STRETCHING FOR

IMPAIRED MOBILITY
By
Ms Erum Naz
Objectives
• Definitions of terms related to mobility and stretching
• Flexibility , Hypomobility , Contracture , Types of Contracture ,
Interventions to Increase Mobility of Soft Tissue , Selective
Stretching , Overstretching and Hypermobility
• Overview of properties of soft tissue—response to
immobilization and stretch.
• Explain determinants, types, and effects Of stretching
interventions.
• Explain indication ,contraindication and precaution of
stretching.
• Explain procedural guideline of stretching technique .
• Demonstrate manual stretching technique of upper limb
,lower limb, spine muscles.
• Demonstrate self stretching technique of upper limb
,lower limb, spine muscles .
Mobility
• the ability of an individual to initiate, control, or sustain
active movements of the body to perform simple to
complex motor skills.
functional ROM

joint integrity

flexibility
Hypomobility

Decreased mobility or restricted range of motion

What influence hypomobility?
1. Prolonged immobilization of a body segment
2. Sedentary lifestyle,
3. Postural malalignment and muscle imbalances
4. Impaired muscle performance (weakness) associated
with an array of musculoskeletal or neuromuscular
disorders,
5. Tissue trauma resulting in inflammation and pain, and
6. Congenital or acquired deformities.
Hypomobility, in turn, can lead to functional limitations and
disability in a person’s life.
Stretching
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
Stretching ( importance )

• fitness and conditioning

• programs designed to promote wellness and reduce the
risk of injury and reinjury.
Flexibility
is the ability to move a single joint or series of joints
smoothly and easily through an unrestricted, pain-free
ROM
flexibility
Dynamic flexibility. Passive flexibility.

• Referred to as active • Referred to as passive

mobility or active ROM, mobility or passive ROM,
• is the degree to which an • is the degree to which a
active muscle contraction joint can be passively
moved through the
moves a body segment available ROM and is
through the available dependent on the
ROM of a joint. extensibility of muscles
and connective tissues
that cross and surround a
joint
Contracture

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.
What is the difference between
tightness contracture and shortening ?
• Tightness
• denote adaptive shortening of the contractile and noncontractile
elements of muscle
Example ?
• Contracture
• an almost complete loss of motion
• Example ?

• Shortening
• denote partial loss of motion.
• Example
Types of Contracture
• Myostatic Contracture
• Musculotendinous unit has adaptively shortened.
• Pseudomyostatic Contracture
• constant state of contraction, giving rise to excessive
resistance to passive stretch.
• Arthrogenic
• intra-articular pathology
• Periarticular Contractures
• connective tissues that cross or attach to a joint or the
joint capsule lose mobility, thus restricting normal
arthrokinematic motion.
Types of Contracture
• Fibrotic 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.
• Irreversible Contracture
• Permanent loss of extensibility of soft tissues that
cannot 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
tissue33 or even heterotopic bone.
Mechanical Properties of Contractile
Tissue
 Overstretching Hypermobility

• Overstretching is a stretch • Result of overstretching

well beyond the normal • creates joint instability
length of muscle and
ROM of a joint and the
surrounding soft tissues,
Response to Immobilization and
Remobilization
Morphological changes.
• Atrophy
• tonic (slow-twitch) postural muscle fibers and phasic
(fast-twitch) fibers.
• The duration and position of immobilization
• sarcomere absorption.
• Immobilization in a lengthened position.
• Immobilization in a shortened position.
• NOTE: The adaptation of the contractile units of muscle
(an increase or decrease in the number of sarcomeres) to
prolonged positioning in either lengthened or shortened
positions is transient, lasting only 3 to 5 weeks if the
muscle resumes its preimmobilization use and degree of
lengthening for functional activities
Stretch reflex
Mechanical Properties of Non-
Contractile Tissue
• Composition of Connective Tissue
• Collagen fibers.
• Elastin fibers.
• Reticulin fibers.
• Ground substance.
Stress

is force per unit area.

• Tension: a force applied perpendicular to the

crosssectional area of the tissue in a direction away fro
the tissue. A stretching force is a tension stress.
• Compression: a force applied perpendicular to the
crosssectional area of the tissue in a direction toward the
tissue. Muscle contraction and loading of a joint during
• Shear: a force applied parallel to the cross-sectional
area of the tissue.
• Strain: the amount of deformation or lengthening that
occurs when a load (stress) or stretch force is applied.
Interpreting Mechanical Behavior of
Connective Tissue: The Stress–Strain
Curve
Connective Tissue Responses to
Loads
• Creep.
• When a load is applied for an extended period of time, the tissue
elongates, resulting in permanent deformation
• time-dependent.
• Low-magnitude loads
Changes in Collagen Affecting
Stress–Strain Response
• Effects of creep.
• Effects of stress–relaxation
• Cyclic loading and connective tissue fatigue.
(A) Effects of creep.
(B) Effects of stress–relaxation
Changes in Collagen Affecting
Stress–Strain Response
• Effects of Immobilization
• Effects of Inactivity (Decrease of Normal Activity)
• Effects of Age
• Effects of Corticosteroids
• Effects of Injury
Types of Stretching
• Static stretching
• Cyclic/intermittent stretching
• Ballistic stretching
• Proprioceptive neuromuscular facilitatio stretching
procedures (PNF stretching)
Static stretching
Cyclic/intermittent stretching
• Cyclic/intermittent stretching
Ballistic stretching
Proprioceptive neuromuscular facilitation
stretching procedures (PNF stretching)
Types of PNF Stretching
• Hold–relax (HR) or contract–relax (CR)
• Agonist contraction (AC)
• Hold–relax with agonist contraction (HR-AC).
Hold–relax (HR) or contract–relax (CR)
Mode of stretch
• Manual stretching
• Mechanical stretching
• Self-stretching
• Passive stretching
 Manual stretching
• During 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.
• The therapist manually controls the site of stabilization as well as
the direction, speed, intensity, and duration of stretch.
• Manual stretching
• controlled,
• end range,
• static,
• progressive stretch applied at an intensity consistent with the patient’s comfort
level,
• held for 15 to 60 seconds and repeated for at least several repetitions.
• When compared to mechanical stretching, manual stretching could be
categorized as a high-intensity, short-duration stretch.
points to consider
• Early stages of a stretching program
• performed passively is an appropriate( if a patient cannot
perform self-stretching e:g, lack of neuromuscular
• if the patient is apprehensive and is having difficulty
relaxing e:g, PNF
•
Mechanical stretching

15 to 30 minutes15,79 to as long as 8 to 10 hours at a time or continuous

throughout the day except for time out of the device for hygiene and exercise
Self-stretching/flexibility exercises or
active stretching
• Static stretching with a 30- to 60-second duration per
repetition is considered the safest type of stretching for a
self-stretching program.
• passively move the distal segment of a restricted joint with one or
both hands to elongate a shortened muscle while stabilizing the
proximal segment.

• distal attachment of a shortened muscle is fixed (stabilized).

• PNF stretching techniques, can be integrated into self-stretching

 Alignment:

Mode
of Stabilization
stretch:

Determents
of
stretching Intensity
Frequency
of stretch: of
stretch:

Speed Duration
of of
stretch: stretch
Alignment

• Correct alignment incorrect alignment

stabilization
Stabilization and alignment
• Stabilization of multiple segments of a patient’s body also
helps maintain the proper alignment necessary for an
effective stretch.
• For example, when stretching the iliopsoas, the pelvis and
lumbar spine must maintain a neutral position as the hip is
extended to avoid stress to the low back region. Sources
of stabilization include manual contacts, body weight, or a
firm surface such as a table, wall,or floor.
Intensity of Stretch
• The intensity (magnitude) of a stretch force is determined
by the load placed on soft tissue to elongate it.

• Low-intensity stretching (coupled with a long duration of

stretch) results in optimal rates of improvement in ROM
without exposing tissues, possibly weakened by
immobilization, to excessive loads and potential injury.

e.g, low intensity is effective –contracture(dense

connective tissue)
Duration of Stretch
• stretching intervention (stretching exercises or use of a
mechanical stretching device) is to determine the duration
of stretch that is expected to be safe, effective, practical,
and efficient for each situation.

• 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 (which is most
often the case), the cumulative time of all the stretch
cycles is also considered an aspect of duration.
• Static Stretching
• Static Progressive Stretching
Duration of Stretch(evidence)
• in a study by Cipriani et al.
• two repetitions of 30-second hamstring
stretches were found to be equally effective
compared to six repetitions of 10-second
stretches
• Roberts and Wilson found that
• 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.
Duration of Stretch
cyclic stretching
• cyclic stretching applied at a slow velocity, in a controlled
manner, and at relatively low intensity at the end range.

• is not synonymous with ballistic stretching, which is

characterized by high-velocity movements.
Duration of Stretch
• In a study of nonimpaired young adults,
• 60 seconds of cyclic stretching of calf muscles
caused tissues to yield at slightly lower loads
than one 60-second, two 30-second, or four 15-
second static stretches, possibly due to
decreased muscle stiffness.
• Heat production might occur because of the
movement inherent in cyclic stretching and
cause soft tissues to yield more readily to
stretch.
Speed of Stretch
• Importance of a Slowly Applied Stretch
• To ensure optimal muscle relaxation and prevent injury to tissues,
the speed of stretch should be slow.
• Ia fibers of the muscle spindle
• sensitive to the velocity of muscle lengthening.
• slow rate stretch affects the viscoelastic properties of connective tissue.

• Ballistic Stretching
A rapid, forceful intermittent stretch—that is, a high-
speed and high-intensity stretch—is commonly
called ballistic
Ballistic Stretching
Indication
• to increase ROM safely in young, healthy subjects participating in a
conditioning program.
Not recommended
• elderly or sedentary individuals or patients with musculoskeletal
pathology or chronic contractures.
Evidence
• Tissues, weakened by immobilization or disuse, are easily injured.
• Dense connective tissue found in chronic contractures does not
yield easily with high-intensity, short-duration stretch; rather, it
becomes more brittle and tears more readily.
High-Velocity Stretching in Conditioning
Programs and Advanced-Phase Rehabilitation
• a highly trained athlete involved in a sport such as
gymnastics that requires significant dynamic flexibility
may need to incorporate high-velocity stretching in a
conditioning program.
• a young, active patient in the final phase of rehabilitation
after a musculoskeletal injury may need to perform
carefully progressed

• High velocity stretching activities prior to beginning

plyometric training or simulated, sport-specific exercises
or drills.
Example (progression)

• Static stretching → Slow, short end-range stretching →

Slow, full-range stretching → Fast, short end-range
stretching → Fast, full-range stretching.
Frequency of Stretch
• Frequency of stretching refers to the number of bouts
(sessions) per day or per week a patient carries out a
stretching regimen
Mode of Stretch
• refers to the form of stretch or the manner in which
stretching exercises are carried out

• who or what is applying the stretch force or whether the patient is

actively participating in the stretching maneuver.

manual
Mode of Stretch

mechanical

Self

Passive

Active or active
assisted
ADJUNCTS TO STRETCHING
INTERVENTIONS
• Relaxation Training
• Heat
• Biofeedback
• Joint Traction or Oscillation
• Massage
PROCEDURAL GUIDELINES FOR APPLICATION OF STRETCHING
INTERVENTIONS

• Examination and Evaluation of the Patient

Preparation for Stretching
PRECAUTIONS FOR
STRETCHING
INDICTION AND
CONTRAINDICATION
THANKS