Definition of Stretching  Stretching is a general term used to describe 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.  systematic examination, evaluation, and diagnosis of a patient's presenting problems determine what structures are restricting motion and when and what types of stretching procedures are indicated. ther 2462

 After gaining desired ROM, Stretching must be supported by an appropriate level of strength and endurance to become permanent.  stretching interventions are designed to elongate the contractile and non-contractile components of muscle-tendon units and periarticular structures. ther 2463

Mobility. Hypomobility. Flexibility. Contracture. ther 2464

the ability of structures or segments of the body to move to allow range of motion for functional activities (functional ROM). OR the ability of an individual to initiate, control, or sustain active movements of the body to perform simple to complex motor skills (functional mobility) ROM needed for the performance of functional activities does not necessarily mean full or “normal” ROM. ther 2465

6 Sufficient mobility must be supported by: muscle strength and endurance neuromuscular control All are important factors in the prevention of injury or reinjury of the musculoskeletal system.

 Decreased mobility or restricted motion  Caused by adaptive shortening of soft tissues can occur as the result of many disorders or situations.  Factors affect mobility: ◦ Prolonged immobilization of a body segment  Extrinsic: cast, splint or skeletal traction.  Intrinsic: pain, inflammation, effusion, Ms disorders, skin disorder, bony block, or vascular disorders ◦ Sedentary lifestyle ◦ Postural malalignment: congenital or acquired deformities. ◦ Paralysis, tonal abnormality, Muscle imbalance. ther 246 7

the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM  related to : ◦ The extensibility of musculotendinous units ◦ Arthrokinematics of the moving joint. (the ability of the joint surfaces to roll and slide) ◦ Deformation of periarticular connective tissues. ther 2468

9 Dynamic flexibility. (active mobility/active ROM) – the degree to which an active muscle contraction moves a body segment through the available ROM of a joint. – 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. (passive mobility/passive ROM) – the degree to which a joint can be passively moved through the available ROM – 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.

ther 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 – limitation of ROM – compromise functional abilities Contracture is defined as an almost complete loss of motion, whereas the term shortness is used to denote partial loss of motion.

Designation of Contractures by Location Contractures are described by identifying the action of the shortened muscle. Example If a patient has shortened elbow flexors and cannot fully extend the elbow, he or she is said to have an elbow flexion contracture. ther 24611

Contracture Versus Contraction ther Contraction: the process of tension developing in a muscle during shortening or lengthening – The terms contracture and contraction are not synonymous and should not be used interchangeably.

Do not passively force a joint beyond its normal ROM Patients with known or suspected osteoporosis Protect newly united fractures Avoid vigorous stretching of tissues that have been immobilized for an extended period of time Progress gradually Avoid stretching edematous tissue Avoid overstretching weak muscles Precautions for Stretching

Indications for Stretching  Limited ROM.  Structural deformities.  Muscle weakness.  Muscle shortening.  Part of a total fitness program designed to prevent musculoskeletal injuries.  Prior to and after vigorous exercise potentially to minimize post-exercise muscle soreness. ther 24614

Contraindications to Stretching  A bony block limits joint motion.  Recent fracture, and incomplete bony union  acute inflammatory or infectious process  sharp, acute pain with joint movement or muscle elongation.  A hematoma or other indication of tissue trauma.  Hypermobility already exists.  Shortened soft tissues provide necessary joint stability in lieu of normal structural stability or neuromuscular control.  Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible. ther

Guidelines for Application of Stretching Perform appropriate Examination and Evaluation for joint that you will apply stretching for its surrounding soft structures.  Explain the procedure to the patient  Review the goals and desired outcomes & obtain consent  Select effective and efficient stretching techniques  Warm up the soft tissues to be stretched  The direction of stretch is exactly opposite the direction of the joint or muscle restriction.  Remove any restrictive clothing, bandages, or splints.  Explain to the patient that it is important to be as relaxed as possible or assist when requested. ther

Apply Cold packs in the lengthened position. Perform active ROM for shorted group of muscles and strengthening exercises for antagonist muscle group through the gained range immediately after stretching. After Stretching Follow with functional movement patterns

A.Total body Relaxation. This methods helps to decrease pain, muscle tension, anxiety or stress and decrease blood pressure. Example for relaxation exercise : Place the patient in a quiet area and in a comfortable position, and remove restrictive clothing. Have the patient breathe in a deep. Ask the patient to contract the distal musculature in the hands or feet voluntarily for several (5 to 7) seconds and then consciously relax those muscles for 20 to 30 seconds.

B.Heat Warming up prior to stretching is a common practice in rehabilitation program. Superficial heat (hot packs, paraffin) or deep- heating modalities (ultrasound, shortwave diathermy). C.Massage Local muscle relaxation can be enhanced by massage. D.Soft Tissue Mobilization Techniques the primary purpose of these techniques is not relaxation but, rather, increasing the mobility of adherent or shortened connective tissues including fascia, tendons, and ligaments. ther 24619

E.Biofeedback Biofeedback is another tool to help a patient learn and practice the process of relaxation. A patient, if properly trained, can electronically monitor and learn to reduce the amount of tension in muscles, as well as heart rate and blood pressure, through biofeedback instrumentation. ther 24620