FLEXIBILITY_IMPORTANCE

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Str
its impor
Wang 1999, Wright 2000). In spite
of its constant use and clinically
Asian, Oriental and Middle-Eastern
cultures as an aid to altering the
Robert Lardner has been commissioned by JBMT to
produce a series of articles, by himself and other
contributors, which will explore the topic of stretching
and flexibility. In this issue he reviews some of the
background to these topics.
Editor
. . . . .
Journa
5(4), 2
# 200
doi: 10.1
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S T R E T C H I N G A N D F L E X I B I L I T Y : S E R I E S
observable results, the research
remains somewhat controversial in
determining how effective stretching
is, and indeed how stretching
achieves its effects. Utilizing various
movement philosophies, for example
Proprioceptive Neuromuscular
Facilitation (PNF) (More 1979),
Feldenkrais1 (Ofir 1990), Pilates
(Swaim 1993), and Tai Chi (Wolf
1997), can help to restore or improve
flexibility, decrease pain and
improve coordination, thereby
improving overall function. The
following article and ensuing articles
by different authors will attempt to
review and explain some basic facts,
individual’s state of mind and also
as a vital component in developing
skills within martial arts.
Chandler et al. (1990) states ‘that
flexibility is the ability to move a
joint through a normal range of
motion without undue stress to the
musculotendinous unit’. In the
therapeutic environment achieving
flexibility in line with this definition
is often a common goal. This is an
important point as the individual
tolerance for pain varies greatly and
the clinician is not always aware of
the damage to healthy or injured
tissue by aggressive attempts to
restore or improve flexibility.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
l of Bodywork and Movement Therapies (2001)
54^263
1Harcourt Publishers Ltd
054/jbmt.2001.0241available online at
ww.idealibrary.com.on
rt Lardner PT
. Ohio St. Suite 610 E,
go, IL 60610, USA
spondence to: R. Lardner
+1312 951 9309;
il: rlpt@winstarmail.com
ved June 2001
ed July 2001
ted July 2001
254
JOURNAL OF BODYWORK AND MOVEMENT THERAPIES OCTOBER 2001
etching and
tance in reh
. . . . . . . . . . . . . .
Robert Lardner
Introduction
Stretching and the improvement of
flexibility has been an important
goal both in the recreational and
therapeutic field in the belief that it
is beneficial in promoting good
physical and mental function
(Travell & Simons 1994, Janda &
Jull 1987, Janda 1988, Bunkan
1920). It is claimed that stretching
can reduce injury risk, relax
hypertonic muscles, lengthen
shortened tissue (Markos 1979,
Etnyre 1986) and help to improve
faulty posture (Janda & Jull 1987,
flexibility:
abilitation
philosophies and observations
regarding flexibility and how and
why it is of such clinical importance.
History and de¢nition
The origins of stretching appear lost
in antiquity. It is thought that the
Greeks employed some form of
flexibility training to enable them to
perform not only acrobatic stunts,
wrestling, etc but also as part of
their gymnastic program. ‘Asanas’
or stretching postures (Fig. 1) have
been used for thousands of years in
p
Stretching and £exibility
Furthermore, from a functional
standpoint flexibility must be
Fig. 1 A yoga pose used with respiration to im
achieved within the context of and
not at the expense of stability and
ecient motor control.
As Alter (1988) states, ‘Flexibility,
hypermobility, and joint laxity are
not synonymous terms’, though they
are often used interchangeably and
with some confusion.
. Flexibility refers to the
extensibility of periarticular
tissues to allow normal or
physiologic motion of a joint or
limb.
. Laxity refers to abnormal degree
of joint range of motion that
affects joint stability.
. Hypermobility refers to range of
motion in excess of the accepted
normal motion in most joints.
The latter two terms are not
normally desirable therapeutic goals
as they imply decreased stability and
ranges of motion in excess of the
normal or physiologic motions of
JOURNAL OF BOD
joints, possibly leading to abnormal
destructive stresses at these joints.
rove spinal flexibility in extension.
Bene¢ts
The benefits of flexibility training
are claimed in the following areas:
. Injury Prevention
. Muscular relaxation
. Improved range of motion
. Improved posture
. Mental relaxation
. Pain relief
What is some of the evidence for
this?
Although Shrier (2000) states that
new evidence suggests that
stretching immediately before
exercise does not prevent overuse or
acute injuries (Pope et al. 2000),
according to Hartig et al. (1999)
increased hamstring flexibility with
multiple stretches per day resulted in
a decrease in lower extremity
injuries. Furthermore it was also
noted by Pope et al. (2000) that age
255
YWORK AND MOVEMENT THERAPIES
and fitness levels were predictive of
injury but height, weight and Body
Mass Index (BMI) were not. There
is evidence that there was a 2-fold
increase in injury risk in recruits
enlisting later in the year (fall
season) compared to those enlisting
at the beginning of the year –
possibly related to other significant
factors as yet unknown – besides a
need to stretch (Pope et al. 2000). In
assessing the risk and rate of ankle
injuries among basketball players,
shoe wear, history of previous injury
and lack of stretching were
considered significant risk factors
(Mckay et al. 2000). Teaching
improved landing technique and
body movement strategies also
showed a 2-fold reduction in
ankle injuries in players during
volleyball (Bahr et al.1997). The
level of skill of performance of an
activity obviously can be an
important factor in injury risk
due to ineciency and early
fatigue and muscle dysfunction
(Elert 1993).
It is possible that giving specific
stretching instructions that are
tailored to the individual’s needs
and range of motion deficits after
careful evaluation may contribute
significantly in reducing injury
incidence but the role of other
factors will have to be considered in
interpreting these observations and
reducing the risks. The multi-
factorial cause of injuries is thus
obvious. Considering this, general
stretching programs whether self
directed or therapeutically applied
purported to ‘generally’ prevent
injury may be fallacious in their
claims.
The use of active and passive
stretching in inducing muscular
relaxation, pain relief and increasing
joint range of motion is well known
and documented. For example,
palpable tonus changes are observed
and the deactivation of painful
trigger points can be achieved with
various relaxation or stretching
OCTOBER 2001
Lardner
techniques, such as post-isometric
relaxation (Lewit & Simons 1984).
PNF stretches and static have been
shown to be effective in improving
flexibility (Etnyre & Abraham 1986,
Etnyre & Lee 1987, Condon &
Hutton 1987, Roberts & Wilson
1999, Godges et al. 1989, Feland et
al. 2001). Some percentage of
improvement in ROM can be
retained for up to several months
(Riddle 1956).
Contrary to popular belief that a
pre-contraction of a muscle lowers
the electro-myographic (EMG)
activity and inhibits a muscle,
Condon and Hutton (1987) and
Hutton and Atwater (1992) have
demonstrated that there is an
increase in post-contraction
excitability. This is evidenced by
increased EMG activity that occurs
within a muscle for several seconds
afterwards. Conversely, there is a
significant lowering of the H reflex
amplitude indicating a decrease in
the excitability of the alpha-
motorneuron pool in the contract-
relax antagonist contract (CRAC)
and a simple antagonist contract
(AC) stretch than in the contract-
relax (CR) or staticstretch (SS)
procedures. Increases in EMG
activity with voluntary muscle
contractions, and an accompanying
increase in alpha-motor neuron
excitability have also been reported
by Suzuki (1990). Since the PNF
techniques and SS can yield the
same results in improving flexibility,
it can be concluded that effectiveness
of a particular stretching procedure
is independent of the EMG activity
at the time of muscle displacement
(Hutton 1992). It appears that either
the prioritization of EMG activity as
playing a major role in deciding if a
muscle can be successfully stretched
is wrong or that the EMG activity
represents a more complex
relationship between those
structures involved in facilitation
and inhibition of muscles than is
understood so far. The importance
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of the Hoffman reflex decrease in
association with passive stretching
has again been shown to be
significant (Avela et al. 1999).
Other mechanisms that may aid
muscle extensibility in acute and
chronic stretching need to be
considered. Among these are:
. The thixotropic nature of the
muscle fibers both intrafusal and
extrafusal themselves, i.e. a
change in viscosity when a muscle
is oscillated or moved actively or
passively which can lead to a
change muscle stiffness (Lakie &
Robson 1988).
. The role of titin isoforms as one
of the modulators of the stiffness
and elastic limits of the
sarcomeres within the muscle
fibers.
. Serial sarcomere and myotubule
addition as a result of increased
muscle length not tension.
. Avoidance of connective tissue
proliferation within the muscle
through maintaining its activity
(Williams et al. 1988).
. An increase in stretch tolerance
without a change in stiffness, i.e.
an increase in extensibility. This
may be more important than a
decrease in muscle stiffness in
reducing pain associated with
stiffness and allowing an
individual to increase his or her
ROM (Halbertsma et al. 1994,
1999).
After a stretching program was
initiated to increase flexibility, an
improvement in performance in
lifting loads, utilizing the stretch
shortening cycle was seen. This was
related directly to the improved
utilization of the elastic strain
energy of the muscles involved as a
result of a measurable decrease of
the stiffness of the series elastic
component (SEC) (Wilson et al.
1992). Janda (1978) indicates that
due to their inhibitory effect the
relaxation and stretching of
hypertonic short muscles should
256
YWORK AND MOVEMENT THERAPIES
precede attempts to strengthen weak
inhibited muscles in the treatment of
muscle imbalance. Stretching
therefore appears to be an important
part of any strengthening program
to benefit both the agonistic and
antagonistic muscle groups. Also, it
is important to note that the
deactivation of trigger points or the
removal of muscle spasm can restore
normal activation and function
within a muscle or a related muscle
(Headley 1994). Therefore in an
attempt to improve motor function,
the contribution of manual therapy
in identifying and eliminating
muscle spasms and trigger points is
significant.
Incidentally, weight training does
not necessarily decrease flexibility, it
may even enhance it, if the principles
as described below are followed
(Wilmore et al. 1978). Two
principles should be observed during
strength training in order to increase
flexibility: (1) the muscle group must
work through its full range; and
(2) emphasis should be placed on the
gradual eccentric phase of work,
allowing greater tensile stress to be
placed on the smaller number of
fibers usually involved in this phase.
In popular weight training, these
two principles are not often
followed, which may result in
muscle imbalance and decreased
flexibility. Two probable reasons for
this is that: (1) with the use high
resistance, e.g. heavy dumbbells, full
range movements can risk injury to
joints and tissues when they reach
mechanically disadvantageous
positions, therefore, shorter ranges
of motion are often utilized and are
advisable; (2) emphasis of the
eccentric phase of work in resistance
training is physiologically more
demanding and unpleasant and thus
is often minimized or avoided as
much as possible. Since not all
people who weight train develop
significant muscle shortness, there
are obviously more complex factors
involved.
OCTOBER 2001
Stretching and £exibility
The research on the utilization
of stretching for delayed onset
muscular soreness (DOMS) appears
to be undecided. However, the
decreased muscle tension after active
or passive stretching may reduce the
pain associated with muscle soreness
even without directly affecting the
muscle damage itself. Passive
stretching has also been shown to
relieve common muscle cramps
(Bertolasi et al. 1993).
That posture can play an
important part in pain syndromes is
well documented (Mannheimer
1991, Wright 2000). Despite the fact
that observed postural aberrations
(Dieck et al. 1985) and anomalies
are not predictive of pain (Boden
et al. 1990, Jensen et al. 1994), there
exists what Irvin calls a
‘manipulable’ or ‘postulational’
causality between posture and pain
within the musculoskeletal system
(Irvin 1995), i.e. change ‘A’ and you
change ‘B’ – if you optimize posture
then pain is reduced. Also, ‘A’
causes ‘B’ – since the likelihood of
joint degeneration due to
biomechanical load osteoarthrosis
increases with ‘normal ageing’
(entropy), if the normal amount of
stress on joints is decreased, aged or
not by optimizing posture, pain
reduction can be obtained.
Moreover there is ample evidence
that the improvement of posture can
bring about pain relief (Irvin 1997).
In other words, recognition of lack
of optimum posture and increased
biomechanical stresses as a probable
predictor of pain is important. Ideal
static or dynamic posture aims to
maintain optimal articular
biomechanical relationships for load
transference and equilibrium based
on gravity, the quality of the motor
function and stereognostic
information available to the CNS.
Poor postural alignment can lead to
altered muscle tone and muscle
imbalance and vice versa. This
muscle imbalance, which tends to
occur in predictable patterns can be
JOURNAL OF BOD
described as the relationship
between tone and muscle length
around a joint (Norris 1998), and
has been used to explain certain
postural deviations and also
consequent incoordination in muscle
activity (Janda & Schmid 1980,
Kendall et al. 1993). However,
posture is not dependent on muscle
lengths and joints but is a dynamic
function of the central nervous
system (Janda 1999). Reflexes play
an important role in muscle tension
(Janda 1988). The CNS relies on
constant input from the
environment both internal and
external in order to regulate posture
appropriately. These postural
reactions and reflexes govern our
posture at all times.
Alteration of erect posture and
coordination were noted in
astronauts after their return to earth
which were attributed to altered
sensory and proprioceptive cues
(Clement & Lestienne 1988, Speers
1998). The cause of postural changes
chronic or temporary as expressed
by the CNS through the
musculoskeletal system are
multifactorial. These may range
from ergonomics in work and
recreational activities, trauma or
structural pathology to pathological
afferent input or emotional
disturbances. Stretching can play a
crucial role in the sphere of postural
improvement by relaxing and
lengthening tight muscles and
allowing inhibited muscles to be
activated again, but if the underlying
cause is not successfully addressed
then a treatment approach primarily
utilizing mainly stretching may be
only partially or temporarily
successful.
Systems that modulate
stretching
In attempting to improve flexibility,
a determination should be made as
to which structures need to be
affected and how. In achievingor
257
YWORK AND MOVEMENT THERAPIES
maintaining flexibility, focus can be
usefully placed on modulating four
subsystems; described as
‘mechanistic constraints’ by Hutton
(1992). Three of these are described
as governing stability according to
Panjabi (1992).
. The Muscular System – active
component
. The Osteo-ligamentous System
– passive component
. The Neural System – control
component
. The Fascial System – passive
component
These subsystems are linked
together not only biomechanically
but also through neural efferent/
afferent impulses and cannot be
isolated from each other when
considering cause and effect.
Basically, whatever is done to one
subsystem will affect the function of
the other three. Stretching
techniques are primarily directed at
the muscular subsystem and its
contractile and non-contractile
elements.
The reflexive relationship between
joints and muscles have been
observed and documented in
research. It was demonstrated that
joint movement and position could
elicit prolonged EMG activity in
muscles (Freeman & Wyke 1967).
Reflex spasms and trigger points in
muscles have been observed to be
present with joint dysfunction,
(Brucini et al. 1981, Denslow et al.
1947, Vernon 1995). The effect of
the normalization of a joint function
on normalizing muscle tone and
restore flexibility has also well
documented and discussed (Lewit
1999a). Joint restrictions may be
mobilized and manipulated to
restore normal range of motion to
the osteoligamentous subsystem.
The manipulation of the osteo-
ligamentous system must be
performed with caution as the
primarily inelastic components
may be irreversibly damaged
OCTOBER 2001
Basic stretching
techniques
‘Basically, any form of sustained or
repetitive stretch that places joints
towards their maximum ROM will
produce an enhancement in their
ROM capacity over time’
(Hutton 1992)
The viscoelastic properties of a
muscle allow it to become elongated
over time by an external constant
force or by stretching it to a
constant length. When the external
load is released it eventually returns
to its original length. Creep and
hysteresis within muscle gives more
permanent elongation. Most general
Lardner
by aggressive or repeated
manipulation thereby leading to
hypermobility or possible instability
(Farfan 1977).
Adverse neural tension (Butler
1991) may affect flexibility quite
Fig. 2 Subsystems that govern flexibility.
significantly, as muscles will always
react to protect the integrity of the
nervous tissue by limiting range of
motion in response to nervous tissue
irritation, e.g. increased hamstring
tone with sciatic nerve irritation
leading to decreased straight leg
raise (SLR) (Lewit 1999b). So, not
only is the actual neural tissue a
participant in determining flexibility
but its function in terms of motor
control and coordination then plays
an important role in maintaining
flexibility through improved muscle
activity and joint function. This may
be achieved through various
reeducation and movement
approaches, e.g. Yoga, Tai Chi,
Feldenkrais1, Pilates, Alexander
technique, etc.
The fascial subsystem consists of
skin and connective tissue and can
be considered as a ‘second skeleton’
that has an important stabilization
JOURNAL OF BOD
function throughout the body
(Schultz & Feitis 1996). It can limit
flexibility if restrictions are present
within it and often has to be
specifically manipulated in order to
restore its flexibility and motion.
Myofascial release techniques are
therefore an indispensable part of
any manual therapist’s
armamentarium.
Table1 Some de¢nitions related to the physicalp
Creep The slow movement of a mater
stresses
Stiffness A material’s resistance to defor
Strain This is the amount of deformat
force
Hysteresis A measurement of permanent d
does not retrace the force–lengt
first applied. It can be observed
Elasticity The property of a material to r
deforming force is removed
Viscosity The measure of shear force tha
rate of deformation. It is time d
Plasticity The property of a material to p
beyond its elastic range
Thixotropy The property exhibited by mate
disturbed or shaken and of sett
Viscoelasticity The property of being both ela
258
YWORK AND MOVEMENT THERAPIES
stretching times 15–30 seconds
utilize primarily the viscoelastic
properties of the muscles, since it
requires a longer stretch time 1–2
mins to cause creep and hysteresis
(Table 1).
In an attempt to increase
flexibility by the reduction of tension
in a muscle, four factors must be
affected
1. Normalizing (1) electrogenic
pathological spasm, i.e. the
lowered threshold of muscle
excitability caused by local
roperties ofmuscle tissue
ial that becomes viscous due to shear
mation
ion that occurs as a result of the applied
eformation of a viscoelastic material that
h tension curve traced when the force was
as a loss in energy.
eturn to its original form or shape when a
t must be applied to a fluid to obtain a
ependent.
ermanently deform when it is loaded
rials such as muscle of becoming fluid when
ing again when allowed to stand
stic and viscous
OCTOBER 2001
deformation to take place (Fig. 3).
In this case post facilitation stretch
(PFS), isolytic stretching (IS) or SS
can be used.
Basic stretching methods
Stretching can be generally divided
into four main techniques (Table 2).
In the following descriptions of
stretching principles and techniques:
same antagonist with varying
degrees of force for a duration of
about 10–30 seconds, depending on
the particular stretch desired. This is
then usually repeated 3–4 times. The
intensity of the contraction can vary
greatly. The PFS (Janda 1992) for
stretching short/tight muscles
requires a 7–10 second maximum
isometric contraction of the
antagonist that can be generated by
C
s
Table 2 Stretchingprinciples fall basically into four principal techniques
Autogenic Inhibition
technique
Reciprocal Inhibition
technique
Static
technique
Ballistic
technique
Post-contraction inhibition stretches Active stretch Static stretch Ballistic stretch
Eccentric Isotonic
stretches
Oscillatory stretch
1b Afferent (Rapid stretch)
Stretching and £exibility
muscle response or by neural
system response to internal or
external stimuli, resulting in for
example, painful muscle spasm,
reflex spasm rigidity or cramps.
(2) Triggerpoints: physiologic
contracture caused by motor end-
plate dysfunction (Mense et al.
2001).
2. Decreasing muscle stiffness or,
thixotropic and viscoelastic
properties.
3. Increasing extensibility through
stretch tolerance.
4. Reducing the shortened
remodelled connective tissue
within and around the muscle.
These four factors may be present in
a muscle to varying degrees. It is the
clinician’s task to assess which
factor or factors predominate and to
prioritize treatment accordingly. In
the case of the painful hyperirritable
muscle, relaxation of the localized
spasm, e.g. trigger point, reflex
spasm or general hypertonicity of
the muscle, is encouraged by
utilizing mild techniques such as
post isometric relaxation (PIR) hold
– relax, static stretching, etc. It is
interesting to note that while muscle
pain may arise from many different
factors that locally affect the muscle,
e.g. trauma, inflammation, ischemia
etc. reflexive mediated muscle spasm
in a muscle seldom causes pain in
the same muscle, the pain and spasm
felt are likely to be referred to that
muscle from another source, e.g. a
triggerpoint or joint (Mense et al.
2001).
Increased stiffness within a muscle
due more to its viscoelastic and
thixotropic properties may require
lengthening of the muscle in
addition to relaxation. In this case
mild to moderate mechanical
lengtheningof the muscle actively or
passively is required to restore it to
an acceptable functional length
probably by affecting primarily the
contractile component (CC). The
connective tissue restriction in this
JOURNAL OF BOD
case is negligible or minimal.
Stretches such as CR, Contract-
Relax-Antagonast-Contract
(CRAC), active–isolated stretch
(AI), etc. can be utilized. If a more
permanent change is desired in a
short or tight muscle whose length is
inadequate due more to contracture
of the connective tissue, an attempt
is made to stretch the parallel elastic
component (PEC) and series elastic
component of the muscle more
aggressively or utilize significantly
longer stretch times for plastic
Fig 3 The basic elements involved in the length
component, the actin and myosin filaments; PE
tissue surrounding muscle filaments; SEC=serie
muscle (adapted from Soderberg 1997).
259
YWORK AND MOVEMENT THERAPIES
the muscle that moves the body
segment in the desired direction is
the AGONIST. The muscle being
stretched or inhibited is the
ANTAGONIST.
Autogenic inhibition stretching
Post-contraction inhibition
techniques basically involve an
isometric contraction of the
antagonist, which is maintained
from 10–30 seconds followed by
relaxation and stretching of the
tension relationship of muscle: CC=contractile
=parallel elastic component, the connective
elastic component, the tendinous portion of the
OCTOBER 2001
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the help of an assistant with the joint
in mid range where the muscle is
strongest and the joint is protected.
After the contraction the muscle
must be immediately voluntarily
relaxed, and then rapidly taken to a
position of stretch for a further 10
seconds. The joint is brought back
passively to mid range for a rest of
20 seconds. The procedure is then
repeated 3–4 times. The ‘Claspknife’
stretch utilizing the inverse stretch
reflex is very similar to PFS only the
muscle contraction is initiated with
the muscle already somewhat
stretched at end range. In PIR
(Lewit 1999c) used for deactivating
trigger points and painful spasm
reduction, the mildest isometric
contraction possible is required for
10–15 seconds or more at the barrier
where resistance is first perceived or
felt. This is followed by a voluntary
relaxation of the muscle until the
next barrier is engaged and the
procedure then repeated 3–4 times.
CRAC is another very popular
technique considered to be superior
to CR in its effect as it utilizes both
autogenic and reciprocal inhibition
techniques. In certain osteopathic
techniques the patient actively
assists in moving the body part
further into the stretch thereby
activating the agonist to the
antagonist being stretched. When
possible, the use of antagonist
contraction is helpful in enhancing
most stretching techniques (Chaitow
2001).
Eccentric isotonic technique is
utilized, for example, in the Isolytic
stretch. The patient’s isometric
contraction in a shortened range is
overcome by the assistant and
converted to an isotonic eccentric
contraction into full range stretch of
the contracted muscle. Several
repetitions are performed with the
patient increasing his contraction
strength from about 20% at the
initial repetition to a maximum
strength contraction that can be
overcome by the assistant. This type
JOURNAL OF BOD
of stretching can be used for
shortened/tight muscles. It can cause
some discomfort not only because of
the nature of the technique, but also
because eccentric muscle activity is
known to give delayed onset muscle
soreness (Stauber 1989).
The so-called 1b Afferent Stretch
(Golgi tendon organ stretch) usually
utilizes an assistant using a toggle
board (optional) to apply 4–5 high
velocity low amplitude (HVLA)
stretches to the antagonist in its
lengthened position. Agonist muscle
contraction may be utilized
simultaneously. In the light of recent
research regarding the Golgi tendon
(Moore 1984, Gandevia et al. 1990,
Macefield et al. 1993) organs it is
doubtful that the inhibition is
primarily or solely caused by
activation of the Golgi tendon organ
via a quick passive stretch because
their threshold for this type of
stimulus is very high (Houk et al.
1971).
Reciprocal inhibition stretching
Active stretching involves stretching
a muscle (antagonist) by full inner
range contraction of the agonist of
that movement. This is then held for
10–20 seconds and then repeated
3–4 times. Active stretching is
probably the most common and
popular form of stretching as it
requires the least technique and
instruction and may be performed
without a partner. However, muscle
weakness, active insuciency of
muscles, faulty movement patterns
and hypermobility may be limiting
obstacles to using this type of
stretching effectively.
Oscillatory stretching is utilized in
stretches such as Mattes method or
active-isolated stretching and
usually involves taking the
antagonist to be stretched to end
range, then performing a short
moderate contraction of the agonist
for 2 seconds followed by assisted
lengthening of the antagonist for 2
260
YWORK AND MOVEMENT THERAPIES
seconds. This oscillating stretch is
performed rhythmically for about
10 repetitions alternating between
contraction and stretch with
successive increases of ROM. A
different type of oscillatory stretch
consists of repeated oscillations
generated by an assistant at about
1 hertz for about 10–15 seconds
against the constantly contracted
agonist at the end range of the
antagonist with incremental increase
in ROM. This type of stretch can be
used to as a variation to (AC) part
of a CRAC stretch. The Ruddy
Method (‘pulsed MET’) is a form of
oscillating stretching in which the
patient performs a series of rapid
low amplitude pulsed contractions
against resistance with the minimum
of energy. Activation and
deactivation at a rate of 20 times in
10 seconds is performed at the
engaged barrier of resistance, and
this procedure is then repeated at the
new resistance barrier as ROM
increases (Ruddy 1962, Chaitow
2001).
Static stretching
Static stretching involves a muscle
that is slowly and passively stretched
to full range, continued tension is
then maintained for an extended
period of time e.g. 2–15min, to
further increase its length. It may or
may not be repeated. For maximum
gains it is important that the person
stretching waits until the muscles
relax in the assumed position. This
may be an important component of
flexibility attained through yoga
exercises that require static holding
times.
Ballistic stretching
Ballistic stretching involves taking
an antagonist to end range and the
employing active large full range
and shorter end range bouncing
movements to increasing ROM. The
use of ballistic stretching within the
OCTOBER 2001
Stretching and £exibility
therapeutic domain has been
controversial because there is an
increased risk for tissue damage, in
addition claims that inadequate
neural and tissue adaptation due to
a lack of creep and increased muscle
tension with rapid stretching are
also made. Since ballistic
movements are an integral part of
many physical activities and it is a
valuable technique in enhancing
flexibility in combination with other
stretching strategies such as static
stretching (Vujnovich 1994), its use
may be considered in the end stages
of rehabilitative programs.
Different combinations of these
techniques are utilized in an attempt
to enhance their effect and improve
clinical results, e.g. CRAC, PIRAC,
HR with oscillation, etc.
Other forms of £exibility
training
The use of Yoga, Tai Chi,
Feldenkrais1, Pilates and similar
movement disciplines in the area of
improving flexibility, mental
relaxation and stress reduction is
well known. In fact relaxation and
the accompanying decrease in
muscle tone enhances the results of
flexibility techniques.Respiratory
and ocular synkinesis (Sachse &
Berger 1989) are often utilizing in
varying degrees, these techniques
that would include the use of
breathing to aid movement, e.g.
deep inhalation facilitates spinal
extension while exhalation facilitates
spinal flexion. Looking in the
direction of intended movement is
so closely linked that it is hard to
consciously rotate the head fully to
the left while looking right. Pilates
exercises have formalized rules of
breathing during their performance
(Friedman 1980). In Feldenkrais1,
awareness is brought to the
individual’ intention of movement,
the effect of breath on movement,
the role of the eyes in coordinating
movement, etc (Feldenkrais 1977).
JOURNAL OF BO
In Tai Chi deep breathing and
awareness of posture are considered
to be important prerequisites to
learning and practicing the
movement forms (Wolf et al. 1997).
In summary, there is a growing
body of evidence for the use of
stretching techniques but there is
still a need to appreciate and
investigate the different techniques
and philosophies from which they
arise. There is also a need to
appreciate how the body responds
and adjusts to varying conditions
both internally and externally under
which the body subtly adjusts and
responds. We are still limited by our
lack of knowledge as to which
conditions are most likely to benefit
from any particular technique. The
response of the body to any
procedure is always global and our
focus only on certain parameters for
assessing that response may be
inadequate to the task, resulting in
contradictory conclusions.
In the ensuing articles various
authors will discuss different aspects
of stretching and flexibility and their
use in the area of musculoskeletal
function.
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Stretching and £exibility
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	Introduction
	History and de¢nition
	Figure 1
	Benefits
	Systems that modulate stretching
	Figure 2
	Basic stretching techniques
	Table 1
	Figure 3
	Basic stretching methods
	Table 2
	Autogenic inhibition stretching
	Reciprocal inhibition stretching
	Static stretching
	Ballistic stretching
	Other forms of flexibility training
	REFERENCES