Component Recommendation
Frequency 2 or more days per week is effective in improving joint range of motion.
Intensity Effective when the stretch is held at a point of tightness or slight discomfort.
Time Hold stretches for 10 to 30 seconds; for older adults, holding a stretch 30 to 60 seconds may be more beneficial.
Type Perform series of exercises for each of the major muscle–tendon units.
Volume 60 seconds total stretching time for each flexibility exercise.
Pattern Repeat each flexibility exercise 2 or 4 times.
Enhancing Effectiveness is improved when the muscle is warmed up using light to moderate aerobic exercise or with the application of heat such as with heat packs or hot baths.
29 Changing Posture
■ A stretching diary can be useful.
■ Develop a portfolio of pictures and ideas to help increase the variety of stretches at your disposal. There are many more stretches available than those provided here. For further information, see Therapeutic Stretching (Johnson 2014).
Passive stretching can take many forms. Tying together the ankles of a client who has bilateral genu valgum and leaving them this way for 10 minutes was advocated by Tidy in 1944 as a means of gently stretching the soft tissue structures of the lateral sides of the knee. Although likely to be useful, such techniques today raise ethical and safety issues. This example, however, demonstrates the novel approaches to stretching that have been used in correcting postural problems. Traditional passive stretches are applied to a limb or the spine and stretch more than one muscle. Tractioning is a less-used form of passive stretching involving a gentle, sustained pull on a joint, stretching the capsule, ligaments and associated muscles and their tendons. Tractioning may reduce muscle spasm and may reduce adhesions. As with gross passive stretching, tractioning stretches more than one muscle and affects multiple soft tissues. Dry stretching may be a technique more frequently used by manual therapists when working on a small, specific area. The therapist uses the fingers or thumbs to take up the slack in the skin.
Holding the skin at the barrier point encourages soft tissues to lengthen. Soft tissue release (STR) is a pin-and-stretch technique in which soft tissues are gently locked; whilst the lock is maintained, the body part is stretched. Muscle energy technique (MET) involves the active contraction of a muscle by the client against a resistive force provided by the therapist before the stretch is performed. These are just some examples of forms of stretching that could be used to lengthen shortened tissues.
Guidelines for a Passive Stretching Programme
■ Screen for contraindications. In addition to general contraindications, note that tractioning should not be used with hypermobile clients or those with a history of subluxation or dislocation in the part to be tractioned. Tractioning should not be used where the broad handhold needed for performing the stretch is likely to damage skin.
■ Begin with your client positioned comfortably. Explain what you are going to do.
■ Encourage your client to breathe normally rather than to hold the breath in anticipation of being stretched.
■ Encourage your client to let you know if he has discomfort or pain, and work only within tolerable levels.
■ When stretching the limbs, be sensitive as to where you position your hands.
■ Take your time. Both the client and body tissues need the opportunity to relax.
Experienced therapists can sense when this occurs. Hold stretches for a minimum of 30 seconds. Only after this should you attempt to take the stretch past the barrier point.
■ When treating clients for the first time, work cautiously and do less rather than more. Sometimes changes are immediate, but sometimes they occur over time. Even minor alterations to joint position can have dramatic effects physically and emotionally in some clients. In some cases a client may have soreness in muscles; you should advise the client on this and reassure him that this usually resolves within about 24 hours.
■ Restoration of mobility in muscles exhibiting moderate tightness takes several weeks (Kendall et al. 1993).
30 Postural Correction
SoFT TiSSUe ReleaSe This form of stretching involves first shortening and then lengthening the muscle to be stretched whilst a lock is applied to the muscle beginning as close to the origin as possible and working towards the insertion with subsequent stretches. Placing a lock on the soft tissues limits the amount by which they can move and seems to localize the stretch to some parts of the muscle more than others. In many cases this is useful because it enables you to focus attention on specific areas of tightness or adhesions. For more information, see Soft Tissue Release (Johnson 2009).
The technique is simple:
1. Shorten the muscle that is to be stretched. This may be done actively or passively.
2. Choose a point close to the muscle’s origin and fix the tissues you intend to stretch using your thumb, fist, fore-arm or elbow. Avoid press-ing into joints or deeply into regions where there are lymph nodes and vas-cular structures.
3. Whilst maintaining the lock, actively or passively stretch the muscle.
Figure 2.1 Soft tissue release to the calf: (a) Apply a gentle lock to the muscle, which already rests in a slightly shortened position when the patient lies prone with feet off the end of the couch; (b) maintain the lock as you gently dorsiflex the ankle using your thigh.
b a
31 Changing Posture
MUSCle eneRGy TeCHniqUe Muscle energy technique is popularly termed MET.
It may be particularly helpful in lengthening postural muscles prone to shortening. It involves the active contraction of a muscle by the client against a resistive force provided by the therapist. The active contraction provided by the client could be beneficial in strengthening muscles and decreases tone in the opposing muscle group. It is not clear what degree of force the client should use, but this should be no more than 25% of the client’s maximal force capacity. There are many variations on this technique. One suggested protocol is described here:
1. Position the client so that both you and he are comfortable. Take the muscle to be stretched to a resistance barrier, that point where both you and the client feel an increase in the client’s tissues to further elongation. This barrier is the point at which you will start to stretch. Tell your client to let you know as soon as you reach the barrier, a point where he may feel a very slight stretch. The entire pro-cedure should be pain free.
2. Ask the client to contract his muscle (i.e., the one in which he feels the slight stretch) using a maximum of 25% of his muscular force whilst you resist this contraction. Maintain the body part that is being stretched in a static position so the effect is an isometric contraction of the muscle you are about to stretch. It is important that the client be the one who sets the level of contraction against which you resist, not the converse. That is, clients should never resist your force; you should resist theirs.
3. After about 10 seconds, ask the client to relax; within the next 3 to 5 seconds, gently ease the body part further into the stretch so you find a new barrier posi-tion. Maintain this position for a few seconds before repeating the procedure up to two more times.
Figure 2.2 Muscle energy technique to the calf: (a) MET to the calf with the client prone, and (b) MET to the calf with the client supine.
a
b
32 Postural Correction
Massage
If the degree of muscle tone is a factor determining the lengthening of muscle, then a reduction in tone may result in a greater ability to lengthen a muscle, whether by stretch or by massage. Massage reduces muscle tone and increases general flexibility. Deep tissue massage may improve joint range and the stretching and compressive compo-nents used as part of trigger point deactivation. The decrease in muscle tone resulting from some types of massage could be helpful before stretching, and stripping-type techniques may help with the adherence of scar tissue. Tapotement techniques could also stimulate muscles before strengthening exercises. No matter what style of massage is used, when applied for the purposes of postural correction, it could be considered therapeutic massage—the ‘manipulation of soft tissues of the body by a trained therapist as a component of a holistic therapeutic intervention’ (Holey and Cook 2003, p. 6).
It is not known how firmly, for how long in a single bout or how frequently massage should be used to facilitate a lengthening of soft tissues for the purposes of postural correction, as is apparent when you look at table 2.5. Some studies reveal an improve-ment in joint range due to an increase in muscle length after massage, but massage protocols have varied, making comparisons difficult and the formulation of a massage-for-muscle-lengthening protocol challenging. For more information on the use of deep tissue massage, see Deep Tissue Massage (Johnson 2010).