1. Stretching Exercises
Mazyad Alotaibi

2. 5/2/2011
Mobility and Flexibility of soft tissues (muscles, tendons, fascia, joint capsule, and skins) surrounding the joint along with adequate joint mobility, are necessary for normal ROM.
Mobility: is the ability of segments of the body to move through range of motion for functional activities.
Flexibility: is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain –free ROM.

3. Types of Flexibility
Dynamic flexibility (active mobility or active ROM )
It is the degree to which an active muscle contraction moves the a body segment through the available ROM of the joint.
It depends on:
The degree to which joint can be moved by a muscle contraction
The amount of soft tissue resistance met during the active movement.

4. Passive flexibility (passive mobility or passive ROM )
It is the degree to which a joint can be passively moved through the available ROM.
It depends on:
- extensibility of muscles and connective tissues (soft tissues ) that crosses and surrounding a joint.
Types of Mobility
1- Hypo-mobility: Refers to decreased mobility or restricted motion.
2- Hyper-mobility: Refers to increased mobility

5. Factors that influence flexibility
 1- Joint structure
The type of joint determine the degree of ROM. For example; a ball-and-socket joint, like shoulder has greater ROM than a hinge joint like wrist.
2- Age
With age, muscles go through a shortening process due to lack of physical activities and a loss of elasticity in the connective tissues surrounding the muscles. As a result, there tends to be a decrease in flexibility with age.

6. Factors that influence flexibility
3- The Elasticity
The elasticity of the skin, tendons and ligaments, (ligaments do not stretch much and tendons should not stretch at all).
4-Gender
Females tend to be more flexible than males of similar age throughout life, generally due to anatomical variations in joint structures.

7. Factors that influence flexibility
5-Exercise
Participation in regular exercise involving full ROM generally enhances flexibility, while a sedentary lifestyle often results in diminished flexibility.
6-Muscle mass
muscle mass can be a factor when the muscle is so heavily developed that it interferes with the ability to take the adjacent joints through their complete range of motion (for example, large hamstrings limits the ability to fully bend the knees). Excess fatty tissue imposes a similar restriction.

8. Factors that influence flexibility
7-Temperature
An increase in either body temperature as a result of exercise or external temperature increases ROM.
8-Pregnancy
During pregnancy, the pelvic joints and ligaments are relaxed and capable of a greater ROM.

9. Causes of soft tissue Shortening
1- Prolonged Immobilization due to: A. Extrinsic factors * casts and splint * skeletal traction B. Intrinsic factors * pain * joint inflammation &stiffness * skin &muscle disorders * bony block * vascular disorders

10. Causes of soft tissue shortening
2- Sedentary lifestyle due to bed rest, work environment 3- Muscle imbalance, paralysis or tone abnormality 4- Postural malalignment which may be * congenital * acquired e.g. Scoliosis, Kyphosis

11. # Contracture it is not equal to Contraction
Is the adaptive shortening of the muscle-tendon unit and other soft tissues that crosses or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM
Contraction
The process of tension developing in a muscle during shortening or lengthening

12. Types of Stretching 1- Passive stretching
2- Active (Neuromuscular) Inhibition stretching.
3- Self stretching
4- Ballistic stretching.

13. 1- Passive Stretching
A sustained external force applied at the end –range manually or mechanically to elongates a shortened muscle-tendon unit, while the patient is relaxed. This type can be classified into:
The tension created in a muscle during ballistic stretch is nearly twice that created with low- intensity static (sustained) stretch.
When a gentle passive stretch position is held for at least 30 to 60 second, the facilitatory effect of stretch reflex on muscle appear to be minimal as the inhibitory action of the GTO may override the facilitatory effect of stretch reflex, so that there is no increase in muscle tension.

14. a- Manual Passive Stretch
The therapist applies an external force and controls the direction, speed, intensity and duration of stretch to shorten soft tissues beyond their resting length.
This technique should not be confused with passive range of motion exercises. Passive stretching takes the structures beyond the free range of motion. Passive range of motion is applied only within the unrestricted available range.

15. The patient must be as relaxed as possible during passive stretching.
The stretch force is usually applied for at least 15 to 30 seconds and repeated several times in an exercise session.
The intensity and duration of the stretch are dependent on the patient’s tolerance and the therapist’s strength and endurance. A low-intensity manual stretch applied for as long a duration as possible will be more comfortable and more readily tolerated by the patient.

16. b- Prolonged Mechanical Passive Stretch
2- Prolonged mechanical passive stretching
A low intensity external force is applied over a prolonged period of time with mechanical equipment.
The stretch force is applied with the patient as relaxed as possible.
The stretch may be maintained for minutes or as long as several days or weeks, depending on the type of apparatus used.
The stretch can be applied through positioning of the patient, with weighted traction and pulley systems, or with serial splints or casts.

17. C-Cyclic (Intermittent) stretch
C-Cyclic (Intermittent) stretch *A short duration stretch force, repeatedly but gradually applied, released, and then reapplied using mechanical device. *Each cycle of stretch is held between 5-10 seconds at the end-range, which is applied gradually at a controlled manner and at a relatively low intensity. These cyclic stretching is applied for many repetitions in each single treatment session. *This type of stretching showed that it is more effective and comfortable than a prolonged static stretch.

18. 2- Active (Neuromuscular) Inhibition stretching
These procedures reflexively relax the tension in shortened muscles prior to or during stretching maneuver.
When a muscle is reflexively inhibited, there is less resistance to elongation by the contractile unites of the muscle.
Inhibition techniques increase muscle length by relaxing and elongating the contractile components of muscle.
This type of stretching is only done with normally innervated muscle and under voluntary control.
It can not be used in patient with severe muscle weakness, spasticity, or paralysis from neuromuscular dysfunction.

19. For example; where you assume a position and then hold it there with no assistance other than using the strength of agonist muscles. E.g., bringing your leg up and then holding it there without anything, other than your leg muscles itself, to keep the leg in that extended position. The tension of the agonists in an active stretch helps to relax the muscles being stretched (antagonists) by reciprocal inhibition. Active stretches are hold and maintained for 10 to 15 seconds.
These techniques have been adapted from Proprioceptive neuromuscular facilitation (PNF) techniques.
There are three variations of neuromuscular inhibition techniques:
1- Contract-relax (Hold- relax).
2- Contract-relax- contract (Hold- relax with agonist contraction).
3- Agonist contraction.

20. 3- Self Stretching
Also known as flexibility exercises or active stretching.
Self stretching is a type of flexibility exercise that a patient can carry out himself as an integral component of a home exercise program.
It may involve relaxation of muscle and a passive stretch applied through the weight of the body.
Self stretching can also be carried out actively by the patient first inhibiting and then lengthening the tight muscle.

21. 4- Ballistic stretching
A rapid, forceful intermittent, high-speed and high-intensity stretch.
Vigorous bouncing movement to force the body segment beyond its range of motion to stretch shortened structures.
It is not advised because the high-velocity and high-intensity movements are difficult to control and can lead to injury in weakened tissues.

22. Goals of Stretching
1- Regain normal range of motion of joints and mobility of soft tissue that surrounding that joint. 2- Prevent irreversible contractures. 3- Increase the general flexibility of muscle and soft tissues before vigorous strengthening exercises. 4- Minimize and prevent the risk of musculo-tendinous injuries related to specific physical activities and sports.

23. Indications of Stretching
1- Limited range of motion due to contractures, adhesions and scar tissue formation leading to shortening of muscles, ligaments, connective tissue and skin.
2- When there are structural (skeletal) deformities as a result of limitation.
3- Whenever contracture interfere with activities of daily living (ADL).
4- When there is muscle imbalance (muscle weakness and opposing tissue tightness). Tight muscle must be stretched first before strength of weak muscle.
5- As part o a total fitness program.
6- Prior to and after vigorous exercise to minimize postexercise muscle soreness.

24. Contra-indications of Stretching
1- Presence of bony block that limits joint motion. 2- Recent fracture. 3- Cases of acute inflammation or infection (presence of heat swelling around the joint). 4- Presence of acute sharp pain with joint movement or muscle elongation. 5- in case of hematoma and hypermobility.

25. TECHNIQUES

26. STRETCH OF PECTORALIS MUSCLE
TEST PECTORALIS FLEXIBILITY

27. PECTORALIS FLEXIBILITY

28. SHOULDER ROTATOR CUFF
The Rotator Cuff: the Teres Minor, the Infraspinatus, the Supraspinatus and the Subscapularis.

29. PECTORALIS TARGET STRETCH
place your palm flat on the wall, keep your weight in your heels, and lean the whole body forward. Use the hand on the wall as your anchor, and feel the stretch along the front of the chest and armpit.

30. PECTORALIS TARGET STRETCH
Lower your hand to about shoulder height, palm facing the wall, stretching the hand behind you. Then turn the whole body away from the wall, pointing the feet, knees, and hips away from the hand. Feel the stretch across the front of the chest and inner arm.

31. STRETCH OF PECTORALIS MUSCLE
1- FROM STANDING POSITION

41. Stretching of Lower Limb
Test of hip flexors shortening (Thomas test)

42. Iliopsoas Stretching

43. Passive Stretch of The Hip Flexors

45. OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY
Ober’s test is the test for tightness of the ITB.
The subject is placed on their side, healthy side down. The knee is flexed 90 degrees and the hip extended to neutral (no flexion).

46. OBER’S TEST FOR ILIOTIBIAL BAND FLEXIBILITY
The PHYSIOTHERAPIST holds the leg up by the foot. Normally, the knee falls down to the exam table. If the ITB is very tight, the leg hangs up in the air (very impressive). If it’s moderately tight, the knee falls halfway to the table.

47. MODIFIED OBER’S TEST

48. Iliotibial Band Flexibility

49. STRETCHING OF HIP ADDUCTORS

50. STRETCHING OF HIP ADDUCTORS AND HAMSTRING

51. TEST OF HAMSTRING FLEXIBILITY

53. HAMSTRING FLEXIBILITY

54. FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

55. FLEXIBILITY OF HAMSTRING AND CALF MUSCLES

56. STRETCHING OF CALF MUSCLE

57. Calf Stretching

58. SELF STRETCHING

59. Stretch of Upper Trunk

60. Lower back flexibility

61. Gluteus flexibility

62. Iliopsoas Flexibility

63. Iliopsoas Flexibility

64. Iliotibial Band flexibility
5/2/2011
Iliotibial Band flexibility

65. Iliotibial Band flexibility

66. 5/2/2011
Hamstring Stretching

67. Hip Adductors Stretching

68. Calf stretching