Stretching for Pain

The activity of stretching your muscles can be very comforting for some people, while being very intense for others. But despite how it feels, stretching has been shown to increase flexibility but also reduce pain.

Before we look at what stretching does to the human body, we first need to look at the objective we want to obtain. In this post we will be looking at musculoskeletal pain conditions that are tension based, meaning muscular and can therefore be influenced by stretching.

A lot of people nowadays have pain that are highly correlated with people staying in the same positions all day long in which muscles tend to shorten and therefore stiffen (mostly due to long sitting times)(Kett et al., 2021). On the other hand, it has been shown that when muscles increase in tone, it can then lead to compression of the fascia and that can lead to painful sensations literally anywhere in the body where muscles happen to be in. Different theories exist as to why an area leads to pain or how so called "trigger points"come into existence, but it usually is due to high tension in the musculature which leads to adhesions between the muscle and the fascia which can lead to discomfort.

Where does stretching fit into all of that? As we just discussed above, the main problem in having high tension in the muscles and stretching is exactly the tool that reduces tension in muscles. And its effectiveness has been shown.

That higher muscular tension is correlated with pain has been shown in the past (Park & Lee, 2020). And static as well as dynamic stretching have been shown to reduce muscle tone (Iwata et al., 2019). Which implies that targeted stretching exercises will lead to a reduction in muscle tone and therefore lower pain.

Other explanations for the reduction in pain are focusing on the increased pain tolerance, myofascial meridians or the gate control theory. The pain reduction seems to already come in after acute stretching protocols but more consistently with chronic stretching programs (Behm et al., 2021).

Other studies have shown that gaining more range of motion (ROM) in a particular joint can reduce pain. For example, when people with Patellofemoral pain increase the ROM of their lower extremity, then in the short-term pain will subside (Ophey et al., 2021). Or for people with low-back-pain disorders, adding stretches to their normal exercise routine has been shown to increase back function (Khalil et al., 1992) as well as reduce pain and disability (Turci et al., 2023).

All in all there exists compelling evidence that a consistent stretching routine can help individuals limit their pain which makes is an intervention worth trying, as it is cost free and doesn't require much time.

As the authors of a 2012 study stated "the increased range of motion is directly linked to decreased pain levels", this is obviously only true for individuals who are in pain due to tightness (hypomobility). People with excessive mobility (hypermobility) that are in pain will very likely see no improvement, maybe even an increase in pain from further stretching (França et al., 2012). While this study found stretching to be highly effective, it still was a slightly less effective intervention compared to stabilization exercises. But this may be due to to an uneven time investment, as the stretching protocol was less time consuming that the strengthening program. As another study suggested, when stretching duration was increased and matched with the training time, the results for pain reduction was equal to the strengthening program (Turci et al., 2023).
Other authors found stretching programs to be nearly as effective as manual therapy, with a pain decrease of 39% (Ylinen et al., 2007) while others showed consistent stretching to "decrease neck and shoulder pain and improve neck function and quality of life for office workers" (Tunwattanapong et al., 2016)  

Time:

As for exemplary intervention, try sticking to a program for around 8-weeks and see if you get any improvements regarding pain out of it. If you don't feel any different at all after regular stretching for eight weeks then it is likely not a cure to your problem.

Stretching Duration and Frequency:

A common recommendation that seems to work stems from a 2018 paper. There, the results showed that you should stretch the targeted muscle for a 30 seconds hold (no more, no less) twice a day and that five times per week (on the workdays). Which leads to a total work load of 1 minute per day and 5 minutes per week (Thomas et al., 2018). This regime has been proven effective in significantly increasing the ROM of a joint, which should also reduce your musculoskeletal pain, but increasing the weekly time spent stretching to 10-30 min is still recommended. Holding each set of stretching for 30 seconds was also recommended by a study specifically focused on reducing pain (Mansoori et al., 2021).

Stretching Intensity:

With different intensities being suggested by different research, there exists compelling evidence for different stretching intensities. Which is great, as you can play around freely with this factor or stick to an intensity that fits you best.

Stretching Techniques:

Three different stretching methods are applicable. Start easy with static stretches and once you hit a plateau try to get out of it by applying PNF or dynamic stretches.

1. PNF: With PNF (Proprioceptive Neuromuscular Facilitation) stretching you will enter a stretch and stay in the stretch for around 10 seconds, then you will start activating (contracting) the agonist (the stretches muscle) without moving the joint (=isometric contraction). This contraction will be held for 5-10 seconds, then you will take a deep breath out, stop the contraction, relax deeper into the stretch and repeat.
2. Static: The simplest form of stretching. Simply get into a position that will elongate your muscle and stay still for a certain amount of time.
3. Dynamic: Put a muscle under elongation and then put it into a shortened position again quickly. E.g.: leg swings, for a dynamic hamstring stretch. You will put the muscle under a stretch of high intensity but low duration.

Create a personal stretching program:

1. Chose a (painful) muscle group (e.g.: m. trapezius)
2. Chose specific stretches for the chosen muscle (ear to shoulder stretch)
3. Chose a stretching type (dynamic, static, PNF)
4. Perform the selected stretches for 10-30 minutes weekly, divided into 30 second repetitions for multiple sets
5. Stick to the program for 8-weeks to see results

Try to keep it simple and stick to a few important stretches but stay disciplined and perform them with the prescribed directions.

To progress the program you can increase stretching time and stretching intensity. If you are not used to stretching start easy with a slight stretching pain and shorter duration (ca. 15 seconds). Then as the pain-threshold increases, increase stretching intensity and duration until you can comfortably do the prescribed program.

Conclusion:

Trying stretching is recommended when trying to deal with musculoskeletal pain but a well rounded program should always also include strengthening exercises well as movement reeducation. As it is a cost free intervention is may be considered as a first choice since it is easy to perform. But make sure you stretch each muscle or body part correctly.

References:

Behm, D. G., Kay, A. D., Trajano, G. S., Alizadeh, S., & Blazevich, A. J. (2021). Effects of Acute and Chronic Stretching on Pain Control. Journal of Clinical Exercise Physiology, 10(4), 150–159. https://doi.org/10.31189/2165-6193-10.4.150

Tunwattanapong P, Kongkasuwan R, Kuptniratsaikul V. The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial. Clinical Rehabilitation. 2016;30(1):64-72. doi:10.1177/0269215515575747

Park, S.-H., & Lee, M.-M. (2020). Effects of Lower Trapezius Strengthening Exercises on Pain, Dysfunction, Posture Alignment, Muscle Thickness and Contraction Rate in Patients with Neck Pain; Randomized Controlled Trial. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 26, e920208. https://doi.org/10.12659/MSM.920208

Iwata, M., Yamamoto, A., Matsuo, S., Hatano, G., Miyazaki, M., Fukaya, T., Fujiwara, M., Asai, Y., & Suzuki, S. (2019). Dynamic Stretching Has Sustained Effects on Range of Motion and Passive Stiffness of the Hamstring Muscles. Journal of Sports Science & Medicine, 18(1), 13–20.

Thomas, E., Bianco, A., Paoli, A., & Palma, A. (2018). The Relation Between Stretching Typology and Stretching Duration: The Effects on Range of Motion. International Journal of Sports Medicine, 39(04), 243–254. https://doi.org/10.1055/s-0044-101146

Kett, A. R., Milani, T. L., & Sichting, F. (2021). Sitting for Too Long, Moving Too Little: Regular Muscle Contractions Can Reduce Muscle Stiffness During Prolonged Periods of Chair-Sitting. Frontiers in Sports and Active Living, 3, 760533. https://doi.org/10.3389/fspor.2021.760533

Khalil, T. M., Asfour, S. S., Martinez, L. M., Waly, S. M., Rosomoff, R. S., & Rosomoff, H. L. (1992). Stretching in the rehabilitation of low-back pain patients. Spine, 17(3), 311–317. https://doi.org/10.1097/00007632-199203000-00012

Turci, A. M., Nogueira, C. G., Nogueira Carrer, H. C., & Chaves, T. C. (2023). Self-administered stretching exercises are as effective as motor control exercises for people with chronic non-specific low back pain: A randomised trial. Journal of Physiotherapy, 69(2), 93–99. https://doi.org/10.1016/j.jphys.2023.02.016

Mansoori, S. S., Moustafa, I. M., Ahbouch, A., & Harrison, D. E. (2021). Optimal duration of stretching exercise in patients with chronic myofascial pain syndrome: A randomized controlled trial. Journal of Rehabilitation Medicine, 53(1), jrm00142. https://doi.org/10.2340/16501977-2781

França, F. R., Burke, T. N., Caffaro, R. R., Ramos, L. A., & Marques, A. P. (2012). Effects of Muscular Stretching and Segmental Stabilization on Functional Disability and Pain in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial. Journal of Manipulative and Physiological Therapeutics, 35(4), 279–285. https://doi.org/10.1016/j.jmpt.2012.04.012

Turci, A. M., Nogueira, C. G., Nogueira Carrer, H. C., & Chaves, T. C. (2023). Self-administered stretching exercises are as effective as motor control exercises for people with chronic non-specific low back pain: A randomised trial. Journal of Physiotherapy, 69(2), 93–99. https://doi.org/10.1016/j.jphys.2023.02.016

Ophey, M. J., Crooijmans, G. A. H. M., Frieling, S. M. W., Kardos, D. M. A., van den Berg, R., Kerkhoffs, G. M. M. J., & Tak, I. J. R. (2021). Short-term effectiveness of an intervention targeting lower limb range of motion on pain and disability in patellofemoral pain patients: A randomized, non-concurrent multiple-baseline study. Journal of Bodywork and Movement Therapies, 26, 300–308. https://doi.org/10.1016/j.jbmt.2020.12.028

Ylinen, J., Wirén, K., & Häkkinen, A. (2007). Stretching exercises vs manual therapy in treatment of chronic neck pain: A randomized, controlled cross-over trial. Journal of Rehabilitation Medicine, 39(2), 126–132. https://doi.org/10.2340/16501977-0015