1. 11 Designing Programs for Flexibility and Low Back Care chapter
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2. Objectives Apply training principles to flexibility programs
Understand issues of safety and efficacy of stretching
Identify guidelines for design of flexibility programs
Individualize flexibility programs based on client goals, starting values, and abilities
Understand low back syndrome and methods to prevent it
Identify exercises useful for low back care

3. Principles of Flexibility Training
Flexibility training is a systematic program of stretching exercises designed to progressively increase the range of motion (ROM) of joints over time.
Flexibility programs should be individualized to address the needs, abilities, and physical activity interests of each client.

4. Training Principles Specificity: Flexibility is joint specific.
Overload: Stretch muscles beyond normal resting length but beneath point of pain.
stretch tolerance
Progression: Increase duration of each stretch or increase repetitions.
Interindividual variability: Point of pain in ROM, stretch tolerance, and perception of stretch and pain vary by individual.

5. Stretching Methods Three methods historically used to improve ROM:
Ballistic: fast, jerky, bouncing
Static stretching: slow, sustained, muscle lengthening
Proprioceptive neuromuscular facilitation (PNF): isometric or dynamic of target (agonist) and opposing (antagonist) muscle groups followed by passive stretching of agonists; requires a knowledgeable assistant

6. Stretching Techniques
Pros and cons for each stretching technique:
Active: Client moves body part without external assistance.
Passive: Client relaxes target muscle group as assistant moves the body part.
Active assisted: Client moves body part to end of its active ROM; assistant then moves body part beyond its active ROM.

7. Table 11.1

8. Types of PNF Stretches
Contract-relax (CR): Client isometrically contracts target muscle group; follows immediately with slow, passive stretching of target muscle group.
Contract-relax agonist contract (CRAC): Initially identical to CR except that client assists CRAC stretching phase by actively contracting opposing muscle group; improves ROM more effectively.

9. Figure 11.1a

10. Figure 11.1b

11. Theories of PNF-Induced Increases in ROM
Neurophysiologic modifications such as inhibition of stretch reflex and Golgi tendon organ (GTO), reflex in target muscles
Voluntary antagonist contraction during CRAC stretching explained by reciprocal inhibition (as the opposing muscle group is voluntarily contracted, the target muscle group is reflexively inhibited)

12. Designing Flexibility Programs: Exercise Prescription
Identify joints and muscle groups needing improvement.
Select appropriate stretching method and specific exercises for the exercise prescription.
Include one stretch per major muscle group.
Select exercises for problem areas; include more than one exercise for these muscle groups.
Workout should take 15 to 30 minutes.
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13. Designing Flexibility Programs: Exercise Prescription (continued)
Familiarize yourself with stretches to avoid— those causing stress for low back and knees.
Intensity is to the point of mild discomfort; below pain threshold.
ACSM recommends 15 to 60 seconds duration for each stretch.
ACSM recommends 4 reps per stretch initially.
For clients with lower flexibility, use shorter stretch duration (10-15 sec) and higher reps.
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14. Designing Flexibility Programs: Exercise Prescription (continued)
Progress the stretch by changing either the stretch duration (10-30 sec) or the number of repetitions so that the total time in stretched position gradually increases.
Gradually increase the total stretching time for each exercise in order to ensure overload and further improvements in ROM.
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15. Designing Flexibility Programs: Exercise Prescription (continued)
Recommended stretching program is minimum of two times weekly (preferably daily) for 10 minutes total per session.
Stretch after moderate to vigorous exercise program.
Stretching is a good cool-down routine from a strength or cardio workout.
Stretching is not a good warm-up; it may actually hinder performance or strength.
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16. Designing Flexibility Programs: Exercise Prescription (continued)
Vibration may be a promising method for increasing ROM beyond what is obtainable with static stretching.
Stretching improves ROM in older adults, especially if a stretch is held for 60 seconds.
Caution is urged using PNF stretches with older adults—they have lower stretch tolerance.
Individualize the stretching program, regardless of client age!

17. Client Guidelines for Stretching Programs
Perform a general warm-up
Increase body temp. and warm muscles
Stretch all major muscle groups and antagonists
Focus on the target muscles
Hold the stretch for 10 to 20 seconds
Stretch to the limit of movement, not to the point of pain
Keep breathing slowly and rhythmically
Stretch in different planes to improve ROM

18. Dynamic Stretching
Dynamic stretching is a type of functionally based stretching that uses sport-specific movements to prepare the body for activity.
Places an emphasis on the movement requirements of the sport or activity
Type of exercise can closely duplicate the movement required for activity
ex. knee lift stretch mimics knee lift of sprinter

19. Dynamic Stretching Avoids bouncing
Performed in a more controlled manner than ballistic.
Actively move a joint through a ROM
Promotes dynamic flexibility
Replicates movement patterns

20. Advantages of Dynamic Stretching
Helps promote temperature-related benefits (warms muscles up)
Can do multiple joints in a single stretch
Can do multiplanar movements similar to those that occur in sport
Time efficient

21. Dynamic Stretching
May be less effective than static or PNF in improving static flexibility
Provides opportunity to combine movments
Can perform in same place or cover a distance
Should start slowly and gradually increase ROM, speed or both
Effective warm-up can be done in min.
Must be coordinated with technique

22. Designing Low Back Care Exercise Programs
No best way yet to prevent and rehabilitate low back injuries.
Select method that matches client’s needs and goals:
Traditional approach: Focus is spinal alignment
Alternative approach: Focus is lumbar stability

23. Traditional Approach to Low Back Care
Improve ROM by strengthening and stretching hip flexors, hamstrings, and low back extensors.
Strengthen abdominal muscles.
Some programs include exercises to increase the strength and endurance of both the abdominal and low back extensor muscles.
Strengthening the low back (lumbar extensor) muscles requires pelvic stabilization.
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24. Traditional Approach to Low Back Care (continued)
Strengthening abs requires exercises that maximize abdominal muscle activation while minimizing compression (load) on lumbar vertebrae.
Minimize influence of psoas muscle to reduce lumbar vertebrae compressive load.

25. Alternative Approach to Low Back Care
Muscle endurance is more protective than muscle strength for reducing low back injury.
Lumbar mobility is directly related to low back injury.
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26. Alternative Approach to Low Back Care (continued)
Brace lumbar spine during activity by isometrically co-contracting the abdominal wall and low back muscles.
Maintain a neutral spine during activity.
Avoid fully flexed or extended ROM positions of trunk while lifting or exercising.
Perform exercises emphasizing endurance rather than strength.