1. Copyright © 2013. F.A. Davis Company Part II: Applied Science of Exercise and Techniques Chapter 4 Stretching for Impaired Mobility

2. Copyright © 2013. F.A. Davis Company  A general term used to describe any therapeutic maneuver designed to increase mobility of soft tissues and subsequently improve ROM by elongating (lengthening) structures that have adaptively shortened and have become hypomobile over time Stretching: Definition and Purpose

3. Copyright © 2013. F.A. Davis Company  Flexibility – Dynamic flexibility – Passive flexibility  Hypomobility – Hypomobility may be allowed selectively to improve function Definitions of Terms Related to Mobility and Stretching

4. Copyright © 2013. F.A. Davis Company  Contracture – Designation of contracture by location – Contracture versus contraction – Types of contracture Myostatic contracture Pseudomyostatic contracture Arthrogenic and periarticular contractures Fibrotic contracture and irreversible contractures Definitions of Terms Related to Mobility and Stretching (cont'd)

5. Copyright © 2013. F.A. Davis Company  Selective Stretching – Hypomobile structures to develop to improve function  Overstretching and Hypermobility – Hypermobility improves function in some circumstances Definitions of Terms Related to Mobility and Stretching (cont'd)

6. Copyright © 2013. F.A. Davis Company  Manual or Mechanical Stretching – Utilizes an external force  Passive Stretching – No patient assistance  Assisted Stretching – Patient assistance  Self-Stretching – Patient performs the stretch Interventions to Increase Mobility of Soft Tissues

7. Copyright © 2013. F.A. Davis Company  Neuromuscular Facilitation and Inhibition Techniques  Muscle Energy Techniques  Joint Mobilization/Manipulation  Soft Tissue Mobilization and Manipulation  Neural Tissue Mobilization (Neuromeningeal Mobilization) Interventions to Increase Mobility of Soft Tissues (cont'd)

8. Copyright © 2013. F.A. Davis Company  Adhesions, Contractures, Scar Tissue Limit ROM  Potential for Structural Deformity d/t Limited ROM  Muscle Weakness, Shortening of Muscles  Part of a Total Fitness Program  Pre and Post Vigorous Exercise Indications for Stretching Exercises

9. Copyright © 2013. F.A. Davis Company  Bony Block  Non-Union Fracture  Acute Inflammation or Infection  Sharp or Acute Pain With Elongation  Hematoma or Tissue Trauma  Hypermobility  Hypomobility Provides Stability or Neuro- muscular Control Contraindications for Stretching Exercises

10. Copyright © 2013. F.A. Davis Company  Increased Flexibility and ROM  General Fitness  Other Potential Benefits – Injury prevention – Reduced post-exercise soreness – Enhanced performance Potential Benefits and Outcomes for Stretching Exercises

11. Copyright © 2013. F.A. Davis Company  Contractile and Non-Contractile Tissue Changes – Elasticity – Viscoelasticity Only non-contractile connective tissue – Plasticity Properties of Soft Tissue: Response to Immobilization and Stretch

12. Copyright © 2013. F.A. Davis Company  Contractile Elements of Muscle  Mechanical Response of the Contractile Unit to Stretch and Immobilization – Response to stretch – Response to immobilization and remobilization Morphological changes Immobilization in a shortened position Immobilization in a lengthened position Mechanical Properties of Contractile Tissue

13. Copyright © 2013. F.A. Davis Company  Muscle Spindle  Golgi Tendon Organ  Neurophysiological Response of Muscle to Stretch Neurophysiological Properties of Contractile Tissue

14. Copyright © 2013. F.A. Davis Company  Ligaments  Tendons  Joint Capsules  Fasciae  Non-Contractile Tissue in Muscles  Skin Types of Connective Tissue

15. Copyright © 2013. F.A. Davis Company  Composition of Connective Tissue – Collagen fibers – Elastin fibers – Reticulin fibers – Ground substance  Mechanical Behavior of Non-Contractile Tissue Mechanical Properties of Non- Contractile Soft Tissue

16. Copyright © 2013. F.A. Davis Company  Interpreting Mechanical Behavior of Connective Tissue: The Stress-Strain Curve  Stress and Strain – Tension – Compression – Shear – Strain Mechanical Properties of Non- Contractile Soft Tissue (cont'd)

17. Copyright © 2013. F.A. Davis Company  Regions of the Stress-Strain Curve – Toe region – Elastic range/linear phase – Elastic limit – Plastic range – Ultimate strength Necking – Failure – Structural stiffness Mechanical Properties of Non- Contractile Soft Tissue (cont'd)

18. Copyright © 2013. F.A. Davis Company  Time and Rate Influences on Tissue Deformation – Creep – Stress-relaxation – Cyclic loading and connective tissue fatigue  Summary of Mechanical Principles for Stretching Connective Tissue Mechanical Properties of Non- Contractile Soft Tissue (cont'd)

19. Copyright © 2013. F.A. Davis Company  Changes in Collagen Affecting Stress–Strain Response – Effects of immobilization – Effects of inactivity (decrease of normal activity) – Effects of age – Effects of corticosteroids – Effects of injury – Other conditions affecting collagen Mechanical Properties of Non- Contractile Soft Tissue (cont'd)

20. Copyright © 2013. F.A. Davis Company  Alignment and Stabilization  Intensity of Stretch  Duration of Stretch – Static stretching Static progressive stretching – Cyclic (intermittent) stretching Determinants and Types of Stretching Exercises

21. Copyright © 2013. F.A. Davis Company  Speed of Stretch – Importance of a slowly applied stretch – Ballistic stretching – High-velocity stretching in conditioning programs and advanced-phase rehabilitation  Frequency of Stretch Determinants and Types of Stretching Exercises (cont'd)

22. Copyright © 2013. F.A. Davis Company  Manual Stretching  Self-Stretching  Mechanical Stretching – Duration of mechanical stretch Mode of Stretch

23. Copyright © 2013. F.A. Davis Company  Types of PNF Stretching – Hold–relax and contract–relax – Agonist contraction – Hold–relax with agonist contraction Proprioceptive Neuromuscular Facilitation Stretching Techniques

24. Copyright © 2013. F.A. Davis Company  Importance of Strength and Muscle Endurance  Use of Increased Mobility for Functional Activities Integration of Function into Stretching

25. Copyright © 2013. F.A. Davis Company  Examination and Evaluation of the Patient  Preparation for Stretching  Application of Manual Stretching Procedures  After Stretch Procedures Procedural Guidelines for Application of Stretching Interventions

26. Copyright © 2013. F.A. Davis Company  General Precautions  Special Precautions for Mass-Market Flexibility Programs – Common errors and potential problems Nonselective or poorly balanced stretching activities Insufficient warm-up Ineffective stabilization Use of ballistic stretching Excessive intensity Abnormal biomechanics Insufficient information about age-related differences – Strategies for risk reduction Precautions for Stretching

27. Copyright © 2013. F.A. Davis Company  Complementary Exercise Approaches – Relaxation training Common elements of relaxation training Examples of approaches to relaxation training – Autogenic training – Progressive relaxation – Awareness through movement Sequence for progressive relaxation techniques – Pilates Adjuncts to Stretching Interventions

28. Copyright © 2013. F.A. Davis Company  Heat – Methods of warm-up – Effectiveness of warm-up methods  Cold  Massage – Massage for relaxation – Soft tissue mobilization/manipulation techniques  Biofeedback  Joint Traction or Oscillation Adjuncts to Stretching Interventions (cont'd)

29. Copyright © 2013. F.A. Davis Company  Upper Extremity Stretching – Hand placement – Patient position – Procedure  Lower Extremity Stretching – Hand placement – Patient position – Procedure Manual Stretching Techniques in Anatomical Planes of Motion

30. Copyright © 2013. F.A. Davis Company  Critical Thinking and Discussion  Laboratory Practice Independent Learning Activities