STRETCHING

Ability of structures or segments of the body to move or

be moved to allow the presence of range of motion for functional activities (functional ROM). ability of an individual to initiate, control, or sustain active movements of the body to perform simple to complex motor skills (functional mobility). Mobility of soft tissues and Joint ROM is supported by the Sufficent amount of muscle strength, endurance & neuromuscular control Prevention of injury needs good mobility, strength, endurance & neuromuscular control to the demands placed.

Hypomobility
Restricted joint motion is caused by following

a. Prolonged immobilization
b. Sedentary lifestyle c. Postural malalignment & muscle imbalances d. Muscle weakness e. Tissue trauma from inflammation, pain etc f.

Congenital and acquired deformities

stretching
Any therapeutic maneuver designed to increase the

extensibility of soft tissues, thereby improving flexibility by elongating (lengthening) structures that have adaptively shortened and have become hypomobile over time. Manual, Mechanical, self and other type of stretching should be appropriately given during the rehabilitation phase and is based on the therapist evaluation of hypomobility. All stretching program is designed to improve elongate the contractile and non contractile components of muscle.-tendon units and peri articular structures

flexibility
ability to move a single joint or series of joints smoothly

and easily through an unrestricted, pain-free ROM. Dynamic flexibility. This form of flexibility, also referred to as 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 degree to which a joint can be moved by a muscle contraction and the amount of tissue resistance met during the active movement.

Passive flexibility.
This aspect of flexibility, also referred to as passive

mobility or passive ROM, is the degree to which a joint can be passively moved through the available ROM and is dependent on the extensibility of muscles and connective tissues that cross and surround a joint. Passive flexibility is a prerequisite for but does not ensure dynamic flexibility.

Contracture vs Shortness
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. In one reference, contracture is defined as an almost complete loss of motion, whereas the term shortness is used to denote partial loss of motion.

Myostatic Contracture
In a myostatic (myogenic) contracture, although the

musculotendinous unit has adaptively shortened and there is a Significant loss of ROM, there is no specific muscle pathology present. From a morphological perspective, although there may be a reduction in the number of sarcomere units in series, there is no decrease in individual sarcomere length. Myostatic contractures can be resolved in a relatively short time with stretching exercises.

Pseudomyostatic Contracture
Impaired mobility and limited ROM may also be the result of hypertonicity (i.e., spasticity or rigidity) associated with a central nervous system lesion such as a cerebral vascular accident, a spinal cord injury, or traumatic brain injury. Muscle spasm or guarding and pain may also cause a pseudomyostatic contracture. In both situations they involve contraction, stretch. Hence, the term

Arthrogenic and Periarticular Contractures

An arthrogenic contracture is the result of intra-articular

pathology. These changes may include adhesions, synovialproliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation.
A periarticular contracture develops when connective

tissues that cross or attach to a joint or the joint capsule lose mobility, thus restricting normal arthrokinematic motion.

Fibrotic Contracture and Irreversible Contracture

Fibrous changes in the connective tissue of muscle and

periarticular structures can cause adherence of these tissues and subsequent development of a fibrotic contracture. Although it is possible to stretch a fibrotic contracture and eventually increase ROM, it is often difficult to re establish optimal tissue length. Permanent loss of extensibility of soft tissues thatcannot be reversed by nonsurgical intervention may occur when normal muscle tissue and organized connective tissue are replaced with a large amount of relatively nonextensible, fibrotic adhesions and scar tissue or even heterotopicbone

Manual Stretching
A sustained or intermittent external, end-range stretch

force, applied with overpressure and by manual contact or a mechanical device, elongates a shortened muscle tendon unit and peri articular connective tissues by moving a restricted joint just past the available ROM.
If the patient is as relaxed as possible, it is called passive

stretching. If the patient assists in moving the joint through a greater range, it is called assisted stretching.

Self-Stretching
Any stretching exercise that is carried out independently

by a patient after instruction and supervision by a therapist is referred to as self-stretching.

stretching exercises that incorporate inhibition or

facilitation techniques into stretching maneuvers have also been referred to as active stretching.

Neuromuscular Facilitation and Inhibition Techniques

Techniques are used to relax tension in shortened

muscles reflexively prior to or during muscle elongation. Inhibition techniques to assist with muscle elongation is associated with an approach to exercise known a proprioceptive neuromuscular facilitation(PNF). These combined inhibition/muscle lengthening procedures as PNF stretching, active inhibition, active stretching, or facilitated stretching.

Muscle Energy Techniques

Manipulative procedures that have evolved out of osteopathic medicine and are designed to lengthen muscle and fascia and to mobilize joints. procedures employ voluntary muscle contractions by the patient in a precisely controlled direction and intensity against a counterforce applied by the practitioner.

Joint mobilization/manipulation
Methods are manual therapy techniques specifically

applied to joint structures and are used to stretch capsular restrictions or reposition a subluxed or dislocated joint.

Soft Tissue Mobilization

Techniques are designed to improve muscle extensibility

and involve the application of specific and progressive manual forces (e.g., by means of sustained manual pressure or slow, deep stroking) to effect change in the myofascial structures that can bind soft tissues and impair mobility. Techniques, like friction massage,acupressure, myofascial release,trigger point therapy, are designed to improve tissue mobility by mobilizing and manipulating connective tissue that binds soft tissues.

Neural Tissue Mobilization

After trauma or surgical procedures, adhesions or scar

tissue may form around the meninges and nerve roots or at the site of injury at the plexus or peripheral nerves. Tension placed on the adhesions or scar tissue leads to pain or neurological symptoms. After tests to determine neural tissue mobility are conducted, the neural pathway is mobilized through selective procedures.

Selective Stretching
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. Most commonly peformed in patient with permanent paralysis(SCI) Selective allowing hypomobility of Low back with routine stretching of Hamstring length

Overstretching & Hypermobility

A stretch well beyond the normal length of muscle and

ROM of a joint and the surrounding soft tissues, resulting in hypermobility (excessive mobility). Creating selective hypermobility by overstretching may be necessary for certain healthy individuals with normal strength and stability participating in sports that require extensive flexibility

Ballistic stretching
A rapid, forceful intermittent stretchthat is, a high-speed

and high-intensity stretchis commonly called ballistic

It is characterized by the use of quick, bouncing

movements that create momentum to carry the body segment through the ROM to stretch shortene structures. ballistic stretching cause greater trauma to stretched tissues and greater residual muscle soreness than static stretching. it is, for the most part, not recommended for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic conditions

High velocity stretching

Static stretching Slow, short end-range stretching

Slow, full-range stretching Fast, short end-range stretching Fast, full-range stretching. The stretch force is initiated by having the patient actively contract the muscle group opposite the muscle and connective tissues to be stretched. Highly recommended for professional atheletes and young adults

Frequency of stretching
Frequency on a weekly basis ranges 2-5 sessions,

allowing time for rest between sessions for tissue healing and to minimize post exercise soreness.

Manual stretching
A therapist or other trained practitioner or caregiver

applies an external force to move the involved body

segment slightly beyond the point of tissue resistance and available ROM. Manual stretching employs a controlled, endrange, static, progressive stretch applied at an intensity consistent with the patients comfort level, held for 15 to 60 seconds and repeated for at least several repetitions. Manual stretching may be most appropriate in the early stages of a stretching program when a therapist wants to determine how a patient responds to varying intensities or durations of stretch and when optimal stabilization is most critical

Self stretching
Self-stretching (also

referred to as flexibility exercises or active stretching) is a type of stretching procedure a patient carries out independently after careful instruction and supervised practice.

Mechanical stretching
There are many ways to use equipment to stretch

shortened tissues and increase ROM. The equipment can be as simple as a cuff weight or weight-pulley system or as sophisticated as some adjustable orthoses or automated stretching machines.

Soft tissue response to Stretch

Decreased Extensibility of the connective tissues(tendon,

ligaments, capsule) is the primary cause of ROM limitation not the contractile elements of muscles. Direction, velocity, intensity (magnitude), duration, and frequency of the stretch force as well as tissue temperature affect the responses of the various types of soft tissue. The exact physiological mechanism by which stretching increased the extensibility of muscles if still unclear

Properties of soft tissues

Elasticity is the ability of soft tissue to return to it

prestretch resting length directly after a short-duration stretch force has been removed. Viscoelasticity is a time-dependent property o that initially resists deformation,when a stretch force is first applied. If a stretch force is sustained, viscoelasticity allows deformation and then enables the tissue to return gradually to its pre-stretch state after the stretch force has been removed. Plasticity is the tendency of soft tissue to assume a new and greater length after the stretch force has been removed.

Mechanical Properties of Contractile.T

Gross Structure of Skeletal Muscle

Ultrastructure of Skeletal Muscle

Sarcomere Functional unit of contractile system in muscle.
Z
H
A

Relaxed Sarcomere

Titin

Myosin

Actin

Contracted Sarcomere

Contractile Vs Noncontractile Connective tissues

Endo, peri and epimysium layers are the primary source

of resistance to elongation. These are the non-contractile tissues In developed Contractures, adhesions in and between collagen fibers resist and restrict movement. Sarcomere made of actin, myosin are the main contractile tissues having the ability to contract the muscle by sliding the filaments

Events During Contraction and Relaxation

1. 2.

3.

4.

Depolararization of T-tubules release of Ca2+ from SR. Calcium binds to troponin/tropomyosin complex. Actin combines with myosin-activated myosin ATPase. ATP splits, energy produces power stroke of X-bridges tension is created. ATP binds to myosin X-bridge, allowing Xbridge to dissociate from actin.

Events During Contraction and Relaxation (cont.)

5. X-bridging activation continues as long as Ca2+ concentration is high enough to inhibit action of troponin/tropomyosin complex. 6. When stimulation ceases, Ca2+ returns to SR. 7. Removal of Ca2+ restores inhibitory action of troponin/tropomyosin. In the presence of ATP, actin and myosin remain in the relaxed state.

Muscle Fibers
I Tonic II A SO Slow Oxidative FO Fast Oxidative FOG Fast Oxidative plus Glycolytic S Slow FR Fast Fatigue Resistant FI Fast Intermediate Fatigueability

II AB

II B

FG Fast Glycolytic

FF Fast Fatigueability

Strength is related to fiber diameter, not type. Type I fibers typically have smaller diameter than type II fibers.

Factors Affecting Muscle Performance

1. Fiber type 2. Fiber diameter 3. Muscle size 4. Force velocity relationship: Active force continually adjusts to the speed at which the contractile system moves.

LengthTension Relationship

Capacity to produce force depends on the length at which muscle is held with maximum force delivered near the muscles normal resting length.

Changes in Numbers of Sarcomeres

Positional Strength

Mechanical response of contractile unit to stretching & Immobilization

When a muscle is stretched and elongates, the stretch force is

transmitted to the muscle fibers via connective tissue (endomysium and perimysium) in and around the fibers.
It is hypothesized that molecular interactions link these noncontractile

elements to the contractile unit of muscle, the sarcomere.

During the passive stretch, initial lengethning of the connective tissue

occurs and then mechanical disruption of cross-bridges occurs leading to sarcomere give and whens strecth force released it returns to resting length and this process is called elasticity.( for plasticity more force needed over time to maintain length)

Response to immobilization
If muscle is immobilized for long time the following

changes occur a) The physica stress on muscle diminished leading to decay of contractile protein b) Decrease in muscle fiber diameter c) Decrease in number of myofibrils d) Decrease in intra-muscular capillary density e) All these changes lead to muscle atrophy and weakness

Immobilization in shortened position

a reduction in the length of the muscle and its fibers and

in the number of sarcomeres in series within myofibrils as the result of sarcomere absorption occcurs A muscle atrophies and weakens at a faster rate when it is immobilized in shortened position when compared to lengthened position. When a muscle immobilized in lengthened position as in serial casts evidence from animal studies indicates that a new length (plascticity) achieved by increasing the number of sarcomered All these changes are temperorary lasts for 3-5 days before returning to preimmobilization use .

Neurophysiological Properties
Muscle spindle and golgi tendon organs(GTO) are the two sensory

organs of the muscle tendon units which convery information about the status of muscle to CNS. Muscle spindle are sensitive to quick and tonic stretch Convey information about the change in the length and the velocity of the length changes of the muscles GTO monitor changes in tension of muscle-tendon units. When tension develops in a muscle, the GTO fires,inhibits alpha motoneuron activity, and decreases tension in the muscle-tendon unit being stretched.
inhibition is a state of decreased neuronal activity and altered

synaptic potential, which reflexively diminishes the capacity of a muscle to contract.

Neurphysilogical response to stretch

When a stretch force is applied to muscle-tendon unit, the

muscle spindle via alpha motor neuron in the spinal cord activates the stretch reflex and increased the tension in the muscle being stretched. The increased tension causes resistance to lengthening and, in turn, is thought to compromise the effectiveness of the stretching procedure. a slowly applied, low-intensity, prolonged stretch is considered prefereable to a quickly applied, short-duration stretch to minimize the effects of stretch-reflex activation GTO on the other hand causes autogenic inhibition which is inhibitory effect on the developed tension from prolonged stretch.

Mechanical properties of non-contractile soft tissue

Ligaments, tendons, joint capsules, fasciae, non-

contractile tissue in muscles and skin have connective tissue characteristics that can lead to the development of adhesions and contractures and thus affect the flexibility of the tissues crossing joints, The non-contractile connective tissues are made up of ground substance(proteoglycans) and 3 types of fibe ie colllagen, elastin and reticulin collagen = responsible for strength and stiffness resist to deformation Elastin = provide extensibility Ground substance= hydrate the matrix, stabilize collagen network

Distribution of 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

Stress vs strain
Stress is force per unit area. Mechanical stress is the

internal reaction or resistance to an external load. Three kinds of stress are tension, compression & shear forces Tension: force (perpendicular to CSA) example stretch compression: force perpendicular to CSA and in direction toward the muscle example :muscle contraction & Joint loading Shear : force parallel to CSA Strain: is the amount of deformation to the stress applied

Creep
A permanent deformation resulting from extended period

of load application. It is related to the viscosity of the tissue and is therefore time-dependent. The amount of deformation depends on the amount of force and the rate at which the force is applied.

Cyclic loading and connective tissue fatigue.

Repetitive loading of tissue increases heat production

and may cause failure below the yield point. The greater the applied load, the fewer number of cycles needed for failure. This principle can be used for stretching by applying repetitive (cyclic) loads at a submaximal level on successive days

Effects of Age & corticosteroids

Age: There is a decrease in the maximum tensile strength

and the elastic modulus, and the rate of adaptation to stress is slower. There is an increased tendency for overuse syndromes, fatigue failures, and tears with stretching. Corticosteroids: There is a long-lasting deleterious efnical properties of collagen with a decrease in tensile strength.

Effects of injury
Excessive tensile loading can lead to rupture of ligaments

and tendons at musculotendinous junctions. Healing follows a predictable pattern (see Chapter 10), with bridging of the rupture site with newly synthesized type III collagen. This is structurally weaker than mature type I collagen. Remodeling progresses, and eventually collagen matures to type I. Remodeling usually begins about 3 weeks postinjury and continues for several months to a year, depending on the size of the connective tissue structure and magnitude of the tear

Duration of stretch
Duration refers to how long a single cycle of stretch is

applied. If more than one repetition of stretch (stretch cycle) is carried out during a treatment session , the cumulative time of all the stretch cycles is also considered an aspect of duration. In general, the shorter the duration of a single stretch cycle, the greater the number of repetitions applied during a stretching session. Over the course of a 5-week period three 15-second hamstring stretches each day yielded significantly greater stretch-induced gains in ROM than nine daily 5-second stretches.