Stretching for Impaired Mobility

• Definition of Terms Associated with Mobility and Stretching

• Indications, Contraindications, and Potential Outcomes of Stretching
Exercises
• Properties of Soft Tissue: Response to Stretch
• Determinants and Types of Stretching Exercises
• Procedural Guidelines for Application of Stretching Interventions
• Precautions for Stretching
• Adjuncts to Stretching Interventions
• Manual Stretching Techniques in Anatomical Planes of Motion
Definition of Terms Associated with Mobility
and Stretching
• Mobility • Selective Stretching
• Flexibility • Overstretching and
• Hypomobility Hypermobility
• Contracture
Mobility
It is the ability of structures or segments of the body to move or be
moved to allow the presence of range of motion for functional
activities (functional ROM).
Flexibility

It is the extensibility of soft tissues that cross or surround joints—

muscles, tendons, fascia, joint capsules, ligaments, nerves, blood

vessels, skin), which are necessary for unrestricted, pain-free

movements of the body during functional tasks of daily living.

Dynamic and Passive Flexibility
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. It is dependent on the
degree to which a joint can be moved by a muscle contraction and the amount
of tissue resistance met during the active movement.

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. Passive flexibility is a
prerequisite for—but does not ensure— dynamic flexibility.
 Hypomobility
Hypomobility (restricted motion) caused by adaptive shortening of soft
tissues can occur as the result of many disorders or situations.
Factors include
(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;
(6) Congenital or acquired deformities.
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.
• It can be range from mild muscle shortening to irreversible
contractures.
Contractures are described by identifying the action of the shortened
muscle.
e.g.
• If a patient has shortened elbow flexors and cannot fully extend the
elbow, he or she is said to have an elbow flexion contracture.
• When a patient cannot fully abduct the leg because of shortened
adductors of the hip, he or she is said to have an adduction
contracture of the hip.
Contracture Versus Contraction

The terms contracture and contraction (the process of tension developing in a

muscle during shortening or lengthening) are not synonymous and should

not be used interchangeably.

Types of Contracture
• Myostatic contracture.

• Pseudomyostatic contracture.

• Arthrogenic and periarticular contracture.

• Fibrotic contracture and irreversible contracture.

Unable to be corrected with stretching exercise
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.
In a patient with spinal cord injury, stability of the trunk is necessary for independence
in sitting. With thoracic and cervical lesions, the patient does not have active control of
the back extensors. If the hamstrings are routinely stretched to improve or maintain their
extensibility and moderate hypomobility is allowed to develop in the extensors of the
low back, this enables a patient to lean into the slightly shortened structures and have
some degree of trunk stability for long term sitting. However, the patient must still have
enough flexibility for independence in dressing and transfers. Too much limitation of
motion in the low back can decrease function.
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

Stretching

Athletes Instability
Overview of Interventions to Increase

Mobility of Soft Tissues

Stretching: Manual or Mechanical/Passive
or Assisted
A sustained or intermittent external, end-range stretch
force, applied with overpressure and by manual contact or
a mechanical device, elongates a shortened muscle-tendon
unit and periarticular connective tissues by moving a
restricted joint just past the available ROM. If the patient
is as relaxed as possible, it is called passive stretching. If the
patient assists in moving the joint through a greater range,
it is called assisted stretching.
Self-Stretching
Any stretching exercise that is carried out independently
by a patient after instruction and supervision by a
therapist is referred to as self-stretching.
Neuromuscular Facilitation and Inhibition
Techniques

Neuromuscular facilitation and inhibition

procedures are purported to relax tension in
shortened muscles reflexively prior to or during
muscle elongation.
Muscle Energy Techniques

Muscle energy techniques are manipulative

procedures that have evolved out of
osteopathic medicine and are designed to
lengthen muscle and fascia and to mobilize
joints.
Joint Mobilization/Manipulation

Joint manipulative techniques are skilled manual

therapy interventions specifically applied to joint
structures to modulate pain and treat joint
impairments that limit ROM.
Soft Tissue Mobilization/Manipulation

Soft tissue manipulative techniques are designed

to improve muscle extensibility and involve the
application of specific and progressive manual
forces (e.g., by means of sustained manual
pressure or slow, deep stroking) to effect change
in the myofascial structures that can bind soft
tissues and impair mobility.
Indications
Contra indication
Potential Benefits and Outcomes of Stretching

reduced postexercise
Increased Flexibility and
(delayed onset) muscle
ROM
soreness

enhanced physical
General Fitness
performance

prevention or
reduction of the risk of soft
tissue injuries
Properties of Soft Tissue:
Response to stretch
When soft tissue is stretched, elastic, viscoelastic, or plastic changes occur.
Both contractile and noncontractile tissues have elastic and plastic
qualities; however, only noncontractile connective tissues, not the
contractile elements of muscle, have viscoelastic properties.

• Elasticity is the ability of soft tissue to return to its pre-stretch resting

length directly after a short-duration stretch force has been removed.
• Viscoelasticity, or viscoelastic deformation, is a time dependent
property of soft tissue that initially resists deformation, such as a change
in length, of the tissue when a stretch force is first applied. If a stretch
force is sustained, viscoelasticity allows a change in the length of the
tissue and then enables the tissue to return gradually to its pre-stretch
state after the stretch force has been removed.

• Plasticity, or plastic deformation, is the tendency of soft tissue to

assume a new and greater length after the stretch force has been
removed.
 • When initial lengthening occurs in the series elastic
(connective tissue) component, tension rises sharply.
Mechanical Response
After a point, there is mechanical disruption
of the Contractile Unit (influenced by neural and biochemical changes) of
to Stretch
the cross bridges as the filaments slide apart, leading
to abrupt lengthening of the sarcomeres

• When the stretch force is released, the individual

sarcomeres return to their resting length

• If longer lasting or more permanent (viscoelastic or

plastic) length increases are to occur, the stretch
force must be maintained over an extended period of
time
 Neurophysiological Properties of Contractile Tissue

 In particular, two sensory organs of muscle

tendon units, the muscle spindle and the Golgi
tendon organ, are mechanoreceptors that
convey information to the central nervous
system about what is occurring in a muscle-
tendon unit and that affect a muscle’s response
to stretch.
When a stretch force is applied to a muscle-tendon unit either
quickly or over a prolonged period of time,

Muscle spindle Golgi tendon organ inhibit

Increase tension tension
Mechanical Properties of Noncontractile
Soft Tissue
• Connective tissue is composed of three types of
fiber: collagen, elastin and reticulin, and
nonfibrous ground substance (proteoglycans and
glycoproteins)

• Collagen fibers. Collagen fibers are responsible

for the strength and stiffness of tissue and resist
tensile deformation.

• Elastin fibers. Elastin fibers provide extensibility.

They show a great deal of elongation with small
loads and fail abruptly without deformation at
higher loads. Tissues with greater amounts of
elastin have greater flexibility.
■ Stress is force (or load) per unit area. Mechanical stress is the
internal reaction or resistance to an external load.

■ Strain is the amount of deformation or lengthening that

occurs when a load (or stretch force ) is applied.
There are three kinds of stress that cause strain to structures:

■ Tension—a force applied perpendicular to the cross-sectional area of the tissue

in a direction away from the tissue. A stretching force is a tension stress.

■ Compression—a force applied perpendicular to the cross sectional area of the

tissue in a direction toward the tissue. Muscle contraction and loading of a joint
during weight bearing cause compression stresses in joints.

■ Shear—a force applied parallel to the cross-sectional area of the tissue.

 Factors affecting collagen stress-strain curve

1. Immobilization 6. Nutritional deficiencies

2. Inactivity (Decrease of 7. Hormonal imbalances
Normal Activity) 8. Dialysis
3. Age
4. Corticosteroids
5. Injury
Time and Rate Influences on Tissue
Deformation

Creep. When a load is applied for an extended period of

time, the tissue elongates, and does not return to its original
length.

Stress-relaxation. When a force (load) is applied to stretch a

tissue and the length of the tissue is kept constant, after the
initial creep, there is a decrease in the force required to
maintain that length, and the tension in the tissue decreases.
 Note
■ Connective tissue deformation (stretch) occurs to different degrees at
different intensities of force and at different rates of application.

■ Healing and adaptive remodeling capabilities allow the tissue to respond to

repetitive and sustained loads if time is allowed between bouts.

■ It is imperative that the individual use any newly gained range to allow the
remodeling of tissue and to train the muscle to control the new range, or the
tissue eventually returns to its shortened length.
Determinants and Types of Stretching Exercises
Alignment
Stabilization
Intensity of Stretch: stretching should be applied at
a low-intensity by means of a low-load.

Duration of Stretch: the shorter the duration of a

single stretch cycle, the greater the number of
repetitions applied during a stretching session.
Speed of Stretch
• a Slowly Applied Stretch
• Ballistic Stretching(A rapid, forceful
intermittent stretch)

Frequency of Stretch
Enough time must be given between session for tissue
healing
Differ from 2 to 5 sessions \ week
Mode of stretch
 Considerations for Selecting Methods of Stretching
■ Based on the results of your examination, what tissues are involved and impairing mobility?
■ Is there evidence of pain or inflammation?
■ How long has the hypomobility existed?
■ What is the stage of healing of restricted tissues?
■ What form(s) of stretching have been implemented previously? How did the patient respond?
■ Are there any underlying diseases, disorders, or deformities that might affect the choice of stretching
procedures?
■ Does the patient have the ability to actively participate in, assist with, or independently perform the
exercises? Consider the patient’s physical capabilities, age, ability to cooperate, or ability to follow and
remember instructions.
■ Is assistance from a therapist or caregiver necessary to execute the stretching procedures and
appropriate stabilization? If so, what is the size and strength of the therapist or the caregiver who is
assisting the patient with a stretching program?
Thank you