Stretching exercises

A general term used to describe any therapeutic maneuver designed to

lenghten (elongate) pathaologically shortened soft tissue structures and
theraby to increase range of motion .

Flexibility
Flexibility is the ability to move a single joint or series of joints
smoothly and easily through an unrestricted, pain-free ROM.
Contracture
Restricted motion can range from mild muscle shortening to
irreversible contractures. Contracture is defined as the adaptive shortening of
the muscle-tendon unit and other soft tissues that cross or surround a joint
that results in significant resistance to passive or active stretch and limitation
of ROM, and it may compromise functional abilities.

Burn contracture

It is an impairment caused by replacement of skin with pathologic scar

tissue of insufficient extensibility and length resulting in a loss of motion or
tissue alignment of an associated joint or anatomic structure.

Contracture Versus Contraction

The terms contracture and contraction (the process of tension
developing in a muscle during shortening or lengthening) are not
synonymous and should not be used interchangeably.
Contractures, leading to loss of joint mobility, are a major clinical
complication of deep dermal and full thickness burns. For the patient,
contractures may have significant negative long-term effects in terms of
functional outcome, needing an intensive rehabilitation program and
eventually several episodes of reconstructive surgery.
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Types of Contracture

Myostatic Contracture
In a myostatic (myogenic) contracture, although the musculotendinous
unit has adaptively shortened and there is a significant loss of ROM, there is
no specific muscle pathology present. It is most common to occur in two joint
muscles. Myostatic contractures can be resolved in a relatively short time
with stretching exercises.

Pseudomyostatic Contracture
Impaired mobility and limited ROM may also be the result of
hypertonicity (i.e., spasticity or rigidity) associated with a central nervous
system lesion.

Fibrotic Contracture and Irreversible Contracture

Fibrous changes in the connective tissue of muscle and periarticular
structures can cause adherence of these tissues and subsequent development
of a fibrotic contracture.this may occur due to chronic inflammation of the
soft tissues.

Contractures can be classified also into:

Reversible contractures
Released by stretching exercises.
Irreversible contractures
Released by surgical treatment.

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 Types of stretching exercises:

stretching
Exercises

passive
stretch Active
inhibition

Manual Mechanical Cyclic

mechanical

Hold- Hold-Relax- Agonist

Relax Contract contraction

Other types of stretching exercises include:

 Self stretch
 Selective stretch
 Over stretch

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Passive stretching Techniques:
While the patient is relaxed, an external force applied either manually or
mechanically, lengthen the shortened tissues.
1-Manual passive stretching:
 External force : applied by the therapist.
 Speed : slow.
 Duration : applied for at least 30 or 45 sec.
 The intensity and the duration of the stretch are dependent on the
patient's tolerance and the therapist's strength and endurance.
 The gains achieved in ROM are transient and are attributed to
temporary sarcomere give (elastic changes).
2-Mechanical passive stretching:
 External force : applied by cast , splint or pully system.
 Duration : 20-30 min. or as long as several hours.
 The gains achieved in ROM are permanent in contractile and non
contractile tissues (plastic changes).
There are many ways to use equipment to stretch shortened tissues and
increase ROM. The equipment can be as simple as a cuff weight or weight-
pulley system or as sophisticated as some adjustable orthoses
Mechanical stretching devices apply a very low intensity stretch force (low
load) over a prolonged period of time to create relatively permanent
lengthening of soft tissues, presumably due to plastic deformation.
Duration of Mechanical Stretch
Mechanical stretching involves a substantially longer overall duration
of stretch than is practical with manual stretching or self-stretching exercises.
The duration of mechanical stretch reported in the literature ranges from15 to
30 minutes to as long as 8 to 10 hours at a time or continuous throughout the
day except for time out of the device for hygiene and exercise.

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3- Cyclic mechanical stretch:
Passive stretching using mechanical device such as the autorange can
be done in a cyclic mode.
Th intensity, duration and the mode of each stretch cycle and the
number of stretch cycle per minutes can be adjusted on the mechanical
stretching unit.
Ballistic Stretching:
Usually associated with bouncing during the stretch. In ballistic
stretching, range of motion is increased by using the momentum of repeated
bouncing up and down. An example of ballistic stretching would be swinging
your arms out to the side so that the momentum is responsible for the
increased flexibility.
N.B: Ballistic stretching has a high risk of injury and is not
recommended for patients.
It is recommended for atheletes.
It improves the dynamic stability.
It is characterized by high intensity, very short duration and facilitate the
stretch reflex.
Active inhibition Techniques :
The patient reflexively relaxes the muscle to be elongated prior to the
stretching maneuver. This type of stretching is only possible if the ms. to be
elongated is normally innervated and under voluntary control.
1-Hold-Relax (Contract-Relax):
With the hold–relax (HR) procedure, the range limiting muscle is first
lengthened to the point of limitation or to the extent that is comfortable for
the patient. The patient then performs a prestretch, end-range, isometric
contraction (for 5 to 10 seconds) followed by voluntary relaxation of the tight
muscle. The limb is then passively moved into the new range as the range-
limiting muscle is elongated.

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This technique depends on autogenic inhibition, the GTO may fire to inhibit
tension in the ms.so that it can more easily lengthened.
2- Contract-Relax-Contract (Hold-Relax-Contract):
To perform this procedure, move the limb to the point that tissue
resistance is felt in the tight (range-limiting) muscle; then have the patient
perform a resisted, prestretch isometric contraction of the range-limiting
muscle followed by relaxation of that muscle and an immediate concentric
contraction of the muscle opposite the tight muscle.
This technique combines autogenic inhibition and reciprocal inhibition to
lengthen the tight muscle.
3-Agonist Contraction:
Another stretching technique is the agonist contraction (AC)
procedure. This term has been used by several authors but can be
misunderstood. The “agonist” refers to the muscle opposite to the range-
limiting muscle.
“Antagonist,” therefore, refers to the range-limiting muscle (tight muscle).
To perform the AC procedure the patient concentrically contracts (shortens)
the muscle opposite the range limiting muscle and then holds the end-range
position for at least several seconds.
It has been suggested that when the agonist is activated and contracts
concentrically, the antagonist (the range- limiting muscle) is reciprocally
inhibited, allowing it to relax and lengthen more easily.
Other types of stretching exercise:
1-Selective Stretching
Selective stretching is a process whereby the overall function of a
patient may be improved by applying stretching techniques selectively to
some muscles and joints but allowing limitation of motion to develop in other
muscles or joints. When determining which muscles to stretch and which to
allow to become slightly shortened, the therapist must always keep in mind

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the functional needs of the patient and the importance of maintaining a
balance between mobility and stability for maximum functional performance.
The decision to allow restrictions to develop in selected musculotendon units
and joints is usually made in patients with permanent paralysis (spinal cord
injuries) as this tightness of the muscles provides more stability.

2-Self-Stretching
Self-stretching (also referred to as flexibility exercises or active
stretching) is a type of stretching procedure a patient carries out
independently after careful instruction and supervised practice. Self-
stretching enables a patient to maintain or increase the ROM gained as the
result of direct intervention by a therapist. This form of stretching is often
an integral component of a home exercise program and is necessary for
long-term self-management of many musculoskeletal and neuromuscular
disorders.
3-Overstretching:
Is a stretch well beyond the normal length of muscle and ROM of a joint
and the surrounding soft tissues, resulting in hypermobility (excessive
mobility).
Creating selective hypermobility by overstretching may be necessary
for certain healthy individuals with normal strength and stability participating
in sports that require extensive flexibility.
Tips:
Static Progressive Stretching
Static progressive stretching is another term that describes how static stretch
is applied for maximum effectiveness. The shortened soft tissues are held in a
comfortably lengthened position until a degree of relaxation is felt by the
patient or therapist. Then the shortened tissues are incrementally lengthened
even further and again held in the new end-range position for an additional

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duration of time. This approach involves continuous displacement of a limb
by varying the stretch force (stretch load). This approach to stretching
capitalizes on the stress relaxation properties of soft tissue.
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.
-Have the patient asssume a comfortable, stable position that allows the
correct plane of motion for the stretching procedure.
-Explain the procedure to the patient and be certain he or she understands.
-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 applied to his
or her tolerance level.
General Precautions
-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.
-Avoid vigorous stretching of muscles and connective tissues that have been
immobilized for an extended period of time.
-Progress the dosage (intensity, duration, and frequency) of stretching
interventions gradually to minimize soft tissue trauma and postexercise
muscle soreness.
-Avoid overstretching weak muscles.

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Indication of stretching:
-Contractures
-Adhesions
-Scar tissue formation
-Anticipated deformities
Contraindication of stretching:
-Bony block
-Recent factures
-Sharp pain
-Recent skin graft
-Exposed tendon
-D.V.T
-Compartment syndrome
Remember to:
 Warm-up your muscles first before stretching (e.g. stretch after
walking).
 Stretch until you feel mild discomfort, not pain.
 Never bounce or force a stretch.
 Hold the stretch for 10-30 seconds and then relax.
 Do not hold your breath when stretching.
 Do stretching exercises at least 2-3 times a week.

Self stretch of upper Self-stretching the pectoralis major

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 trapezius ms ms. Arms in a reverse T to stretch the
clavicular portion (A), and in a V to
stretch the sternal portion (B).

Passive stretching of the Self stretch of neck muscles.

pectoralis major muscle.

Stretching lateral trunk ms. Self stretch of the hamstrings ms.

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 Manual passive stretch of the Self stretch of the hamstrings ms
hamstrings ms.

Stretching exercise for the soleus ms. Stretching exercise for the calf
Only ms.

Self stretching of calf ms Self stretching of hip adductors

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 ms

Self stretch of quadriceps ms.(Rectus Self stretch of hip flexors

femoris)

Suggested Readings:

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Stretching anatomy, Arnold G. Nelson, Jouko Kokkonen. Copyright © 2007.
Therapeutic Exercise Foundations and Techniques, Carolyn Kisner Lynn
Allen Colby, third edition Copyright © 2018.
Therapeutic Exercise Foundations and Techniques, Carolyn Kisner, Lynn
Allen Cobly, fourth edition, Copyright © 2002.
Therapeutic Exercise Foundations and Techniques, Carolyn Kisner, Lynn
Allen Colby, fifth edition, Copyright © 2007.
Handbook of Burns Reconstruction and Rehabilitation, Lars-Peter
Kamolz, Marc G. Jeschke, Raymund E. Horch, Markus Küntscher, Pavel
BrychtaVolume 2, Copyright © 2012.
Plastic and Reconstructive Surgery, Maria Z. Siemionow and Marita
Eisenmann-Klein,Copyright © 2010.
Burn Care and Rehabilitation: Principles and Practice, Reginald L.
Richard and Marlys J. Staley, Copyright © 1994.
Stretching The stress-free way to stay supple, keep fit, and exercise safely,
Suzanne Martin, Copyright © 2005
Color Atlas of Burn Reconstructive Surgery, Hiko Hyakusoku · Dennis P.
Orgill, Luc Téot · Julian J. and Pribaz Rei Ogawa Copyright © 2010.
Orthopaedic physical therapy secrets, Jeffrey D. Placzek and David A.
Boyce, second edition, Copyright © 2006.

References

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Blanton, S, Grissom, SP, Riolo, L. (2002): Use of a static adjustable ankle-
foot orthosis following tibial nerve block to reduce plantarflexion contracture
in an individual with brain injury. Phys Ther82(11):1087–1097.
Bonutti, PM, et al. (1994): Static progressive stretch to re-establish elbow
range of motion. Clin Orthop 303:128.
Brody, LT. (2005): Impaired joint mobility and range of motion. In Hall,
CM, Brody, LT (eds): Therapeutic Exercise–Moving Toward Function, ed 2.
Lippincott Williams & Wilkins, Philadelphia, pp 113–148.
Carolyn Kisner and Lynn Allen Colby. (2002): Therapeutic Exercise
Foundations and Techniques, fourth edition, Copyright © 2002.
Carolyn Kisner and Lynn Allen Colby.(2007): Therapeutic Exercise
Foundations and Techniques, fifth edition, Copyright © 2007.
Carolyn Kisner and Lynn Allen Colby.(2018): Therapeutic Exercise
Foundations and Techniques, seventh edition, Copyright © 2018.
Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. (2006):
Burn rehabilitation: state of the science. Am J Phys Med Rehabil.85(April
(4)):383–413.
Harrison CA, Macneil S. (2008): The mechanism of skin graft contraction:
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In O’Sullivan, SB, Schmitz, TJ (2001): Physical Rehabilitation:
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Kendall, F, McCreary, EK, Provance, PG, et al. (2005): Muscles, Testing
and Function: With Posture and Pain, ed 5. Lippincott Williams & Wilkins,
Philadelphia, 2005.
Leblebici B, Adam M, Bag˘ is¸ S, Tarim AM, Noyan T, Akman MN, et
al.(2006): Quality of life after burn injury: the impact of joint contracture. J
Burn Care Res 27(November– December (6)):864–8.

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Richard R.L., Lester M.E., Miller B., Travis L. Dewey W.S., Renz E.M.
Steven E.M. (2009): Journal of Burn Care & Research: July/August -
Volume 30 - Issue 4 - pp 625-631.

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