Kelompok 3

STRETCHING EXERCISE
 Definition
The stretching interventions described in this chapter
are designed to improve the extensibility of the
contractile and noncontractile components of muscle-
tendon units and periarticular structures.
 Terms Associated with Mobility
and Stretching

Flexibility
Flexibility is the ability to move a single joint or
series of joints smoothly and easily through an
unrestricted. Flexibility is divided into two parts:
1. Dynamic flexibility
This form of flexibility, also referred to as active
mobility or active ROM, is the degree to which an
active muscle contraction moves a body segment
through the available ROM of a joint
2. Passive flexibility
This aspect of flexibility, also referred to as
passive mobility or passive ROM, is the degree
to which a body segment can be passively
moved through the available ROM and is
dependent on the extensibility of muscles and
connective tissues that cross and surround a
joint.
Hypomobility
Hypomobility refers to decreased mobility or
restricted motion. A wide range of pathological
processes can restrict movement and impair
mobility. There are many factors that may
contribute to hypomobility and stiffness of soft
tissues, the potential loss of ROM, and the
development of contractures.
Contracture
Contracture is defined as the adaptive shortening
of the muscle-tendon unit and other soft tissues
that cross or surround a joint resulting in
significant resistance to passive or active stretch
and limitation of ROM, which may compromise
functional abilities
Selective Stretching
Selective stretching is a process whereby the
overall function of a patient may be improved by
applying stretching techniques selectively to
some muscles and joints but allowing limitation
of motion to develop in other muscles or joints.
Overstretching and Hypermobility
Overstretching is a stretch well beyond the
normal length of muscle and ROM of a joint and
the surrounding soft tissues resulting in
hypermobility (excessive mobility).
Overview of Interventions 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/manipulation are
general terms that describe any therapeutic
maneuver that increases the extensibility of
restricted soft tissues.
Terms that describe a number of techniques
designed to increase soft tissue extensibility and
joint mobility:
• Stretching Manual or Mechanical/Passive or Assisted
• Self-Stretching
• Neuromuscular Facilitation and Inhibition Techniques
• Muscle Energy Techniques
• Joint Mobilization/Manipulation
• Soft Tissue Mobilization/Manipulation
• Neural Tissue Mobilization (Neuromeningeal Mobilization)
 Indications for Use of Stretching
• ROM is limited because soft tissues have lost their
extensibility as the result of adhesions, contractures, and scar
tissue formation, causing activity limitations (functional
limitations) or participation restrictions (disabilities).
• Restricted motion may lead to structural deformities that are
otherwise preventable.
• Muscle weakness and shortening of opposing tissue have led
to limited ROM.
• May be a component of a total fitness or sport-specific
• conditioning program designed to prevent or reduce the risk of
musculoskeletal injuries.
• May be used prior to and after vigorous exercise to potentially
reduce postexercise muscle soreness.
 Contraindications to Stretching
• A bony block limits joint motion.
• There was a recent fracture, and bony union is incomplete.
• There is evidence of an acute inflammatory or infectious
process (heat and swelling), or soft tissue healing could be
disrupted in the restricted tissues and surrounding region.
• There is sharp, acute pain with joint movement or muscle
elongation.
• A hematoma or other indication of tissue trauma is observed.
• 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.
 Determinants and Types of Stretching
Exercises

Alignment and Stabilization

• Alignment: Positioning a limb or the body
such that the stretch force is directed to the
appropriate muscle group.
• Stabilization: Fixation of one site of
attachment of the muscle as the stretch force is
applied to the other bony attachment.
Example of Alignment
Example of Stabilization
Intensity of Stretch
The intensity (magnitude) of a stretch force is determined by the
load placed on soft tissue to elongate it.

Duration of Stretch
Length of time the stretch force is applied during a stretch cycle.
1. Static Stretching
2. Cyclic (Intermittent) Stretching
Speed of Stretch
Speed of stretch: Speed of initial application
of the stretch force. Importance of a Slowly
Applied Stretch To minimize muscle activation
during stretching and reduce the risk of injury to
tissues and poststretch muscle soreness, the
speed of stretch should be slow.
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. The recommended
frequency of stretching is based on the underlying
cause of impaired mobility, the quality and level of
healing of tissues, the chronicity and severity of a
contracture, as well as a patient’s age, use of
corticosteroids, and previous response to stretching.
Frequency on a weekly basis ranges from two to five
sessions, allowing time for rest between sessions for
tissue healing and to minimize postexercise
soreness.
Procedural Guidelines for Application of
Stretching Interventions
1. Examination and Evaluation of the Patient
• Carefully review the patient’s history and perform a
thorough systems review.
• Select and perform appropriate tests and measurements.
Determine the ROM available in involved and adjacent
joints and if either active or passive mobility is
impaired.
• Determine if hypomobility is related to other
impairments of body structure or function and if it is
causing activity limitations (functional limitations) or
participation restrictions (disability).
• Ascertain if—and if so, which—soft tissues are the source of the impaired
mobility. In particular, differentiate between joint capsule, periarticular,
noncontractile tissue, and muscle length restrictions as the cause of
limited ROM. Be sure to assess joint play and fascial mobility.
• Evaluate the irritability of the involved tissues and determine their stage
of healing. When moving the patient’s extremities or spine, pay close
attention to the patient’s reaction to movements. This not only helps
identify the stage of healing of involved tissues, it helps determine the
probable dosage (such as intensity and duration) of stretch that stays
within the patient’s comfort range.
• Assess the underlying strength of muscles in which there is limitation of
motion and realistically consider the value of stretching the range-limiting
structures. An individual must have the capability of developing adequate
strength to control and use the new ROM safely.
• Be sure to determine what outcome goals (i.e., functional improvements)
the patient is seeking to achieve as the result of the intervention program
and determine if those goals are realistic.
• Analyze the impact of any factors that could adversely affect the
projected outcomes of the stretching program.
2. Preparation for Stretching
• Review the goals and desired outcomes of the stretching program with the
patient. Obtain the patient’s consent to initiate treatment.
• Select the stretching techniques that will be most effective and efficient.
• Warm up the soft tissues to be stretched by the application of local heat or
by active, low-intensity exercises. Warming up tight structures may
increase their extensibility and may decrease the risk of injury from
stretching.
• have the patient assume a comfortable, stable position that allows the
correct plane of motion for the stretching procedure. The direction of
stretch is exactly opposite the direction of the joint or muscle restriction.
• Explain the procedure to the patient and be certain he or she understands.
• Free the area to be stretched of any restrictive clothing, bandages, or
splints.
• Explain to the patient that it is important to be as relaxed as possible.
Also, explain that the stretching procedures are geared to his or her
tolerance level.
3.Application of Manual Stretching Procedures
•Move the extremity slowly through the free range to the point of tissue restriction.
•Grasp the areas proximal and distal to the joint in which motion is to occur. The grasp should
be firm but not uncomfortable for the patient. Use padding, if necessary, in areas with
minimal subcutaneous tissue, reduced sensation, or over a bony surface. Use the broad
surfaces of your hands to apply all forces.
•Firmly stabilize the proximal segment (manually or with equipment) and move the distal
segment.
•To stretch a multijoint muscle, stabilize either the proximal or distal segment to which the
range-limiting muscle attaches. Stretch the muscle over one joint at a time and then over all
joints simultaneously until the optimal length of soft tissues is achieved. To minimize
compressive forces in small joints, stretch the distal joints first and proceed proximally.
•Consider incorporating a prestretch, isometric contraction of the range-limiting muscle (the
hold-relax procedure) theoretically designed to relax the muscle reflexively prior to
stretching it.
•To avoid joint compression during the stretching procedure, apply gentle (grade I) distraction
to the moving joint.
• Apply a low-intensity stretch in a slow, sustained manner. Remember, the
direction of the stretching movement is directly opposite the line of pull of the
range-limiting muscle. Ask the patient to assist you with the stretch, or apply a
passive stretch to lengthen the tissues. Take the hypomobile soft tissues to the
point of firm tissue resistance and then move just beyond that point. The force
must be enough to place tension on soft tissue structures but not so great as to
cause pain or injure the structures. The patient should experience a pulling
sensation, but not pain, in the structures being stretched. When stretching
adhesions of a tendon within its sheath, the patient may experience a “stinging”
sensation.
• Maintain the stretched position for 30 seconds or longer. During this time, the
tension in the tissues should slowly decrease. When tension decreases, move
the extremity or joint a little farther to progressively lengthen the hypomobile
tissues.
• Gradually release the stretch force and allow the patient and therapist to rest
momentarily while maintaining the range-limiting tissues in a comfortably
elongated position. Then repeat the sequence several times.
• If the patient does not seem to tolerate a sustained stretch, use several very
slow, gentle, intermittent stretches with the muscle in a lengthened position.
• If deemed appropriate, apply selected soft tissue mobilization
procedures, such as fascial massage or cross-fiber friction
massage, at or near the sites of adhesion during the stretching
maneuver.
4. After Stretching
• Apply cold to the soft tissues that have been stretched and allow
these structures to cool in a lengthened position. Cold may
minimize poststretch muscle soreness that can occur as the result
of microtrauma during stretching. When soft tissues are cooled in
a lengthened position, increases in ROM are more readily
maintained.
• Regardless of the type of stretching intervention used, have the
patient perform active ROM and strengthening exercises through
the gained range immediately after stretching. With your
supervision and feedback, have the patient use the gained range
by performing simulated functional movement patterns that are
part of daily living, occupational, or recreational tasks.
• Develop a balance in strength in the antagonistic muscles in the
new range, so there is adequate neuromuscular control and
stability as flexibility increases.
Manual Stretching Techniques in Anatomical
Planes of Motion