Stretching

PASSIVE STRETCHING

• Manual stretching
• 1) static stretching
• 2) ballistic stretching
• Mechanical stretching
• 1)long duration  mechanical  stretching
• 2)cyclic mechanical stretching

PNF (PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION)

• Hold and relax
• Contract relax
• slow reversal

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.

PASSIVE STRETCHING

MANUAL STRETCHING:  it is done by the therapist or by the physician. The stretching may be given for 15-30 seconds, sometimes it may be extended up to 60 seconds.

The stretching duration and the force applied may change depending on the condition and the tolerance power of the patients. It is of two types;

• Static stretching
• Ballistic stretching

1)Static stretching:  

• static stretching is a commonly used method of stretching in which soft tissues are elongated just past the point of tissue resistance and then held in the lengthened position with a sustained stretch force over a period of time.
• other terms used interchangeably are sustained, maintained, or prolonged stretching.
• In this slow and prolonged stretch is applied to avoid the reflex contraction from the muscle spindle and Golgi tendon or organ.
• The Golgi tendon organ protects the muscle from the stretch by firing the type 1b fibers further relaxes the muscle by efferent impulse.so, the muscle fiber goes for more relaxation and flexibility.

2)Ballistic stretching:

• It is the bouncing or jerky type of stretching.
• It is a high velocity and short duration stretching.
• Even though the ballistic stretching increases the flexibility, it may  cause injury because the movements may exceed the limits of extensibility and it has poor control over the movements.
• This exercise can be dangerous if done without supervision or training by a  professional.

STUDY: A comparative study involving the stretching of hamstrings in 40 individuals between the age of 20 and 40 with tight hamstrings was done in  2010 and published in the british journal of sports medicine.static stretching of hamstrings was compared to ballistic stretching over the course of six weeks. Results showed that after six weeks in this population ballistic stretching was better than static stretching in improving flexibility of the hamstrings.

MECHANICAL STRETCHING: Mechanical stretching devices apply a very low-intensity stretch force(low-load) over a prolonged period of time to create relatively permanent lengthening of soft tissues, presumably due to plastic deformation.

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, some adjustable orthotic devices or automated stretching machines.

1)long duration mechanical stretching:

• The low intensity and long duration stretch gives more flexibility in the muscle and connective tissue than the less duration stretch.
• The stretch, which is given from 20 minutes to several hours, gives good effect than the stretch applied for less than 20 minutes.
• The serial cast, pulleys, dynamic splints, tilting table, traction are some of the mechanical devices made for prolonged mechanical stretching.

2) Cyclic mechanical stretching:

• The stretching program can be given in cyclic manner with the help of mechanical devices.
• The intensity of stretch, duration of stretch and number of stretch cycle per minute can be set in the mechanical device itself.

PNF ( PROPRIOCEPTIVE  NEUROMUSCULAR FACILITATION):

According to Knott and Ros, facilitation the proprioceptor with help of neuromuscular activities can be used to stretch a particular muscle some main PNF techniques are used for the stretching, they are:

1)Hold relax:

• Here the therapist keeps the limb in the end range of ROM.
• For example, in hamstring stretching, the muscle is kept at the end range by flexing the hip and extends the knee with the patient in supine lying. then the patient is asked to perform the isometric contraction against the force applied by the therapist. this contraction activates the GTO and it sends impulses to spinal cord, from there to the brain.
• The brain responds by relaxation impulse through 1b fibers.
• After some relaxation, the therapist flexes the hip some more and achives a new position. after reaching the new position, the above said process may be repeated again.

2) Contract relax:

• Here the therapist takes the limb to the end range.
• For example, in hamstring stretching, the knee is extended and hip is flexed with the patient in supine lying. after attanining the end range, the patient is asked to contract the opposite muscle to the muscle being stretched, i.e.the hip flexor is asked to contract which results in maximum stretching of the hamstrings.
• Normally, in any synergic group, contraction of agonist result in reflexive relaxation of the antagonist, i.e. hip flexors contraction causes the hamstring relaxation.
• After the consecutive contraction of the hip flexor, the therapist moves the limb still more forward, i.e. hip flexion and new position is attained.
• The same procedure is followed without lowering the legs.

3)slow reversal:

• Here too the therapist takes the limb to the end ranges for example,in hamstring stretching, the knee is extended with hip flexed and end range is attained.
• In the end range,the patient asked to do the isometric contraction of the hamstring muscle, by opposing the force given by the therpist.
• This isometric contraction activates the GTO and results in relaxation impulse as we have seen earlier.
• Then the patient is asked to do the isotonic contraction of the opposite muscle to the muscle being stretched, i.e. hip flexors, so that more amount of stretching is achieved.
• After the isotonic contraction, the new position is attained, i.e. the stretch is increased because, due to the isotonic contraction, the hamstring muscle gets more flexibility.
• So, it can go for maximum stretch, then the patient is asked to relax for some time.Again the same procedure is followed without lowering the leg.

• Post- traumatic stiffness.
• Post-immobilization stiffness
• Restrictive mobility.
• congenital and acquired bony deformity
• joint pathology resulting in soft tissue stiffness
• soft tissue pathology leading to relative soft tissue stiffness
• Healed burn scars
• Fear of pain spasm
• Adhesion formation over soft tissue.
• Contracture of the joint and soft tissue
• Any type of muscular spasm
• Spasticity (UMS cause)

•  Synovial effusion
• Recent fracture
• Sharp pain while doing stretch
• Inflammation in the tight tissue
• Infection over tight tissue
• Immediately after dislocation
• Edema
• Osteoporosis
• Hemophilic joint
• Hemarthrosis
• Malignant tumors
• Flial joint
• After joint arthroplasty
• Neuropathic joint
• Unhealed scars
• Unhealed burns
• Chronic rheumatoid arthritis

The assertive method that increases the quality of stretch can be given before the stretching regime. some of them are:

1. Heat
2. Massage
3. Oscillation
4. Joint mobilization
5. Active exercise

Heat:

• heat increases relaxation, circulation,and nutrition, to tissue and decreases spasm and tightness.
• stretching performed after applying heat modality requires less force to stretch.
• heat will activate the GTO and results in relaxation response from the higher center, which reduces the tension in the muscles.

Massage: Effective maneuver of massage produces-

• it increases blood circulation
• it increases blood nutrition
• it enhances local relaxation
• it decreases spasm

Massage can be  done after application of heat therapy, which improves the effect of massage thereby helpful in stretching.

Active exercise: Active exercise produces heat inside the body. warm tissue can be stretched easily.

Joint mobilization:

• Before doing the joint stretching, joint mobilization is done; it reduces the stiffness of the joint by breaking the adhesion formed and makes the joint free.
• joint traction breaks the adhesion and stretches the tightened structure.
• the pendular and oscillation movement relaxes and reduces the tightness of the soft tissue.

*If the microtrauma occurs during stretching the iceing can be done to constricting the blood vessels thereby reducing the local blood circulation thus prevent further damage.Iceing also reduces the post-stretching muscular soreness.

• Increased flexibility and ROM(range of motion)
• Improve general fitness
• Injury prevention and reduced postexercise muscle soreness
• Enhanced performance of physical activities