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: 9 Establish companywide standards for the Equistretch program 9 Establish a systematic approach, which includes client screening, flexibility assessment, and proper program design. 9 Ensure that every Equinox Fitness Professional is familiar with these standards and is qualified to assist members with their flexibility goals. 9 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: 9 Hold Time: 30 seconds 9 Repetitions: Minimum of 4 repetitions 9 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: 9 Isometric Contraction Time: 6‐10 seconds 9 Static Stretch Hold Time: 30 seconds 9 Repetitions: Minimum of 4 repetitions 9 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: 9 Time: 5‐10 minutes 9 Movements: Activity or Sports Specific 9 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 9
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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 9 Prolonged joint pain or muscle soreness lasting more than 24 hours after stretching 9 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: 9 The clients “willingness” and ability to move their joints and extremities 9 The available joint ROM for both sides of the body (bilateral comparison) 9 The presence of joint or muscle length deficits 9 Any abnormal pain or sensations that are elicited with movement 9 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) 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°°.. 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) Findings: Test ankle is unable to dorsiflex to at least neutral which indicates decreased Gastroc length. Sidelying Flexibility Screen Illustration Description 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” Assessment: Available symptom‐free ROM (+) Findings: Test leg does not fall to the table which indicates decreased Abductor length. Prone Flexibility Screen Illustration Description 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” Assessment: Available symptom‐free ROM (+) 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” Assessment: Available symptom‐free ROM (+) 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: 9 Prior to stretching, the client must be screened for any “red flags” 9 When stretching, it’s important to begin with gentle force then gradually increase with each repetition. 9 Client should be asked if they are feeling any “pain” or “abnormal symptoms” throughout the session in order to ensure safety. 9 Stretching may be more effective if done after the client’s exercise session or warm‐up. 9 Stretching should be done to both sides of the body to ensure symmetry. 9 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 Illustration Description 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. Contraindications: Recent spine surgery Thoracic Spine Illustration Description 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. Contraindications: Recent spine surgery 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. Contraindications: Recent spine surgery Chest/Shoulder Illustration Description 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. Precautions: Abnormal symptoms that are referred into the neck or arms. 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. Precautions: Abnormal symptoms that are referred into the neck or arms. Contraindications: Recent shoulder surgery, Shoulder Impingement Forearm/Wrist Illustration Description 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 Illustration Description 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 Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. 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. Contraindications: Recent back or hip surgery 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery, Quad muscle strain Knee/Foot Illustration Description 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 Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery, muscle strain 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery, muscle strain 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. Contraindications: Recent back or hip surgery, muscle strain 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 Illustration Description 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. 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. Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery 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 Precautions: Abnormal symptoms that are referred into the low back, hips, or legs. Contraindications: Recent back or hip surgery 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 9 Hip Flexion greater that 90° 9 Hip Adduction past the midline of the body 9 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 9 Combined hip External Rotation & Flexion 9 Hip Adduction past the midline of the body 9 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 9 Hyperextension of the hip 9 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
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length over the course of 24-hours. J Orthop Sports Phys Ther.2003;33:727-733
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Exercise Science.2006;14: 357–362
10) Faigenbaum A, McFarland JE. Guidelines for implementing a dynamic warm-up for physical education.
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range of motion in overhand athletes. J of Sports Med and Phys Fitness. 2005; 45:183-192
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neuromuscular facilitation stretching on muscle strength and power output. J of Athletic Training.2005;
40(2):94-104
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flexibility using consistent stretching parameters. J of Strength and Cond.Res.2005;19(1):27-33
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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
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25) Kennon R et al (2004).Anterior approach for total hip arthroplasty: beyond the minimally invasive
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appendix A Equistretch Client Health Screening Form 1) Has it been more than 30 days since you participated in a stretching program? 2) Have you had a joint replacement or have any metal hardware in your body? 3) Do you have any current or previous injuries to your muscles, joints, or bones? 4) Do you have any joint or back pain that limits your activity? 5) Do you have any sensations of numbness/tingling, pins/needles, or coldness? 6) Have you had any recent or previous surgeries? 7) Have you recently had a trauma, such as a vehicle accident, fall, or sports injury? 8) Have you been diagnosed with Osteoarthritis or Rheumatoid Arthritis? 9) Have you been diagnosed with severe Osteoporosis? 10) Do you have any heart or circulatory problems? 11) Do you have high blood pressure? 12) Do you suffer from “dizziness” or “lightheadedness” (e.g. changes in position) 13) Do take any medications? 14) Do you have any other medical conditions that may make stretching unsafe? If you answered YES to any of the questions, please explain in more detail below: Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No No No No No No No No No No No No No No 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