Equistretch Flexibility Program 2009 - PT on the · PDF fileEquistretch Flexibility Program...

Equistretch

Flexibility Program

2009

Participant Training Manual

By

Scott Cheatham DPT, OCS, ATC, CSCS, NSCA‐CPT

Revised 11/10/08

Program Overview

Equinox continues to be the leader in the fitness industry by offering cutting edge

programs and highly trained staff for all of our members. The success of the EFTI is built on a

foundation of modern science, practical application, and customer service. Feedback from

members across the country has shown the need to add flexibility training to the many great

services we already offer. In response, we have created the Equistretch Flexibility Program.

This program will give the Equinox team the ability to offer a new level of service by helping

every member with their flexibility needs.

Program Goals

Equinox has established specific program goals that will help to ensure the success of the program. They are as follows:

Establish companywide standards for the Equistretch program

Establish a systematic approach, which includes client screening, flexibility assessment, and proper program design.

Ensure that every Equinox Fitness Professional is familiar with these standards and is qualified to assist members with their flexibility goals.

Provide members with easy access to expert instruction and quality literature.

Types of Stretching Adopted by Equinox

The fitness industry has evolved tremendously and the demands on the fitness

professional have increased. The fitness professional must have a broad base of knowledge and

the ability to create safe, effective programs that are specific to the client’s goals. In response,

experts have created or adopted various stretching methods (e.g. Active Isolated Stretching,

Muscle Energy Techniques, Active Release Technique, etc.) that are being used in the fitness

industry. However, these methods have very little support in the literature despite their clinical

value. The lack of research can create a certain level of risk to the client.

This is why Equinox has chosen stretching techniques that have support in the literature

and most of all are commonly used by medical doctors, physical therapists, personal trainers,

and other health professionals. Equinox has chosen to use Static Stretching, PNF Stretching, and

Dynamic Warm‐up as the modalities of choice. These techniques can be considered a

“standard” within the health and fitness industry due to their widespread application.

There is a wide array of techniques and protocols that are currently being taught. The

definitions and guidelines below are what Equinox has adopted and should be followed by the

fitness professional.

Static Stretching

Static stretching is often considered a slow passive stretch. A slow deliberate movement

is used to facilitate lengthening of the muscle.1 Typically the slack in the muscle is taken up to

the first barrier or “tension” and held for a specific amount of time. With each repetition, the

goal is to “stretch more” and further lengthen the muscle. The client should never feel any type

of pain or sensations such as: “sharp”, “burning”, “numbness” or “tearing”. Appropriate

responses to static stretching may include: “slight discomfort”, “increased muscle tension”, or

“increased tightness”. It’s important to note that recent evidence has challenged the efficacy of

static stretching as a warm‐up activity and has shown it to cause a decrease in performance. 1‐10

The following sections will further discuss adopted parameters and specific applications.

PNF Stretching

Proprioceptive Neuromuscular Facilitation (PNF) is often considered an effective

technique in improving flexibility.11‐15 The PNF technique of “contract/relax” is the technique of

choice for Equinox. The technique includes passively bringing the target muscle into a

stretched position followed by an isometric contraction of the target muscle. The target muscle

is then further moved into a new position of stretch.11 The goal is to contract long enough to

elicit the Myotatic Stretch Reflex of the target muscle prior to moving into the static stretch.

The following sections will further discuss the adopted parameters and specific applications.

Dynamic Warm‐Ups

The Dynamic Warm‐up (DWU) is a ballistic activity that takes the body through a gradual

increase of ROM and speed of movement.15 DWU activities are typically movements that

replicate the desired activity or sport which create a seamless transition from the DWU to the

actual activity. The goal is to elevate core body temperature, improve kinesthetic awareness,

maximize active range of motion, and enhance motor unit excitability. 10 DWU is different from

ballistic stretching which takes a muscle and joint to its end of range and then imposes a

ballistic movement that stresses its physiological limits. Pushing a muscle or joint beyond its

limits can be a risk for injury. DWU works in the midrange of movement and progressively

lengthens the muscle which controls the risk of injury. The following sections will further

discuss adopted parameters and specific applications.

Stretching Parameters

Static Stretching

The research regarding the parameters and application for static stretching has been

questioned in recent years. Static stretching has not been shown to reduce the risk of injury or

improve performance.19‐21 In fact; recent studies have shown that static stretching prior to

athletic activity can decrease performance. 1‐10 This is why DWU is gaining support in the

literature as an effective method for a pre‐activity warm‐up. 5,10,16‐18 However, static stretching

has been shown to improve muscle length and joint range of motion. In fact 27 studies since

1962 have proven these outcomes. 19 The traditional methods of stretching after the activity as

a “cool down” seems to be the most appropriate time. The guidelines presented are based on

current research and standards used throughout the industry. ACSM’s (1998) most current

position statement recommends that static stretches should be held for 10 to 30 seconds for at

least 4 repetitions for a minimum of 2‐3 days per week.22 A large amount of the literature on

static stretching have used 30 seconds holds for 3‐5 repetitions.1‐10 Based on the evidence,

Equinox has adopted the following guidelines:

Hold Time: 30 seconds

Repetitions: Minimum of 4 repetitions

Frequency: Minimum of 2‐3 days per week

PNF Stretching

PNF stretching has been shown to improved flexibility but with mixed results in regards

to the lasting effects. Studies have shown ROM gains that last up to 7 days after stretching

twice daily for 1 week. 11‐15 Other studies have shown that stretching 3 times per week was

necessary to improve ROM. 11‐15 Overall, stretching 1‐2 times weekly may be necessary in order

to maintain ROM.

With PNF stretching, there is a wide array of applications and modifications that have

been published. ACSM (1998) recommends a 6 second isometric contraction followed by a 10‐

30 second assisted stretch for at least 4 repetitions for 2‐3 days per week.22 Previous literature

addressing PNF stretching has utilized isometric contraction times between 3‐10 seconds.11‐15

Based on the evidence, Equinox’s guidelines for the “contract‐relax” PNF stretching technique

are as follows:

Isometric Contraction Time: 6‐10 seconds

Static Stretch Hold Time: 30 seconds

Repetitions: Minimum of 4 repetitions

Frequency: Minimum of 2‐3 days per week

Dynamic Warm‐Up

In the absence of sufficient evidence to support static stretching as a warm‐up,

attention has turned to warm‐up procedures that encompass dynamic movements. 10 This has

made DWU’s a more favorable choice than static stretching prior to athletic activity. Dynamic

Warm‐ups should attempt to replicate the movements of the activity or sport. 5,10,16‐18 There

has been a recent surge of interest in this topic but there still is a sparcity of research on DWU.

The development of specific protocols or guidelines is still in its infancy. 5,10,16‐18 Based on the

current evidence, Equinox’s guidelines are as follows:

Time: 5‐10 minutes

Movements: Activity or Sports Specific

Frequency: Prior to doing activity

Stretching Precautions

If the client has a medical condition that could make stretching unsafe it should be

considered a “red‐flag” precaution and further screening or referral to a medical professional

should be considered. The following list of “red flags” should be considered precautions for

stretching. The following precautions include but are not limited to: 23

Pain Post‐surgical conditions or restrictions by the MD A fracture site that is healing A hypermobile joint Prolonged immobilization of muscles and connective tissue Joint swelling (effusion) from trauma or disease Area of inflammation or infection Individuals with severe Osteoporosis Area of malignancy Rheumatoid Arthritis Older individuals who have been immobile or have severe ROM limitations Individuals with a history of prolonged steroid use Other medical conditions

Overstretching

Overstretching can occur if the muscle and joint is taken beyond in physiological limits.

Aggressive stretching can cause local trauma and injury to the musculotendonous unit. The

Equinox fitness professional must understand how to screen for proper muscle length and how

far to stretch the muscle & joint without injuring the client. Proper stretching procedures will

be discussed in the practical training portion of this program. Signs of overstretching include

but are not limited to: 23

Prolonged joint pain or muscle soreness lasting more than 24 hours after stretching Edema or inflammation of the involved area

Policy for Referral to a Medical Professional

If a client has a medical condition that is a “red flag” precaution for stretching they must

obtain a clearance from their medical doctor prior to entering into the program. This will ensure

client safety and will give the fitness professional specific guidelines to follow. Equinox values

client safety and the success of this program depend on proper screening and appropriate

referral when necessary.

Client Screening

The Client Screening Questionnaire is a series of questions that are designed to clear the

client for any potential “red flag” precautions thus ensuring safety prior to any manual

stretching by the fitness professional. (see appendix A) The Questionnaire helps to answer the

most important question: Is the client appropriate for the program or should they be referred

out?

If the client answers “YES” to any question, further investigation must be done prior to

any program implementation. If any answer qualifies as a “red flag” then clearance must be

obtained by their medical doctor in order to ensure safety. Once clearance is obtained, then a

modified program must be created that reflects the restrictions given by the medical doctor. If

the clients answer does not qualify as a “red flag” their condition must still be noted and

monitored. A modified program should also be created in order to ensure client safety. In both

cases, the client must sign the waiver prior to any hands‐on work by the fitness professional.

If the client answers “NO” to all the questions, then the fitness professional can proceed

with the program. The client must sign the waiver prior to any program implementation. Note:

Personal training clients are exempt from this process since they will have been screened and

have signed the appropriate waivers. A chart review is recommended prior to the session in

order to ensure that stretching is appropriate.

Important!

If the client has a new medical condition or is absent from the program for more than 3

months they must fill out a new client questionnaire and re‐sign the liability waiver.

The Client Screening Process

Program Implementation

Once the client is cleared for activity and has signed the waiver, then the fitness

professional should administer the Flexibility Screen in order to assess the following:

The clients “willingness” and ability to move their joints and extremities

The available joint ROM for both sides of the body (bilateral comparison)

The presence of joint or muscle length deficits

Any abnormal pain or sensations that are elicited with movement

Develop an idea of what flexibility activities will be appropriate for the client

This will give the fitness professional some key information on what the client is able to

physically do. Based on the findings, a more accurate program can be created that will help the

trainer understand the clients level of flexibility. A comprehensive discussion on the upper and

lower Flexibility Screen will be covered in the practical portion of this program. Below are the

preferred screening motions for the upper and lower extremity. The preferred sequence used

is seated, supine, side lying, and then prone. This allows the client to transition easily into each

test position. If the client has a pathology that prevents certain positions then modified testing

should be done.

Seated Flexibility Screen

Illustrations Description

Cervical Flexion

Target Motions: Client is seated and bends their neck towards their chest

Norms: 80‐90°° (Chin to chest)

Verbal Cues: “Bring your chin down to your chest” Assess: Available symptom‐free ROM (+) Findings: Unable to bring chin down to chest indicates restricted ROM.

Cervical Extension

Target Motions: Client is seated and bends their neck up toward the ceiling

Norms: 70° (Eyes to the ceiling)

Verbal Cues: “Look up towards the ceiling” Assess: Available symptom‐free ROM

(+) Findings: Unable to look up to the ceiling indicates restricted ROM.

Cervical Rotation

Target Motions: Client is seated and turns their neck to look over shoulder

Norms: 80‐90° (Nose even with shoulder)

Verbal Cues: “Look over your shoulder” Assessment: Available symptom‐free ROM (+) Findings: Unable to look over shoulder indicates restricted ROM.

Cervical Sidebending

Target Motions: Client sidebends towards shoulder

Norms: 20‐45° (Ear close to shoulder)

Verbal Cues: “Bring you ear to your shoulder” Assessment: Available symptom‐free ROM (+) Findings: Unable to bring ear close to shoulder indicates restricted ROM.

Shoulder Elevation

Target Motions: Client lifts arms above head in scapular plane (45°°))

Norms: 170‐180°° (Arms parallel with ear)

Verbal Cues: “Lift your arm above your head”

Assessment: Available symptom‐free ROM

(+) Findings: Unable to lift arm above head indicates restricted ROM.

Hands Behind Head

Target Motions: Client brings the shoulders into combined abduction & external rotation

Norms: Fingers to base of the neck (C‐7)

Verbal Cues: “Reach behind your head”


(+) Findings: Unable to bring fingers to base of neck indicates restricted ROM.

Hands Behind Back

Target Motions: Client brings the shoulders into combined adduction & internal rotation

Norms: Fingers to inferior angle of scapula (T‐7)

Verbal Cues: “Reach behind your back”


(+) Findings: Unable to bring fingers to inferior angle of scapula indicates restricted ROM.

Supine Flexibility Screen

Illustration Description

Lat Length Test

Target Motions: Client is supine and elevates arms above head

Norms: Full shoulder ROM while chest and back remain flat

Verbal Cues: “Reach above your head”


(+) Findings: Chest and back arch as arms are raised above head indicates decreased Latissmus Dorsi length.

Hip Flexor Length (Thomas Test)

Target Motions: Client lies supine with the test leg extended. The opposite hip and knee are brought to the chest.

Norms: Test knee should remain straight as opposite knee/hip are flexed

Verbal Cues: “Relax your leg as you bend the opposite hip and knee to your chest”


(+) Findings: The test knee and hip rise up (bend) as the opposite hip and knee is bent towards the chest.

Adductor Length Test

Target Motions: Client lies supine with the test knee bent to 45°°. The opposite knee is straight. The examiner then passively allows the leg to drop towards the table.

Norms: Test knee falls to the table

Verbal Cues: “Relax your leg and let it fall towards the table”


(+) Findings: Unable to touch knee to the table indicates decreased Adductor length.

Active Straight Leg Raise

Target Motions: Client is supine with the test hip flexed to 90°

Sidelying Flexibility Screen

°.. The opposite knee straight. The client then actively straightens the knee.

Norms: Leg straightens to within 20°° of full extension (slight bend of knee)

Verbal Cues: “Lift your leg while it straight”


(+) Findings: Unable to straighten knee to within 20°° of full extension indicates decreased Hamstring length.

Gastroc Length Test

Target Motions: Client is supine with leg straight and test foot relaxed. The examiner then passively dorsiflexes the foot.

Norms: The ankle dorsiflexes between neutral and 10°° (toes towards nose)

Verbal Cues: “Relax your foot/ankle as I move it up”


(+) Findings: Test ankle is unable to dorsiflex to at least neutral which indicates decreased Gastroc length.


Hip Abductor Length Test (Ober’s Test)

Target Motions: Client is sidelying with test leg up. The examiner bends the knee to 90 °° then passively lowers the hip towards the table while bracing the pelvis with the opposite hand.

Norms: Test leg falls to the table

Verbal Cues: “Relax as I lower your leg”


(+) Findings: Test leg does not fall to the table which indicates decreased Abductor length.

Prone Flexibility Screen


Prone Knee Flexion (Ely’s Test)

Target Motions: Examiner passively bends knee.

Norms: Knee should bend to the buttocks with no elevation (hiking) of the hip or pelvis.

Verbal Cues: “Relax as I bend your knee”


(+) Findings: Unable to touch foot to buttocks or hiking of the hip or pelvis indicates decreased Quadriceps (Rectus) length.

Soleus Length Test

Target Motions: Client is prone with the knee bent to 90 °°. The examiner passively dorsiflexes the foot.

Norms: The ankle flexes between neutral and 10°° of dorsiflexion. (toes towards table)

Verbal Cues: “Relax your foot/ankle as I bend it down”


(+) Findings: Test ankle is unable to dorsiflex to at least neutral which indicates decreased Soleus length.

Once the Flexibility Screen is finished, a brief summary of findings should be communicated

to the client with a proposed plan of care. A final “verbal” consent should be obtained from the

client. At this point, it is safe to proceed with the flexibility program. Once the client is finished,

the fitness professional is encouraged to educate the client on self stretching and give them

some literature. This may be an ideal time to propose other services to the client such as

personal training or massage therapy. Note: The Flexibility Screen is designed to give a cursory

look at the clients’ overall flexibility and further answer the most important question: Is this

client appropriate for the flexibility program or should they be referred out?. However, further

testing (E.g. FMS, Sit and Reach) may be indicated if more complex flexibility issues are present.

Equistretch Program Process

Preferred Stretches

Equinox recommends a flexibility program that stretches all major muscles of the body. The

stretches illustrated below are chosen to give the fitness professional an idea of common

stretches but are not all inclusive. The descriptions below provide a brief explanation of the

target muscles and specific precautions. The fitness professional is encouraged to further study

this subject to understand the complete anatomy involved and to learn new stretches in order

to enhance their program design. Further discussion and training will be included in the

practical workshop.

General Stretching Principles

Regardless of which stretching technique (e.g. static or PNF) is done, some fundamental

principles must be followed in order to ensure a safe, effective program for the client. The

following recommendations are provided:

Prior to stretching, the client must be screened for any “red flags”

When stretching, it’s important to begin with gentle force then gradually increase with each

repetition.

Client should be asked if they are feeling any “pain” or “abnormal symptoms” throughout the

session in order to ensure safety.

Stretching may be more effective if done after the client’s exercise session or warm‐up.

Stretching should be done to both sides of the body to ensure symmetry.

Client should be reminded to breath during the session.

Very Important!

The trainer must use proper draping, positioning, and distance at all times when stretching the client. This especially applies to stretching the opposite gender. The trainer should choose

a place that is most comfortable for the client.

Upper Quarter Stretches

Cervical Spine


Levator Scapula Stretch

Target Muscle: Levator Scapula

Target Motions: Client is sitting. Examiner passively rotates and flexes the neck down to opposite shoulder (axilla) until a stretch is felt in the Levator Scapula region.

Precautions: Abnormal symptoms that are referred into neck, shoulder, and arm.

Contraindications: Recent spine surgery

Upper Trapezius Stretch

Target Muscle: Upper Trapezius

Target Motions: Client is sitting. Examiner passively side bends neck away from target muscle until a stretch is felt in the Upper Trapezius region.

Precautions: Abnormal symptoms that are referred into neck, shoulder, and arm.


Thoracic Spine


Angry Cat Stretch

Target Muscle: Rhomboids, Mid‐Traps

Target Motions: Client is either seated or quadruped and arches their back until they feel a stretch between the shoulder blades and Upper Thoracic region (between shoulder blades) is felt.

Precautions: Abnormal symptoms that are referred into neck, arm, or Thoracic region.


Childs Pose

Target Muscle: Latissmus Dorsi, Pectoralis

Target Motions: Client begins in the quadruped position and sits back on their feet with arms above head until a stretch is felt in the shoulders and Thoracic region.

Precautions: Abnormal symptoms that are referred into neck, arm, or Thoracic region.

Contraindications: Recent spine, hip or knee surgery, Shoulder Impingement

Modified Cobra

Target Muscle: Abdominals

Target Motions: Client is lying prone with arms at shoulder level. The client presses‐up with the pelvis resting on table until a stretch is felt in the abdominals and mild pressure in the low back region.

Precautions: Abnormal symptoms that are referred into low back, hips, or legs.


Chest/Shoulder


Seated Pectoral Stretch

Target Muscle: Pectoralis, Anterior Deltoids

Target Motions: Client is seated with hands behind their head. The examiner stands behind the client and grasps the elbows. A posterior force is applied until a stretch is felt in the Pectoralis region.

Precautions: Abnormal symptoms that are referred into the neck or arms.

Contraindications: Shoulder Impingement

Seated Latissmus Dorsi Stretch

Target Muscle: Latissmus Dorsi

Target Motions: Client is seated with target hand behind their head. The examiner stands behind the client and grasps the elbows. An adduction force is applied until a stretch is felt in the Axillary region and Latissmus Dorsi muscle.


Contraindications: Shoulder Impingement

Supine Shoulder External Rotation Stretch

Target Muscle: Subscapularis, Latissmus Dorsi, Teres Major, Anterior Deltoid

Target Motions: Client is supine with target arm at the edge of the table. The examiner abducts the arm to 90°° then gently takes the shoulder into external rotation until a stretch is feltin the anterior shoulder region.

Precautions: Abnormal symptom that are referred into the neck or arms.

Contraindications: Recent shoulder surgery, Shoulder Impingement

Supine Shoulder Internal Rotation Stretch

Target Muscle: Infraspinatus, Teres Minor, Posterior Deltoid

Target Motions: Client is supine with target arm at the edge of the table. The examiner abducts the arm to 90°° then gently takes the shoulder into internal rotation until a stretch is felt in the posterior shoulder region.


Contraindications: Recent shoulder surgery, Shoulder Impingement

Forearm/Wrist


Supine Wrist Flexor Stretch

Target Muscle: Wrist Flexors

Target Motions: Client is supine with target arm at the edge of the table. The examiner straightens the arm with palm up. The examiner then extends the wrist until a stretch is felt in the forearm flexor region (palm side).

Precautions: Abnormal symptoms that are referred into the forearm or hand.

Contraindications: Carpel Tunnel Syndrome, Wrist/Elbow tendonitis

Supine Wrist Extensor Stretch

Target Muscle: Wrist Extensors

Target Motions: Client is supine with target arm at the edge of the table. The arm is straight with palm down. The wrist is then flexes the wrist until a stretch is felt in the forearm extensor region (dorsal side).

Precautions: See above

Contraindications: Carpel Tunnel Syndrome, Wrist/Elbow tendonitis

Lower Quarter Stretches

Lumbar Spine/Hips


Hip External Rotator Stretch

Target Muscle: Piriformis, Gemelli, Quadratus Femoris, Obturators, Gluteals

Target Motions: Client is supine with knees bent and target leg crossed over opposite. The examiner pushes the knee towards the opposite shoulder (Hip flexion, adduction, internal rotation) until a stretch in felt in the hip external rotators. Stretch should be felt in the external rotators of the target hip.

Precautions: Abnormal symptoms that are referred into the low back, hips, or legs.

Contraindications: Recent hip surgery

Single Knee to Chest

Target Muscles: Gluteals

Target Motions: Client is supine with knees straight. The examiner pushes the target knee towards the chest until a stretch in felt in the Gluteal region

Modification: Opposite knee bent


Contraindications: Recent back or hip surgery

Double Knee to Chest

Target Muscles: Gluteals

Target Motions: Client is supine with knees bent. The examiner pushes both knees towards the chest until a stretch in felt in the Gluteal region.

Precautions: Abnormal symptom referral into low back, hips, or legs.


Hip Flexor (Thomas Stretch)

Target Muscle: Hip Flexors, Rectus Femoris

Target Motions: Client is supine with knees bent to the chest at the edge of the table. The client passively lowers the target leg while holding the opposite knee to chest. The examiner gently pushes the target leg towards the floor until a stretch in felt in the Hip Flexor (anterior hip) & Quadriceps region.


Contraindications: Recent back or hip surgery, Quad muscle strain

Knee/Foot


Supine Hamstring

Target Muscle: Hamstrings

Target Motions: Client is supine with legs straight. The examiner raises the target leg while keeping the knee straight until a stretch is felt in the Hamstring region.

Modification: Opposite knee bent


Contraindications: Recent back or hip surgery, Hamstring muscle strain

Sidelying ITB Stretch

Target Muscle: ITB, Glut Medius, TFL

Target Motions: Client is sidelying with target leg up. The examiner straightens out the target leg with the knee straight until a stretch is felt along the ITB track.


Contraindications: Recent back or hip surgery, muscle strain

Sidelying Quad Stretch

Target Muscle: Quads

Target Motions: Client is sidelying with target leg up and bottom knee flexed to the chest. The examiner extends the target hip and bends the knee until a stretch is felt in the Quadriceps group.



Supine Adductor Stretch

Target Muscle: Adductors

Target Motions: Client is supine with the target knee bent to 45°°. The opposite knee is straight. The examiner then applies a downward force until a stretch is felt in the groin while bracing the pelvis with the other hand on the opposite Illiac Spine.



Supine Gastrocnemius Stretch

Target Muscle: Gastroc and Soleus

Target Motions: Client is supine with legs straight. The examiner grasps the target ankle and dorsiflexes until a stretch is felt in the Gastroc while bracing the knee with the opposite hand.

Precautions: Abnormal symptoms that are referred into the calf or foot.

Contraindications: Recent calf or ankle surgery, muscle strain

Prone Soleus Stretch

Target Muscle: Soleus, Gastroc

Target Motions: Client is prone with the knee bent to 90 °°. The examiner grasps the target ankle and dorsiflexes until a stretch is felt in the soleus while bracing the knee with the opposite hand.

Precautions: Abnormal symptom that are referred into the calf or foot.


Modified Positioning for Special Populations

Lumbar Pathology

When a client has lumbar spine pathology, it’s important to place the client in a position that is most comfortable (supine vs. sitting) The following recommendations are provided for proper positioning of the client:

General Positioning Principles

Supine Position

1) In general, activities in the supine (e.g. back supported) position tend to be most comfortable

2) Bending the knees and hips (hooklying) in the supine position can also unload the low back by decreasing hip flexor length and tilting the pelvis posteriorly.

3) Towels or a foam roll under the legs can help maintain the bent knee position and unload the low back.

4) If client has pain or symptoms in supine, alternate positions such as sitting or prone should be considered.

Prone Position 1) Pillows under the pelvis in the prone position bring the pelvis towards neutral which

may be optimal to relieve symptoms. 2) If client has pain or symptoms in prone, alternate positions such as sitting or supine

should be considered.

Alternate Positions for Stretching


Modified Supine Hamstring Stretch

Target Motions: Client is supine with knees bent. The examiner bends the target hip to 90°° and then passively straightens the knee until a stretch is felt in the hamstring region.

Modification: The client can actively straighten the

knee until a stretch is felt.



Modified Seated Hamstring Stretch

Target Motions: Client is seated with the spine in neutral and the knees bent off the table. The client actively extends target knee until a stretch is felt in the hamstrings. The client must remain in spinal neutral in order for the stretch to be felt.

Modification: The examiner can passively (gently) extend knees.


Contraindications: Recent back or hip surgery,

Modified Prone Quad Stretch

Target Motions: Client is lying prone at the end of the table with the target knee straight and the opposite leg down to the floor. The examiner passively bends the target knee until a stretch is felt in the quads.

Modification: Pillows can put under pelvis.



Modified Sidelying ITB Stretch

Target Motions: Client is sidelying with target leg down and top leg bent with foot flat on mat. The examiner passively bends (adducts) the hip upwards until a stretch is felt in the ITB while

bracing the pelvis with opposite hand.

Modification: None



Age Related Changes

Age related changes such as severe Thoracic Kyphosis or forward head could be present

in the elderly client. It’s important to place the client in a position of comfort that prevents

excessive stress to their spine. These clients may also have Osteoporosis which may be a “red

flag” precaution. The following recommendations are provided:

Positioning

1) Determine which positions are most comfortable for the client (e.g. supine vs. sitting) 2) In general, there are no positional precautions for the client but they should be in the

position of most comfort. 3) Consider using towels or pillows behind the neck and upper back for support when

supine.

Stretching 1) Refer to the General Stretching Principles

Precautions

1) “Pain”, “numbness” or “burning” in the neck or back 2) Presence of Osteoporosis‐ Avoid extreme Thoracic flexion with rotation

Total Hip Replacement

When training a client with a Total Hip Replacement (THR), it important to remember that

the new prosthetic joint will have less ROM that a human joint. For clients with THR, there are

specific precautions that may be present up to 1 year after surgery. There are 3 common

surgical techniques which all have their own precautions. It’s important for the fitness

professional to know these precautions and modify the program accordingly. The following

recommendations are provided:

Positioning

1) Determine which positions are most comfortable for the client (e.g. supine vs. sitting). 2) In general, activities in the supine (e.g. back supported) position tend to be most

comfortable. 3) If client has pain or symptoms in supine, alternate positions should be considered.

Stretching 3) Refer to the General Stretching Principles Precautions

Posterior Lateral Approach

This technique includes cutting the hip external rotators (e.g. Piriformis, Gemelli,

Obturators, Quadratus femoris, and Gluteus Maximus) and posterior hip capsule through an

incision between the Gluteus Maximus and Medius. This technique spares the hip abductors

but makes the hip susceptible to posterior dislocation because the posterior supporting

structures are cut in order to perform the surgery. If under precautions, the client should

avoid the following movements: 24

Hip Flexion greater that 90°

Hip Adduction past the midline of the body

Hip Internal Rotation past neutral

Anterior Lateral Approach

This surgical technique utilizes a lateral curved incision that cuts through the

Gluteus Minimus, Gluteus Maximus, Tensor Fascia Lata, Vastus Lateralis and anterior

capsule. This technique spares the posterior elements of the hip (e.g. hip external rotators,

posterior capsule) but does violate the hip abductors. If under precautions, the client should

avoid the following movements:24

Combined hip External Rotation & Flexion

Hip Adduction past the midline of the body

Hip Internal Rotation beyond neutral

Anterior Approach

This surgical technique is considered newer than the other two procedures. The

procedure utilizes an anterior incision between the Tensor Fascia Lata and Sartorius which

affects only the anterior capsule. The anterior incision does not violate the contractile (e.g.

hip external rotators & abductors) or connective tissue (e.g. hip capsule) structures around

the hip, except for the surgical site. The procedure is done with a special table that positions

the patient supine allowing clear access to the hip joint. If under precautions, the client

should avoid the following movements:25‐26

Hyperextension of the hip

Extreme hip External Rotation

Total Knee Replacement

Post‐operative muscle tightness is common with patients who have undergone a Total

Knee Replacement (TKR). Stretching the muscles around the knee will be important to restore

adequate flexibility. In particular, the quadriceps group can become tight at the incision site and

throughout the muscle group. Specific stretching and myofascial release of the hip muscles,

quadriceps, hamstrings, and calves will also help to maintain flexibility throughout the lower

kinetic chain.27 The following recommendations are provided:

Positioning

1) Determine which positions are most comfortable for the client. (e.g. supine vs. sitting) 2) In general, there are no positional precautions for the client. They should be in the

position of most comfort. Stretching 1) Refer to the General Stretching Principles

Precautions

1) “Pain”, “numbness” or “burning” in the knee or foot 2) Knee pain 3) Muscle cramping

Program Conclusion

As the fitness industry evolves, the need for evidenced based programs is becoming a

necessity. Equinox has met this challenge by offering such evidence, based programs. The

Equistretch program will help the fitness team reach a higher level of service by offering such a

comprehensive service.

Along with the manual each team member will participate in a practical training

workshop and will have the opportunity to get certified in the program through specific testing.

Please refer to your clubs fitness manager for more program details. The EFTI team thanks you

for all your efforts in making Equinox Fitness Clubs the leader in the fitness industry.

References

1) Yamaguchi T, Ishii K. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. J of Strength and Cond. Res. 2005; 19(3): 677-684

2) Vetter RE. Effects of six warm-up protocols on sprint and jump performance. J of Strength and Cond.Res.2007; 21(3):819-823

3) Bradley PS, Olsen PD, Portas MD. The effect of static, ballistic, and proprioceptive neuromuscular facilitation stretching on vertical jump performance. J of Strength and Cond.Res. 2007; 21 (1):223-227

4) Brandenburg JP. Duration of stretch does not influence the degree of force loss following static stretching.J of Sports Med and Phys Fitness. 2006; 46(4):526-535

5) McMillian DJ, Moore JH, Hatler BS, Taylor DC. Dynamic vs. static-stretching warm up: the effect on power and agility performance. J of Strength and Cond. Res.2006;20(3):492-500

6) Ercole C, Rubini EC, Costa AL, Gomes PS. The effects of stretching on strength performance. Sports Med 2007; 37(3): 213-224

7) Ogura Y, Miyahara Y, Naito H, Katamoto S, Aoki J. Duration of static stretching influences muscle force production in hamstring muscles. J of Strength and Cond.Res.2007; 21(3):788-793

8) Weijer VC, Gorniak GC, Shamus E. The effect of static stretching and warm-up exercise on hamstring length over the course of 24-hours. J Orthop Sports Phys Ther.2003;33:727-733

9) Zakas A, Galazoulas C, Doganis G, Zakas N. Effect of two acute static stretching durations of the rectus femoris muscle on quadriceps isokinetic peak torque in professional soccer players. Isokinetics and Exercise Science.2006;14: 357–362

10) Faigenbaum A, McFarland JE. Guidelines for implementing a dynamic warm-up for physical education. JOPERD.2007;78(3):25-30

11) Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mechanisms and clinical implications. Sports Med. 2006; 36 (11): 929-939

12) Rees SS, Murphy AJ, Watsford ML, Mclachlan KA, Coutts AJ. Effects of proprioceptive neuromuscular facilitation stretching on stiffness. J of Strength and Cond.Res.2007; 21: 222-229

13) Decicco PV, Fisher MM. The effects of proprioceptive neuromuscular facilitation stretching on shoulder range of motion in overhand athletes. J of Sports Med and Phys Fitness. 2005; 45:183-192

14) Marek SM, Cramer JT, Fincher AL, Massey LL, et al. Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output. J of Athletic Training.2005; 40(2):94-104

15) Davis DS, Ashby PE, McCale KL, et al. The effectiveness of 3 stretching techniques on hamstring flexibility using consistent stretching parameters. J of Strength and Cond.Res.2005;19(1):27-33

16) Little T, Williams AG. Effects of differential stretching protocols during warm-ups and high speed motor capacities in professional soccer players. J Strength and Cond. Res. 2006;20(1):230-237

17) Faigenbaum AD, et al. Dynamic Warm-Up Protocols, With and Without a Weighted Vest, and Fitness Performance in High School Female Athletes. J of Athletic Training.2006; 41(4): 357-363

18) Stone M, O’Braynt H, Ayers C, Sands WA. Stretching: acute and chronic? the potential consequences. Strength and Cond J. 2006;28(6):66-74

19) Thacker S, Gilchrist J, Stroup D, Kimsey CJ. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004; 36:371–8

20) Werapong P, Hume PA, Kolt GS. Stretching: mechanisms and benefits for sport performance and injury prevention. Phy Ther Reviews.2004;9:189–206

21) Woods K, Bishop P, Jones E. Warm-up and stretching in the prevention of muscular injury. Sports Med 2007; 37 (12): 1089-1099

22) ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Adults. Med. Sci. Sports Exerc., Vol. 30, No. 6, pp. 975-991, 1998

23) Kisner C, Colby L (2002). Therapeutic Exercise: Foundations and Techniques. 4th ed. F.A. Davis Company: Philadelphia

24) Maxey L, Magnusson J (2001). Rehabilitation for the Post Surgical Orthopedic Patient. 1st ed. St Louis Missouri: Mosby

25) Kennon R et al (2004).Anterior approach for total hip arthroplasty: beyond the minimally invasive technique. Journal of Bone and Joint Surgery, 86, 91-98

26) Matta JM, Shahrdar C, Ferguson T (2005). Single-incision anterior approach for total hip arthroplasty on an orthopedic table. Clinical Orthopedics and Related Research, 441,115-124

27) Brotzman B, Wilk K (2003). Clinical Orthopedic Rehabilitation 2nd ed. St Louis Missouri: Mosby

appendix A

Equistretch Client Health Screening Form

1) Has it been more than 30 days since you participated in a stretching program? Yes � No �2) Have you had a joint replacement or have any metal hardware in your body? Yes � No �3) Do you have any current or previous injuries to your muscles, joints, or bones? Yes � No �4) Do you have any joint or back pain that limits your activity? Yes � No �5) Do you have any sensations of numbness/tingling, pins/needles, or coldness? Yes � No �6) Have you had any recent or previous surgeries? Yes � No �7) Have you recently had a trauma, such as a vehicle accident, fall, or sports injury? Yes � No �8) Have you been diagnosed with Osteoarthritis or Rheumatoid Arthritis? Yes � No �9) Have you been diagnosed with severe Osteoporosis? Yes � No �10) Do you have any heart or circulatory problems? Yes � No �11) Do you have high blood pressure? Yes � No �12) Do you suffer from “dizziness” or “lightheadedness” (e.g. changes in position) Yes � No �13) Do take any medications? Yes � No �14) Do you have any other medical conditions that may make stretching unsafe? Yes � No �

If you answered YES to any of the questions, please explain in more detail below:

I am voluntarily agreeing to participate in the stretching program and I hereby agree to expressly assume and accept any

and all risks of injury, physical harm or death associated with the program. I acknowledge and represent that I am physically sound

and I do not suffer from any illness, impairment, disease or other condition that would prevent me from participating in the stretching

program. In consideration of being allowed to participate in the stretching program, I do hereby knowingly and voluntarily, on behalf

of myself and my heirs and assigns, forever waive, release, discharge and hold harmless Equinox Holdings, Inc. and its subsidiaries

and affiliates and their respective employees, agents, representatives and successors and assigns from any and all liability,

damages, losses, suits, demands, causes of action (including, without limitation, negligence) or other claims of any nature

whatsoever, including, without limitation, any losses for property damage, personal injury or death, arising out of or relating in any

way to my participation in the stretching program.

Print Name ________________________________________________________

Signature ______________________________________________ Date__________________

Witness _______________________________________________ Date_________________

Notes

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