Stretching in Physical Therapy: Problem or Solution?

Jul 8, 2020
9 min read
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Flexibility is relative. The length-tension relationship for muscle fibers means that the muscle fiber length must be optimal to generate optimal force. However, the optimal length is not always the entire length.

Of late, there has been an exponential surge in online healthcare content; lifestyle/health coaches, clinicians, and many professionals are trending for debunking various myths. Of these, articles/blogs focusing on merits/demerits of stretching caught my eye. Two ideas are commonly shared:

  1. Stretching has no benefits, except for some sports and rehabilitation.
  2. Stretching is beneficial for everyone and is part of general fitness.

Both cannot be true, so let’s find out

Flex, Flexibility, and Mobility:

Strength and endurance exercises require mobility and optimal muscle length.

Flexibility is relative. The length-tension relationship for muscle fibers means that the muscle fiber length must be optimal to generate optimal force. However, the optimal length is not always the entire length. Additionally, we are born with differing amounts and sizes of skeletal muscles (fast-twitch and slow-twitch). We can control and convert them to an extent with exercises and training, but they depend on non-modifiable factors (genetics) as well. It comes down to our fitness/athletic goals and daily activities.

While flexibility has its terms and conditions, mobility is necessary. Mobility refers to the joint range of motion, while flexibility is the extent of lengthening of the active (muscles) and passive structures (ligaments). Both are co-dependent. We use these terms interchangeably, but it has a high stake.

The Problem

stretch 1

  1. There is a plethora of research studies exploring the spectrum of ideal warm-ups and stretching. There is a constantly evolving debate, yet inconclusive, about the parameters and benefits of stretching/flexibility training in sports as well as rehabilitation. The caveat is that most of these studies are sport-specific and with many inconsistencies. Even the meta-analyses and systematic reviews are questionable due to no universal standardization.
  2. There is a contrast in many rehab protocols, often blurring the lines between mobility, myofascial release, and stretching. Furthermore, inadequate periodization and dosage can do more harm than good.
  3. An abundance of anecdotal evidence, personal bias, and conflicting information from various sources further add to the confusion.

Here’s what we know:

*Flexibility training includes warm-ups, stretches, cool-downs, and myofascial rolling.

Warm-up:

warm up

General warm-ups are pulse raisers, increasing the core body temperature and blood circulation to the muscles. For example, most cardio exercises - bikes, jumping jacks, brisk walking, and treadmills.

Specific warm-ups are relevant exercises for muscle groups or movements that ease us into the routine. They are like a controlled rehearsal for the final performance. For example, dynamic warm-ups for runners, and static hamstring stretches for squats, lunges.

Cooldown:

After any physical activity (exercise, sports), the heart rate should be gradually brought back to the normal range. If the patient stops too fast, they could pass out or feel sick.

Stretching:

cool down

Research so far:

Research so far:

  1. Dynamic stretches performed prior to strength and high velocity exercises may be more beneficial than static stretching.[1][2][3][13]
  2. Prolonged static stretching (> 60-90 s) may have a negative effect on the following exercises. This also depends on the physical fitness level of the individual/athlete as well as the intensity of the workout. [2][3][4]
  3. All forms of stretching (static, dynamic, PNF, myofascial rolling) usually improve the ROM (short-term improvements).[5][6][9]
  4. There is lack of significant and homogenous evidence to show that stretching/flexibility training decreases soreness or reduces the incidence and intensity of future injury.[5][7][12]
  5. Following exercise/sports, massage and cold temperature treatments may be efficient for reducing post-exercise soreness and pain.[8]
  6. Myofascial rolling/release (Foam roller/massage stick/massager) is neither superior, nor a substitute to stretching exercises.
  7. Myofascial rolling/release may be beneficial during the warm-up phase rather than the cool-down.
  8. Myofascial rolling/release for 2-3 minutes for each muscle may help with decreasing pain and soreness (short-term improvements). However, it may not be resourceful for chronic pain conditions.[6][9][10][11]

Relevance to Physical Therapy:

stretch 2

  1. While there is little to no statistical correlation between fitness and flexibility, it reserves its importance in therapy. The most relevant take-home message would be to maximize its use for ROM gains.
  2. Consider the order of exercises since the acute and long-term effects of stretching/recovery differ. It may be preferable to use dynamic stretches/warm-ups before exercises and static exercises after.
  3. The treatment plan should be customized depending on individual patient goals. More caution should be taken with athletes’ plan of care (recreational/seasonal/elite). Stretching and flexibility training MAY NOT BE FOR EVERYONE. Some high-intensity sports and neurological disorders benefit from the stiffness of the muscle-tendon unit.
  4. Emphasis should be on continuing education courses and updated future research for flexibility metrics and dose-response relationships.
  5. Get the facts right; make sure the referred research studies/sources are reliable, recent, and valid.

The Solution: Elevate the clinical practice

Numerous confounding variables affect the results from stretching and flexibility training. Our skills and professional experience give us a competitive advantage; let's make most of it.

1.Understand the patient, not just the injury:

With telehealth and the growing importance of preventive health care, patient education is of utmost priority. On the first visit, in addition to history and assessments, try to understand their lifestyle as well.

When we treat objectively, we fix the symptoms and the cause. When we treat subjectively, we improve the quality of life. We need to balance both for patient-centered care.

2. Find the Missing Piece!

Collateral damage is inevitable; local injury has a global impact. See the bigger picture; evaluate for secondary deficits and hidden causes. Asking relevant questions about the patient’s occupation, ADLs can reveal useful information. An integrated approach must include the entire biomechanical chain.

3. Patient Education: Evidence-based Rehab

Explain the mechanism of injury and the best therapy approach. Patients may not be interested. They prefer to re-route to the treatment. Lay it out for them; they ought to know what's wrong and how to fix it. There are many misconceptions in the community about fitness, stretching, yoga, and flexibility. The least we can do is clarify.

  1. Community awareness: With telehealth, injury screens, video conferencing, and other digital marketing options, it is easy to deliver information.
  2. Clinic: Infographics, posters, and hand-outs about the relevant anatomy, injury prevention tips, and fitness myths.
  3. Often, patients don’t get the connection between exercises. I get these a lot; “ But this is not hurting.”, “How is this exercise related to the injury?” and “ Should I keep doing these even if nothing hurts?” Tell them why they are doing seemingly unrelated exercises, they will be more mindful.

On a Personal Note:

  1. There is a time and place for all types of exercises. With more clinical experience, we observe trends and use them for tricks of the trade.
  2. Strength alone is not enough; functional mobility and endurance are essential for daily activities.
  3. Physical activity and flexibility training are not just for athletes.
  4. Our daily postures and movements form muscle memory; the more repetitive we are more is the risk of overuse injuries. Postural awareness and flexibility training can help break faulty patterns.
  5. The first phase of rehab should focus on joint range of motion (ROM) and flexibility training to maximize future strength gains. However, with the progression towards the return to function, flexibility should not be entirely discounted.


References:

[1] Ayala F, De Ste Croix M, Sainz De Baranda P, et al. Acute effects of two different stretching techniques on isokinetic strength and power. Rev. Andaluza Med. del Deport. [Internet]. 2015;8:93–102. Available from: http://dx.doi.org/10.1016/j.ramd.2014.06.003.

[2] Lima CD, Ruas C V, Behm DG, et al. Acute Effects of Stretching on Flexibility and Performance: A Narrative Review. J. Sci. Sport Exerc. [Internet]. 2019;1:29–37. Available from: https://doi.org/10.1007/s42978-019-0011-x.

[3] Chaabene H, Behm DG, Negra Y, et al. Acute Effects of Static Stretching on Muscle Strength and Power: An Attempt to Clarify Previous Caveats. Front. Physiol. 2019;10.

[4] Kay AD, Blazevich AJ. Effect of acute static stretch on maximal muscle performance: a systematic review. Med. Sci. Sports Exerc. 2012;44:154–164.

[5] Behm DG, Blazevich AJ, Kay AD, et al. Acute effects of muscle stretching on physical performance , range of motion , and injury incidence in healthy active individuals : a systematic review. 2016;11:1–11.

[6] Wilke J, Müller A-L, Giesche F, et al. Acute Effects of Foam Rolling on Range of Motion in Healthy Adults: A Systematic Review with Multilevel Meta-analysis. Sports Med. 2020;50:387–402.

[7] Herbert RD, de Noronha M, Kamper SJ. Stretching to prevent or reduce muscle soreness after exercise. Cochrane database Syst. Rev. 2011;CD004577.

[8] Dupuy O, Douzi W, Theurot D, et al. An evidence-based approach for choosing post-exercise recovery techniques to reduce markers of muscle damage, Soreness, fatigue, and inflammation: A systematic review with meta-analysis. Front. Physiol. 2018;9:1–15.

[9] Hughes GA, Ramer LM. DURATION OF MYOFASCIAL ROLLING FOR OPTIMAL RECOVERY, RANGE OF MOTION, AND PERFORMANCE: A SYSTEMATIC REVIEW OF THE LITERATURE. Int. J. Sports Phys. Ther. 2019;14:845–859.

[10] Kalichman L, Ben David C. Effect of self-myofascial release on myofascial pain, muscle flexibility, and strength: A narrative review. J. Bodyw. Mov. Ther. [Internet]. 2017;21:446–451. Available from: https://doi.org/10.1016/j.jbmt.2016.11.006.

[11] Laimi K, Mäkilä A, Bärlund E, et al. Effectiveness of myofascial release in treatment of chronic musculoskeletal pain: a systematic review. Clin. Rehabil. 2018;32:440–450.

[12] Witvrouw E, Mahieu N, Danneels L, et al. Stretching and Injury Prevention. Sport. Med. [Internet]. 2004;34:443–449. Available from: https://doi.org/10.2165/00007256-200434070-00003.

[13] Silva LM, Neiva HP, Marques MC, et al. Effects of Warm-Up, Post-Warm-Up, and Re-Warm-Up Strategies on Explosive Efforts in Team Sports: A Systematic Review. Sport. Med. [Internet]. 2018;48:2285–2299. Available from: https://doi.org/10.1007/s40279-018-0958-5.

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About Radhika Patel, PT, MS, MBA

I am an enthusiastic Physical Therapist with a passion for health and wellness promotion. I was introduced to clinical research during my Master's in Rehabilitation Sciences (UIC, Chicago) program, and I fell in love with evidence-based rehabilitation. I recently moved to Canada after working for 3 years in outpatient PT (Novacare Rehabilitation, Chicago). Currently, I work as a Clinical Researcher for the University Health Network (Canada). When I am not working, I am an avid traveler, gastronome, and a recent fan of board games.


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