Stretching II

Drs. Adnan Wshah & Zaid Modhi

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Properties of Soft Tissue: Response
to Immobilization and Stretch​
•  Decreased extensibility of connective tissue, not the contractile elements of
muscle tissue, is the primary cause of restricted ROM in both healthy individuals
and patients with impaired mobility as the result of injury, disease, or surgery.​
•  Mechanical characteristics of contractile and non-contractile soft tissue and the
neurophysiological properties of contractile tissue affect tissue lengthening.​
•  An understanding of the properties of these tissues and their responses to
immobilization and stretch is the basis for selecting and applying the safest, most
effective stretching procedures in a therapeutic exercise program for patients
with impaired mobility. ​
•  When soft tissue is stretched, elastic, viscoelastic, or plastic changes occur.​

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Elasticity, Viscoelasticity, and Plasticity:
•  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 have a
new and greater length after the stretch force has been removed.​
• Viscoelastic property is found only in non-contractile tissue.​
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A- Mechanical response in the Contractile
Unit:​
1. Response to Stretch:​
•  During passive stretch, when initial lengthening occurs in the elastic
component (connective tissue), tension rises sharply. After a point, there
is mechanical disruption of the cross-bridges as the filaments slide apart,
leading to sudden lengthening of the sarcomeres, sometimes referred to
as sarcomere give. 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 required, the stretch force must be maintained over an
extended period of time. ​

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A- Mechanical response in the Contractile
Unit:​
2. Response to Immobilization and Remobilization:​
• Atrophy:  The longer the duration of immobilization, the greater is the
atrophy of muscle and loss of functional strength. ​
• Atrophy can begin within as little as a few days to a week. The cross-sectional
size of the muscle fiber decreases. Additionally a significant deterioration
in motor unit recruitment occurs as reflected by electromyographic (EMG)
activity. Both affect the force-producing abilities of the muscle.​
• The effects of immobilization of a muscle in a shortened or lengthened
position result in plastic adaptations, but the pre-immobilization state can be
regained in few weeks depending on the degree of lengthening and
functional activities.​
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B- Mechanical Properties of Non-contractile
Soft Tissue: ​
•  Ligaments, tendons, joint capsules, fasciae, non-contractile tissue in
muscles, and skin have connective tissue characteristics that can lead to the
development of adhesions and contractures and, thus, affect the flexibility
of the tissues crossing joints.​
• In tendons, collagen fibers are parallel and can resist the greatest tensile
load. They transmit forces to the bone created by the muscle.​
• In skin, collagen fibers are random and weakest in resisting tension.​
• In ligaments, joint capsules, and fasciae, the collagen fibers vary between
the two extremes, and they resist multidirectional forces. Ligaments that
resist major joint stresses have a more parallel orientation of collagen fibers
and a larger cross-sectional area.​
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Factors affecting non-contractile tissues:​
• Immobilization ​
• Inactivity (decreased activity)​
• Ageing​
• Corticosteroids​
• Injury​
• Nutritional deficiencies ​
• Hormonal imbalances​

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Summary of Mechanical Principles for
Stretching Connective Tissue​
• Connective tissue deformation (stretch) occurs to different degrees at different intensities of
force and at different rates of application.​
• Complete tissue failure can occur as a single maximal event (acute tear from a traumatic
injury or manipulation that exceeds the failure point) or from repetitive submaximal stress
(fatigue or stress failure from cyclic loading).​
• Healing and adaptive remodeling capabilities allow the tissue to respond to repetitive and
sustained loads if time is allowed between bouts.​
• If healing and remodeling time is not allowed, a breakdown of tissue (failure) occurs as
in overuse syndromes and stress fractures.​
• Intensive stretching is usually not done every day in order to allow time for healing.​
• 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.​

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Preparation for stretching: ​
• Review the goals and desired outcomes of the stretching program with the
patient.​
• Select the stretching techniques that will be most effective and efficient.​
• Warm up the soft tissues to be stretched. ​
• Have the patient assume a comfortable, stable position that allows the
correct plane of motion for the stretching procedure. ​
• 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. ​
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Procedural guidelines for application
of stretching interventions:​
Examination and Evaluation of the patient:​
• Review history​
• Appropriate tests and measurements​
• Determine hypomobility, functional limitations, and disabilities​
• Determine which structure is causing the restriction of movement​
• Evaluate the irritability of the involved structures, and what is the stage
of healing ​
• Assess the strength of the muscles involved ​
• Determine outcome goals ​
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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 post-stretch 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
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.​

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Adjuncts to Stretching Interventions:​
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.​
• 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.

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Adjuncts to Stretching Interventions:​
Heat:​
• Superficial heat (Hot packs, paraffin)​
• Deep heat (Ultrasound, Shortwave diathermy)​
• Low-intensity, active exercise (walking, Jogging, cycling)​
Cold:​
• Prior (cryostretching); as in stretching for upper motor neuron lesions, spasticity or rigidity​
• Post: help in regeneration of tissues healing of microtrauma.​
Therapeutic Massage: ​
• Can be used during relaxation techniques​
• After strenuous physical activity​
Biofeedback ​
Joint Traction or Oscillation ​

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Thank you!

Questions?

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