

High speed High intensity Not recommended for elderly or sedentary patients Avoid in most cases If used, rapid, low intensity stretches should occur

Question 27

PNF Stretching

Answer 27

Hold-Relax Contract-Relax Agonist Contraction Combination of these

Question 28

Manual Stretching

Answer 28

``` Therapist controls... Site of stabilization Direction Speed Intensity Duration of stretch ```

Question 29

Mechanical Stretching

Answer 29

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

Question 30

Self-Stretching

Answer 30

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

Question 31

Active/Dynamic Stretching

Answer 31

Different than ballistic stretching Momentum from static-active stretching Doesn’t exceed the static-passive stretching ability Commonly used prior to athletic events

Question 32

Teaching Self-Stretching Exercises

Answer 32

``` 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

Question 33

Different Dynamic Stretches

Answer 33

``` Knee to Chests Straight Leg Kicks Straight Leg Kick Cross-Overs Bottom Kicks Lunges Side Lunges Karaoke ``` UE too!

Question 34

Stretching Considerations

Answer 34

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

Question 35

Effects of Modalities on Stretching

Answer 35

Superficial Heat Deep Heat Cryotherapy Primarily heat / cool small areas... Individual joints Muscle groups Tendons

Question 36

Cryotherapy

Answer 36

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

Question 37

Spray and Stretch

Answer 37

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

Question 38

Thermotherapy

Answer 38

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

Question 39

Thermo- vs Cryo-therapy

Answer 39

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

Question 40

Active Warm-Up

Answer 40

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