1. Stretching Exercises IIiBy
Dr. Michael Banoub

2. Intensity, Duration, Frequency, and Mode of Stretch—Interrelationships and Impact on Stretching Outcomes
There is an inverse relationship between intensity and duration as well as between intensity and frequency of stretch.
The lower the intensity of stretch, the longer the time the patient will tolerate stretching and the soft tissues can be held in a lengthened position.
The higher the intensity, the less frequently the stretching intervention can be applied to allow time for tissue healing and resolution of residual muscle soreness.

3. A low-load (low-intensity), long-duration stretch is considered the safest form of stretch and yields the most significant, elastic deformation and long-term, plastic changes in soft tissues.
Manual stretching and self-stretching in hypomobile but healthy subjectsand prolonged mechanical stretching in patients with chronic contractures yield significant stretch-induced gains in ROM.

4. 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.
Warming up tight structures may increase their extensibility and may decrease the risk of injury from stretching.

5. Preparation for Stretching
Have the patient assume a comfortable, stable position that allows the correct plane of motion for the stretching procedure. The direction of stretch is exactly opposite the direction of the joint or muscle restriction.
Explain the procedure to the patient and be certain he or she understands.

6. Preparation for Stretching
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 or assist when requested.
Also explain that the stretching procedures are geared to his or her tolerance level.

7. 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.

8. Application of Manual Stretching Procedures
Firmly stabilize the proximal segment (manually or with equipment) and move the distal segment.
To stretch a multijoint muscle, 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.

9. Application of Manual Stretching Procedures
Consider incorporating a prestretch, isometric contraction of the range-limiting muscle (the hold– relax procedure) to relax the muscle reflexively prior to stretching it.
To avoid joint compression during the stretching procedure, apply gentle (grade I) distraction to the moving joint.
The force must be enough to place tension on soft tissue structures but not so great as to cause pain or injure the structures. The patient should experience a pulling sensation, but not pain, in the structures being stretched. When stretching adhesions of a tendon within its sheath, the patient may experience a “stinging” sensation.

10. Application of Manual Stretching Procedures
Maintain the stretched position for 30 seconds or longer. During this time, the tension in the tissues should slowly decrease. When tension decreases, move the extremity or joint a little farther to progressively lengthen the hypomobile tissues.
Gradually release the stretch force and allow the patient and therapist to rest while maintaining the range-limiting tissues in a comfortably elongated position. Then repeat the sequence several times.

11. Application of Manual Stretching Procedures
If deemed appropriate, apply selected soft tissue mobilization procedures, such as fascial massage or crossfiber friction massage, at or near the sites of adhesion during the stretching maneuver.
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 poststretch 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 readily maintained.

12. Application of Manual Stretching Procedures
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.

13. PRECAUTIONS FOR STRETCHING
Do not passively force a joint beyond its normal ROM. Remember, normal (typical) ROM varies among individuals. In adults, flexibility is greater in women than in men. When treating older adults, be aware of agerelated 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; be certain there is appropriate stabilization between the fracture site and the joint in which the motion takes place

14. PRECAUTIONS FOR STRETCHING
Avoid vigorous stretching of muscles and connective tissues that have been immobilized for an extended period of time. Connective tissues, such as tendons and ligaments, lose their tensile strength after prolonged immobilization. High-intensity short-duration stretching procedures tend to cause more trauma and resulting weakness of soft tissues than low-intensity, long-duration stretch.

15. PRECAUTIONS FOR STRETCHING
Progress the dosage (intensity, duration, and frequency) of stretching interventions gradually to minimize soft tissue trauma and postexercise muscle soreness. If a patient experiences joint pain or muscle soreness lasting more than 24 hours after stretching, too much force has been used during stretching, causing an an inflammatory response. This, in turn, causes increased scar tissue formation. Patients should experience no more residual discomfort than a feeling of tenderness.

16. PRECAUTIONS FOR STRETCHING
Avoid stretching edematous tissue, as it is more susceptible to injury than normal tissue. Continued irritation of edematous tissue usually causes increased pain and edema.
Avoid overstretching weak muscles, particularly those that support body structures in relation to gravity.

17. FIT Formula (Static Stretching)
F times per week
I 10% beyond normal length of muscle
T seconds, 3-5 reps (rest 30 sec between reps)