Treatment plans that include Therapeutic Muscle Stretching (TMS) should be developed as a result of a thorough examination. This may only involve the addition of specific observations and muscle flexibility checks, while performing the initial examination of your new patients.
Range of motion can be influenced by several structures: skin, subcutaneous tissue (fascia, adipose, etc.), muscles, ligaments, joint capsules, joint surfaces, and intra-articular structures. All should be considered when evaluating an abnormal range of motion.
One would expect to find normal muscle tissue to be pain free, with good tone, strength, and elasticity. Movement, contractions and relaxation should be unrestricted and smooth. Testing should reveal normal innervation and circulation.
If a biomechanical examination, which should include assessment of joint play and "end feel," identifies shortened muscles, then a "trial treatment" may be performed. If the treatment results in a reduction of pain and restoration of normal ROM, the "working diagnosis" is confirmed, and treatment may proceed.
Within the locomotor system, muscle tissue is among the most vulnerable to injury and dysfunction. The coordination of movement depends on their continual readjusting to the proprioceptive input of the various receptors. Misuse, disuse, and overuse frequently occur and many times result in muscle shortening and impaired function.
Shortened muscles may cause local pain in periosteal attachment, tendons or the muscle itself, or it may result in referred pain to other structures and/or organs.
According to Evjenth and Hamberg1, shortened, stiff muscles are often activated in movements in which they otherwise would not take part. This overuse in turn leads to injury and/or excess inhibition of their antagonists. Thus, the shorter the muscle, the greater its potential for inhibition of its antagonists.
Therefore, stimulating and strengthening a shortened muscle's antagonist always aids in treatment. However, the shortened muscle should always be stretched before its antagonists are strengthened.
With experience, careful observation and palpation, one can detect specific muscles that are shortened and restrict the ROM. In addition to the office procedure, properly instructed home stretching exercises should be taught to the patient, with care directed to isolating the shortened muscular tissue. Often over-zealous self-stretching is nonspecific and may do more harm than good.
In some cases, irreversible changes may have occurred, e.g., collagen replacement of sarcomeres. Normal ROM and movement patterns may not be completely restored. However, even in cases where increases in ROM are very limited, stretching can still be valuable, particularly because of its pain reducing effect.
Research Considerations
There is considerable research supporting the efficacy of Therapeutic Muscle Stretching (TMS). The bulk of this research, as it concerns flexibility techniques, has been performed by physical therapists.
The work of Voss, Ionta, and Myers form the basis of the Proprioceptive Neuromuscular Facilitation technique (PNF). Their work stemmed from the concepts developed by Dr. Herman Kabat in the 1940s for the treatment of paralysis. Kabat's concepts were a result of his observations of the "Kenny technique" and his knowledge of Sir Charles Sherrington's work in neurophysiology.
PNF has been more broadly applied to patients whose deficits can include motor pattern imbalances as a result of more minor injuries; such as contractures that developed while leg or arm fractures heal.
Since the development of these techniques, investigations into their efficiency have been performed by various researchers.
Entyre and Abraham2,3 conducted studies comparing static stretching (SS), contract-relax-antagonist-contract (CRAC), of the soleus muscle. The latter two are methods used in the proprioceptive neuromuscular facilitation technique. In these studies, it was found that CRAC was most effective for increasing range of motion as compared with the other methods studied.
Sady, Wortman and Blanke4 performed a flexibility study, and evaluated the efficacy of different types of stretching; ballistic (repetitive bouncing), static (extended passive positioning), and PNF (alternating contractions and stretching). Their findings indicated that the PNF stretch produced the greatest increase in range of motion. increase in range of motion.
Not all studies have consistently found significant differences between stretching techniques5. However, while debate remains as to the findings when the various types of stretching techniques are compared, clinical experience has shown the CRAC technique to be effective for the purpose of increasing flexibility and to aid in resolving muscular imbalances.
Therapeutic Muscle Stretching is presented as a derivative of the CRAC technique. It is best applied to patients who are without degenerative neurologic or myopathic conditions, but who have restriction due to adaptive shortening of the soft tissue structures. Care is taken to stretch one muscle or group of synergists, in a direction opposite of the compound action of the muscle(s), with minimal joint compression or compromise.
In conclusion, it is well to remember that the antagonist/agonist relationship is complex in its nature, requiring a concerted response for smooth, coordinated movements. Therefore, remedial exercises should be given in regards to function and ROM, and not with regard to findings of static muscle tests.
- Evjenth, O., J. Hamberg. Muscle Stretching in Manual Therapy. Sweden, Alfta Rehab, 1980.
- Entyre, B.R., L.D. Abraham. "Gains in Range of Ankle Dorsiflexion Using Three Popular Stretching Techniques." American Journal of Physical Medicine. Vol. 65, pp. 189-196, 1986.
- Entyre, B.R., L.D. Abraham. "H-Reflex Changes During Static Stretching and Two Variations of Proprioceptive Neuromuscular Facilitation Techniques." Electroencephalography and Clinical Neurophysiology. Vol. 63, pp. 174-179, 1986.
- Sady, S.P., M. Wortman, D. Blanke. "Flexibility Training: Ballistic, Static or Proprioceptive Neuromuscular Facilitation." Archives of Physical Medicine and Rehabilitation. Vol 63, pp. 261-263, 1982.
- Condon, S.M., R.S. Hutton. "Soleus Muscle Electromyographic Activity and Ankle Dorsiflexion Range of Motion During Four Stretching Procedures." Physical Therapy. Vol 67 (1): pp 24-30, 1987.
