 Is a general term used to describe any therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility by elongating (lengthening) structure that have adaptively shortened and have become hypomobile over time

• Increase flexibility
  -(jnt ROM+soft tissue extensibility)
  
  
  

• improving general fitness:
  -(stretching exercises routinely are recommended for warm-up prior to or cool-down following strenuous physical activity, essential part of conditioning programs for general fitness, for recreational or workplace activities, and for training in preparation for competitive sports).
  
  
  

• increased power:
  -Increasing distance over which they are able to contract potential increase to our muscles power and therefore increases our athletic ability, while also leading to an improvement in dynamic balance, or the ability to control our muscles.
  
  
  

• Injury prevention & reduced postexercise muscle soreness:
  -Few studies have suggested that stretching, as part of a warm-up routine immediately before vigorous physical activity prevents or reduces the risk of injury.
  
  
  

• Enhanced performance:
  -Enhanced physical performance such as increased muscular strength, power or endurance or improvements in physical functioning, including walking & running speed & jumping ability

1-A bony block limits jnt motion

2- Recent fracture, & bony union is incomplete.

3- There is evidence of an acute inflammatory or
infectious process (heat & swelling) , or soft tissue healing could be disrupted in the restricted tissues & surrounding region.

4- There is sharp acute pain with jnt movement or ms elongation.

5- A hematoma or any other indication of tissue trauma is observed.

6-Hypermobility already exists.

7- Shortened soft tissues provide necessary jnt stability in lieu of normal structural stability or neuromuscular control

8- Shortened soft tissues enable a patient with paralysis or severe ms weakness to perform specific functional skills otherwise not possible

1-ROM is limited because soft tissues have lost their extensibility as the result od adhesions, contractures, & scar tissue formation, causing activity limitations (functional limitations) or participation restrictions (disabilities)

2- Restricted motion may lead to structural deformities that are otherwise preventable.

3- Muscle weakness and shortening of opposing tissue have led to limited ROM.

4- May be a component of a total fitness or sport-specific conditioning program designed to prevent or reduce the risk of musculoskeletal injuries

5- May be used to and after vigorous exercise to potentially reduce postexercise muscle soreness.

• Form or manner in which the stretch force is applied (static, ballistic, cyclic)
• Degree of patient participation. (passive, assisted, active)
• Or the source of the stretch force. (manual, mechanical, self)
  

• • Proper alignment or positioning of the patient & the specific muscles & jnts to be stretched is necessary for the patient comfort & stability during stretching. Alignment influences the amnt of tension present in soft tissue & consequently affects the ROM available in jnts.
  
  
  

• For eg: To stretch rectus femoris ( a ms that crosses 2 jnts) effectively, as the knee is flexed & hip extended, the lumbar spine & pelvis should be aligned in a neutral position. The pelvis should not tilt anteriorly nor should the low back hyperextend.

• o To achieve an effective stretch of a specific muscle or ms group & associated periarticular structures, it is imperative to stabilize (fixate) either the proximal or distal attachment site of the muscle-tendon unit being elongated.
  
  
  

o Eg: When stretching the iliopsoas, the pelvis & lumbar spine must maintain a neutral position as the hip is extended to avoid stress to the low back region. Sources of stabilization include manual contacts, body weight, or a firm surface such as a table, wall.

• o The intensity (magnitude) of a stretch force is determined by the load placed on soft tissue to elongate it.
  
  
  

o There is a general agreement among clinicians & researchers that stretching should be applied at low intensity by means of a low load.

o Low intensity stretching in comparison to high-intensity stretching makes the stretching maneuver more comfortable for the patient & minimizes voluntary or involuntary muscle guarding so a patient can either remain relaxed or involuntary ms guarding so a patient can either remain relaxed or assist with the stretching maneuver.

o Low-intensity stretching (coupled with a long duration of stretch) results in optimal rates of improvement in ROM without exposing tissues, possibly weakened by immobilization, to excessive loads & potential injury.

o Low-intensity stretching has also been shown to elongate dense connective tissue, a significant component of chronic contractures more effectively & with less soft tissue damage & post-exercise soreness than a high intensity stretch.

• A commonly used method of stretching in which soft tissues are elongated just past the point of tissue resistance & then held in the lengthened position with a sustained stretch force over a period of time.
  
  
  

• Other terms used interchangeably are sustained, maintained, or prolonged stretching. The duration of static stretch
  is predetermined prior to stretching or is based on the patient’s tolerance and response during the stretching procedure.
  
  
  

• In research studies the term “static stretching “has been linked to durations of a single stretch cycle ranging from as few as 5s to 5mins per repetition when either a manual stretch or self stretching procedure is employed.
  
  
  

• During static stretching it is thought that the GTO which monitors tension created by stretch of a muscle-tenon unit, may contribute to ms elongation by overriding any facilitative impulses from the primary afferents of the ms spindle ( Ia afferent fibers) and may contribute to ms relaxation by inhibiting tension in the contractile units of the ms being stretched.
  

• Progressive stretching is another term that describes how static stretch is applied for maximum effectiveness. The shortened soft tissues are comfortably held in a lengthened position until a degree of relaxation is felt by the patient or therapist.
  
  
  

• Then the shortened tissues are incrementally lengthened even further & again held in the new end-range position for an additional duration of time.
  
  
  

• This approach involves continuous displacement of a limb by varying the stretch force (stretch load).
  

• Short duration stretch cycle. A relatively short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied is describe as a cyclic (intermittent) stretch.
  
  
  

• Cyclic stretching, by its very nature, is applied for multiple repetitions (stretch cycles) during a single treatment session. With cyclic stretching the end-range stretch force is applied at a slow velocity, in a controlled manner, and at relatively low intensity. For these reasons, cyclic stretching is not synonymous with ballistic stretching, which is characterized by high-velocity movements.
  

• To ensure optimal ms relaxation & prevent injury to tissues, the speed of stretch should be slow. The stretch force should be applied & released gradually.
  
  
  

• Slowly applied stretch is less likely to increase tensile stresses on connective tissues or to activate the stretch reflex & increase tension in the contractile structures of the ms being stretched.
  
  
  

• Stretch force applied at a low velocity is also easier for the therapist or patient to control & is therefore safer than a high-velocity stretch.
  

• Refers to the number of bout (sessions) per day or per week a patient carries out a stretching regimen.
  
  
  

• The recommended frequency of stretching is often based on the underlying cause of impaired mobility, the quality & level of healing of tissues, the chronicity & severity of a contracture as well as a patient’s age.
  
  
  

• 3 to 5 repetitions per session & done 3 times a week is considered as an adequate for gaining improvements in the flexibility of soft tissues
  
  

.

• Further the decision relies upon the therapist according to the clinical scenario.
  

During manual stretching
a therapist or other trained practitioner applies an external force to move the involved body segment slightly beyond the point of tissue resistance & available ROM.
-
The therapist manually controls the

• site of stabilization as well as the
• direction,
• speed,
• intensity
• & duration of stretch
  

Devices which are commonly used for mechanical stretching are

• weight cuffs,
• mechanical pulley devices with springs,
• CPM &
• orthosis such as serial casting or splints.

Sometimes referred to as active stretching or facilitative stretching.
-
Integrate active ms contractions into stretching maneuvers purportedly to inhibit or facilitate ms activation & to increase the likelihood that the ms to be lengthened remains as relaxed as possible as it is stretched.

• Proprioceptive:
  -Having to do with any of the sensory receptors that give information concerning movement & position of the body.
  -
• Neuromuscular:
  -Involving the nerves & ms
  -
• Facilitation:
  -Making easier
  

The methods comprising these factors were formulated frm findings on neuromuscular development of all movements
frm a stage of motor immaturity
to a stage of motor maturity
in the growing child
in a definite sequence of
progressing logically from:

• Total to individual
• Proximal to distal & distal to proximal
• Mobile to stable
• Gross to selective
• Reflexive to voluntary
• Overlapping to integrative
• Uncoordinated to coordinated
  

This adapts certain PNF techniques & principles for application by hand or apparatus in physical conditioning.
Eg: springs, weights, therabands etc

5 imp factors to be kept in mind while giving PNF:

• Principles
• Procedures
• Patterns
• Positions
• Postures
  

• The capacity of motor activity performed by an individual depends upon his learned neuromuscular response.
  -
• This capacity even under normal circumstances is much less than the actual potential of the individual.
  -
• Such untapped potential can be developed under environmental situations, stressful situations, or by increased voluntary efforts
  -.
• PNF is based on this principle where the remaining potential in the patient is used to reach the maximum performance level in him or her.
  

• During normal growth & development, motor activity first develops in the head & lastly in the extremities (cephalocaudal) & proximal to distal.
  -
• Thus, the treatment using PNF also should progress in the same developmental sequence.
  

• With maturity, the primitive reflexes get integrated & become useful for various activities like crawling, rolling, etc.
  -
• Even in normal individuals, some of these reflexes have been shown to influence tonic changes in the ms ( Helebrant & associates).
  -
• Thus, reflexes may be used to facilitate movement at some body parts by using various developmental posture or by using the head & trunk with extremity patterns.
  

• These movements are rhythemic & oscillatory
  -
• This principle means that any goal directed movement that we perform has 2 directions,
• one to accomplish the task
• & the other for unwinding the task.
  -
• Hence, when we treat a patient we should give the movement patterns in both the direction.
  
  

• During growth, it is noted that milestones are reached in a specific sequence,
• initially simple movements are achieved,
• & finally complex skillful activities are learned.
• The movem patterns of the extremities usually require proper contribution from specific movem pattern & position of the head, neck & trunk
  (eg while bowling; hand moves along with specific movement of trunk for speed, power, accuracy, & timings).
  -
• Thus, while treating patients, fundamental movements are first taught & then more complex movements are given.
  -
• Emphasize on proximal stability before going for coordinated skillful movements of the distal part.
  

• During normal growth development, there exists shifts between the agonist and antagonists in terms of its dominance which is essential to establish a balance between the agonist and antagonists.
  -
• Otherwise, one group would have been weak and other strong. Eg: A child practicing
  rocking movements before crawling.
  -
• PNF also aims at developing balance between the opposite group of muscles, working on the weak muscle.
  

• During normal growth and development, the child does not necessarily perfect one activity before
  going to next task.
  -
• In training a patient for a specific task against a certain postural background, it is necessary to follow the developmental sequence.
  For eg: If you are not able to teach positioning
  the UE to a stroke patient in sitting posture, then we need to teach him the same activity in supine
  lying then progress.
  -
• On the contrary, some activities are benefitted by making the patient to perform on a higher level activity.
  -

• For instance, while gait training, even before the patient walks perfectly on a level surface, the patient can be taught to walk on uneven surface or climb stairs.

  
  

  -

  
  

• This development will enable the patient to walk better on even surfaces.

  
  

• Functional movements depend upon the balance between reflex activity, flexor extensor
  dominance and reversing movement – Main objective of PNF.
  -
• Eg: If a patient is not able to sit due
  to dominance of back extensors or if a hemiplegic patient has poor release due to dominant flexor
  synergy, then the opposite movements have to be given to restore balance between the two
  groups.
  

• PNF approach uses multisensory input to enhance motor learning. Visual, auditory, verbal and
  tactile inputs are given to the patient.
  -
• Eg: When working on the shoulder flexion and adduction by
  asking the patient to take his hand towards the mouth, at the same time, the patient may be asked
  to see the movement and the therapist appropriate hold provides the multisensory input that helps
  in learning the task.
  -
• Motor learning is said to be accomplished only when the patient does not need such external cues to perform a task.
  

The patient needs the opportunity to practice the learned motor skills. Only after repeated practice
will the activity become automatic and efficient.

• Realistic functional goals are continually set for the patient through-out the treatment.
  -
• Activities that have meaning for the patient are more effectively integrated into motor learning.
  -
• Improvement in function cannot be achieved with instruction and practice alone, it is essential that
  the therapist provides manual contacts and techniques to facilitate a desired response.
  Eg: To train
  a stroke patient for release of hand, sudden stretch to finger extensors may be given or joint
  approximation to the shoulder can be given to develop proximal fixation in cerebellar lesion.
  
  

• The patient should be positioned appropriately so that movements are
  free to occur without any hindrance.
  -
• The therapist position should be comfortable and such that he is able to maintain the manual contact without any discontinuity.
  

• Manual contact of the therapist is necessary to facilitate and guide movement.
  -
• The specific manual contact recommended is lumbrical grip.
  -
• The grip should offer exteroception,
  stretch, resistance and traction / approximation.
  -
• Multiple grips may cause a conflict in the sensory information sent to the brain and hence should be prevented.
  

• Stretch is used to facilitate movement or to increase the power of the weak muscle.
  -
  
  • According to Sherrington’s principle, when a muscle is stretched, the Ia and Il fibres in the muscle
    spindle send excitatory messages to the alpha motor neurons which innervate the stretched
    muscle.
    Inhibitory messages are sent to the antagonistic muscle simultaneously.
    -
  • In PNF, while giving stretch, the muscle is kept in the lengthened position which is the starting position of the
    pattern.
    -
  • Stretch produces reflex activation of the muscle which is then synchronized with the volitional effort using the visual, verbal and auditory cueing.
    -
  • The applied stretch should be appropriate as stretching too enthusiastically can only be harmful.
    

• The therapeutic movement given in PNF are usually mass movement pattern that is
  used for our activity of daily living.
  -
• The patterns given are spiral or diagonal movement pattern forming an angle of approximately 45 degrees to the trunk.
  -
• These should be movements which are
  essentially crossing the midline of the body.
  

• There is a normal sequence in which various components of a movement pattern occur.
  -
• The timing for which each component should work is determined by the control exhibited by the
  cerebellum.
  -
• Under normal circumstances, the movement is initiated by the rotary components,
  -
• because the rotary component initiates the movement, the movement starts in the distal most components, then the intermediate and lastly the proximal components.
  This is called as
  appropriate timing and sequencing of all movements.
  -
• It is important that the movement at the
  distal components gets completed before the movement at the proximal components gets completed.
  

• This means there is a spread of impulses or energy from a strong muscle to weak muscle especially when the stronger muscles work against a very high resistance.
  -
• Irradiation is possible from proximal to distal or from distal to proximal.
• Weaker muscle group is usually benefitted with this irradiation.
  -
  -In order to stimulate irradiation of impulses from stronger muscles to weaker muscle, the therapist
  must give a very high resistance to the strong muscle such that there is spread of impulse to the
  weaker muscle and that in turn facilitates the weak muscle.
  -
  -Therapist can stimulate the contraction
  of quadriceps by giving resistance to the dorsiflexor, or can give very high resistance to the hip flexors to stimulate dorsiflexors.
• Irradiation is also possible from the stronger arm to the weaker arm.
  -
• In spasticity, irradiation of impulses give rise to associated reaction which is pathological and should
  be discouraged otherwise, the patient will habituate.
  -
• In normal circumstances, associated movements are noted like swinging of arm while walking,
  clenching of teeth while lifting heavy weight.
• These reactions are also due to irradiation but they
  are physiological.
  

• The therapist should be skillful enough to give maximal resistance and not
  maximum resistance.
  -
• Maximal resistance is the one against which the patient is able to perform full
  range of movement in a smooth manner for an isotonic muscle work.
  -
• For an isometric muscle work,
  maximal resistance is the one which stimulates the muscle to work to its maximum capacity
  without the therapist breaking the hold of the patient.
• However, it should be noted that the
  therapist needs to also assist the patient when he or she finds it difficult to perform the
  movement smoothly against resistance.
  

The joint structures are the articular cartilage, capsule, synovium, ligaments, etc.

is necessary to stimulate co-contraction of muscles around a joint that will
help in stability.

• Approximation is given in PNF when the movement is performed towards
  gravity.
• It is also given through the use of weight bearing postures in addition to the manual forces.
  

on the contrary is given when the movement is done against gravity and it
produces a stretch stimulus and enhances movement by elongating the adjacent muscles.

• The auditory input given by the patient can be used very effectively both to facilitate as
  well as inhibit.
  -
• Input should be very simple, easy for the patient to understand.
• The therapist should avoid
  long sentences as this will confuse the patient.
  -
  -Buchwald states the tones of moderate intensity evoke gamma motor neuron activity
• while louder ones alter the alpha motor neuron activity.
  -
• Strong commands are used when the maximal motor stimulation is desired.
  -
• A soft voice is used to offer
  reassurance and to relax the muscle.
  

• Visual stimuli help in initiation and coordination of movement.
  
  • It also guides the
    movement in proper direction.
    -
  • Using these various sensory feedbacks will cause summation of the stimulus provided that will help in maximizing the motor output which is the ultimate aim of any therapy.
    

Facilitatory impulse are given simultaneously to promote excitation of a maximal response.

Facilitatory impulse are given one after the other
but very close to each other in time
so that there is overlapping of input
given to produce
maximal output from the patient.

It involves repeating the chosen pattern several times
through full range against maximum resistance ensuring movement at all times.
-
Once the pattern has been completed,
the therapist passively returns the limb to the lengthened position
ready for the next repetition.
-
Repetition helps in the bombardment of the motor neurons by many impulses – summation.
-
Best suited for conditions with generalized weakness of the ms or stroke where the patient is not able to perform a specific pattern or if the movement is performed in a faulty way.

it is the part
distal to the pivot
& ms at this part is contracting at their inner range.

part proximal to pivot
and this part is contracting at the middle range.

joints across which the weak ms or weak component of the pattern is present.
Movement is allowed to take place in full range.
Muscles are allowed to contract for a longer time than usual.

• Patient is asked to perform isotonic work of the agonist ms till further movement cannot be brought about due to weakness.
  -
• At this point the therapist gives resistance & makes the ms contract isometrically to bring about requirement of all the motor units in the ms
  -.
• Immediately following which the patient is asked to take the limb further into the agonist pattern by making the weak ms contract isotonically.
  -
• Thus, this technique is effective to facilitate contraction of ms which have not been active for some time in this shortened range, also it helps to bring about the lengthening effect in the antagonist ms through the principle of reciprocal inhibition
  (contraction of a ms caused relaxation of its antagonist)
  

In PNF, the therapist can bring about lengthening of ms by 2 ways

Eg: if elbow flexion is restricted due to hypertonic elbow extensors, then according to this method, the elbow extensors should be made to contract maximally so that it follows up with complete relaxation.

• the contraction of the antagonist ms is brought about in an isotonic way

• the contraction of the antagonist ms is brought about in an isometric way
  

Helps in relaxation & strengthening.
It aims to bring about stability around a joint by correcting the muscular imbalance.
-
It is very effective in patients with cerebella lesions who exhibits problems in proximal fixation.
-
Co-contraction occurs if the patient is not allowed to relax.
-
The skills lies in rhythmically alternating the resistance between both the group of muscles (agonist & antagonist).
-

• There is coordinated transitions between antagonists.
• The resistance should be increased gradually taking care never to break the patient’s hold.
  -
  The therapist should asses both group of muscles around a joint & find out which group needs relaxation & which group needs strengthening.
  -
  It may be possible that both groups of muscles may need to be strengthened for a particular case.
  -
  The therapist takes the part passively to the point where co-contraction is desired.
  -
  The therapist gives command “hold”.
  -
  Emphasizing on the rotatory component of the pattern, the therapist alternates the resistance between the agonist & antagonist pattern.
  -
  Gradually the resistance is increased until the patient is working maximally.
  -
  The final hold is in the pattern antagonist to the tightness or on the side that needs to be strengthened.
  -
  The patient is then asked to contract isotonically by moving through as much range as possible.
  -
  Then the co-contraction can be trained in a new range.

The therapist selects the pattern to be trained and begins to move it through full range in a smooth manner.
(relax & let me move your hand).
-
As the therapist feels complete relaxation, the patient is instructed to contribute actively in the movement performance without increasing the tone or tension in the muscles
(now do it with me without getting too excited).
-
After the patient is able to master several repetitions of active movement without increase in generalized tone, resistance is incorporated into the exercise.