Streching is a general term used to describe any therapeutic technique which is used to increase the flexibility of soft tissue structures and subsequently improve range of motion by lengthening the soft tissue structures which are responsible for hypomobility of the joint.

Some professionals like gymnasts, dancers move their joint beyond the normal range of motion as their soft tissue structures allow the joint to move beyond the range of motion. This is because these professionals start stretching of the soft tissue structures from childhood which is required for their profession. It is known as hypermobility.

On the other hand, soft tissue structures (muscles, ligaments, tendons, joint capsule, fascia and skin) can tighten due to internal or external injuries which restrict the joint motion, and is known as hypomobility of the joint, that causes difficulty to perform the activities. Therefore, the tighten structure requires stretching to bring it into normal functional capacity.

Purpose of stretching

Normal muscle
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Injury or Trauma
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Immobilization of the joint
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Decreased cross-sectional area of the muscle
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Sarcomere absorption
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Reduction in length of the muscle fibres
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Tightness of the muscle
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Difficulty in performing ADL
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Application of stretching techniques
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Muscle length return back to normal

Neurophysiology of stretching

Muscle proprioceptors

There are two important muscle receptors present in the skeletal muscles. Understanding of these receptor function helps the physiotherapist to apply various therapeutic techniques to the muscles.

Muscle spindle present in the intrafusal fibres of the skeletal muscles. It monitors the rate of velocity of changes in muscle length.

Golgi Tendon Organ present in the tendons of the skeletal muscle. It monitors the amount of tension created in the muscle.

Mechanism

Quick stretching

Quick stretching technique can be applied to activate the weak muscle. Therefore, it is not recommended for lengthening the tight muscles.

Weak / Normal muscle -> Quick stretch -> Muscle spindle activation -> Type 1a afferents -> Efferent signals (Alpha & Gamma) -> Contraction of the muscle

Static stretching

Static stretching is most commonly applied stretching method in therapeutic practice. It involves holding the stretch position for 15 to 30 sec.

Static stretching -> Holding for 15 to 30 sec -> Increased muscle tension -> Activation of GTO -> Type 1b afferents -> Efferent signals (Alpha & Gamma) -> Relaxation of the muscle.

PNF stretching

Proprioceptive neuromuscular streching method is an advanced form of traditional stretching in which therapist activates GTO to gain advantage of brain induced relaxation of the muscle.

Hold-relax stretching -> Isometrics to the tight muscle -> increased tension in the muscle -> Activation of the GTO -> Autogenic inhibition of the muscle.

Indications

• Muscle spasm/Guading
• Muscle tightness
• Muscle spasticity
• Muscle rigidity
• Skin & Fascia tightness (Post burn stiffness)
• Joint capsule tightness

Contraindications

• Acute inflammation
• Muscle strain
• Ligament sprain
• Muscle rupture
• Muscle tear
• Fracture
• Subluxation or Dislocation of the joint
• Myositis ossificans
• < 3 weeks of tendon transfer
• Severe osteoporosis

Parameters of stretching

1. Intensity of stretch

The force which is applied to stretch the soft tissue structures is termed as the intensity of stretch. The intensity of stretch depends on the soft tissue structure which is being stretched. For example, to stretch the trapezius muscle, less intensity of stretch is required than the gastrocnemius. The general rule of intensity to stretch the soft tissues is to be low. Though an experienced therapist can only stretch the structure with an optimal intensity.

2. Speed of stretch

For the purpose of treatment the exercise should be performed in a smooth, slow and rhythmical manner. High speed / quick stretch can cause increase in stretch reflex which prevents stretching of the muscles. A slow speed stretch is also easier for the therapist as well as patient to control and prevent injury to the stretched structures. In addition a slow speed stretch affects the viscoelastic properties of connective tissues making them more compliant.

3. Frequency of stretch

It refers to the number of sessions per day or week. The frequency of stretch depends on the severity and underlying cause of tightness of the soft tissue structures. Structures immobilized for long period of time, often require more frequent treatment twice or thrice daily while those structures immobillized for short period of time require only twice or thrice a week.

4. Duration of stretch

The structures are held at the stretched position for a sufficient period of time with an optimal intensity to lengthen the soft tissue structures, so that they do not go back to the original position. The length of time a stretch must be held to facilitate muscle flexibility remains a point of disaggreement among clinicians. Lantell G et al. state that a low load prolonged stretch (15-30sec) is more effective and that there does not appear to be any advantage to hold the stretch longer than 30 sec.

Classification of stretching

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1. Stretching exercises: A Guide to flexibility training., Martin Fobi.