Chapter 12 After completing this chapter, the student will be able to perform the following: 2 Explain stretching as an intervention. 3 List assessments used to determine whether stretching would be beneficial. 4 Define active and passive stretching. 6 Use joint movement methods to assess for reduced or excessive range of motion. 7 Describe symptoms related to hypomobility or hypermobility. 8 Describe anatomic, physiologic, and pathologic barriers. 9 Use stretching methods effectively and safely. 10 Define muscle energy techniques. 11 Explain why muscle energy techniques complement stretching methods. 12 Define and demonstrate three types of muscle contractions used during muscle energy techniques. 13 Explain and demonstrate the use of breath and eye movement during muscle energy techniques. 14 Explain and demonstrate seven variations of muscle energy techniques. 15 Define direct tissue stretching. 16 Demonstrate longitudinal and cross-directional direct tissue stretching. 17 Combine stretching methods for increased effect. 18 Define and demonstrate active release and pin and stretch. 2. Explain stretching as an intervention. 3. List assessments used to determine if stretching would be beneficial. Stretching is an intervention that is used purposefully to cause an adaptation in the soft tissues, including tissue around joints of the body. Joint movement and palpation are the assessments used to determine whether stretching should be used to address areas of tissue shortening and increased density involved in lack of flexibility. See Chapter 10 for more assessment information. Stretching methods are often included in the athlete’s training program. Stretching methods used by athletes can be passive or active. Passive stretching occurs when a second person applies the force to stretch the tissue. Active is seen when individuals stretch themselves. Stretching of both types can also be included in the massage session. During massage, each jointed area should be moved actively, passively, or both ways as part of an assessment to determine the available range of motion. It is important to not confuse joint movement with stretching. Joint movement assesses the limits of movement as indicated by palpation of the resistance barrier, often called bind. Stretching begins at the bind and moves into it to change the amount of movement available (Box 12-1). • The current condition is resourceful compensation that is productive and should not be changed. • The client has sufficient adaptive capacity and time to respond to the change. Stretching as an intervention method needs to be used carefully to avoid adverse outcomes (McHugh and Cosgrave, 2010). Refer back to Chapter 3 to read about the research on stretching. 6. Use joint movement methods to assess for reduced or excessive range of motion. 7. Describe symptoms related to hypomobility or hypermobility. As described, flexibility refers to the ability of joints to move through a full range of motion. Range of motion (ROM) is the distance and direction of movement of a joint. As described in Chapter 10, each specific joint has a normal range of motion that is expressed in degrees. Gender, age, and genetics are important when determining appropriate levels of flexibility. When range of motion is found to be limited through joint movement assessment, stretching methods may be indicated to increase flexibility. Stretching should be directed at the muscle’s fascia, because fascial tissue has the most elastic tissue, and because ligaments and tendons (because they have less elastic tissue) are not intended to stretch very much at all (Morse et al, 2008). Overstretching of ligaments may weaken the joint’s integrity, causing destabilization (which increases the risk of injury). Once the fascia associated with the muscle has reached its maximum length, attempting to stretch further only serves to stretch the ligaments and put undue stress upon the tendons (two parts of the body that you do not want to stretch). Through proper stretching techniques, we can safely elongate the myofascia (the connective tissues surrounding a muscle). This is important because our fascial network allows muscles, bones, and blood vessels to communicate down to a cellular level, continuously coordinating and restoring the body’s proper physiologic functions. • Where pain and stiffness occur when joint movement assessment identifies reduced ROM, or hypomobility. Stretching may be indicated. • Where lack of resistance is experienced when normal ROM is reached during assessment, indicating hypermobility. Do not stretch—strengthening is required. • Stretch tissues only when they are warm and pliable. • Begin the stretch sequence by using massage to prepare the tissues. • Stabilize the body so that only the target area moves during stretching. • Move the area to the pathologic barrier, and back off a bit. • Instruct the client to breathe in (inhale) right before the stretch, and then to breathe out (exhale) slowly as you move him or her into the stretch. • Stretching should always be done within comfortable limits of ROM of the client. • Stretching should be controlled and performed at a slow pace. • A stretch does not need to be held longer than 20 seconds and is performed in sets of 2 to 5 repetitions, with a 15- to 30-second rest between stretches. • Static stretches are done so that the joints are placed in the outer limits of the available range of motion and held (considered passive). • Dynamic stretching occurs when opposing muscles are used to produce the force needed to stretch the short tissues (considered active). • An increase of 10% in ROM is sufficient during a massage session. Do not attempt to increase the ROM by more than 25% during a massage session. 10. Define muscle energy techniques. 11. Explain why muscle energy techniques complement stretching methods. 12. Define and demonstrate three types of muscle contractions used during muscle energy techniques. 13. Explain and demonstrate the use of breath and eye movement during muscle energy techniques. 14. Explain and demonstrate seven variations of muscle energy techniques. Research (see Chapter 3) indicates that use of proprioceptive neuromuscular facilitation (PNF)/muscle energy techniques (MET) to facilitate stretching is more efficient than static passive stretching. Our understanding of the mechanism of benefit of MET has changed over the past few years; most notable is the realization that post-isometric and reciprocal inhibition effects do not account for the ability to increase tissue length. Instead, increased tolerance to stretch that results from MET application is now considered to be the mechanism of benefit (Fryer, 2006). Theories as to why stretch sensation tolerance increases include the following: • Nociceptive inhibition of the dorsal horn of the spinal cord via mechanoreceptor stimulation during MET • Localized activation of the periaqueductal grey, producing descending pain modulation • Increased activity of analgesic endocannabinoids (Fryer and Fossum, 2009) • Altered fluid content of connective tissue due to sponge-like behavior during contractions (and compression) associated with MET-isometric contractions (Klingler et al, 2004) • Viscoelastic changes in connective tissue pliability (Lederman, 1997), and/or Regardless, using controlled contraction before stretching is more effective than stretching alone.
Stretching
Stretching
Flexibility
Reduced Range of Motion
Stretching Principles
Stretching Procedures
Muscle Energy Techniques
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