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Instructions: Choose a research article from a peer-reviewed journal that is relevant to musculoskeletal rehabilitation. Make sure it is a research article, and not a case study or a meta-analysis.Summarize the history of the research related to the topic as communicated in the article.Describe the experiment (see rubric for details)Discuss relevant implications for the research to musculoskeletal rehabilitationFormat Requirements:One pageDouble spacedNo spelling or grammar errorsInclude a title page with journal article properly cited (APA 7 format)
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IJSPT
CLINICAL COMMENTARY
CURRENT CONCEPTS IN MUSCLE STRETCHING
FOR EXERCISE AND REHABILITATION
Phil Page, PT, PhD, ATC, CSCS, FACSM
ABSTRACT
Stretching is a common activity used by athletes, older adults, rehabilitation patients, and anyone participating in a fitness program. While the benefits of stretching are known, controversy remains about the best
type of stretching for a particular goal or outcome. The purpose of this clinical commentary is to discuss the
current concepts of muscle stretching interventions and summarize the evidence related to stretching as
used in both exercise and rehabilitation.
Key words: Exercise, fitness, rehabilitation, stretching
CORRESPONDING AUTHOR
Phil Page, PT, PhD, ATC, CSCS, FACSM
Baton Rouge, Louisiana USA
Email: [email protected]
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 109
INTRODUCTION
Human movement is dependent on the amount of
range of motion (ROM) available in synovial joints. In
general, ROM may be limited by 2 anatomical entities:
joints and muscles. Joint restraints include joint geometry and congruency as well as the capsuloligamentous structures that surround the joint. Muscle provides
both passive and active tension: passive muscle tension is dependent on structural properties of the muscle and surrounding fascia, while dynamic muscle
contraction provides active tension (Figure 1). Structurally, muscle has viscoelastic properties that provide
passive tension. Active tension results from the neuroreflexive properties of muscle, specifically peripheral
motor neuron innervation (alpha motor neuron) and
reflexive activation (gamma motor neuron).
Obviously, there are many factors and reasons for
reduced joint ROM only one of which is muscular
tightness. Muscle “tightness” results from an increase
in tension from active or passive mechanisms. Passively, muscles can become shortened through postural adaptation or scarring; actively, muscles can
become shorter due to spasm or contraction. Regardless of the cause, tightness limits range of motion
and may create a muscle imbalance.
Clinicians must choose the appropriate intervention or
technique to improve muscle tension based on the
cause of the tightness. Stretching generally focuses on
increasing the length of a musculotendinous unit, in
essence increasing the distance between a muscle’s
origin and insertion. In terms of stretching, muscle
tension is usually inversely related to length: decreased
muscular tension is related to increased muscle length,
while increased muscular tension is related to decreased
muscle length. Inevitably, stretching of muscle applies
tension to other structures such as the joint capsule
and fascia, which are made up of different tissue than
muscle with different biomechanical properties.
Three muscle stretching techniques are frequently
described in the literature: Static, Dynamic, and PreContraction stretches (Figure 2). The traditional and
most common type is static stretching, where a specific position is held with the muscle on tension to a
point of a stretching sensation and repeated. This
can be performed passively by a partner, or actively
by the subject (Figure 3).
There are 2 types of dynamic stretching: active and
ballistic stretching. Active stretching generally involves
moving a limb through its full range of motion to the
end ranges and repeating several times. Ballistic
stretching includes rapid, alternating movements or
‘bouncing’ at end-range of motion; however, because
of increased risk for injury, ballistic stretching is no
longer recommended.1
Pre-contraction stretching involves a contraction of
the muscle being stretched or its antagonist before
Figure 1. Factors contributing to muscle tension.
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 110
Figure 2. Techniques of Muscle Stretching. HR=Hold relax; CR=Contract relax; CRAC= Contract relax, agonist contract;
PIR= Post-isometric relaxation; PFS=Post-facilitation stretching, MET= Medical exercise therapy.
stretching. The most common type of pre-contraction stretching is proprioceptive neuromuscular
facilitation (PNF) stretching. There are several different types of PNF stretching (Table 1) including “contract relax” (C-R), “hold relax” (H-R), and “contract-relax
agonist contract” (CRAC); these are generally performed by having the patient or client contract the
muscle being used during the technique at 75 to
100% of maximal contraction, holding for 10 seconds,
and then relaxing. Resistance can be provided by a
partner or with an elastic band or strap (Figure 4).
Figure 3. Static stretching of the posterior shoulder (Used
with permission of the Hygenic Corporation).
Other types of pre-contraction stretching include
“post-isometric relaxation” (PIR). This type of technique uses a much smaller amount of muscle contraction (25%) followed by a stretch. Post-facilitation
stretch (PFS) is a technique developed by Dr. Vladimir Janda that involves a maximal contraction of the
Table 1. Types of PNF stretching.
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 111
Figure 4. Contract-Relax stretching with stretching strap
(Used with permission of the Hygenic Corporation).
Figure 5. Post-Facilitation Stretching of hamstrings (Used
with permission of the Hygenic Corporation).
muscle at mid-range (Figure 5) with a rapid movement to maximal length followed by a 15-second
static stretch.2
important question to consider when interpreting
the results of studies: was the improvement based
on actual muscle lengthening (ie, increased extensibility) or just an increase in tolerance to stretch?7
Chan and colleagues8 showed that 8 weeks of static
stretching increased muscle extensibility; however,
most static stretching training studies show an
increase in ROM due to an increase in stretch tolerance (ability to withstand more stretching force), not
extensibility (increased muscle length).9-12
STRETCHING RESEARCH
Many studies have evaluated various effects of different types and durations of stretching. Outcomes of
these studies can be categorized as either acute or
training effects. Acute effects measure the immediate results of stretching, while training effects are the
results of stretching over a period of time. Stretching
studies also vary by the different muscles or muscle
groups that are being examined and the variety of
populations studied, thereby making interpretation
and recommendations somewhat difficult and relative. Each of these factors must therefore be considered when making conclusions based on research
studies. Several systematic reviews of stretching are
available to provide general recommendations.3-6
The effectiveness of stretching is usually reported as an
increase in joint ROM (usually passive ROM); for example, knee or hip ROM is used to determine changes in
hamstring length. Static stretching often results in
increases in joint ROM. Interestingly, the increase
in ROM may not be caused by increased length
(decreased tension) of the muscle; rather, the subject
may simply have an increased tolerance to stretching.
Increases in muscle length are measured by “extensibility”, usually where a standardized load is placed on the
limb and joint motion is measured. Increased tolerance
to stretch is quantified by measuring the joint range of
motion with a non-standardized load. This is an
Static stretching is effective at increasing ROM. The
greatest change in ROM with a static stretch occurs
between 15 and 30 seconds;13,14 most authors suggest
that 10 to 30 seconds is sufficient for increasing flexibility.14-17 In addition, no increase in muscle elongation occurs after 2 to 4 repetitions.18
Unfortunately, however, static stretching as part of a
warm-up immediately prior to exercise has been
shown detrimental to dynamometer-measured muscle strength19-29 and performance in running and
jumping.30-39 The loss of strength resulting from
acute static stretching has been termed, “stretchinduced strength loss.”3 The specific causes for this
type of stretch induced loss in strength is not clear;
some suggest neural factors,31,40 while others suggest
mechanical factors.19,23 Furthermore, the strength
loss may be related to the length of the muscle at the
time of testing23 or the duration of the stretch.25
Interestingly, a maximal contraction of the muscle
being stretched before static stretching may decrease
stretch-induced strength loss.41
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 112
Table 2. Stretching Techniques Comparative Matrix, based on studies comparing at least 2 techniques.
Contraction of a muscle performed immediately
before it is stretched is effective at increasing ROM.
While most pre-contraction stretching is associated
with PNF-type contract-relax or hold-relax techniques using 75 to 100% of a maximal contraction,
Feland et al42 showed that submaximal contractions
of 20 or 60% are just as effective, thus supporting the
effectiveness of post-isometric relaxation stretching.
Interestingly, ROM increases are seen bilaterally
with pre-contraction stretching,43 supporting a possible neurologic phenomenon.
that Hoffman reflexes (H-reflexes) are depressed with
a pre-contraction stretch.45,53 The H-reflex is an EMG
measurement of the level of excitability of a muscle:
lower H-reflexes are associated with lower excitability.
It is possible that the lowered excitability levels may
allow muscle to relax through the gamma motor neuron system despite an increased activation through the
alpha system. Obviously, more research is needed to
investigate these neurological effects of pre-contraction stretching.
The specific phenomenon associated with an increase
in flexibility following a pre-stretch contraction remains
unclear. Many have assumed that muscle experiences
a refractory period after contraction known as ‘autogenic inhibition’, where muscle relaxes due to neuroreflexive mechanisms, thus increasing muscle length.
Interestingly, electromyographic (EMG) studies have
shown that muscle activation remains the same7,44 or
increases after contraction.45-50 Some researchers have
speculated that the associated increases in ROM are
related to increased stretch tolerance51,52 rather than a
neurological phenomenon. Some researchers suggest
COMPARING STRETCHING MODES
Several authors have compared static and dynamic
stretching on ROM, strength, and performance (See
Table 2). Both static and dynamic stretching appear
equally effective at improving ROM acutely or over
time with training.54-57 Several authors have found no
improvement in performance when comparing static
and dynamic stretching.55,58-61 In contrast to static stretching, dynamic stretching is not associated with strength
or performance deficits, and actually has been shown
to improve dynamometer-measured power27,62 as well
as jumping and running performance.31,32,34,56,59,63,64
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 113
The literature is conflicting regarding the effects of
warm-up stretching prior to exercise. Static and
dynamic warm-ups are equally effective at increasing ROM prior to exercise.56,57 Some researchers
report static stretching after warm-up decreases performance,32,33,35 while others report no change or an
increase in performance.32,38,64,65 While static stretching is generally followed by an immediate decrease
in strength, static stretching performed before66 or
after warm-up57 does not decrease strength. The volume of static stretching may also affect performance:
Robbins et al37 reported that 4 repetitions of 15second holds of static stretching did not affect vertical jump, while 6 repetitions reduced performance.
A pre-stretch contraction has been associated with
greater acute gains in ROM compared to static
stretching in many studies;48,50,67-75 however, several
studies show similar increases in ROM45,76-84 and performance77,81,82,84 when comparing pre-contraction
stretching and static stretching. Both acute static
stretching and pre-contraction stretching have been
shown to decrease strength.26,83
RECOMMENDATIONS
Static, dynamic, and pre-contraction stretching are
all effective methods of increasing flexibility and
muscle extensibility; however, these modes may be
more effective in specific populations. Several
authors have noted an individualized response to
stretching;48,56,60 therefore, stretching programs may
need to be individualized.
Well-rounded Exercise Programs
For a general fitness program, the American College
of Sports Medicine1 recommends static stretching for
most individuals that is preceded by an active warmup, at least 2 to 3 days per week. Each stretch should
be held 15-30 seconds and repeated 2 to 4 times.
Many exercise studies on older adults include stretching exercises as part of a well-rounded exercise program. Unfortunately, there is no clear dose-response
for flexibility training in older adults because stretching interventions are often combined with strengthening, balance, and cardiovascular activities, making
it difficult to isolate stretching’s effectiveness. Older
adults may need longer stretch times than the recommended 15 to 30 seconds; Feland et al85 found
that 60-second holds of static stretches were associated with greater improvements in hamstring flexibility in older adults compared to shorter duration
holds. Ten weeks of static stretching of the trunk
muscles was able to increase spinal mobility (combined flexion and extension ROM) in older adults.86
Static stretching of the hip flexors and extensors may
also improve gait in older adults.87 Furthermore, the
effectiveness of type of stretching seems to be related
to age and sex: men and older adults under 65 years
respond better to contract-relax stretching, while
women and older adults over 65 benefit more from
static stretching.
Warm-up for Sports and Exercise
Stretching performed as part of a warm-up prior to
exercise is thought to reduce passive stiffness and
increase range of movement during exercise. In general, it appears that static stretching is most beneficial for athletes requiring flexibility for their sports
(e.g. gymnastics, dance, etc.). Dynamic stretching
may be better suited for athletes requiring running
or jumping performance30 during their sport such as
basketball players or sprinters.
Stretching has not been shown to be effective at
reducing the incidence of overall injuries.88 While
there is some evidence of stretching reducing musculotendinous injuries,88 more evidence is needed to
determine if stretching programs alone can reduce
muscular injuries.3
Rehabilitation
Stretching is a common intervention performed during rehabilitation. Stretching is prescribed to increase
muscle length and ROM, or to align collagen fibers
during healing muscle.
Several researchers have investigated different muscle stretching techniques on subjects with tight hamstrings. Some authors report that both static and
pre-contraction stretching are able increase acute
hamstring flexibility,47,54,89 while others suggest static
stretching90-92 or PNF stretching10,71 are more effective. It appears that 6 to 8 weeks of static stretching
is sufficient to increase hamstring length.14,93,94
Stretching is effective for the treatment of orthopedic conditions or injury; however, as with other populations, outcomes may be based on the individual
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 114
patient. Static stretching has been shown to be more
effective than dynamic stretching for those recovering from hamstring strains.95 In addition, it has been
reported that athletes with hamstring strains recover
faster by performing more intensive stretching than
by performing less intensive stretching.96 Patients
with knee osteoarthritis can benefit from static
stretching to increase knee ROM;97 however, PNF
stretching may be more effective.68 Chow et al
reported that total knee replacement patients benefited from 2 weeks of either static, dynamic or PNF
stretching to increase ROM.76
Stretching is often included in physical therapy
interventions for management of shoulder, back and
knee pain. Despite positive outcomes of these types
of studies and improvements in flexibility, it is difficult to isolate the effectiveness of the stretching
component of the total treatment plan because the
protocols usually include strengthening and other
interventions in addition to stretching.
A recent review98 of stretching for contractures found
no improvement in joint mobility orthopedic-related
contractures. Orthopedic contractures often result from
shortness in non-contractile tissues such as capsuloligamentous structures rather than muscle tightness.
Researchers have shown that 12 months of stretching
is as effective as strengthening exercises or manual
therapy in patients with chronic neck pain.99,100 In
addition, patients with chronic musculoskeletal pain
demonstrate an increased tolerance to stretch after
3 weeks of static stretching.12 Lewit and Simons101
reported an immediate 94% reduction in pain associated with trigger points after applying a PIR technique. These studies support stretching in pain
management programs.
Stretching appears to have no benefit for neurological patients who have had a stroke or spinal cord
injury.98 Because of a strong neurological component
and long-standing muscle shortening associated with
these conditions, it’s no surprise that simple muscle
stretching techniques are not effective.
SUMMARY
The benefits of stretching seem to be individual to
the population studied. Several factors must be considered when making clinical recommendations
from the literature. To increase ROM, all types of stretching are effective, although PNF-type stretching may be
more effective for immediate gains. To avoid decrease
in strength and performance that may occur in athletes
due to static stretching before competition or activity,
dynamic stretching is recommended for warm-up.
Older adults over 65 years old should incorporate static
stretching into an exercise regimen. A variety of orthopedic patients can benefit from both static and pre-contraction stretching, although patients with joint
contractures do not appear to benefit from stretching.
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