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Ta k e 5 a n d t r y t h e A B M P F i v e - M i n u t e M u s c l e s a t w w w. a b m p . c o m / f i v e - m i n u t e - m u s c l e s . 73 Supine Position—Mixing Lateral Rotation with Horizontal Adduction If the supine client's piriformis can be stretched with lateral rotation and it can be stretched with horizontal adduction, then these two motions can be combined into one stretching protocol. To perform this protocol, the therapist stands on the same side of the table as the piriformis being stretched. The client's foot is placed flat on the table on the other side of the client's other lower extremity. This position laterally rotates and horizontally adducts the client's thigh at the hip joint. The therapist then pushes on the client's distal thigh, further horizontally adducting it (Image 8). As with the pure horizontal adduction approaches, the angle of force should be horizontal and slightly downward so the client's pelvis remains on the table. An advantage to this stretching protocol is that the likelihood that the client will experience pinching pain in the anterior hip flexor region is decreased compared to the pure horizontal adduction approaches. Pin and Stretch Technique As with the stretches shown so far, the pin and stretch technique is a mechanical stretch that works by lengthening the target muscle. However, the advantage to pin and stretch is that it allows the therapist to focus the stretch to one region (one end) of the muscle that contains hypertonic tissue; for example, a myofascial trigger point. This is accomplished by placing a pin somewhere along the course of the target muscle; then, one attachment of the muscle is brought away from this stabilization pin (Image 9). The stretch creates a line of tension that spreads along the muscle from the attachment that is moved until the pin is reached. In this manner, pin and stretch focuses the stretch to the region of the muscle between the attachment that is moved and the placement of the pin. Generally, pin and stretch technique is most effective when the pin is placed directly next to the hypertonic tissue, on the "other" side from the attachment that is moved. Neural Inhibition Techniques As described earlier, stretching is essentially a mechanical process of making a soft tissue longer. However, a neurologic effect can also be added. This is done by adding a neurologic reflex to the stretching protocol. The neurologic reflex inhibits the tone of the muscle so the stretch movement can be greater than by simply mechanically lengthening it. There are two neurologic reflexes that can be used to facilitate a stretch: Golgi tendon organ (GTO) reflex and reciprocal inhibition (RI) reflex. Contract Relax (CR) Technique. When the GTO reflex is used, the technique protocol is known as contract relax (CR) stretching. It can also be called post-isometric relaxation (PIR) stretching. And it is often referred to as proprioceptive neuromuscular facilitation (PNF) stretching. It should be noted that CR stretching technique has classically been stated to utilize the GTO reflex. However, there is controversy as to whether the GTO reflex is the underlying neuromechanical reflex for CR stretching technique. With this controversy in mind, we will address this technique as if the GTO reflex is the neurologic reflex at play. Although there are variations with how CR stretching is performed, it is classically done with the following steps. Note: One repetition of these steps is shown for the right-side piriformis with the client supine, and the therapist pushing the thigh into horizontal adduction at the hip joint (Images 10A–10C). 1. The therapist stretches the piriformis to tissue tension barrier (Image 10A). 2. The client isometrically contracts the piriformis against the therapist's resistance, for a count of approximately 5–8 seconds, with approximately 30 percent of maximum force (Image 10B). The isometric contraction of the piriformis is stated to engage the GTO reflex, thereby inhibiting the piriformis. 3. The client relaxes, and the therapist stretches the piriformis to its new tissue tension barrier position, stretching it further than would otherwise be possible with only a pure mechanical stretch (Image 10C). Stretching the right-side piriformis by combining horizontal adduction with lateral rotation in supine position. Stretching the right-side piriformis by utilizing the pin and stretch technique with the client prone. 8 9