GENERAL CHARACTERISTICS
There are several types of stretching that can be used for different purposes: passive, active, passive-active, and stretching as a part of muscle energy techniques. We will discuss here only passive stretching because this technique is an integral part of the therapeutic massage and stress reduction massage session, and does not requires the participation of the client.
THE PLACE AND ROLE OF PASSIVE STRETCHING AS A STRUCTURAL COMPONENT OF THE MASSAGE SESSION
During passive stretching, the practitioner stretches a part or segment of the client’s body with the client’s muscles completely relaxed. The stretching technique is usually applied to the segment or part of the body at the end of its treatment.
For example, say the practitioner is working on the upper extremity: After he or she has finished the massage of the hand, 1 or 2 passive stretches should be applied to the hand and wrist joint.
After massage of the forearm, 1 or 2 passive stretches should be applied with one hand placed above (proximal to) the client’s wrist joint and the other placed above (proximal to) the client’s elbow joint, stretching thus the forearm in opposite directions.
After having completed the massage of the upper arm, the practitioner should apply 1 or 2 stretches with one hand placed above (proximal to) the client’s elbow and the other placed on the upper shoulder, and pulling the hands in opposite directions.
Finally, the practitioner should finish the massage of the upper extremity with 1 or 2 passive stretches of the entire limb by holding the client’s hand below (distal to) the wrist joint using one hand, placing the other hand on the upper shoulder or the posterior neck, and pulling the hands in opposite directions.
PHYSIOLOGICAL ROLE OF PASSIVE STRETCHING
The main therapeutic effects of passive stretching are:
– additional muscle relaxation through the activation of the Goldgi tendon organ receptors;
– the straightening of the tendons and ligaments around the joints;
– the releasing of pressure inside of the joints;
– the restoration of elasticity of the soft tissue;
– the stimulation of blood circulation in the skeletal muscles; and
– the inactivation of recently formed trigger points in the muscles.
Any mechanical stimulus, especially stretching, stimulates the tone of the vascular walls: i.e., causes vasoconstriction with subsequent vasodilation after the release of pressure. The passive stretching of large muscles by 0.5 cm increases blood circulation by up to 30%.
There are numerous studies which have shown that regular active and passive stretching are directly responsible for the formation of new capillary networks in the skeletal muscles.
Stretching is a simple technique, however the client can be easily hurt by its inappropriate application. As a result of overstretching, for instance, muscles, tendons and ligaments can be pulled and strained. To avoid this, the client’s muscles have to be completely relaxed, and the practitioner has to carefully estimate the degree of stretching to be applied.
TECHNICAL DISTINCTIONS OF PASSIVE STRETCHING AS COMPARED WITH OTHER MASSAGE TECHNIQUES
For the correct application of stretching, the practitioner must tightly grasp the segment of the body. Thus, the main contact areas are the whole of the palms and the fingers.
Stretching can be applied in longitudinal, diagonal or perpendicular directions to the axis of the extremity or the orientation of muscle fibers on the flat parts of the body.
The individual elasticity of the client’s soft tissue is a factor which determines the intensity of the stretch and varies from person to person. A simple Elasticity Test allows the practitioner to estimate this important parameter of the individual’s soft tissue.
This video demonstrates the Elasticity Test. Before treatment is begun, ask the patient to passively adduct the thumb in the direction of the forearm using his or her other hand. The video shows two outcomes of the Elasticity Test. At the beginning of the video a person with low elasticity of the soft tissue performs the test, while in the second part of the video the same test is performed by a person with high elasticity of the soft tissue. The white arrows indicate the direction of applied pressure.
If the practitioner calls upon the range of motion in the joint as a tool to stretch the soft tissue, he or she must, before the stretch, determine the comfortable (i.e., physiological) range of motion (in medical parlance, often abbreviated as ‘ROM’) of the joint. This allows to avoid unexpected injuries.
The pressure applied by the grasping hand has to be strong enough to securely hold the segment of the body during the stretch. For this reason, it is best to remove any lubricant from the skin before the stretch, or to use a towel to prevent your hand(s) from slipping off the skin.
TYPES OF PASSIVE STRETCHING
SEGMENTAL STRETCHING (SS)
During SS the practitioner stretches the extremity either along its axis or by using the physiological range of motion in the joint(s). In any case, the client must be completely relaxed. SS is a simple technique, but it has one very important element which we wish to discuss separately.
During every passive stretch, all soft tissue is affected. The first tissue to be stretched is the skin and connective tissue structures. Only after they are stretched will the muscles start to stretch as well. Thus, the practitioner has to pay close attention to his or her tactile sensations.
Ask the client to inhale quickly and exhale slowly through the mouth until all air from the lungs is gone. Immediately after the start of the exhalation, the practitioner begins the stretch (see videos below) and will feel an elastic resistance of skin, connective tissue structures and muscles. With further, slow increase of the stretch, this resistance lessens. The further careful increase of the intensity of the stretch activates the Goldgi tendon organ receptors in the tendons and the muscles, and they relax some more.
The practitioner feels this as a sudden, small additional giving-in of the stretched muscles. At this point, the practitioner should not go any further but should maintain at this same level of stretch until the exhalation completely subsides. The practitioner then releases the stretch during the client’s inhalation, and waits until a new exhalation begins before repeating the stretch.
SS ALONG THE AXIS OF AN EXTREMITY
To stretch the upper or lower extremity along its axis, the practitioner must grasp the most distal part (i.e., the hand or the foot) and gently stretch the entire limb. As we discussed above the stretch is conducted during the client’s exhalation. The video shows the passive stretching of the upper extremity.
The practitioner can also choose to stretch only a certain segment of the extremity: for example, the forearm and the areas of the wrist and elbow joints, or even only a single joint. To do this, the practitioner must create counterpressure between both hands along the axis of the extremity being stretched.
Notice in the video that to stretch the forearm, the practitioner needs to place one hand below (i.e., distal to) the wrist joint and the other hand above (i.e., proximal to) the elbow joint.
The practitioner can maintain the same intensity of pull throughout the stretch (see previous video), or can apply the pull intermittently. The video shows an intermittent passive stretch, taking as an example the arm.
The major distinction of this type of passive stretch is that it requires two exhalations per stretch. During the first slow exhalation the practitioner stretches the arm to the basic level, which is approximately 50% of the maximum possible stretch allowable by the elasticity of the soft tissue.
During the client’s upcoming inhalation, the practitioner does not release the pressure and maintains the 50% stretch.
During the second exhalation, the practitioner applies 3 or 4 additional short stretches, each of these starting from the 50% level of pressure achieved during the previous inhalation and progressively reaching 100% of the maximum possible stretch.
As soon as the second inhalation begins, the practitioner completely releases the pull, waits for the upcoming exhalation, and repeats the cycle, again using two exhalations per stretch.
SS USING THE RANGE OF MOTION
By using the physiological range of motion in joints and changing the position of the stretched extremity, the practitioner is able to target a particular muscle group, isolate a muscle, or even stretch simply a part of the muscle.
Let’s take as an example the passive stretch of the extensor digitorum communis muscle. This muscle is responsible for the extension of the fingers and wrist. Also, tension in the extensor digitorum communis muscle is one of the causes or complications of Tennis Elbow.
The first part of the video shows the passive stretch of the forearm muscles along the axis of the extremity. During this stretch the practitioner stretches the extensor and flexor muscles at the same time and in equal degree.
The second part of the video shows the passive stretch of the proximal part of the extensor digitorum communis muscle. In this case, the practitioner uses passive flexion at the wrist to address the proximal part of the extensor digitorum communis muscle. The active trigger point in the extensor digitorum communis muscle is located in its proximal part.
The third part of the video shows the passive stretch of the distal part of the extensor digitorum communis muscle. To address this part of the muscle, the practitioner should flex the wrist joint after the elbow has been flexed.
This approach to the passive stretching allows precise delivery of the therapeutic impact to the affected part of the muscle.
COMBINATION OF STRETCHING AND PERCUSSION/COMPRESSION
Another valuable technique of passive stretching is a combination of stretching and percussion or repetitive compression. During the contraction of a muscle its muscle antagonists must relax. This reflex can be used to additionally reinforce the passive stretch.
The practitioner should apply percussion or quick repetitive compressions to the tendons of the muscle antagonist of the stretched muscle. As a result of the compression or percussion, the muscle spindle receptors in the muscle antagonist of the stretched muscle are activated and the tone of the muscle antagonist slightly increases. This increase in muscle tone in the muscle antagonists brings about additional relaxation in the stretched muscles.
Let’s discuss this technique taking as an example the passive stretching of the triceps brachii muscle. During the client’s prolonged exhalation, the practitioner flexes the elbow joint to use the range of motion in the elbow to stretch the triceps brachii muscle.
During this stretch, the practitioner simultaneously applies quick repetitive compressions on the tendon of the biceps brachii muscle which is the antagonist of the triceps brachii muscle. Because the flexed elbow blocks the view of the left thumb, at the end of the video we show the application of the repetitive compressions on the tendon of the biceps brachii muscle.
LOCAL STRETCHING (LS)
LS uses the same principles as Segmental Stretching. The main difference between this technique and Segmental Stretching is in the area of the technique’s application. LS can be applied to a joint, or to skeletal muscles and fascia on a local level. LS can be applied in all possible directions. The direction chosen will depend upon the anatomy of the segment and the therapeutic goal of the stretching.
This video shows the application of LS to the flexor muscles on the inner surface of the forearm. Notice in the video that before LS is begun, the practitioner employs mild pressure to form a fold of skin between his hands.
To do so, the practitioner should push the skin in the direction opposite to the local stretching. When a fold of skin is formed, the practitioner slightly increases his or her grip and pulls both hands in opposite directions, stretching the forearm muscles. Without a fold of skin between the hands, the local stretch of the forearm muscles will be restricted by the tension in the skin.