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Flexibility . Definition The ROM available in a jt. or group of jts. The ability of a m. to relax & yield to a stretching force. The freedom or ability to move part or parts of body in a wide R of purposeful movs at the required speed.

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The ROM available in a jt. or group of jts.

The ability of a m. to relax & yield to a stretching force.

The freedom or ability to move part or parts of body in a wide R of purposeful movs at the required speed.

The ability to move a jt. Through a normal ROM with undue stress to musculo-tendinous unit.

  • Extensibility of periarticular tissues to allow normal motion of a joint. or a limb.

* Hypermobility

  • The ROM in excess of the accepted normal in most of joints. (may be normal)

* Laxity

  • Excessive jt. instability & abnormal motion of a given joint. (pathological)
types of flexibility
Types of Flexibility
  • Ballistic Flexibility:

Normal ROM associated with bouncing & rhythmic movements.

  • Dynamic Functional Flexibility:

Activities that need certain angle to certain joints. & particular patterns (usual activities).

factors affecting flexibility
Factors Affecting Flexibility
  • Wrong habits: ↓flexibility sitting for a long period (in school, watching TV, computer work, sedentary games)
  • Good habits: →↑flexibility.
  • Genetic factors: females > males.
  • Hormonal factors: females> males.
  • Body build proportion & ↑ height → ↑flexibility .
  • Body wt. ↑ → ↓flexibility
  • Age: flexibility changes during a certain age ↑2 - 6 y ↓ 6 - 12 y ↑18 - 22 y ↓35 - up
  • Skills &sport activities→↑flexibility.
contractile non contractile tissue
Contractile & Non-contractile Tissue
  • Contractile
    • Ms
  • Non-contractile
    • Skin
    • CT
    • Ligaments
    • Tendons
    • Capsules
    • Synovial Membrane
  • Soft tissues that can restrict joint motionare:
    • Skin
    • CT, tendons, ligaments
    • Ms

Each one has unique qualities affecting its extensibility (ability to elongate).

  • Factors affecting soft tissues lengthening:
    • Velocity of stretch force
    • Intensity of stretch force
    • Duration of stretch force
    • Mechanical properties of contractile & non-contractile tissues
    • Neuro-physiological properties of contractile tissues
when soft tissue is stretched either elastic or plastic changes occur
When soft tissue is stretched, either elastic or plastic changes occur
  • Elasticity

Ability of soft tissue to return to its resting length after passive stretching.

  • Plasticity

Tendency of soft tissue to assume new & greater length after the stretch force has been removed.

  • Both contractile & non-contractile tissues have elastic & plastic properties.
degrees of deformity
Degrees of Deformity
  • 1st degree (grade I): can be corrected actively (shortness).
  • 2nd degree (grade II):can be corrected passively (shortness).
  • 3rd degree (grade III):can’t be corrected neither activelynor passively (contractures).
indications of stretching
Indications of Stretching
  • Limited ROM due to adhesions & scar tissues formation leading to shortening of Muscles, CT & Skin.
  • Prevention of structural (neglected soft tissue →shortening →structural limitations →skeletal deformities

(prophylactic intervention)

  • When contractures interfere with every day functional activities or nursing care.
  • When there’s muscle weakness & opposing tissue tightness.

* Tight muscle must be elongated before weak m. can be effectively strengthened.

goals of stretching
Goals of Stretching

1.To regain or re-establish normal joint. ROM & mobility of soft tissue surrounding a jt..

2. To prevent irreversible contractures.

  • To ↑ general flexibility of a part of the body prior to vigorous strengthening excerises.

4. To prevent or minimize risk of musculo-tendinous injuries related to specific physical activities & sports.

precautions to stretching
Precautions to Stretching
  • Don’t passively stretch (force) a joint beyond its normal ROM

(Remember that normal ROM varies among normal individuals).

  • Newly united # should be protected by stabilization between # site & the joint where motion takes place.
  • Extra caution in pts. with known or suspected osteoporosis due to:
      • Disease b. Prolonged bed rest

c. Aging d. Prolonged use of steroids (cortisone)

  • Avoid vigorous stretching of muscles & CT that have been immobilized over a long period of time. CT (tendons & ligaments) lose their tensile strength after prolonged immobilization.
precautions to stretching1
Precautions to Stretching
  • High intensity, short duration procedures→ traumas → soft tissue weakness
  • Stretching should be low intensity for long duration stretch.
  • Strengthening excerises should be added to stretching program at some point, so patient will be able to develop appropriate balance between flexibility & strength.
contraindications to stretching
Acute infections.

Signs of inflammation.

Pain at the site to be stretched.

Osteomyelites (acute stage).

Bone tumors.

Advanced osteoporosis.

7. Severe spasticity.

8. Pain that isn’t yet evaluated by the PT or physician.

Joint laxity (hypermobility).

10. Joint subluxation.

11. Joint dislocation.

12. Joint fusion.

13. Joint deformity.

14. Tissue adhesions (contractures).

15.Acute Traumas

Contraindications to Stretching
principles of stretching
Principles of Stretching
  • Consider the best stretching type to ↑ ROM.
  • Explain goals of stretching to the pt.
  • Position the pt. in a comfortable relaxed pos. → allow the best plane of motion to conduct stretching.
  • Free the area from restrictive clothing, bandage, splints.
  • Apply superficial heating to the soft tissues to be stretched.
  • It will ↓ possibility of injury.
  • Stretch direction is done opposite to tightness.

7. The pt. must be completely relaxed throughout stretching ,employ relaxation techniques before stretching.

Stretching movs. or exs. are performed at least 3 times/week to maintain flexibility. Progress to daily stretching routines.
  • 1-3 repetitions of each stretch must be done. The No. of repetitions can be ↑if the goal is to↑ROM.

10. Degree of stretch can be ↑or↓ depending on time of stretch & external force applied.

11. Tension produced shouldn’t cause pain, the pt should only feel a slight tension, which ↓ with stretching. (due to adaptation)

12. Stretch ↑gradually, building to a max. as the tissues release.

13. Stretch should be removed gradually to prevent rebouncing ortighteningof the ms.

stretching depends on
Stretching depends on:
  • Type of stretching force.
  • Intensity.
  • Duration
  • Velocity.
types a passive stretching
Types: A. Passive Stretching
  • PT applies an external force & controls stretch

1direction, 2speed, 3intensity & 4duration to the tight m..

  • Don’t confuse between:
    • Passive stretching→ elongation of soft tissues beyond full R of restriction.
    • Passive ROM exs.→ applied within the unrestricted(available)ROM.
  • Pt. must be completely relaxed during passive stretching.
  • Time of stretch force is usually 15 : 30 sec& repeated several times during ex. session.
1 manual passive stretching
1. Manual Passive Stretching
  • Usually considered a short-duration stretch.
  • No specific No. of secs. are determined to be the most effective duration.
  • In a study to stretch hip abd. of healthy subjects15, 45sec & 2 min at the same speed → no difference.
  • Intensity & duration of stretch depend on:
      • Pt’s tolerance
      • PT strength & endurance
  • Low intensity, long duration manual stretch is more comfortable & tolerated by pt.
maintained versus ballistic stretch


Maintained versus Ballistic Stretch

Inhibit stretch reflex


↓Muscle tension

Facilitate muscle contraction


↑ tension

2 prolonged mechanical stretch
2. Prolonged Mechanical Stretch
  • Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened tissues over a prolonged period by mech. equipments.
  • Stretch force is applied through positioning with weighted traction, pulley system, dynamic splint & serial casts.
  • Prolonged stretch may be maintained for 20-30 min. or longer → effective stretch &↑ ROM

(low intensity mechanical stretch).

  • Comparing long-duration mech. stretch & manual passive stretch ( the latter is rather short & there’s transient & temporary achievement of ROM).
  • Bohannon evaluated the effectiveness of an 8 min mechanical hamstring stretch compared to a 20 min or longer using overhead pulley system. The 8 min stretch resulted in a small ↑ in hamstring flexibility, which was lost in 24 hrs.

It was suggested that 20 min or longer stretch is more effective to ↑ ROM & has a more permanent basis.

  • Use of tilt table-wedge board standing for 30 min/daily →↑ dorsiflexion in neurological pts.
  • Dynasplint (dynamic splint) → prolonged low intensity stretch of elbow, wrist, knee & ankle → ↑ ROM.
  • Low intensity prolonged stretch of 5-12 lb applied for 1 hr/daily has been found to be more effective than manual passive stretch over a 4-week period with pt’s with bilateral knee flexion contractures. It is more comfortable
permanent lengthening
Permanent lengthening

(Plastic changes in contractile & non-contractile tissues)has been reported with long duration stretch.

  • The term “Permanent lengthening” means that the length is maintained after the stretching force is removed.
3 cyclic mechanical stretching
3. Cyclic Mechanical Stretching
  • It is passive stretching using a mechanical devices as an Autorange using a 20-sec high intensity (up to the patient’s pain tolerance).
  • Intensity of stretch,
  • Length of each cycle,
  • No. of stretch cycles/minCan be adjusted with the unit.
  • It is similar & may be used as a useful alternative to manual passive stretching.
b active inhibition
B. Active Inhibition
  • Is a tech. in which the patient reflexively relaxes muscles to be elongated prior to stretching maneuver. When the patyent is relaxed → minimal R to elongate the m.
  • It relaxes only the: - Contractile structures, - Not the CT.
  • The m. must be: Normally innervated and Under voluntary control.
  • It Can’t be used with pts having: 1. Weakness, 2. Spasticity 3. Paralysis(From a neuromuscular disease).
  • It Can be used in: Post-operative patient. (to avoid tightness).
active inhibition techniques
Active Inhibition Techniques.
  • Contract-relax(hold-relax):

Pt performs an isometric contraction of tight muscle before it is

passively stretched (lengthened).

M. will relax as a result of ”autogenic inhibition” (Golgi tendon organ may fire at ↓ tension).

  • Contract-relax-contract(hold-relax-contract).
    • 1st a contraction of tight muscle.
    • 2ndrelaxation of tight muscle. (autogenic inhibition).
    • 3rdconcentric contraction of opposite muscle (reciprocal

inhibition of tight m.).

In a study, the contract-relax-contract produced a greater ↑ in ankle dorsiflexion > contract-relax tech. (in short calf m ).

* Both techs produce ↑ ROM > manual stretching.

3 agonist contraction
3. Agonist Contraction
  • Agonist= muscle opposite to the tight muscle.
  • Antagonist= Tight muscle.
  • Patient dynamically contracts (shortens) the muscle opposite to the tight muscle against resistance → reciprocal inhibition of tight muscle.
c self stretching
C. Self-Stretching
  • Is a type of flexibility excerises. the patient carries out by himself.
  • Pt. may passively stretch his tightness by:
    • His/her own body weight. (&gravity)
    • Active inhibition.
    • Manual passive stretch (using sound limb)
p eripheral j oint m obilization
Peripheral joint mobilization


Peripheral joint mobilization (PJM) is the use of skilled graded forces to mobilize joints:to improve motion & normalize joint function.

mobilization techniques are used to
Mobilization Techniques are used to
  • Improve jt. nutrition.
  • Improve m. spasm & tension
  • Reduce pain.
  • Reverse jt. hypomobility.
  • Improve or restore motion.
  • Treat jt. dysfunction as stiffness.
the pt should recognize
The PT should recognize
  • When the mobilizing techniques are indicated (at any ROM), or
  • If other stretching techniques are more effective (stretching, stretching ex’s or CTM)

To regain the lost motion

a joint mobilization
A. Joint Mobilization
  • Is a type of passive mov performed by the PT at a speed slow enough that the pt. can stop the mov.
  • The tech. may be applied with:1. Oscillatory motion or

2. Sustained stretch


      • ↓Pain or
      • ↑mobility.
  • The tech. may use:
    • Physiologicor
    • Accessory movs.
mobilization techniques
Physiologic movements

Movs. that the pt can perform voluntarily as flex, ext, abd, add & rot.

2. Described as (Osteokinematic). i.e. mov of bones in relation to each others

Accessory movements

Movs within the jt & surrounding tissues that are necessary for normal ROM,can’tbe doneby pt.

2. Described as a.Component motionsb.joint play.

Mobilization Techniques
accessory motions
Accessory motions

Motions that accompany active mov, but

Aren’t under voluntary control

Component mov is the often used term with accessory mov.

As: upward rot. of scapula & clavicle occurring in sh. flex.

B. Joint Play

Motions that occur in jts & distensibilityorgive in of the jt capsule, which allow bones to move.

Are necessary for normal functioning through the ROM.

Can be demonstrated passively,

Can’t be performed actively by the pt.

Include:distraction, sliding, compression, rolling, spinning of the jt surfaces.

Arthrokinematic is used to describe these motions of bone surfaces within the jt.

Accessory motions
b manipulation
B. Manipulation
  • Is a passive movusing physiologicoraccessory motions.It may be applied:1. With a thrust , (cyropractic) or 2. Under anesthesia
b manipulation1

A sudden mov performed with a high velocity.

Without anaesthesia.

Short amplitude motion, can’t be prevented by the pt.

Performed At end of pathologic limit(end of available ROM, when there’s restriction).

Using:1. Physiologic, or 2. Accessory movs.


1. Snaps adhesions.

2. Stimulates jt receptors.


Medical procedure used to restore full ROM by breaking adhesions surrounding jt.

With anaesthesia.

Performedthrough:1. Rapid thrust, or 2. Passive stretch.

Using:1. Physiologic, or 2. Accessory movs.

B. Manipulation
factors affecting jt motion
Factors Affecting Jt. Motion

A. Jt. shape.

B. Types of Motion.

C. Other Accessory motions.

factors affecting joint motion
Factors Affecting Joint motion

A. Joint Shape

The type of motion is influenced by jt. shape.

  • Ovoid: one convex surface & one concave (as A).
  • Sellar(Saddle):one surfaceis concave in one direction & convex in the other, with the opposing surface convex& concave (as a horse back rider) (as B).
b types of motion
B. Types of Motion
  • When a bony lever (bone)moves about an axis of motion→mov of bony surfaces on the opposing bone surface within the jt.


    • Movement of bony lever- Called swing as (flex, ext, add, abd & rot.)

- Measured in degrees. - Called ROM.

2.Motion of the bony surfaces- Within jt is a combination of rolling, sliding & spinning.

- These accessory motions allow greater angulation of bone as it swings.

- This needs adequate capsule laxity or jt. play.

a roll
a. Roll
  • One bone rolls on another. The surfaces are incongruent.
  • New points on one surface meet new points on the opposing surface.
  • Results in angular motion.
  • Always rolling occur in the same direction of the mov., whether the surface is convex or concave.
  • There’s compression of the surface on the side to which the bone is angulating & separation on the other side.
  • In normal functioning jts, pure rolling doesn’t occur alone, but in combination with sliding & spinning.
b slide
b. Slide
  • One bone slides across another.
  • For pure slide, the surface must be congruent either flat or curved.
  • There’s no pure slide as jt surfaces aren’t completely congruent.
  • Same point on one surface comes into contact with new points on the opposing surface.
  • Direction of slides depends on whether the surface is convex or concave.
If the moving surface is convex → Sliding is in the opposite direction of angular mov.
  • If the moving surface is concave →Sliding is in the same direction as the angular mov.
  • This mechanical relationship is known as convex-concave rule. It determinesthe direction of the mobilization force, when jt mobilization gliding techniques are used.
c combined roll sliding in a joint
c. Combined roll-sliding in a joint
  • The more congruent the jt surface → the more sliding of one bony partner on the other with movs.

(e.g. metatarsals & metacarpals)

  • The more incongruent the jt surface → the more rolling movs.

(e.g. hip & sh)

for joint mobilization techniques

Is used to

Restore jt. play

Reverse jt. Hypomobility


Is not used, as

Jt. Compression

E.g. hip abd &add

sh abd &add

For Joint Mobilization Techniques
When PT passively moves the articulating surface in the direction in which the slide normally occurs→ Translatory glide (glide)

used to

1.Control pain or 2.Stretch capsule

If applied gently If with stretch force

d spin
d. Spin
  • Rotation of one bony segment about a stationary mechanical axis.
  • Spinning rarely occurs alone, but in combination with rolling & sliding.
  • 3 examples of spinning in the body jts:
    • Sh.: with flex/ext.
    • Hip: with flex/ext.
    • Radio-humeral: with sup./pron.
    • **Knee ext either by closed or open chain
c other accessory motions that affect the joint
C. Other Accessory Motions that affect the Joint

e. Compression.

f. Traction (A&B).

e compression
  • Is the ↓ in jt space.
  • Occurs in LL&spinal jts with wt. bearing.
  • Some compression occurs as m. cont→provide stability to jt.
  • As one bone rollson the other, some compression occurs on the side to which the bone is angulating.
  • Normal intermittent compression loads→ help in moving synovial fluid so → maintain cartilage health.
  • Abnormal high compression loads→articular cartilage changes & deterioration.(friction → erosion & OA)
f traction
  • Distraction or separation of jt surfaces.
  • For distraction to occur, the surfaces must be pulled apart. The mov isn’t always the same.
  • Pulling on the long axis of one bone(as pulling the shaft of humerus →glide jt surface) (long axis traction).
  • Distraction of gleno-humeral jt requires a pull at a 90° to the glenoid fossa → distraction & jt traction or jt separation.
  • Distraction is used to:
    • Control or relieve pain: If applied gently.
    • Stretch the capsules: If applied with stretching force.
effects of joint motion
Effects of Joint Motion
  • Skim. biologic activity by moving synovial fluid →brings nutrients to the avasculararticular cartilage of jt surfaces & intra-articular fibrocartilage of the menisci.
  • Maintains extensibility & strength of: articular & periarticular tissues (ligs, ms, tendons & capsules).
    • With immobilization→ fibrofatty prolifiration → intra-articular adhesions & biochemical changes in [tendons, ligs & jt capsule]→ m. contractures , jt stiffness & lig. weakening.
  • Provide proprioceptive feedback (awareness of pos. & mov. sense)
      • Static pos. & sense of speed of mov.
      • Change of speed of mov.
      • Sense of direction of mov.
      • Regulation of m. tone.
indications of joint mobilization
Indications of Joint Mobilization
  • Pain, m. guarding& spasm

All can be treated with gentle jt play tech to stim. neurophysiological&mechanical effects.

    • Neurophysiological effect:Small amplitude oscillatory mov →stim mechanoreceptors →↓transmission of nociceptive stimuli at spinal cord & brain stem levels.
    • Mechanical effects:
    • Small-amplitude distraction or gliding mov →synovial fluid motion → bring nutrients to the avascular portions of articular cartilage. (↓ pain of ischemia)
    • Gentle jt-play → maintain nutrient exchange → prevent painful effects of stasis when a jt is painful or swollen &can’t move through a ROM. (but not in acute or massive swelling)
reversible jt hypomobility
Reversible Jt. Hypomobility

Can be treated with:

1. Progressive vigorous jt. play stretching techs.→ elongate hypomobile structures.

2.Sustained or oscillatory stretch forces→mechanically distend shortened tissues.

Progressive Limitations

Diseases that progressively limit movement can be treated by jt. play techs to:

1.Maintain available motion.

2. Retard progressive mechanical restrictions.

4.Functional Immobility(obligatory bedriddeness)

In this case the aim is to:

1. Maintainavailable jt. play.

2. Prevent degenerating.

3. Delay or reduce the effects of immobility.

n b mobilization techniques
N.B. Mobilization techniques
  • Can’tchange the disease process ofdisorders as:
      • Rheumatoid arthritis.
      • Inflammation.
  • It only can:
      • Minimizes pain.
      • Maintain available jt. Play.
      • Reduces effects of mech. limitations.
contra indications
  • Hypermobility: AS PJM →
    • Potential necrosis of ligs. or capsules.

(Hypermobile pts may benefit from jt. play tech.if kept within the limits of motion).

2.Joint Effusion
  • Nevermobilize or stretch a swollen jt with: 1.mobilizationor2.passive stretching.The capsule is already stretched by the extra fluid. Extra fluid & m. response to pain (spasm) →limited motion.
  • Gentle oscillating motions that don’t stretch capsuleorstress it →:
      • Improve fluid flow.
      • ↓ pain.
      • Maintains available jt play.
  • If pt response to jt play is ↑pain or jt. Irritability: The techs. were either:
      • Toovigorous,or
      • Don’tsuit the current state of pathology.
  • Stretching in presence ofinflammation →
    • ↑Pain.
    • ↑muscle guarding.
    • Greatertissue damage.
    • Spreadingthe inflam. process &infection.
  • In most cases jt mobilization is safer than passive angular stretching.


  • Sometimes Jt mobilization can be used with extreme care in:
    • Malignancy -»spread & growth.
    • Excessive pain-»m. guarding, prevent mov.
    • Total jt. replacement -»disl.or loosen int. fixation.
    • Bone disease(Osteoporosis, TB, Rickets).
    • Unhealed #(site &stabilization) -»re-fracture.
    • Hypomobility(in associated jts & m. weak) -»↑ capsule laxity, lig. Weakness & jtdisl.
3 possibilities for pain
3 Possibilities for pain

!!!! While moving or mobilizing & found!!!!

  • Before tissue limitation(after acute injury or active stage of a disease), use pain inhibiting jt. tech to relieve pain& maintain jt. play.
  • With tissue limitation (as damaged tissue begins to heal) (subacute),usegradual gentle stretching tech to tight tissue, but Don’texacerbate pain by injuring the tissues.
  • After tissue limitations (as stretching a tight capsule or a peri-articular tissue of ch. stiff jts),use↓ force ofthestretching techniques.
b grades of mov dosage amplitude
B. Grades of mov. (Dosage, Amplitude)

2 systems of techniques:

1. Graded oscillation.

2. Sustainedtranslatory jt. Play.

  • Oscillations may be done using:

1- Physiologic (osteokinematic) motions.

2- Jt. play (arthrokinematic) techs.

sustained translatory jt play technique
Sustained Translatory jt. Play Technique
  • Grade I(Loosen):

Small amplitude distraction, applied where no stress is placed on the capsule.

  • Equalizes cohesive force,
  • 2. M. tension
  • 3. Atmospheric pressure actingon the jt.
  • Grade II(Till tightness):

Distractionor glide applied to tightend tissues around jt.

  • Grade III:

Distraction or glide with large enough amplitude to place

a stretch on jt. capsule & surrounding peri-articular structures.

  • Grade I:Used with gliding motions to relieve pain.
  • Grade II:Used to determine how sensitive the jt is.
  • Grade III:Used to stretch jt. structures &↑jt play.
  • Technique:

This grading system describes jt. play techniques that separate or glide (slide) jt surfaces.

  • The consistencybetween the dosage of the two grading systems is grade I (no tension on the jt capsule or surroundings).
  • Grade III (sustained stretch) & IV(oscillation) are similar in dosage as they are applied with a stretch force at the limit of the motion.
  • Using oscillating or sustained tech., depends on the pt’s response.
  • Pain management: use oscillating tech.
  • Loss of jt. play &↓function: use sustained stretch.
  • To maintain available R.:Use either grade II! oscillating orII sustained technique.
c patient position
C. Patient Position
  • C. Patient PositionThe pt. & treated extremity should be carefully positioned & relaxed.

2. The jt. is positioned so that the capsule has greatest laxity.

d stabilization
D. Stabilization
  • Firm & comfortable stabilization for proximal parts by using:
    • Belt.
    • PT hand.
    • External assistance.
e force
E. Force
  • Treatment force (gentle or strong)is applied as close to the opposing jt. surfaces as possible.
  • The larger the contact surface of PT hand

→ the more comfortable procedurewill be.

e.g. use flat surface of the hand instead of forcing with the thumb.

f direction of movement
F. Direction of Movement
  • Either parallel to, or perpendicular to ttt plane.
  • Jt. traction: Perpendicular to ttt plane.

The entire bone is moved → jt surfaces are separated.

  • Gliding tech.: Parallel to the ttt plane.

This is determined by using the convex-concave rule.

- If the surface of moving bone is convex -→ opposite direction glide.

- If the surface of moving bone is concave → glide in the same direction.

The entire bone is moved, so there’s gliding of one jt. surface on the other.

No swing of the bone that causes rolling & compression of the jt. surfaces