1. Therapeutic Exercise I Chapter 4
Stretching for Impaired Mobility

2. Selective Stretching Mobility Functional Mobility Flexibility
Contractures
Overstretching
Tightness
Selective Stretching
ROM needs vary among individuals

3. Stretching as an integral component to rehab
The supervising PT will determine what structures are restricted and what type of stretches to be implemented
Designed to increase the extensibility of soft tissues
Includes: manual, self, and mechanical stretching
There must be a balance between mobility and stability for MAXIMUM FUNCTION

4. Hypomobility Prolonged immobilization Sedentary lifestyle
Postural malalignment & muscle imbalances
Impaired muscle performance (weakness) associated with musculoskeletal or neuromuscular disorders
Tissue trauma resulting in inflammation & pain
Congenital or acquired deformities

5. Types of Contractures Myostatic Contractures
Pseudomyostatic Contractures
Arthrogenic and Periarticular Contractures
Fibrotic Contracture and Irreversible Contracture

6. Goals of Stretching Increased flexibility & ROM
General Fitness – warm up & cool down
Prevention/reduction of soft tissue injuries
Decreased post exercise soreness
Enhanced performance

7. Properties of Soft Tissue
Elasticity- the ability of soft tissue to its pre-stretch resting length directly after a short-duration stretch force has been removed
Viscoelasticity- Time dependent property of soft tissue that initially resists deformation, such as change in length, of the tissue when a stretch is first applied. But if the stretch is sustained…it allows a change in the length of the tissue and then enables the tissue to return gradually to its pre-stretched 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
Muscles (contractile and non-contractile) have both elastic and plastic
qualities; however, only the connective tissues have viscoelastic qualities

8. Mechanical Properties of Contractile Tissue
When contractures develop, adhesions in and between collagen fibers resist and restrict movement
If a muscle is immobilized for a prolonged period of time, the outcome is atrophy or weakness….which can result in an increase in fibrous and fatty tissue in the muscle, and disorganizes collagen
Atrophy can occur in days/weeks and duration plays a major part in the severity of the atrophy

9. Neurophysiological Properties of Contractile Tissue
Muscle Spindles – changes in length & velocity of length changes
Golgi Tendon Organs – changes in tension;
Autogenic inhibition
Reciprocal inhibition

10. Mechanical Properties of Non-Contractile Soft Tissue
Non-contractile soft tissue comes in various types of connective tissue: ligaments, tendons, joint capsule, fascia, non-contractile tissue in muscles, and skin (adhesions)
Creep can occur- amount of deformation will depend on the severity of the position and the period of time in the position i.e.: significant thoracic kyphosis

11. Non-contractile Tissue
Only way to increase extensibility is to remodel its basic structure
Collagen – strength & stiffness; resists tensile deformation
Elastin – provides extensibility
Reticulin – provides tissue bulk
PG’s & GP’s – reduce friction, transports nutrients, maintains space between fibers

12. Stress Strain Curve Toe Region Elastic Range Elastic Limit
Plastic Range
Failure

13. Determinants of Stretching Interventions
Alignment
Stabilization
Intensity
Duration
Speed
Frequency
Mode

14. Mode (types) of Stretching
Manual
Self
Mechanical
PNF

15. Types of Proprioceptive Neuromuscular Facilitation (PNF) Stretching Techniques
Hold Relax (HR) or Contract Relax (CR)
Agonist Contraction
Hold-Relax with Antagonist Contraction (HR-AC)

16. Stabilize Proximal versus Distal
When being stretched by the supervising PT/PTA it is common for them to stabilize the proximal attachment and move the distal attachment
When performing a self-stretch often the distal attachment is stabilized as the proximal segment moves
Duration of Stretch-30 second stretch has been identified as the median time frame
Types of stretching: static (static progressive stretching), cyclic (intermittent), ballistic (rapid force)

17. Adjuncts to Stretching Interventions
Relaxation Training (autogenic training, progressive relaxation, awareness through movement)
Heat (warming of the tissue) – see article
Exercise
Massage (warming of the tissue with a manual technique)
Biofeedback (audio or visual awareness)
Joint traction or oscillation (any joint mobilization techniques to be done by the PT only)
Ice should be used after stretching-preferred in a lengthened

18. Indications
Limited ROM – adhesions, contractures, scar tissue formation
Structural deformities caused by restricted motion
Muscle weakness & shortening of opposing muscle groups
Total fitness/sports conditioning
Warm up & cool down to decrease soreness

19. Contraindications Bony block Fracture/incomplete union
Acute inflammation/infection
Sharp acute pain with movement
Hematoma
Hypermobility
Shortened soft tissue necessary for function
Shortened soft tissue providing joint stability

20. (If time permits may review LE’s)
Break for Lab with Lecture on UE Stretching Techniques in Anatomical Planes of Motion
(If time permits may review LE’s)