Introduction to Flexibility Techniques:

by Brent Brookbush MS, PES, CES, CSCS, ACSM H/FS

What should we release and lengthen?

Movement assessment is always recommended before designing any program or intervention and should dictate the practice of every human movement professional. However, understanding common patterns of dysfunction/impairment can highlight the common behavior of structures and imply the type of techniques (inhibitory, lengthening, mobilization, activation, stabilization, integration, etc) we will use to address them. These common patterns help to create a list of techniques that we should have in our repertoire and may highlight gaps in practice that should be the focus of our continued ingenuity. Certain postural dysfunctions are so common that they may give inference to compensatory patterns being a “hard-wired” alternative to optimal movement. Of the common compensation patterns, Upper-Body Dysfunction (UBD) , Lumbo Pelvic Hip Dysfunction (LPHCD), and Lower Leg Dysfunction (LLD) are likely the most common, followed by Lumbosacral Dysfunction  and dysfunctions of the periphery including Foot/Ankle Dysfunction, Forearm/Wrist Dysfunction, and Cervical Spine Dysfunction (in the works). If we take a close look at these dysfunction we start to notice trends in muscle “behavior”. Certain muscles have a propensity toward over-activity and adaptive shortening, while other muscles have a tendency toward under-activity and adaptive lengthening. Various texts have discussed this tendency of relative activity, most commonly referring to these groups of muscles as “tonic” (overactive) and “phasic” (underactive) (2,3). In regard to flexibility techniques, it is more practical to note the relative length of muscles based on movement analysis as lengthening techniques are only appropriate for short muscles regardless of relative level of activity (This results in a few key changes, that differ from the over-active and under-active muscles listed in Introduction to Activation Exercise ). We will make special note of certain muscles that adopt a relative length and activity of long/overactive, implying that these muscles should be released, but not stretched. Most often these muscles are Overactive Synergists for inhibited prime movers (example, the biceps femoris  becoming synergistically dominant for an inhibited gluteus maximus  in Lumbo Pelvic Hip Complex Dysfunction). It is from this list of short muscles that we start to develop the techniques and exercise progressions described in this series of articles - Flexibility .

What is the goal of static release techniques?

Self myofascial (same as static release in this case) release is used to alleviate myofascial trigger points and areas of hyperirritability located within a band of muscle (7).” The development of these hyperirritable points has been linked to postural dysfunction, congenital factors, occupational and leisure overuse patterns, and referred or reflex involvement of the viscera (internal organs)(1). The goal of these techniques is to reduce adhesion developed around these hyperirritable points and reflexively inhibit over-activity to return muscle tissue to an optimal level of activity. Three mechanisms have been hypothesized for the reduction of trigger points in response to pressure:

• Pressure may stimulate mechanoreceptors (golgi-tendon organ, etc.) and initiate autogenic inhibition(7-8).
• Acute mechanical stress to the hypertonic region may locally deform connective tissue and prompt soft tissue adaptation (1,8).
• Ischemic pressure may decrease local blood flow and the transport of chemical messengers that fuel inflammatory processes and dysfunctional local metabolism (1,8).

Click here for more on Guidelines for Self-Administered Release Techniques

Self-administered Dynamic Release:

The popularity of "active release" and "pin and stretch" techniques has grown in manual therapy. The goal of these techniques is to improve "flossing", or the ability of soft tissues (fascia, nerve and muscle tissue) to slide along one another. These techniques lack significant research, but clinical outcomes are promising and the idea serves as a promising progression to static release techniques. Self-administered variations of these techniques are few, but several companies and individuals are working to refine the practice. Filling this void in self-administered exercise selection and researching the effect and outcomes of this modality should be the focus of our continued ingenuity and effort.

Adaptation to Static Stretching:

It is important to clarify that the body adapts to a static or PNF stretching differently than the body adapts to an active or dynamic stretch. Each stretching technique has its inherent benefits, drawbacks, and best use. To understand the best use of static and PNF stretching we should consider the hypothesized adaptation to a static stretch.

Davis’ Law states that soft tissue will remodel along lines of stress (10, 13). The forces created during static and dynamic postures, as well as the intentional forces applied during stretching, create a stimulus for connective tissue adaptation. The direction, duration, and amount of force applied will have an effect on that adaptation (11, 12, 14). However, every force imparted on muscle and connective tissue does not result in adaptation. Muscle tonicity and stretch reflex ensure that muscle tissue protects fascia from most forces that would result in unwanted change.

It is hypothesized that static and PNF stretches reduce muscle tonicity and inhibit stretch reflex via autogenic inhibition (10-12, 14). When adaptive shortening leads to tightness and restriction we can use static and PNF stretches to reduce muscle tonicity, inhibit stretch reflex1-2, and impart a force on connective tissue. A lengthening force on connective tissue will act as a stimulus for adaptation via Davis’ law (10, 13).

Based on the hypothesis above, it is important that we carefully assess muscle length using movement assessment and only stretch those muscles that are short. It is not recommended to stretch muscles that are not assessed as short. In regard to recent research, if optimal flexibility is reached with release techniques alone there is no benefit to be gained from adding stretching techniques for the same structures. In essence, static and PNF stretching are techniques used specifically for structures that are believed to be adaptively shortened, including maladaptive length change of fascial tissue. For more information on static stretching check out these two articles:

• * Refined Static Stretching Protocol
  • What Can We Learn From Static Stretching Research

Active Stretching:

As mentioned above, the proposed adaptation to active stretching is not the same as those gained from static stretching. The hypothesized mechanism of gains made from active stretching include returning optimal reciprocal inhibition and improving strength in end range (2, 15). These techniques are unlikely to have a positive effect on adaptively shortened tissue, but are an important progression from static stretching to ensure that the new range 0f motion gained are not lost due to a lack of strength and altered reciprocal inhibition due to movement impairment . The techniques and positions utilized for active stretching generally mimick those used for static stretching, but include rhythmic contractions of the functional antagonist of target tissues.

Static vs. Active Stretching:

Dynamic Stretching:

Dynamic stretching uses the force produced by muscles and the body’s momentum to take a joint through a full available range of motion (2). That is to say that this technique utilizes dynamic activities such as leg swings, lunges, butt-kicks, and med ball chops, to stretch muscles at a tempo that is more activity specific. This stretching technique may be the best method for warming-up before activities requiring muscular power. as several studies have shown an increase in performance post dynamic stretching (16-19). The proposed mechanism of gains made through dynamic stretching are increased neuromuscular control through a full range at tempos closer recreational activity and sport.

Flexibility Techniques:

• Scapular Muscle Flexibility (UBD)
• Back and Posterior Shoulder Flexibility (UBD)
• Pectoralis Major, Pectoralis Minor and Subscapularis Flexibility (UBD)
• Lumbar Extensor Flexibility (UBD/LPHCD)
• Hip Flexor Flexibility (LPHCD/LLD)
• Adductor Flexibility (LPHCD/LLD)
• Hip External Rotator Flexibility (LPHCD/LLD)
• Tibial External Rotator Flexibility (LLD)
• Lower Leg Flexibility (LLD)

Acute Variables:

Static Release Technique:

• NASM’s - Essentials of Performance Enhancement Training (7) – “After a sensitive region has been identified, hold the foam roller on that region for 30 seconds.” Note: Thirty seconds will generally reduce sensitivity of a tender region, but more fibrous structures, thicker musculature, and deeper trigger points may require more time.
• Leon Chaitow - Muscle Energy Techniques (1) - “Locate a sensitive region, apply 5 seconds of pressure, release for 2-3 seconds, apply 5 seconds of pressure again, release for 2-3 seconds, and repeat until the sensitivity of the tender area is significantly reduced.”
• Frequency 1 - 2/day, 2 - 7 days per week
• Progression: Pressure = Force/Area (Foam roll, medicine ball, softball, baseball, lacrosse ball)

Refining Self-administered Release Technique:

Dynamic Release Techniques:

• Intensity: Slow controlled repetitions using functional antagonist to pull through adhesion
• Reps: 10 - 15 repetitions (2 second hold at end range)
• Sets: 1 - 3
• Frequency 1 - 2/day, 2 - 7 days per week

Static Stretching (34)

• Intensity: Held at first resistance barrier (mild discomfort)
• Duration: 30 seconds to 2 minutes (or until a release or change in extensibility is noted)
• Sets: 1 - 3
• Frequency 1 - 2/day, 2 - 7 days per week

PNF Stretching:

For the purpose of lengthening tight muscles and increasing mobility long term, research suggests that the most effective means of stretching is a technique termed PNF stretching (22, 25-28, 30-32, 34). PNF is short for Proprioceptive Neuromuscular Facilitation. This method or technique is described in detail in the text “PNF in Practice” by Susan S. Adler, Dominiek Beckers, and Math Buck. The positions and acute variables used are similar to static stretching with the addition of the following protocol. There are 3 phases that should be repeated at least 3 times when using PNF stretching: relaxation in an elongated position, agonist contraction, and antagonist contraction. Research suggests that a muscle be elongated to the first resistance barrier, followed by at least a 6 - 10 second isometric contraction of the muscle being stretched (21, 23, 27, 30-33), followed by a 10-30 sec contraction of the opposing musculature to bring you to the next tissue barrier (21, 26), followed by 15 to 30 seconds of rest in the new position (31), and then repeated (20, 22, 28, 31), optimally 3 times (33). More research is desperately needed to update and further define the length of each phase of this technique. This type of stretching is obviously complex, and for best results requires the assistance of an experienced certified professional, proficient in this technique (33).

Active Stretching (2, 15, 34):

• Intensity: 2-5 second hold of antagonist contraction
• Reps: 10 - 15 repetitions (or until change in extensibility is noted)
• Sets: 1 - 3
• Frequency 1 - 2/day, 2 - 7 days per week

Dynamic Stretching (2, 16-19, 34):

• Intensity: Fastest tempo that can be optimally controlled
• Reps: 10 - 20 repetitions (or until change in extensibility is noted)
• Sets: 1 - 2
• Frequency 1 - 2/day, 2 - 7 days per week (best used as a warm for power and sporting activity)

Notes on Programming:

Just as exercise must progress to continue seeing results, so must your flexibility program:

• Over-active muscles:
  • Self-administered Release: Static release to active release (when an effective technique is available)
• Short Muscles:
  • Self-administered Stretching: Static stretching to active stretching to dynamic stretching.
• Restricted Joint Motion:
  • Self-administered Mobilization: Arthrokinematic motion in pain free range to arthrokinematic motion at end range to arthorkinematic motion with osteokinematic motion

Although sufficient research is lacking to make an evidence-based statement regarding the time-course that improvements can be expected using self-administered release techniques, in practice one to two weeks seems to be normal for a reduction in tenderness. This assumes, however, that release techniques are not used exclusively, but rather as one modality in an integrated program to correct movement dysfunction .

It is likely not safe to use self-administered release techniques for the iliacus , psoas , lumbar multifidus , scalenes or sternocleidomastoid. These muscles lay close to structures that may be compromised (nerves, arteries, passive support system of the lumbar spine) by regularly imparting compression and shear forces. Please leave release of these muscles to the skilled hands of a licensed manual therapist.

Stretching techniques should be progressed every 4 - 6 weeks as research shows that the majority of gains that will be made from a stretching technique are generally made within in this time period (34). However, it is also important to regularly reassess, as effective corrective strategies will alter findings in the movement assessment and may highlight other structures that should be targeted with flexibility techniques (starting with static release and stretching).

Generally you will stretch the same muscles that you release, however, it is important that we carefully assess muscle length using movement assessment and only stretch those muscles that are short. It is not recommended to stretch muscles that are not assessed as short. In regard to recent research, if optimal flexibility is reached with release techniques alone there is no benefit to be gained from adding stretching techniques for the same structures. Concurrently, if a muscle is assessed as short, release techniques alone will not return optimal length

Generally, these long and over-active muscles are released only and rarely if ever stretched. If stretching techniques are used, only active and dynamic stretches are appropriate - the goal being increased neuromuscular control and functional extensibility without imposing a stress that leads to further maladaptive lengthening soft tissues.

• Commonly long and over-active:
  • Biceps Femoris
  • Posterior Deltoid
    • These muscles are generally release and not stretched
• It is likely not safe to use self-administered release techniques for the iliacus, psoas, lumbar multifidus, scalenes or sternocleidomastoid

Self-administered mobilization techniques will generally be appropriate for those joints crossed by muscles that show signs of altered length and activity. For example, the ankle in Lower Leg Dsyfunction . As mentioned above, this will be the focus of future articles.

Order of Exercise and Activation Circuits:

• First Mobility:
  • Release, lengthening and mobilization techniques should precede activation techniques. The premise is based on altering length/tension relationships, reducing altered reciprocal inhibition, decreasing the activity of over-active synergists and improving arthrokinematics. This reduces the chance that synergistic muscle activity will result in compensation, and makes the lost range of motion available for use during activation techniques. In essence, you cannot train an individual to use a ROM they do not currently possess. The techniques considered under mobility include trigger point (static) release, active release, positional release, instrument assisted soft-tissue techniques, static stretching, active stretching, joint mobilization/manipulation.
• Second Activate and Integrate (2):
  • Activation and integration techniques are placed in order of relative isolation, relative intensity and relative complexity (number of moving joints). Initially specific structures are targeted (2), followed by integrating under-active muscle synergies (this could be viewed from the perspective of motor control, i.e. Richardson et. al (4)), then more intense exercise with the goal of improving firing rate (2), and finally cued practice and facilitation of integrated functional tasks. The modalities of exercise in this category would include activation, reactive activation, rhythmic perturbation, core activation, PNF, RNT, stability integration, subsystem integration , functional training for optimal performance of ADL’s, and potentially taping techniques. The order of treatment and integrated warm-up templates used by the Brookbush Institute :

Rehabilitation Template (For use by licensed professionals only!):

1. Pain management, fascial mobilization, edema control
2. Release
3. Joint Mobility
4. Neural Mobility (when appropriate)
5. Stretch
6. Isolated Activation
7. Core Activation
8. Inter-muscular Coordination/Stability Integration (Optional)
9. Intra-muscular Coordination/Reactive Integration (Optional)
10. Subsystem Integration (Optional)
11. Functional Tasks (may be integrated into steps 8-10)
12. Reinforce with taping, home exercise program, educational materials, and follow-up.

Brookbush Institute - Integrated Warm-up Template (For use by all professionals):

• Mobility:
  • Release
  • Stretch
  • Mobilize (When Appropriate)
• Activation & Integration (Perform each exercise for 12-20 reps, in circuit, for 1-3 sets):
  • Isolated Activation
  • Core Support (Optional)
  • Stability Integration (Optional)
  • Reactive Integration (Optional)
  • Subsystem Integration

Download a printable PDF version: Integrated Warm Up Template

I know this appears to be more techniques than are possible in the time allotted for a single appointment, but I assure you that practice will lead to proficiency, efficiency, and allow you to flow through the template with ease. I would expect to finish the Integrated Warm-Up Template in 20-30 minutes of an hour session, with activation portion taking 8 - 10 minutes per circuit. Note: this will likely take some practice and may not occur for several sessions. Some Helpful Tips:

• Practice the programs on yourself
• Practice on co-workers
• Have sample programs (protocols) for each dysfunction/joint to fall back on
• Move the equipment used for a particular set of techniques to one small area
• Initially, write your program before the session (make corrective exercise as simple as following a list of exercises)
• Instruct an individual about the next exercise while waiting for a release, or for a client to finish a set.
• Consider the activation and integration portions of the “integrated warm-up template” to be a circuit, and perform the activities accordingly (1 set per exercise with no rest between exercises, repeat the entire activation portion of the program in circuit if you wish to increase volume.
• Be setting-up exercises and grabbing equipment as it is safe to leave your client to do so.

Selected Bibliography

1. Leon Chaitow, Muscle Energy Techniques: Third Edition, © Pearson Professional Limited 2007
2. Dr. Mike Clark & Scott Lucette, “NASM Essentials of Corrective Exercise Training” © 2011 Lippincott Williams & Wilkins
3. Phillip Page, Clare Frank, Robert Lardner, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
4. Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004
5. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
6. Michael A. Clark & Scott Lucett, NASM Essentials of Sports Performance Training © 2010 Lippincott Williams & Wilkins
7. Michael A. Clark, Scott C. Lucett, NASM Essentials of Performance Enhancement Training, © 2010 Lippincott Williams and Wilkins
8. David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens
9. Tom Myers, Anatomy Trains. © Elsevier Limited 2001
10. Adler S, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. © 2008 Spinger Medizin Verlag
11. Alter M. Science of Flexibility – 3rd Edition. The Science of Flexibility. © 2004 Human Kinetics
12. Davis DS, Ashby P, McCale K, McQuain J, Wine J. The Effectiveness of 3 Stretching Techniques on Hamstring Flexibility Using Consistent Stretching Parameters.  J Strength Cond Res. 2005;19(1):27-32
13. Serrano R, Russo A, Marino J, Lamonte, A, Wygand J, Otto R. A Comparison of the Traditional Vs The Unilateral Back Saver Sit and Reach Hamstring Stretch: 490 Board #81 2:00 PM – 3:30 PM. Med Sci Sports and Exerc. 2005;37(5) S92
14. Tippet S, Voight M. Functional Progressions for Sports Rehabilitation. Human Kinetics, Champaign, Illinois, USA 1995
15. Liemohn, W.; Mazis, N.; Zhang, S. Effect of Active Isolated and Static Stretch Training on Active Straight Leg Raise Performance. Medicine and Science in Sports and Exercise: Volume 31(5) Supplement May 1999 p. S116, Copyright 2005 American College of Sports Medicin
16. Faigenbaum, Avery D.; Bellucci, Mario; Bernieri, Angelo; Bekker, Bart; Hoorens, Karlyn. Acute Effects of Pre-event Static Stretching on Fitness Performance in Children. Medicine and Science in Sports and Exercise: Volume 36(5) Supplement May 2004 p. S356, Copyright 2005 American College of Sports Medicine
17. Iain M. Fletcher and Bethan Jones. The Effect of Different Warm-UP Stretch Protocols on 20 Meter Sprint Performance in Trained Rugby Union Players. J. Strength Cond. Res. 18(4), 885-888, Copyright 2004 National Strength & Conditioning Association
18. Woolstenhulme, Mandy; Multer, Christine E.; Woolenstenhulme, Emily; Parcell, Allen C.. Ballistic Stretching Increases Flexibility and Acute Vertical Jump Height When Combined with Basketball Activity. Medicine and Science in Sports and Exercise: Volume 36(5) Supplement May 2004 p. S346-S347, Copyright 2005 American College of Sports Medicine
19. Taichi Yamguchi and Kojiro Ishii. Effects of Static Stretching for 30 Seconds and Dynamic Stretching on Leg Extension Power. J. Strength Cond. Res. 19(3), 677-683, Copyright 2005 National Strength & Conditioning Association
20. Darren G. Burke, Christopher J. Culligan, Laurence E. Holt, and Natalie C. MacKinnon. Equipment Designed to Simulate Proprioceptive Neuromuscular Facilitation Flexibility Training. J. Strength Cond. Res. 14(2), 135-139, Copyright 2000 National Strength & Conditioning Associatio
21. J. Brian Church, Matthew S. Wiggins, F. Michael Moode, and Randall Christ. Effect of Warm-Up and Flexibility Treatments on Vertical Jump Performance. J. Strength Cond. Res. 15(3), 332-336, Copyright 2001 National Strength & Conditioning Association
22. William I. Cornelius and Karen K Hayes. A Comparison of Single vs. Repeated MVIC Maneuvers Used in PNF Flexibility Techniques for Improvements in ROM. Journal of Applied Sport Science Research 1(4) p. 72-73, 1987, Copyright 1987 National Strength and Conditioning Association
23. William I. Cornelius and Mary R. Rauschuber. The Relationship Between Isometric Contraction Durations and Improvement in Acute Hip Joint Flexibility. Journal of Applied Sport Science Research 1(3) p. 39-41, 1987, Copyright 1987 National Strength and Conditioning Association.
24. D. Scott Davis, Paul E. Ashley, Kristi L. McCale, Jerry A. McQuain, and Jaime M. Wine. The Effectiveness of 3 Stretching Techniques on Hamstring Flexibility Using Consistent Stretching Parameters. J. Strength Cond. Res. 19(1), 27-32, Copyright 2005 National Strength & Conditioning Association
25. Feland, J. B.; Myer, J. W.; Merril, R. M.. PNF Vs Static Stretch: Acute Responses in Hamstring Flexibility of Senior Athletes. Medicine and Science in Sports and Exercise: Volume 33(5) Supplement 1 May 2001 p. S10, Copyright 2005 American College of Sports Medicine
26. Ferber, R. ; Ostering, L. R.; Gravelle, D. Range of Motion and EMG Response to Proprioceptive Neuromuscular Facilitation Stretch Techniques in Trained and Untrained Older Adults. Medicine and Science in Sports and Exercise: Volume 30(5) Supplement May 1998 p. S213, Copyright 2005 American College of Sports Medicine
27. Daniel C. Funk, Ann M. Swank, Benjamin M. Mikla, Todd A. Fagan, and Brian K. Farr. Impact of Prior Exercise on Hamstring Flexibility: A Comparison of Proprioceptive Neuromuscular Facilitation and Static Stretching. J. Strength Cond. Res. 17(3), 489-492, Copyright 2003 National Strength & Conditioning Association
28. Gerlach, K. E.; Burton, H. W.; Dorn, J. M.; Leddy, J. J.; White, S. C.; Horvath, P.J.. Fatigue, Balance, Running Mechanics and Flexibility as Risk Factors For Injury Among Female Runners. Medicine and Science in Sports and Exercise: Volume 35(5) Supplement 1 May 2003 p. S279, Copyright 2005 American College of Sports Medicine
29. Lai K.; O’Kroy, J. A.; Torok, D. J.; Graves, B. S.. Active Isolation Stretching Does Not Improve Hamstring Flexibility Better Than Traditional Stretching Methods. Medicine and Science in Sports and Exercise: Volume 35)5) Supplement 1 May 2003 p. S79, Copyright 2005 American College of Sports Medicine
30. Mello, Monica L.; Pereira, Marta; Gomes, Paulo Sergio Chagas. Acute Effect of Static and PNF Stretching ON Dominant Knee Flexion and Extension Strength: 951 Board #173 10:30 AM - 12:00 PM. Medicine and Science in Sports and Exercise: Volume 33(5) Supplement 1 May 2001 p. S10, Copyright 2005 American College of Sports Medicine
31. Mello, Monica L.; Pereira, Marta; Gomes, Paulo Sergio Chagas. Acute Effect of Static and PNF Stretching ON Dominant Knee Flexion and Extension Strength: 951 Board #173 10:30 AM - 12:00 PM. Medicine and Science in Sports and Exercise: Volume 33(5) Supplement 1 May 2001 p. S10, Copyright 2005 American College of Sports Medicine
32. Rubini, Ercole D.; Pereira, Marta; Gomez, Paulo Sergio C.. Acute Effect of Static Stretching and PNF Stretching on Hip Adductor Isometric Strength: 953 Board #175 10: 30 AM - 12:00 PM. Medicine and Science in Sports and Exercise: Volume 37(5) Supplement May 2005 p. S183-184, Copyright 2005 American College of Sports Medicine
33. Schwellnus, M. P.; Cobbing, S.; Noakes, T. D.. Proprioceptive Neuromuscular Facilitation (PNF) Stretching: What is the Optimum Duration, Type, and Frequency. Medicine and Science in Sports and Exercise: Volume 33(5) Supplement 1 May 2001 p. S197, Copyright 2005 American College of Sports Medicine
34. Brent Brookbush, Fitness or Fiction: The Truth About Diet and Exercise © 2011 Brent Brookbush – http://www.amazon.com/Fitness-Fiction-Truth-About-Exercise/dp/0615503012

© 2014 Brent Brookbush Questions, comments, and criticisms are welcomed and encouraged –