See also figures p 78,79, 83, 84

1.Alignment: positioning a limb or the body such that the stretch force is directed to the appropriate muscle group

2.Stabilization: fixation of one site of attachment of the muscle as the stretch force is applied to the other bony attachment 3.Intensity of stretch: Magnitude of the stretch force applied Stretching should be applied at a Low intensity Proximal attachment stabilization Distal attachment stabilization

4.Duration of stretch: length of time the stretch force is applied during a stretch cycle 2 types: Long-duration stretch & short- duration stretch. The shorter the duration of a single stretch cycle, the greater the number of repetitions applied during a stretching session. Soft tissues are elongated just past the point of tissue resistance and then held in the lengthened position with a sustained stretch force over a period of time More safe and more effective A.Static Stretching

B.Static Progressive Stretching Continuous displacement of a limb by varying the stretch force

C.Cyclic (Intermittent) Stretching short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied cyclic stretching each cycle of stretch is held between 5 and 10 seconds. appropriately applied, end-range cyclic stretching is effective and more comfortable than static stretch particularly if the static stretch is applied continuously for more than 30 seconds

5. Frequency: The number of bouts (sessions) per day or per week. Depend on:  Cause of Hypomobility.  the quality and level of healing of tissues.  chronicity and severity of a contracture.  Age of patient.  Previous response to stretching. Ranges from two to five sessions per week to promote tissue healing and to minimize postexercise soreness

Excessive frequency Tissue breakdown exceeds repair Tissue failure Progressive loss of ROM over time Continued low-grade inflammation Excessive collagen formation

6.Mode of Stretch The form of stretch or the manner in which stretching exercises are carried out manual and mechanical stretching or self-stretching as well as passive, assisted, or active stretching Regardless form of stretching, Low-intensity active exercise or therapeutic heat should be done before stretching to warm up the tissues and decrease tissue resistance.

Based on the results of your examination. Is there evidence of pain or inflammation? How long has the hypomobility existed? What is the stage of healing of restricted tissues? What form(s) of stretching have been used previously? How did the patient respond? Are there any underlying abnormalities that might affect the choice of stretching procedures? Does the patient have the ability to actively participate Is assistance from a therapist or caregiver necessary to apply the stretching what is and strength of the therapist?

A.Manual Stretching: Applying an external force by therapist to move the involved body segment slightly beyond the point of tissue resistance and available ROM. Indication: Manual stretching may be most appropriate in the early stages of a stretching program. If a patient cannot perform self-stretching due to a lack of neuromuscular control of the body segment to be stretched. If a patient has control of the body segment to be stretched, but he needs assistance.

B.Self-Stretching: It is a type of stretching procedure a patient carries out independently after careful instruction and supervised practice. Goal: To enables a patient to maintain or increase the ROM gained. 30sec to 60sec duration per repetition is considered the safest type of stretching for a self-stretching program

C.Mechanical Stretching: It use of equipment as a method for stretching It ranged from simple equipment as a cuff weight or weight-pulley system to sophisticated as some adjustable orthoses or automated stretching machines. Duration ranged from 15 min to 30 or it may be reach 10 hours or n some case it reach few days or weeks.

7.Speed of Stretch should be slow. applied and released gradually. Why????? To ensure optimal muscle relaxation and prevent injury to tissues to prevent activation of the stretch reflex and increase tension in the contractile structures of the muscle being stretched. To increase safety of patient and it is much easier to therapist to control the motion.

A rapid, forceful intermittent stretch Quick, bouncing movements that create momentum to carry the body segment through the ROM to stretch shortened structures Side effect: Can cause greater trauma to stretched tissues and greater residual muscle soreness. Indication: increase ROM safely in young, healthy subjects participating in a conditioning program.

Contraindication: for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures. Why????? Tissues, weakened by immobilization or disuse, are easily injured. Dense connective tissue found in chronic contractures does not yield easily with high-intensity, short-duration stretch; rather, it becomes more brittle and tears more rapidly.

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.