Mechanical Stretching

JAS orthosis is a patient-directed

device that applies a static
progressive stretch. (Courtesy of
Joint Active Systems, Effingham,
IL.)
Each of the following forms of mechanical
stretching has been shown to be effective,
particularly in reducing long-standing
contractures.
• An effective stretch load
applied with a
cuff weight can be
as low as a few
pounds.
 Duration of Mechanical Stretch

• Mechanical stretching involves a substantially

longer overall duration of stretch than is practical
with manual stretching or self-stretching exercises.
• The duration of mechanical stretch reported in the
literature ranges from 15 to 30 minutes 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.
• Serial casts are worn for days or weeks at a time
before being removed and then reapplied.
 Proprioceptive Neuromuscular
Facilitation Stretching Techniques
Proprioceptive neuromuscular facilitation techniques, used
for stretching (PNF stretching), also referred to as active
stretching or facilitative stretching, integrate active
muscle contractions into stretching maneuvers
purportedly to facilitate or inhibit muscle activation and
to increase the likelihood that the muscle to be
lengthened remains as relaxed as possible as it is
stretched.
• It is believed that when muscle fibers are reflexively
inhibited through autogenic or reciprocal inhibition, there
is less resistance to elongation by the contractile elements
of the muscle
 Types of PNF Stretching

• There are several types of PNF stretching procedures. They

• include:
• Hold–relax (HR) or contract–relax (CR)
• Agonist contraction (AC)
• Hold–relax with agonist contraction (HR-AC).
 Hold–Relax and Contract–Relax
Hold–relax (HR) procedure to stretch the pectoralis
major muscles bilaterally. (A) The therapist
horizontally abducts the shoulders bilaterally to a
comfortable position. The patient isometrically
contracts the pectoralis major muscles against the
therapist’s resistance for 5 to 10 seconds
B) The patient relaxes, and the therapist passively
lengthens the pectoralis major muscles by
horizontally abducting the shoulders into the newly
gained range. After a 10-second rest with the
muscle maintained in a comfortably lengthened
position, the entire sequence is repeated
Agonist Contraction
 Hold–Relax with Agonist Contraction

The HR-AC stretching technique combines the HR and

AC procedures. The HR-AC technique is also referred to
as the slow reversal hold–relax technique.
• To perform the HR-AC procedure, move the limb to
the point that tissue resistance is felt in the tight
(range-limiting) muscle; then have the patient
perform a resisted, prestretch isometric contraction
of the range-limiting muscle followed by relaxation of
that muscle and an immediate concentric contraction
of the muscle opposite the tight muscle.
The Hold-relax-swing

This technique (and a similar technique called the hold

relax-bounce) actually involves the use of dynamic or
ballistic stretches in conjunction with static and isometric
stretches. It is very risky, and is successfully used only by
the most advanced of athletes and dancers that have
managed to achieve a high level of control over their
muscle stretch reflex. It is similar to the hold-relax
technique except that a dynamic or ballistic stretch is
employed in place of the final passive stretch.
Integration of Function into Stretching

(A, B) Stretching-induced gains in ROM are used during

daily activities
 PROCEDURAL GUIDELINES FOR
APPLICATION OF STRETCHING
INTERVENTIONS

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
and if it is causing functional limitations or
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.
 Examination and Evaluation of the Patient

• 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 safely use the
new ROM.

• 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.
 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 asssume 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
 Preparation for Stretching
• 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 or assist when requested. Also explain that the
stretching procedures are geared to his or her tolerance
level
 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.
 ADJUNCTS TO STRETCHING
INTERVENTIONS
Relaxation Training
•Relaxation training, using methods of general
relaxation (total body relaxation), has been used for
many years by a variety of practitioners to help
patients learn to relieve or reduce pain, muscle
tension, anxiety or stress, and associated physical
impairments including tension headaches, high
blood pressure, and respiratory distress.
Common Elements of Relaxation Training

Relaxation training involves a reduction in muscle tension

in the entire body or the region that is painful or
restricted by conscious effort and thought. Training
occurs in a quiet environment with low lighting and
soothing music or an auditory cue on which the
patient may focus. The patient performs deep
breathing exercises or visualizes a peaceful scene.
When giving instructions the therapist uses a soft tone
of voice
 Examples of Approaches to Relaxation Training

• Progressive relaxation
• Awareness through movement.
• Sequence for Progressive Relaxation Techniques
• Place the patient in a quiet area and in a comfortable
• position, and be sure that restrictive clothing is loosened.
• Have the patient breathe in a deep, relaxed manner
• Ask the patient to contract the distal musculature in the hands
or feet voluntarily for several (5 to 7) seconds and then
consciously relax those muscles for 20 to 30 seconds.
• Suggest that the patient try to feel a sense of heaviness in the
hands or feet and a sense of warmth in the muscles just
relaxed
• Progress to a more proximal area of the body and have the
patient actively contract and actively relax the more proximal
musculature. Eventually have the patient isometrically contract
and consciously relax the entire extremity.
• Suggest to the patient that he or she should feel a sense of
relaxation and warmth throughout the entire limb and
eventually throughout the whole body.
 Indicators of Relaxation
• Decreased muscle tension
• Lowered heart and respiratory rates and blood
pressure
• Increased skin temperature in the extremities
associated with vasodilation
• Constricted pupils
• Little to no body movement
• Eyes closed and flat facial expression
• Jaw and hands relaxed with palms open
• Decreased distractability
• Heat
Warming up prior to stretching is a common practice
in rehabilitation and fitness programs.109 It is well
documented in human and animal studies that as
intramuscular temperature increases the
extensibility of contractile and non contractile soft
tissues likewise increases. In addition, as the
temperature of muscle increases, the amount of
force required and the time the stretch force must
be applied decrease.
There is also a decrease in the rate of firing of the type II
efferents from the muscle spindles and an increase in the
sensitivity of the GTO, which makes it more likely to fire
• Methods of Warm-up
• Superficial heat (hot packs, paraffin) or deep-heating
modalities (ultrasound, shortwave diathermy) provide different
mechanisms to heat tissues
• Low-intensity, active exercises, which generally
increase circulation and core body temperature, also have been
used as a mechanism to warm up large muscle groups prior to
stretching
• Some common warm-up exercises are a brief walk, non
fatiguing cycling on a stationary
bicycle, use of a stair-stepping machine, active heel raises, or a
few minutes of active arm exercises
• Effectiveness of Warm-up Methods
The use of heat alone (a thermal agent or warm-up
exercises)without stretching has been shown to have either
little or no effect on improving muscle flexibility
 Massage

• Massage for Relaxation

• Local muscle relaxation can be enhanced by
massage, particularly with light or deep stroking
techniques In some approaches to stress and
anxiety or pain management, self-massage, using
light stroking techniques (effleurage), is performed
during the relaxation process.
Soft Tissue Mobilization Techniques
 Joint Traction or Oscillation
Slight manual distraction of joint surfaces prior to or
in conjunction with joint mobilization or muscle-
tendon stretching techniques can be used to
inhibit joint pain and spasm of muscles around a
joint