Objectives

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).

Because stretching is an intervention that requires adaptation, it is important to determine whether:

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.

Objectives

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.

Reduced Range of Motion

Limited range of motion is a reduction in the normal distance and direction through which a joint can move. Loss of flexibility can be a predisposing factor for physical issues such as pain syndromes or balance disorders. Motion may be limited by a mechanical problem within the joint, by swelling of tissue around the joint, by stiffness of soft tissues, or by pain. When a joint does not move fully and easily in its normal manner, it is considered to have a limited range of motion. Motion may be limited by a mechanical problem within the joint, swelling of tissue around the joint, spasticity of the muscles, altered connective tissue pliability, pain, or disease. Diseases that prevent a joint from fully extending may, over time, produce contracture deformities, causing permanent inability to extend the joint beyond a certain fixed position.

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.

Excessive Joint Range of Motion

It is possible for a joint to become too flexible. Excessive flexibility can be just as bad as not enough flexibility because both increase the risk of injury. Joint hypermobility means that some or all of the joints have an unusually large range of movement. Joint hypermobility can cause symptoms such as

Excessive joint range of motion affects women more than men because female hormones increase flexibility. Joint hypermobility is treated with an exercise program to improve fitness and muscle strength resulting in increased stability. Do not overstretch hypermobile joints.

Objective

During stretching, the client should experience a pulling sensation in the short soft tissue and never a pain or strain in the joint or any other part of the body that is not being stretched. Anatomic barriers are determined by the shape and fit of bones at the joint. Do not stretch any jointed area beyond anatomic barriers, to prevent serious joint injury. Physiologic barriers are caused by the limits of the range of motion imposed by nerve and sensory function. When the physiologic barrier is reached, the client experiences appropriate stiffness and a pulling sensation into the area being stretched; this acts as a protective mechanism and prevents movement to the anatomic limits and potential injury. The pathologic barrier is of two types:

When moving a joint during assessment, it is important to stay within the normal physiologic barriers, and if limits of ROM are identified, to gently and slowly encourage the joint to increase the range of motion only if hypomobility exists. It may take multiple sessions supported by client self-stretching for sustained results to become evident. Expect flexibility to increase gradually.

Stretching Procedures

Objectives

Muscle energy techniques (MET) involve voluntary contraction of the client’s muscles in a specific and controlled direction, at varying levels of intensity, against a specific counterforce applied by the massage therapist. Muscle energy procedures have a variety of applications and are considered active techniques in which the client contributes the corrective force. The amount of effort may vary from a small muscle twitch to a maximal muscle contraction. The duration may be a fraction of a second to several seconds. All contractions begin and end slowly, gradually building to the desired intensity.

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:

Regardless, using controlled contraction before stretching is more effective than stretching alone.

As has been mentioned, the focus of muscle energy techniques is to increase tolerance to stretch. Muscle energy techniques are focused on dysfunctional movement patterns, primarily where hypomobility exists. To effectively perform MET methods, it is important for the practitioner to be able to position muscles so that the muscle attachments are close together or in a lengthening phase with the attachments separated. Study muscle charts until you understand the configuration of the muscle patterns, and practice isolating as many functional movements as possible, keeping in mind that proper positioning is important. When practicing, make sure that the muscle structures can be isolated, regardless of whether the client is in a supine, prone, side-lying, or seated position.

The massage practitioner uses three types of muscle contraction to activate muscle energy techniques.

Counterpressure is the force applied to an area that is contracting that is designed to match the effort or force exactly (isometric contraction) or partially (isotonic contraction) and multiple isotonic contractions. In an isometric contraction, the distance between the proximal and distal (origin and insertion) attachments of the target muscle(s) is maintained at a constant length. A fixed tension develops in the target muscle(s) as the client contracts the muscle against an equal counterforce applied by the massage therapist, preventing shortening of the muscle. In this contraction; the effort of the muscle, or group of muscles, is matched exactly by a counterpressure, so that no movement occurs, only effort.

An isotonic contraction is one in which the effort of the target muscle or muscles is not matched by the counterpressure, allowing a degree of resisted movement to occur. With a concentric isotonic contraction, the massage practitioner applies a counterforce but allows the client to move the proximal and distal (origin and insertion) attachments of the target muscle(s) together against the pressure. In an eccentric isotonic movement, the massage practitioner applies a counterforce but allows the client to move the jointed area so that the proximal and distal (origin and insertion) attachments of the target muscle separate as the muscle lengthens against the pressure.

Multiple isotonic contractions require the client to move the joint through a full range of motion against partial resistance applied by the massage practitioner.

Muscle energy techniques usually do not use the full contraction strength of the client. With most isometric work, the contraction should start at about 25% of the strength of the muscle. Subsequent contractions can involve progressively greater degrees of effort, but never more than 50% of available strength. Many experts such as Dr. Leon Chaitow use only about 10% of available strength in muscles being treated in this way, and find that they can increase effectiveness by using longer periods of contraction. Pulsed contractions (a rapid series of repetitions) using minimal strength are also effective.