Stretching is a therapeutic maneuver to increase flexibility by elongating shortened soft tissues. Several factors can contribute to hypomobility including immobilization, poor posture, and injury. Stretching protocols should involve proper alignment, stabilization, low intensity stretches held for 20-30 seconds repeated 3-5 times per week. Common stretching types include static, PNF, and ballistic stretching. Stretching is contraindicated for acute injuries, infections, or joint instability.

1. Stretching
By: Sankari Nedunsaliyan
Dip PT (MAL)
Bsc Hons Applied Rehab (UK)
By: Sankari Nedunsaliyan
Dip PT (MAL)
Bsc Hons Applied Rehab (UK)

2. Chapter Outline
Definition
Stretching Protocol
Hypomobility and Flexibility
Anatomic factors affecting flexibility
Neurophysiologic basic of stretching
Phases of stretching
Stretching Protocols
Contraindication
Types of stretching

3. Stretching is a general term used to describe any
therapeutic maneuver designed to increase the
extensibility of soft tissues, thereby improving
flexibility by elongating (lengthening) structures
that have adaptively shortened and have become
hypomobile over time

4. 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.

5. • Prolonged immobilization of a body segment
• Sedentary lifestyle
• Postural malalignment and muscle imbalances
• Impaired muscle performance (weakness) associated with
list of musculoskeletal or neuromuscular disorders
• Tissue trauma resulting in inflammation and pain
• Congenital or acquired deformities

6. • Term used for interchangeably with extensibility
• the range of motion that is available to a joint or joints
• Refers to ability of the muscles to relax and yield to a
stretch force
• Flexibility exercises are stretching exercises designed to
increase range of motion
Flexibility

7. Muscles, tendons and their surrounding fascial sheaths
•Stretching attempts to take advantage of highly elastic
properties of muscle
•Overtime it is possible to increase elasticity , or the length
a given muscle can be stretched
Connective tissue (ligaments and joint capsule)
•Become shortened and stiff during periods of
immobilization
•People can also be loose jointed from slack or increased
laxity in connective tissue
•Creates some instability

8. Bony structures
•Restrict end point in the range of motion
•Good for stability
•After fracture excess calcium can develop which
interferes with normal range
Fat
•Excess fatty tissue can restrict range of motion
•For example; excess abdominal fat can restrict trunk
movement

9. Skin
•Inelastic scar tissue can develop after surgery or injury
•Incapable of stretching with joint movement
•Overtime can improve elasticity to varying degrees
through stretching

10. Neural tissue
•Tightness develops in neural tissues from acute compression,
chronic repetitive microtrauma, muscle imbalances, joint
dysfunctions, or poor posture
•Can create structural changes in tissue that can
cause pain
•Pain can cause muscle guarding and spasm
•Can eventually lad to neural fibrosis or scarring

11. Mechanoreceptors in muscle tell CNS what is happening
within that muscle
•2 of these are important in the stretch reflex
•Muscle spindle and the Golgi tendon organ (GTO)
•Sensitive to changes in muscle length
•GTO also sensitive to change in muscle tension

12. •Muscle spindle initially sends sensory impulse to spinal
cord which then sends a message back to muscle spindle
causing the muscle to reflexively contract

13. •If stretch last longer than 6 seconds, impulses from GTO
begin to override muscle spindle
•autogenic inhibition, or a reflex relaxation of the
antagonist muscle
•Protective mechanism to allow stretch to avoid
damage to muscle fibers
•Reciprocal inhibition
•Contraction of agonist causes a reflex relaxation in
the antagonist muscle
•Allows antagonist to stretch and protects from injury

14. Autogenic Inhibition &
Reciprocal Inhibition
Autogenic Inhibition:
Relaxation in the same muscle that is experiencing
increased tension.
– Tension built up during the active contraction
stimulates the GTO, causing a reflexive relaxation of
the muscle during the subsequent passive stretch.

15. Reciprocal Inhibition:
Relaxation that occurs in the opposing muscle experiencing
increased tension.
– This is accomplished by simultaneously contracting
the muscle opposing the muscle being passively
stretched.
– The tension in the contracting muscle stimulates the
GTO and causes simultaneous reflexive relaxation of
the stretched muscle
Autogenic Inhibition &
Reciprocal Inhibition

16. •Muscle temperature should be increased prior to stretching
•Positive effect of collagen and elastin components to deform
•Capability of GTO to reflexively relax is enhanced
•Can be achieved through low intensity warm up or through
various therapeutic modalities
•However exercise is recommended over modalities
•If muscle guarding occurs cold therapy can also be used
prior to stretching

17. muscle spindles & GTO.mp4

18. • This stage is the first 72 hours after the injury.
• During this stage, there should not be any stretching at all…
completely avoid it.
• Instead, focus on what is called the R.I.C.E.R. treatment.
This is the acronym for rest, ice, compression, elevation,
referral
• Stage one, no stretching at all to avoid further injury.

19. • The second stage is the next 1-2 weeks following the
injury and resting period. Stage 1 might be a bit longer for
some people
• Relatively light static and passive stretches, following heat
or massage treatments, will aid in speeding up the
healing process.
• Stretching not necessarily supposed to cause pain. If that
occurs, ease up on the amount of tension you are
applying to the muscles. Discomfort is expected, but not
pain.

20. • This stage is the time period from approximately 2-5 weeks
post injury
• This stage is more intense, but will bring the greatest
amount of recovery
• Regain most, if not all of your strength, flexibility, and
endurance, as well as coordination and balance
• PNF can be introduced along with static and passive
stretch depending on clients perfomance

21. • This really isn’t a stage, it’s a new way of stretching for life
• The long term outlook can be determined by a lifetime
practice of appropriate stretching
• Two areas of stretching should now be considering are
dynamic and active stretching.

22. • 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
• Intensity of stretch: magnitude of the stretch force
applied
• Duration of stretch: length of time the stretch force is
applied during a stretch cycle
Stretching Protocols

23. • Speed of stretch: speed of initial application of the stretch
force
• Frequency of stretch: number of stretching sessions per
day or per week
• Mode of stretch: form or manner in which the stretch force
is applied (static, ballistic, cyclic); degree of patient
participation (passive, assisted, active); or the source of the
stretchforce (manual, mechanical, self)
Stretching Protocols

24. • Proper alignment or positioning of the patient and the
specific muscles and joints to be stretched is necessary for
patient comfort and stability during stretching.
• Alignment influences the amount of tension present in soft
tissue and consequently affects the ROM available in
joints.
• For eg: to stretch the rectus femoris (a muscle that crosses
two joints) effectively, as the knee is flexed and the hip
extended, the lumbar spine and pelvis should be aligned in
a neutral position. The pelvis should not tilt anteriorly nor
should the low back hyperextend
Stretching Protocols
(Alignment)

25. Stretching Protocols
(Stabilization)
• To achieve an effective stretch of a specific muscle or
muscle group and associated periarticular structures, it is
imperative to stabilize (fixate) either the proximal or distal
attachment site of the muscle-tendon unit being elongated.
• Example: when stretching the iliopsoas, the pelvis and
lumbar spine must maintain a neutral position as the hip is
extended to avoid stress to the low back region. Sources of
stabilization include manual contacts, body weight, or a firm
surface such as a table, wall

26. • The intensity (magnitude) of a stretch force is determined
by the load placed on soft tissue to elongate it.
• There is general agreement among clinicians and
researchers that stretching should be applied at a low
intensity by means of a low load.
• Low-intensity stretching in comparison to highintensity
stretching makes the stretching maneuver more
comfortable for the patient and minimizes voluntary or
involuntary muscle guarding so a patient can either remain
relaxed or assist with the stretching maneuver.
Stretching Protocols
(Intensity )

27. • Low-intensity stretching (coupled with a long duration of
stretch) results in optimal rates of improvement in ROM
• Low-intensity stretching has also been shown to elongate
dense connective tissue, a significant component of chronic
contractures, more effectively and with less soft tissue
damage and post-exercise soreness than a high-intensity
stretch
Stretching Protocols
(Intensity )

28. Stretching Protocols
(Duration )
• The duration of stretch refers to the period of time a
stretch force is applied and shortened tissues are held in
a lengthened position.
• Duration most often refers to how long a single cycle of
stretch is applied.
• If more than one repetition of stretch (stretch cycle) is
carried out during a treatment session, the cumulative
time of all the stretch cycles is also considered an aspect
of duration
• Ideal duration for a stretch cycle: 20-30 seconds

29. Example: Two repetitions daily of a 30-second static stretch
of the hamstrings yield significant gains in hamstring
flexibility similar to those seen with six repetitions of 10-
secondstatic stretches daily
Stretching Protocols
(Duration )

30. Stretching Protocols
(Speed )
• To ensure optimal muscle relaxation and prevent injury to
tissues, the speed of stretch should be slow.
• The stretch force should be applied and released gradually.
• Slowly applied stretch is less likely to increase tensile
stresses on connective tissues or to activate the stretch
reflex and increase tension in the contractile structures of
the muscle being stretched
• Stretch force applied at a low velocity is also easier for the
therapist or patient to control and is therefore safer than a
high-velocity stretch.

31. Stretching Protocols (Frequency )
• 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 often 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.
• 3 to 5 repetitions per session and done 3 times a week is
considered as adequate for gaining improvements in the
flexibility of soft tissues.
• Frequencies are also determined by clinicians according
to the impairments

32. Stretching Protocols
(Mode of stretch)
Mode of Stretching
•Manual Stretching
•Self Stretching
•Mechanical Stretching
•PNF stretching techniques

33. Stretching Protocols (Warm Up)
• Prepares your body physically and psychologically
• Increases blood flow to your muscles and increases your
body temperature
• The warm-up should last about five minutes
• Slow walking is a good warm-up for a moderate-paced
walk. Brisk walking is a good warm-up for more vigorous
activity.
• Make sure your warm-up does the following:
Increases heart rate ,Increases breathing rate
Elevates body temperature, Utilizes muscles you will use
in the upcoming activity , Takes your joints through a full
rage of motion needed for the upcoming activity

34. Stretching Protocols (Cool Down)
• Never skip this step of your workout!
• If you abruptly stop an intense activity, you risk:
 Increasing your chance of experiencing heart
arrhythmias,
 Hindering the removal of cellular waste from your
muscles,
 Increasing the likelihood of muscle soreness,
 Blood pooling
 Becoming light-headed

35. • Slow the intensity of the activity you are doing
• Gradually slow your pace down to a walk
• End the cool-down by doing some deep stretching.
• Focus on the muscles that you were using during your
workout, this will help reduce the incidence of stiffness or
soreness later.
• After the entire workout, stretch the whole body, focus on
the muscles that were used during the workout.
• Each stretch should last 20-30 seconds and be repeated.
Stretching Protocols (Cool Down)

36. • Static / Dynamic stretching
• Static Progressive Stretching
• Proprioceptive neuromuscular facilitation stretching
procedures
• Ballistic stretching
• Cyclic/intermittent stretching
• Manual stretching
• Mechanical stretching
• Self-stretching
• Passive stretching
• Active stretching
Types of Stretching

37. • Stretch the muscle to the point of slight or mild
discomfort (overload)
• Hold each stretch for 10 to 30 seconds
• Repeat the stretch 4 times
• Flexibility exercise sessions should occur
• 3 to 5 times per week
Static Stretching:

38. • Static progressive stretching is another term that describes
how static stretch is applied for maximum effectiveness.
• The shortened soft tissues are comfortably held in a
lengthened position until a degree of relaxation is felt by
the patient or therapist.
• Then the shortened tissues are incrementally lengthened
even further and again held in the new end-range position
for an additional duration of time.
Static Progressive Stretching:

39. • Most dangerous of the stretching
procedures
• Involves the use of repetitive, bouncing
• Virtually abandoned
• May lead to soreness and muscle injury
Dynamic Stretching:

40. • Isometric contraction
• Contraction and relaxation phases (stretch phase)
• Normally performed with a partner
• Hold the isometric contraction 6 seconds
• Repeat 4 times each session
• 3-5 times per week
PNF Involves:

41. Ballistic Stretching
• Involves active muscular effort and uses a bouncing
motion in which the position is not held.
• High speed, high intensity
Cyclic / Intermittent Stretching
• A relatively short-duration stretch force that is repeatedly
but gradually applied, released, and then reapplied is
described as a cyclic (intermittent) stretch
• With cyclic stretching the end-range stretch force is
applied at a slow velocity, in a controlled manner, and at
relatively low intensity.

42. Manual Stretching :
• During manual stretching a therapist or other trained
practitioner applies an external force to move the
involved body segment slightly beyond the point of
tissue resistance and available ROM.
• The therapist manually controls the site of stabilization
as well as the direction, speed, intensity, and duration of
stretch.
• Remember, stretching and ROM exercises are not
synonymous terms.
• Stretching takes soft tissue structures beyond their
available length to increase ROM.

43. Mechanical Stretching :
• Mechanical stretching devices apply a very low intensity
stretch force (low load) over a prolonged period of time
• The equipment can be as simple as a cuff weight or weight-
pulley system
• The duration of mechanical stretch reported in the literature
ranges from 15 to 30 minutes
• The longer durations of stretch are required for patients with
chronic contractures
• Devices which are commonly used for mechanical
stretching are weight cuffs, mechanical pulley devices with
springs, CPM and orthosis such as serial casts or splins

44. Self Stretching :
• Self-stretching (also referred to as flexibility exercises or
active stretching) is a type of stretching procedure a patient
carries out independently after careful instruction and
supervised practice.
• This form of stretching is often an integral component of a
home exercise program and is necessary for long-term self-
management
• Teaching a patient to carry out self-stretching procedures
correctly and safely is fundamental for preventing re-injury or
future dysfunction

45. Contraindication
Joint Instability
Joint instability can be the result of a prior dislocation, fracture, or
sprain.
Diseases Affecting the Tissues Being Stretched
Conditions such as rheumatoid arthritis can leave joint structures
weakened. Those with connective tissue disorders also have
altered connective tissue viscoelastic properties. Stretching can
lead to disability, instability or deformity.
Infection
Consult your family doctor prior to stretcing an area that is
infected to avoid tissue damage or spread of the infection.

46. Contraindication
Acute Injury
Scar tissue takes time to mature. Premature stretching can
cause re-injury and the deposition of more scar tissue
prolonging the rehabilitation process.
Vascular injury
Recovering from a vascular trauma or are on anticoagulants.
Premature or excessive stretching can lead to further vascular
injury and thromboembolism

47. Contraindication
Excessive Pain When Stretching
If stretching is excessively painful an underlying medical
condition may present.
Inflammation or Joint Effusion
Be careful when starting a stretching program around an area of
inflammation. Inflammation can change the viscoelastic
properties of connective tissues and can cause injury if not
undertaken correctly. Aggressively stretching a joint with an
effusion can damage capsular structures. See your physical
therapist.