STRETCHING FOR IMPAIRED

MOBILITY
LECTURE 6

DR. MOMENA SHAHZAD

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 Procedural Guidelines
for
Application of Stretching Interventions

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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
• Determine if hypomobility is related to other impairments and if it is causing activity limitations or
participation restrictions.
• Differentiate between the cause of limited ROM.
• Be sure to assess joint play and fascial mobility.

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• Evaluate the irritability of the involved tissues and determine their stage of healing.
• Assess the underlying strength of muscles in which there is limitation of motion.
• Be sure to determine what outcome goals (i.e., functional improvements) the patient is seeking to
achieve as the result of the intervention program.
• Analyze the impact of any factors that could adversely affect the projected outcomes of the stretching
program.

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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.
• Have the patient assume a comfortable, stable position.
• 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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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.

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• To stretch a multi joint 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.
• 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.

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• Maintain the stretched position for 30 seconds or longer.
• 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 seem 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.

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AFTER STRETCHING

• Apply cold to the soft tissues that have been stretched in a lengthened position.
• Cold may minimize post stretch muscle soreness.
• When soft tissues are cooled in a lengthened position, increases in ROM are more readily
maintained.
• Patient perform active ROM and strengthening exercises through the gained range immediately after
stretching.
• 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 for adequate neuromuscular control, stability
and flexibility.

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Precautions for Stretching

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GENERAL PRECAUTIONS

• Do not passively force a joint beyond its normal ROM.

• In adults, flexibility is greater in women than in men.
• When treating older adults, be aware of age-related changes in flexibility.
• Use extra caution in patients with known or suspected osteoporosis due to disease, prolonged bed rest,
age, or prolonged use of steroids.
• Protect newly united fractures.
• Avoid vigorous stretching of muscles and connective tissues that have been immobilized for an
extended period of time.
• High- intensity, short-duration stretching procedures tend to cause more trauma and resulting weakness
of soft tissues than low-intensity, long-duration stretch.
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• Gradually progress the dosage (intensity, duration, and frequency) of stretching interventions to
minimize soft tissue trauma and post exercise muscle soreness.
• Joint pain or muscle soreness lasting more than 24 hours after stretching shows too much force has
been used during stretching.
• Avoid stretching edematous tissue, as it is more susceptible to injury than normal tissue.
• Avoid overstretching weak muscles, particularly those that support body structures in relation to gravity.

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SPECIAL PRECAUTIONS FOR MASS-
MARKET FLEXIBILITY PROGRAMS

• Self-stretching exercises are an integral component of physical conditioning programs at home or in the
community.
• Although much of the information in these resources is usually safe and accurate, there may be some
errors and potential problems in flexibility programs designed for the mass market.

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•Common Errors and Potential Problems

1) Nonselective or poorly balanced stretching activities

• General flexibility programs may include stretching regions of the body that are already
mobile or even hypermobile but may neglect regions that are tight from faulty posture or
inactivity.
2) Insufficient warm-up.

3) Ineffective stabilization.
• Programs often lack effective methods of self-stabilization.
• Therefore, an exercise may fail to stretch the intended tight structures and may transfer the
stretch force to structures that are already mobile or even hypermobile.

4) Use of ballistic stretching.

• Because this form of stretching is not well controlled, it increases the likelihood of post
exercise muscle soreness and significant injury to soft tissues.
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5) Excessive intensity.
• The phrase “no pain, no gain” is often used inappropriately as the guideline for
intensity of stretch.
• An effective flexibility routine should be progressed gradually and should not cause
pain or excessive stress to tissues.

6) Abnormal biomechanics.
• Some popular stretching exercises do not respect the biomechanics of the region.

7) Insufficient information about age-related differences.

• One flexibility program does not fit all age groups.
• Elderly individuals, whose physical activity level has diminished with age, typically
exhibit less flexibility than young adults.

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Strategies for Risk Reduction

■ Assess and review the exercises and determine their appropriateness and safety of exercises
in a “prepackaged” flexibility program.
■ Stay up-to-date on current exercise programs, products, and trends.
■ Determine whether a class or video is geared for individuals of the same age or with similar
pathological conditions.
■ Eliminate or modify those exercises that are inconsistent with your intervention plan.
■ Teach your patient basic principles of self-stretching and how to apply those principles to
select safe and appropriate stretching exercises.
■ Make sure your patient understands the importance of warming up prior to stretching.
■ Be certain that the patient knows how to provide effective self-stabilization to isolate stretch
to specific muscle groups.
■ Teach your patient how to determine the appropriate intensity of stretch.

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Adjuncts to Stretching
Interventions

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COMPLEMENTARY EXERCISE
APPROACHES

• Relaxation Training
• Total body relaxation help patients learn to relieve or reduce pain, muscle tension, anxiety or stress, and
associated physical impairments or medical conditions including tension headaches, high blood pressure,
and respiratory distress.
• It involves a reduction in muscle tension in the entire body or the region that is painful or restricted by
using conscious effort and thought.

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• 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.
• Suggest to the patient that he or she should feel a sense of relaxation and
warmth.
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HEAT

• Warming up increase intramuscular temperature which likewise increases extensibility of contractile

and noncontractile soft tissues.
• 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.

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COLD

• The application of cold prior to stretching (cryo-stretching) is done to decrease muscle tone and make
the muscle less sensitive during stretch in healthy subjects and in patients with spasticity or rigidity
secondary to upper motor neuron lesions.
• The use of cold immediately after soft tissue injury effectively decreases pain and muscle spasm.
• Once healing and scar formation begin, cold makes healing tissues less extensible and more susceptible
to microtrauma during stretching.
• Cooling soft tissues in a lengthened position after stretching has been shown to promote more lasting
increases in soft tissue length and minimize post stretch muscle soreness.

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MASSAGE

• Local muscle relaxation can be enhanced by massage, particularly with light or deep stroking
techniques.
• Massage increase circulation to muscles and decrease muscle spasm, so it is a useful adjunct to
stretching exercises.

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BIOFEEDBACK

• Biofeedback is another tool to help a patient learn and practice the

process of relaxation.
• Biofeedback is also a useful means to help a patient learn how to activate a
muscle, rather than relax it.

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JOINT TRACTION OR OSCILLATION

• Slight manual distraction of joint surfaces prior to or in conjunction with stretching a muscle-tendon
unit can be used to inhibit joint pain and spasm of muscles around a joint
• Pendular motions of a joint use the weight of the limb to distract the joint surfaces and simultaneously
oscillate and relax the limb.
• The joint may be further distracted by adding a 1- or 2-lb weight to the extremity, which causes a stretch
force on joint tissues.

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