The Future of Stretching
Active, Isolated Stretching as a Treatment for the Massage Client

By Timothy Agnew
Photos by Timothy Agnew

For a long time, stretching as a benefit to health has been cast in an ambiguous light, with some medical journals reporting inconclusive research. While some say stretching does no good at all, most experts in the field believe it is crucial for uninhibited daily movement and injury prevention.#1 In the field of massage therapy and bodywork, stretching is a popular modality, especially with many sports and medical massage programs. There are many different types of stretching and most massage therapists have learned at least one particular form to use in their practice. The goals of stretching are to increase range of motion (ROM) in the joint by lengthening tissue, increasing circulation and purging toxins from the body. But which forms of stretching work best and are the most suitable for the massage therapist?
Let's take a look at the many different types of stretches and compare them to one which is gaining wide popularity with massage therapists, physical therapists and athletes alike - Active Isolated Stretching (AIS). AIS will be discussed as a form of treatment to be included in the therapist's toolbox.

Stretching Understood
Many different forms of stretching use similar characteristics. For example, yoga postures involve a static stretch; the hold is usually 10 to 30 seconds or longer. Professional dancers employ the same type of stretch when they place a leg on a balance rail while leaning into the stretch and holding it. If they bounce into the stretch it becomes a ballistic stretch. All stretching can be classified into one of the categories shown in Fig. 1. In all but one of these forms, a single element makes them generally the same: The stretch is held for a long period of time (10-30 seconds).
It is important for the therapist to understand exactly what happens to the muscle fibers when we stretch our clients. A muscle fiber, composed of thin (actin) and thick (myosin) threads, is an elongated cell enclosed in sarcolemma, a thin, structureless membrane. The sarcolemma keeps adjacent fibers (such as the hamstring group and the adductors) from merging into a mass, and allows them to act as separate units.2 Each separate unit is called a sarcomere. Thus, sarcomeres, the basic structural unit of the muscle, are actually compartments in which the muscle fibers are held. To visualize this, think of long pieces of bundled spaghetti enclosed in small boxes. A long muscle like the sartorius is made up of boxes of spaghetti sitting end to end. Z disks, the dark bands in Fig. 2, separate these compartments. When we lengthen a muscle, the thick and thin (actin and myosin) filaments slide past each other as tension develops. Hence, the muscle fiber is pulled to its full length sarcomere by sarcomere (Fig. 3).#3
When we injure muscle tissue, collagen is spun in the fibers to help heal the muscle by cells called fibroblasts.4 The mass of collagen usually remains embedded in the fibers (massage therapists feel these as "lumps" when they massage a client). Because in a stretch we are getting the deepest form of movement in the fibers themselves, the sliding of the fibers in a lengthened muscle breaks up this unnecessary "glue" and sends it into the bloodstream. This allows circulation to improve in the injured tissue. Also, muscles often used in sports (such as the gastrocnemius) frequently become twisted, with the "spaghetti" actually tangled around one another. By stretching these disorganized fibers, the "spaghetti" in the direction of the applied tension will be realigned. This realignment is what helps scar tissue from injuries heal faster, and is a good example of why the body needs flexibility as a prevention to injuries.

The Stretch Reflex
The body has its own built-in safety mechanism for overstretch of a muscle. Lying parallel to the muscle fibers, proprioceptors called muscle spindles record any changes in the physical displacement (movement) and changes in tension or force within the body. During a stretch, these spindles detect the change itension and relay that information to the spinal cord, which in turn relays it to the muscle. After two seconds of holding a muscle in a lengthened position, the stretch reflex (also called the myotatic reflex arc) causes the muscle to resist the change in the muscle length by initiating a contraction in the muscle. It is important to note that the more violent the sudden change in the muscle length (as occurs in bouncing or jerky movements), the stronger the muscle contraction will be; the stretch reflex will match the amount of force put into the movement. Because of the stretch reflex, therapists should always use gentle movements when stretching clients.

If the therapist's goal is to lengthen muscle tissue, the massage therapist must take into consideration the stretch reflex which produces a contraction of the muscle. With most common forms of stretching, this is an unfortunate by-product. If the stretch reflex occurs after two seconds of holding a stretch, how can we expect to safely lengthen muscle tissue if the tissue is suddenly contracted (shortened) by the stretch reflex?
Another concern is the possibility of aggravating injuries with the "hold" of a lengthened muscle. Micro tears can develop while the muscle is held and the stretch reflex is occurring.5# In a clinical setting, this works against the therapist who is trying to help the patient. How do we avoid the stretch reflex and still lengthen the muscle without the risk of injury?

Active Isolated Stretching
Active Isolated Stretching (AIS) is a method gaining recognition with athletes, therapists and the general public. Pioneered by kinesiologist Aaron Mattes, this method uses active components to lengthen tissue and only holds the stretched tissue two seconds, hence avoiding the stretch reflex. This "pumping" of the tissue with a gentle stretch for two seconds releases the muscle with each repetition. AIS uses full range repetitions for each stretch, and on each movement the tissue is slowly pushed beyond the stagnate range. This approach results in a lengthened tissue without holding the stretch for a long period of time.

In Active Isolated Stretching, an agonist muscle is always doing the work to allow the antagonist to lengthen, a technique also known as reciprocal innervation.6# In Fig. 4, the rectus femoris (agonist) is doing the work by lifting the leg, and the hamstring group (the antagonist) is being stretched. The hamstring is reciprocating to the contraction of the rectus femoris by lengthening. The client contribution is always 100%, and this can help the client in many ways.

For example, stroke, Parkinson's, and neural-disabled patients re-educate their muscles and neural pathways because of the active component in AIS. The therapist palpates the agonist to "remind" the stroke patient where to send the neural signal, and the client actively lifts the arm or leg to go into the stretch. Thus, muscle re-education takes place with each movement. The client also strengthens the agonist due to the lift involved in the stretch. In Fig 4, lifting the leg strengthens the quadriceps. Repeating this method several times, the client's range of motion can be improved, and strength is developed simultaneously.

AIS also allows for specificity. For example, if the therapist believes there is dysfunction in the pelvis, the often overlooked deep external rotators could be at fault. These small, horizontal muscles are hard to reach, as they are very deep in the body. With AIS, the therapist can isolate each of these muscles with the client prone (Fig 5) and an isolation belt placed across the sacrum (ASIS). Using the leg, bent at 90 degrees as a lever, the therapist can rotate the hip and stretch each rotator, moving the femur 10 degrees for each muscle. Specifically isolating the muscle and avoiding compensation at the hip reaches the fascia and every part of the muscle fiber, including any tissue damage too deep to physically touch.
Sciatic pain is a problem many massage therapists encounter in their patients, and AIS treats this pathology in an interesting way. Though it is common to treat the piriformis muscle first ("piriformis syndrome") with anything from cross-fiber friction to neuromuscular re-education, AIS approaches treatment by addressing other muscles which may be contributing to pain in the hip. After a careful assessment, the client is taken through a series of stretches to open the larger muscle groups (hamstring, adductors) first, and then the biceps femoris is carefully examined for limited ROM. This muscle, with the long head attachment at the ischial tuberosity, and the short head along the lateral lip of the linea aspera, can contribute substantially to sciatic pain. If we trace the path of the sciatic nerve as it comes out of the sacrum, it passes just under the piriformis muscle, and the peroneal part of the nerve may perforate the muscle itself.7# This is an obvious example of why treating the piriformis is usually the action of choice. The piriformis muscle could be in a protective contraction, impinging the nerve. But as we continue to follow the nerve down the posterior leg, we find it is sandwiched between the biceps femoris and semitendinosis muscles before it separates above the popliteal fossa. Contracture in the fibers of the large belly of the biceps femoris is more than enough to further impinge the sciatic nerve. Also, the fibers of the biceps femoris have a strong line of pull in relation to the back and pelvis, and tightness of this muscle will contribute to low back pain.

To isolate the biceps femoris using AIS, an isolation belt is strapped across the anterior superior iliac spine (ASIS) to prevent compensation at the origin of the hamstring group, the ischial tuberosity (Fig.6). The therapist externally rotates the entire leg (femur) to isolate the fibers of the biceps femoris. This also places the fibers in the proper plane to be lengthened. The client is instructed to lift the leg to the opposite shoulder while keeping the knee straight (Fig. 7). If the therapist is working with a Parkinson's patient, the anterior thigh is palpated to help the patient know which muscle to activate. As in all AIS stretches, this is repeated 10 times, and several sets may be required to completely open the ischemic tissue. Remember, as mentioned earlier, part of the philosophy of AIS is that absolute movement in the muscle fibers is necessary to completely heal injured tissue; deep pressure will not change the length of a muscle unless a stretch is applied at the same time.

What else is examined using AIS for sciatica? Because treating the imbalance in the body is always the goal in AIS, there are at least 20 different exercises and assessment tools a therapist trained in AIS uses to completely solve a sciatic problem. Let's examine how AIS addresses the piriformis muscle. The piriformis muscle's action is lateral rotation of the thigh and abduction of the flexed thigh. In AIS, we must consider the action of the muscle and position the joint in a manner which takes the muscle into every position it moves (rotation, abduction, etc.) to lengthen the tissue.

To begin with, we can stretch the piriformis as an abductor. With an isolation belt across the ASIS, the patient's uninvolved leg comes across the midline to help prevent compensation at the pelvis. The client lifts the involved leg 90 degrees, with the knee flexed at 3 degrees (Fig. 8). Standing on the opposite side, the therapist takes the leg (with help from the client using the adductors) across the midline horizontally (Fig 9). The knee should travel in a direct line to the bottom of the rib cage, with the knee held flexed at 3 degrees. Again, the stretch is held two seconds, then repeated.
Since the piriformis muscle is also a lateral rotator of the hip, we now must address the rotation component to lengthen these fibers completely. With the patient prone, the isolation belt goes across the PSIS to prevent compensation at the sacral iliac joint (Fig. 10). With the involved leg bent at 90 degrees, the therapist places one hand under the anterior thigh, just above the knee, and the other on the inside at the medial malleolus. The leg is abducted 60 degrees before the stretch to further isolate the piriformis. The client rotates the femur internally, and the therapist assists in a gentle stretch at the end of the movement. After completion of the abduction-rotation stretches, the therapist has lengthened the piriformis muscle in every position the muscle works, thus obtaining the deepest form of movement in the muscle tissue.

Case Histories
How effective is AIS as a treatment? The case histories below outline brief success stories from clients who have found great relief from AIS treatments and from learning AIS.

Olympic Tendinitis
Bill Plifka is a 22-year-old rower for the United States Olympic Team. His position in the boat is Sweep Rower, and the strokes require both hands on one oar, pulling back with both arms. The Olympic team will participate in the 2,000-meter race at the games in Australia this year, and during practice, this distance is repeated again and again, 24 miles a day, five days a week, with approximately 159 strokes for each practice race. Not surprisingly, when Plifka came to my clinic he complained of recurring tendinitis at the lateral epicondyle of the elbow; he was unable to grasp a glass of water. As Plifka said, "I tried everything. The coaches had me see at least 10 different people (therapists), but it just kept coming back. My training was disrupted. I had to keep training because the trials were coming up (for the games in Australia). Then I learned AIS, and the techniques work. I was good after two treatments, and now I continue the stretches in my training."

Plifka flexes his elbow and smiles. "It's never come back this fast." Using AIS, Plifka was treated by examining not only the flexor and extensor muscles of his arm, but the rotators, or the supination/ pronation mechanism of his radius and ulna. What this client needed was specific flexibility and strengthening of all the small muscles in his forearm, including exercises using supination and pronation with resistance, something he was not doing with his coaches. A large part of his conditioning was for the larger, power muscles - such as pectoralis major and the biceps. These muscles were overworked and tight, limiting his ROM. Since AIS allows for specificity of the forearm muscles in a series of exercises which involve the hand and wrist, Plifka is headed to the Olympic Games with stronger, healthier forearms.

Thomas: A Parkinson's Patient
Thomas is a 54-year-old man with a kind face and a positive attitude. I first started working with Thomas fours years ago. He was diagnosed with Parkinson's disease eight years ago. "The doctors basically told us that exercise was not necessary at this point, but maybe down the line," said his wife, Doreen. "They were so wrong."

Doctors often place little importance on the preventive approach to treating Parkinson's because a large majority of physicians were trained to prescribe a pill and treat disease, not work toward prevention. I cannot overemphasize the importance of daily exercise for the Parkinson's patient. As Doreen said, "We started AIS with Thomas immediately, and I don't want to think what his condition would be like if he hadn't started the program. His posture was very bad (kyphosis) and it was affecting his walk and his daily activities. Tom is able to do more, and has a better quality life." Parkinson's patients become immobile, in part, because they stop stretching and using their muscles. Inertia leads to atrophy. Yes, Parkinson's develops in the basal ganglia (and substantia nigra) of the brain, but it is very much a muscular disease. Using AIS re-educates and builds the muscle tissue, combating atrophy and giving the patient better movement.

Ed Landis: AIS is a Miracle
Ed Landis is a 67-year-old chief financial officer of a large firm. He swims and works out with weights, but came to me because of pain in his shoulder. He recounted how AIS helped him.

"My workouts usually go well, but something was missing as I kept encountering minor injuries, like my shoulder. My opinion was that males basically are inflexible and there's nothing you can do about it. I never realized how inflexible I was until I went on the program with AIS. My rotator cuff problem vanished. I was amazed at the gains in my range of motion. And my energy level has improved dramatically. AIS stretching goes against everything I thought I knew about flexibility, but I found the missing link and I feel great."

DON'T FORGET YOURSELF
Landis is a good example of how healthy people can benefit from specific flexibility, and massage therapists should heed his advice. Preparing for your clients with proper stretching before your appointment is vital to giving a good treatment, but also for low back, neck and wrist problems (see "Lower Body Basics," page 84).
The above examples illustrate how increasing flexibility using AIS can be a valuable healing and preventive treatment for the massage therapist or health care provider. Any kind of movement will aid the body, but in a clinical setting, the therapist needs several things at his or her calling:
Specificity - The ability to get to specific muscle and cause.
Isolation - The ability to isolate one muscle at a time and cause absolute movement in the fibers.
Safety - The ability to treat the tissue without further injury.
Other protocols have been developed to follow in AIS, both for upper and lower extremities. These protocols can be used to treat every kind of injury a therapist may encounter. Does this mean that all other stretch methods are obsolete? Not at all. There are many forms of stretching and the massage therapist should find a modality which helps their clients. Flexibility must be included in the massage therapist's treatment, and the client should be taught how to use flexibility as a daily regimen. The physiological benefits of flexibility are manifold, and, combined with massage therapy, can be very powerful. Instead of taking a book, workshop, or even this article as the last word on which stretch protocol to use, the therapist should experiment and let the evidence guide the decision.

Timothy Agnew has a private clinic specializing in traditional kinesiology in Sarasota, Fla., and is a member of the National Strength Conditioning Assoc. Agnew interned with kinesiologist Aaron Mattes, pioneer of Active Isolated Stretching, and he travels widely teaching Clinical Flexibility and Therapeutic Exercise for the massage therapist workshops (featuring AIS protocols). To sponsor a workshop or for other information, call Agnew at 942/362-9627, Fax: 942/362-0275.

Footnotes
1 #Mattes, Aaron, Active Isolated Stretching (Aaron Mattes, 1995), 2.
2 Rasch, Philip, Kinesiology and Applied Anatomy (Philadelphia: Lea and Febiger, 1977), 68-71.
3 Marieb, Elaine N, Human Anatomy and Physiology (New York: Cummings, 1995), 114.
4 Ibid.
5 Mattes, 8.
6 Rasch, Philip, Kinesiology and Applied Anatomy (Philadelphia: Lea and Febiger, 1977), 70-71.
7 McMinn, R.M.H. et al., Atlas of Human Anatomy (Chicago: Mosby-Wolfe, 1993), 291.

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