1. Stretching Exercises

2. 5/2/2011
Mobility and Flexibility of soft tissues (muscles, tendons, fascia, joint capsule, and skins) surrounding the joint along with adequate joint mobility, are necessary for normal ROM.
Mobility: is the ability of segments of the body to move through range of motion for functional activities.
Flexibility: is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain –free ROM.

3. Types of Flexibility
Dynamic flexibility (active mobility or active ROM )
It is the degree to which an active muscle contraction moves the a body segment through the available ROM of the joint.
It depends on:
The degree to which joint can be moved by a muscle contraction
The amount of soft tissue resistance met during the active movement.

4. Passive flexibility (passive mobility or passive ROM )
It is the degree to which a joint can be passively moved through the available ROM.
It depends on:
- extensibility of muscles and connective tissues (soft tissues ) that crosses and surrounding a joint.

5. Types of Mobility
1- Hypo-mobility: Refers to decreased mobility or restricted motion.
2- Hyper-mobility: Refers to increased mobility

6. Muscle Anatomy
Made up of many muscle fibers that lie parallel with one another
Single fiber – made up of many myofibrils
Myofibrils - composed of sarcomeres
Sarcomere – contractile unit of the myofibril
Gives muscle ability to contract & relax
Composed of overlapping myofilaments of Actin & Myosin (form cross-bridges)
Motor unit stimulated = m. contraction -actin-myosin filaments slide together & the muscle actively shortens
Muscle relaxes = cross-bridges slide apart slightly & the muscle returns to its resting length

8. Myofilament A myofilament shows several distinct bands
Each band has been given a special letter
The lightest (least electron dense) band is the “I band”
Consists primarily of actin
In the center of the “I band” is the “Z-line”, an electron dense line
The wide, dark band is the “A band”
Consists primarily of myosin
In the middle of the “A band” is the “M line”, another dense line

9. Myofilament Sliding

10. Skeletal Muscle
CT structures of muscle-tendon unit:
Endomysium: the innermost fascial sheath that envelops individual muscle fiber.
Perimysium: the fascial sheath that binds groups of muscle fibers into individual fasciculi.
Epimysium: the outermost fascial sheath that binds entire fasciculi.

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Nerves connect the signals (action potential) to the muscle through the neuromuscular junction then transmitted deep inside muscle fibers. As a result the calcium will flow and cause the sliding of the thick and thin filaments across each other. When this occur billions of sarcomeres in the muscle shorten at once result in contraction of muscle.
How Muscle Contracts

12. First the Golgi Tendon Organ (GTO),
The muscle has two structures control its function:
First the Golgi Tendon Organ (GTO),
wraps around the ends of an extrafusal fibers
and is sensitive to tension in muscle caused
either by passive stretch or active muscle
contraction.
The GTO is a protective mechanism that
inhibits contraction of the muscle in which
it lies. It fires easily (low threshold) after
an active muscle contraction and has a high
threshold for firing with passive stretch.

13. The GTO may be the neurophysiologic basis for the inhibition of muscle that occurs with passive stretching. When passive stretch is applied, tension will increase in the muscle and cause firing of GTO and subsequent inhibition (relaxation) of the muscle.

14. Second, the Stretch Reflex:
The muscle spindle is sensitive to both quick stretch (ballistic stretch) and static or maintained stretch of the muscle.
When the muscle is stretched, the intrafusal and extrafusal muscle fibers are stretched.
The Phasic Ia afferent fibers that arise from the nuclear bag of the muscle spindle are sensitive to a quick stretch of the muscle.
The tonic Ia afferent fibers that arise from the nuclear chain of the muscle spindle are sensitive to maintained stretch.

15. When the primary afferents fire, the extrafusal fibers of the muscle being stretched contract. Tension momentarily increases in the muscle because of this reflex contraction.
The stretch reflex acts as a protective mechanism so that the muscle being lengthened will not be over stretched.
If a muscle is stretched quickly, the stretch reflex will be facilitated than if a muscle is stretched slowly.
For this reason, static or sustained stretch is preferable than ballistic stretch.

17. Factors that influence flexibility
 1- Joint structure
The type of joint determine the degree of ROM. For example; a ball-and-socket joint, like shoulder has greater ROM than a hinge joint like wrist.
2- Age
With age, muscles go through a shortening process due to lack of physical activities and a loss of elasticity in the connective tissues surrounding the muscles. As a result, there tends to be a decrease in flexibility with age.

18. Factors that influence flexibility
3- The Elasticity
The elasticity of the skin, tendons and ligaments, (ligaments do not stretch much and tendons should not stretch at all).
4-Gender
Females tend to be more flexible than males of similar age throughout life, generally due to anatomical variations in joint structures.

19. Factors that influence flexibility
5-Exercise
Participation in regular exercise involving full ROM generally enhances flexibility, while a sedentary lifestyle often results in diminished flexibility.
6-Muscle mass
muscle mass can be a factor when the muscle is so heavily developed that it interferes with the ability to take the adjacent joints through their complete range of motion (for example, large hamstrings limits the ability to fully bend the knees). Excess fatty tissue imposes a similar restriction.

20. Factors that influence flexibility
7-Temperature
An increase in either body temperature as a result of exercise or external temperature increases ROM.
8-Pregnancy
During pregnancy, the pelvic joints and ligaments are relaxed and capable of a greater ROM.

21. Causes of soft tissue Shortening
1- Prolonged Immobilization due to: A. Extrinsic factors * casts and splint * skeletal traction B. Intrinsic factors * pain * joint inflammation &stiffness * skin &muscle disorders * bony block * vascular disorders

22. Causes of soft tissue shortening
2- Sedentary lifestyle due to bed rest, work environment 3- Muscle imbalance, paralysis or tone abnormality 4- Postural malalignment which may be * congenital * acquired e.g. Scoliosis, Kyphosis

23. # Contracture it is not equal to Contraction
Is the adaptive shortening of the muscle-tendon unit and other soft tissues that crosses or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM
Contraction
The process of tension developing in a muscle during shortening or lengthening

24. Intervention to Increase Mobility of Soft Tissues
Many therapeutic interventions have been designed to improve the mobility of soft tissues and consequently increase ROM and flexibility. Stretching and mobilization are general terms that described any therapeutic maneuvers that increases the extensibility of restricted soft tissues.

25. Excitability: the ability of the muscle to respond to stimuli.
What are four physiological properties of muscle tissue that Affect Elongation (Stretching)
Excitability: the ability of the muscle to respond to stimuli.
Contractility: the ability of the muscle to produce tension
Extensibility: the ability of the muscle to be extended beyond its normal length
Elasticity – ability of the muscle to return to its resting length from extended position

26. CONTRACTURE Is the adaptive shortening of muscle-tendon unit
and other soft tissues that cross or surround a joint,
which result in significant limitation of ROM.
Types of contractures
1- Myotatic contracture (Myogenic): there is no
specific muscle pathology present, although there is
a significant loss of ROM.
2- Pseudo myotatic contracture: the limited ROM may be the result of hyper tonicity (spasticity or rigidity).
3- Arthrogenic &periarticular contracture: the limited ROM may be the result of intraarticular pathology e.g. adhesions, joint inflammation, osteophyte formation.
4- Irreversible contracture: permanent loss of mobility of soft tissue including muscles due to fibrotic changes that cannot be reversed by non surgical intervention.

27. Types of Stretching 1- Passive stretching
2- Active (Neuromuscular) Inhibition stretching.
3- Self stretching
4- Ballistic stretching.

28. 1- Passive Stretching
A sustained external force applied at the end –range manually or mechanically to elongates a shortened muscle-tendon unit, while the patient is relaxed. This type can be classified into:
The tension created in a muscle during ballistic stretch is nearly twice that created with low- intensity static (sustained) stretch.
When a gentle passive stretch position is held for at least 30 to 60 second, the facilitatory effect of stretch reflex on muscle appear to be minimal as the inhibitory action of the GTO may override the facilitatory effect of stretch reflex, so that there is no increase in muscle tension.

29. a- Manual Passive Stretch
The therapist applies an external force and controls the direction, speed, intensity and duration of stretch to shorten soft tissues beyond their resting length.
This technique should not be confused with passive range of motion exercises. Passive stretching takes the structures beyond the free range of motion. Passive range of motion is applied only within the unrestricted available range.

30. The patient must be as relaxed as possible during passive stretching.
The stretch force is usually applied for at least 15 to 30 seconds and repeated several times in an exercise session.
The intensity and duration of the stretch are dependent on the patient’s tolerance and the therapist’s strength and endurance. A low-intensity manual stretch applied for as long a duration as possible will be more comfortable and more readily tolerated by the patient.

31. b- Prolonged Mechanical Passive Stretch
2- Prolonged mechanical passive stretching
A low intensity external force is applied over a prolonged period of time with mechanical equipment.
The stretch force is applied with the patient as relaxed as possible.
The stretch may be maintained for minutes or as long as several days or weeks, depending on the type of apparatus used.
The stretch can be applied through positioning of the patient, with weighted traction and pulley systems, or with serial splints or casts.

32. C-Cyclic (Intermittent) stretch
C-Cyclic (Intermittent) stretch *A short duration stretch force, repeatedly but gradually applied, released, and then reapplied using mechanical device. *Each cycle of stretch is held between 5-10 seconds at the end-range, which is applied gradually at a controlled manner and at a relatively low intensity. These cyclic stretching is applied for many repetitions in each single treatment session. *This type of stretching showed that it is more effective and comfortable than a prolonged static stretch.

33. 2- Active (Neuromuscular) Inhibition stretching
These procedures reflexively relax the tension in shortened muscles prior to or during stretching maneuver.
When a muscle is reflexively inhibited, there is less resistance to elongation by the contractile unites of the muscle.
Inhibition techniques increase muscle length by relaxing and elongating the contractile components of muscle.
This type of stretching is only done with normally innervated muscle and under voluntary control.
It can not be used in patient with severe muscle weakness, spasticity, or paralysis from neuromuscular dysfunction.

34. For example; where you assume a position and then hold it there with no assistance other than using the strength of agonist muscles. E.g., bringing your leg up and then holding it there without anything, other than your leg muscles itself, to keep the leg in that extended position. The tension of the agonists in an active stretch helps to relax the muscles being stretched (antagonists) by reciprocal inhibition. Active stretches are hold and maintained for 10 to 15 seconds.
These techniques have been adapted from Proprioceptive neuromuscular facilitation (PNF) techniques.
There are three variations of neuromuscular inhibition techniques:
1- Contract-relax (Hold- relax).
2- Contract-relax- contract (Hold- relax with agonist contraction).
3- Agonist contraction.

35. 3- Self Stretching
Also known as flexibility exercises or active stretching.
Self stretching is a type of flexibility exercise that a patient can carry out himself as an integral component of a home exercise program.
It may involve relaxation of muscle and a passive stretch applied through the weight of the body.
Self stretching can also be carried out actively by the patient first inhibiting and then lengthening the tight muscle.

36. 4- Ballistic stretching
A rapid, forceful intermittent, high-speed and high-intensity stretch.
Vigorous bouncing movement to force the body segment beyond its range of motion to stretch shortened structures.
It is not advised because the high-velocity and high-intensity movements are difficult to control and can lead to injury in weakened tissues.

37. Comparing Stretching Techniques
Ballistic stretching is recommended for athletes engaged in dynamic activity
Static stretching most widely used
Safe & effective
PNF techniques
Capable of producing dramatic increases in ROM
Limitation – partner is required
Maintaining flexibility
Can decrease considerable after only 2 weeks
Should be engaged in at least once per week

38. Goals of Stretching
1- Regain normal range of motion of joints and mobility of soft tissue that surrounding that joint. 2- Prevent irreversible contractures. 3- Increase the general flexibility of muscle and soft tissues before vigorous strengthening exercises. 4- Minimize and prevent the risk of musculo-tendinous injuries related to specific physical activities and sports.

39. Indications of Stretching
1- Limited range of motion due to contractures, adhesions and scar tissue formation leading to shortening of muscles, ligaments, connective tissue and skin.
2- When there are structural (skeletal) deformities as a result of limitation.
3- Whenever contracture interfere with activities of daily living (ADL).
4- When there is muscle imbalance (muscle weakness and opposing tissue tightness). Tight muscle must be stretched first before strength of weak muscle.
5- As part o a total fitness program.
6- Prior to and after vigorous exercise to minimize postexercise muscle soreness.

40. Contra-indications of Stretching
1- Presence of bony block that limits joint motion. 2- Recent fracture. 3- Cases of acute inflammation or infection (presence of heat swelling around the joint). 4- Presence of acute sharp pain with joint movement or muscle elongation. 5- in case of hematoma and hypermobility.

41. Precautions of Stretching
1-Don’t force the joint beyond its normal range of motion (remember ROM varies in normal subjects). 2-Newly united fractures should be protected by stabilization between the fracture site and the joint where the movement takes place. 3-Patient known or suspected osteoporosis as, prolonged bed rest, old age, and prolonged use of steroids, due to change in flexibility.

42. Precautions of Stretching
4-Avoid vigorous stretching of muscles and connective tissues that have been immobilized for long time (connective tissues as tendons and ligaments lose their tensile stretching after prolonged immobilization) 5-If there is joint pain or muscle soreness lasting for more than 24 hours, it is preferable to take rest and if you start to make stretch take care don’t use too much force during stretch. 6-Avoid stretching edematous tissues because it is more susceptible to injury. 7-Avoid overstretch the weak muscles because it may lead to more pain and edema.

43. Principles of Stretching
Alignment &Stabilization:
Proper alignment and positioning of the patient and the muscle to be stretched is necessary for patient comfort and stability.
Stabilization and fixation of the proximal or distal attachment site of the muscle-tendon unit is important to achieve effective stretching.
Intensity of stretch:
The intensity should be applied gently, at a low intensity by means of a low load.
Duration of stretch:
The period of time a stretch force is applied. How long a single cycle of stretch is applied. The cumulative time of all stretch cycles in a treatment session.
A low load, long duration stretch is the safest form of stretch.
In general, stretch cycle from seconds applied 4-6 times have shown to produce significant gain in ROM.
Speed of stretch:
- The stretch force should be applied and released gradually in order to be more safer and prevent injury.
frequency stretch:
The number of bouts per day or per week.
It is based on the under lying cause, the level of healing process, the chronicity of contracture and the patient age.

44. Guidelines for stretching procedure
Examination
&
Evaluation
Prior to stretching
Procedure of stretching
After stretching

45. Examination and evaluation
Review the patient’s history
Determine the available ROM.
Determine if the hypomobility related to pain & functional limitations
Determine the cause of limited ROM e.g. capsule, muscle
Identify the stage of healing to determine the intensity and duration of stretch
Assess the strength of the underlying muscles
State the outcome goals
Analyze any factors that could affect the outcome

46. Prior to stretching
Position the patient in a comfortable and stable position which allow best plane of motion.
Explain the goals and procedures to the patient.
Free the area to be stretched from any restricted clothing, or splint.
Employ relaxation techniques prior to stretching.
Apply heat to the soft tissues to be stretched.
Advice and ask the patient to be relaxed as possible throught the stretching period.

47. Technique of relaxed stretching
Preparation of stretching
1- Assess the patient and know the amount and cause of limitation (soft tissue or connective tissue)
2- Choose the best type of stretching according to the cause of limitation.
3- Explain the goal and way of stretching to the patient.
4- Choose a comfortable position and ask patient to be free from restricted clothes, bandages or splints.
5- Apply relaxation technique (general or local), and ask patient to be relax as possible as he can during stretching.
6- Apply any source of heat to increase the extensibility of the shortened and tight structures.

48. Technique of relaxed stretching
How to apply stretch?
1- Grasp firmly and comfortably proximal and distal to the joint where motion is to occur.
2- Move the distal part of the limb slowly to the point of limitation.
3-To stretch a multi-joint muscle, start stretch with only one joint at a time, then over all joints until optimum length of soft tissue is obtained.
4- To minimize compression forces in small joints, stretch the distal joints first and proceed proximally.
5- It is better to apply gentle, slow and sustained stretch force on the joint until point of tightness and then move just beyond.

49. Technique of Relaxed Stretching
6-Gradually release the stretch force. Give the patient enough time to rest and then repeat the maneuver.
7- Don’t try to gain full range in one or two sessions. Increasing flexibility is a slow and gradual process. It may take several weeks of treatment to see significant results.

50. After stretching
Apply cold to the stretched soft tissues to minimize post stretch muscle soreness.
Ask the patient to apply active ROM and strengthening exercise to the gained ROM.
Ask the patient to use the regained ROM in the ADL.
Develop balancing exercise between the agonist and the antagonist groups to maintain the balance in the new range.
Use splint to maintained the regained ROM.

51. TECHNIQUES

52. STRETCH OF PECTORALIS MUSCLE
TEST PECTORALIS FLEXIBILITY

53. PECTORALIS FLEXIBILITY

54. SHOULDER ROTATOR CUFF
The Rotator Cuff: the Teres Minor, the Infraspinatus, the Supraspinatus and the Subscapularis.

55. PECTORALIS TARGET STRETCH
place your palm flat on the wall, keep your weight in your heels, and lean the whole body forward. Use the hand on the wall as your anchor, and feel the stretch along the front of the chest and armpit.

56. PECTORALIS TARGET STRETCH
Lower your hand to about shoulder height, palm facing the wall, stretching the hand behind you. Then turn the whole body away from the wall, pointing the feet, knees, and hips away from the hand. Feel the stretch across the front of the chest and inner arm.

57. STRETCH OF PECTORALIS MUSCLE
1- FROM STANDING POSITION

67. Stretching of Lower Limb
Test of hip flexors shortening (Thomas test)

68. Iliopsoas Stretching

69. Passive Stretch of The Hip Flexors

71. OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY
Ober’s test is the test for tightness of the ITB.
The subject is placed on their side, healthy side down. The knee is flexed 90 degrees and the hip extended to neutral (no flexion).

72. OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY
The PHYSIOTHERAPIST holds the leg up by the foot. Normally, the knee falls down to the exam table. If the ITB is very tight, the leg hangs up in the air (very impressive). If it’s moderately tight, the knee falls halfway to the table.

73. MODIFIED OBER’S TEST

74. Iliotibial Band Flexibility

75. STRETCHING OF HIP ADDUCTORS

76. STRETCHING OF HIP ADDUCTORS AND HAMSTRING

77. TEST OF HAMSTRING FLEXIBILITY

79. HAMSTRING FLEXIBILITY

80. FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

81. FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

82. STRETCHING OF CALF MUSCLE

83. Calf Stretching

84. SELF STRETCHING

85. Stretch of Upper Trunk

86. Lower back flexibility

87. Gluteus flexibility

88. Iliopsoas Flexibility

89. Iliopsoas Flexibility

90. Iliotibial Band flexibility
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Iliotibial Band flexibility

91. Iliotibial Band flexibility

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Hamstring Stretching

93. Hip Adductors Stretching

94. Calf stretching