I mom onsiolmome
Robert Stalker, MD
and their Place in Patient Education
Warm-up has been poorly studied Malgre le peu d'etudes scientifiques concernant le
scientifically, but there is a growing body of rechauffement,les preuves s'accumulent pour
evidence to suggest that if properly executed, suggerer que, lorsque 1'exercice est bien fait, il
apporte des b1nefices psychologiques et physiques.
it benefits the exerciser both psychologically Le medecin de famille se doit d'etre familier avec les
and physically. The family practitioner should principes et les etapes du rechauffement s'il veut en
be familiar with the principles and phases of informer correctement ses patients, le tout dans un
warm-up in order to instruct athletic patients but de prevention des blessures
properly, with the purpose of preventing musculo-squelettiques.
musculoskeletal injury. (Can Fam Physician
Key words: sports medicine, warm-up exercise, patient education
Dr. Stalker is the Director of the ity, strengthening, mechanical mala- Warm-up is defined as the "indi-
Dalhousie University Sport lignment, and the use of appropriate vidual optimal psychophysical pre-
Medicine Clinic and is a member of equipment. paration for strenuous motor exertion
the College of Family Practice. It is widely recognized that one of in training and contests'.' It is
Requests for reprints to: Dr. the most common causes of overuse widely reported that warm-up may en-
Robert Stalker, Dalhousie injuries is improper training. Trying hance athletic performance and de-
University Health Service, Halifax, to do too much, too soon, and too crease musculoskeletal injury. This
N.S. B3H 4J5 quickly are common errors. The ath- concept has never been adequately
lete, when asked why he was injured, tested scientifically, because of the
often suggests that he had not warmed multiple factors that influence muscu-
T HE FITNESS EXPLOSION has up properly. The warm-up is believed loskeletal injury and that are difficult
resulted in a new population of to be an important component of pre- to control in the scientific model. In-
patients for many family practitioners. paring for an athletic event. A coach or tuitively, most sports-medicine scien-
These patients seek appropriate treat- a physician would never suggest that tists consider that warm-up is of bene-
ment for a variety of musculoskeletal an athlete perform a 100-metre sprint fit, and that the lack of hard scientific
injuries and want expert advice on in- or compete in a pole-vaulting competi- data should not deter the physician
jury prevention. The importance of tion or, for that matter, take part in any from promoting the concept.
preventive education cannot be over- vigorous sporting event without an ap-
stressed, as many sports-medicine ex- propriate period of preparing the body Physiological Effects
perts believe that most athletic inju- for these activities. The physician of Warm-Up
ries are preventable. The physician should educate the athlete about the
should discuss with the athlete the im- benefits and proper techniques of Chart 1 lists a number of the bene-
portance of proper training, flexibil- warm-up. fits of warming-up, and this list can be
CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988 177
used in the education process.2 In- General Warm-Up Phase ence swimmer's shoulder during the
creasing the body temperature and, in swim season. His predictions were
particular, the temperature of the mus- The general component of warm-up 93% accurate, showing a strong cor-
cles and soft tissues is probably the can be active or passive in nature. Ac- relation between lack of flexibility
most important componenrt of warm- tive warm-up should be encouraged. and soft-tissue shoulder injury.8 Re-
Up.3 Athletes who are informed that Advocate the use of an aerobic activity ports from professional basketball
warming up for strenuous activities using the large muscles, such as light teams who incorporated flexibility ex-
may benefit their physical perfor- jogging, calisthenics, or bicycling. ercises into their training programs
mance and not just loosen up stiff mus- This method is more effective in rais- showed significant decreases in the
cles will be more likely to take the ing the core temperature than are pas- number of muscle injuries.9 DeVries'
time to do the warm-up properly. sive activities such as massage, heat- studies found that stretching increased
ing pads, or sitting in a sauna. flexibility and was very helpful in the
The activity should be continued prevention of muscle soreness and the
Components until the core temperature is raised by reduction of muscle tension. '0 Chart 2
of the Wann-Up Period one to two degrees centigrade. Clini- lists several of the benefits of flexibil-
Warm-up can be divided into three cally, this is the temperature rise nec- ity exercises.
phases: general, flexibility, and spe- essary to bring on a light to moderate
cific activities. The purpose of the sweat. The activity should be begun at Methods of Stretching
warm-up is to increase the temperature a low intensity and gradually increased
to a vigorous or moderate intensity. As There are a number of stretching
of the body. This is best achieved by techniques. Stretching exercises have
gradually stimulating the cardiore- the athlete becomes better condi-
tioned, the body's thermoregulatory been found superior in increasing
spiratory system, which increases the flexibility in the lower extremities as
blood flow to the working muscle. system becomes more efficient, and so
a longer or more intense w,arm-up will compared to general warm-up and
The rise in temperature results from massage. 1 I This finding would sug-
the dissipation of heat produced by be required to raise the core tempera-
ture.f6 gest that an active approach to flexi-
friction from sliding filaments during bility is necessary to obtain benefit. It
muscular contraction.4 is necessary to stretch on a regular
Stressing the body by gradually in- Flexibility Phase basis, as well. It is a difficult task to
creasing the intensity of the activity is ensure that athletes stretch regularly.
important. Overwhelming the heart The purpose of performing an activ-
ity to raise the core temperature is to This activity is often sacrificed be-
with a very strenuous activity may cause the athlete is late for practice or
carry with it some risk. Barnard5 did make the muscles more elastic and, of
course, to protect the heart. This initial the coach wants more time for spe-
an interesting study: subjects per- cific activities. Most athletes, when
formed a treadmill run at moderate in- period should be followed by a period questioned, claim that they stretch be-
tensity with no prior warm-up. At the of flexibility exercises. Muscle tight-
ness is thought to predispose athletes fore each activity. Levine found,
end of the test, 30% of the subjects however, that only 30% of men and
displayed abnormal electro-cardio- to certain injuries.7 It would follow
that developing flexible soft tissues 58% of women on varsity teams actu-
grams. If these same subjects had done ally stretched, and many did not
two minutes of easy jogging before might reduce injuries. stretch following the activity.7 His
their run, the ECG abnormalities were While research has not been pub- study found that many important soft-
eliminated or reduced. The heart needs lished to substantiate the claim that tissue areas were neglected. The phy-
warming up. flexibility exercises are beneficial in sician should try to obtain specific in-
reducing the incidence of soft-tissue formation from patients about what
injuries, the typical physician's im- areas are stretched and, just as impor-
Chart 1 pression would be that an athlete who
Beneficial Effects of Warm-Up tant, what areas are ignored.
stretches regularly seems to sustain Flexibility exercises can be simply
1. The break-down of oxyhemoglobin fewer injuries. Gripp studied a group
for the delivery of oxygen to the of elite swimmers and after assessing
working muscle is increased. Figure 1
their shoulder flexibility tried to pre- Static Stretch for Gastrognemus
2. The release of oxygen from dict the number who would experi-
myoglobin is increased.
3. The activation energy for vital
cellular metabolic chemical Chart 2
reactions is lowered. Benefits of Flexibility Exercises
4. Muscle viscosity is reduced,
producing an improvement in 1. Increased range of motion about a
mechanical efficiency. joint
5. Nervous impulses travel more 2. Retention of muscle elasticity
rapidly, and the sensitivity of nerve 3. Reduced risk of injury
receptors is augmented. 4. Reduced muscle soreness and
6. Blood flow to muscle is increased. fatique
7. The cardiovascular response to 5. Enhanced athletic performance by
sudden strenuous exercise is improving the efficiency of motor
6. Enhanced ability to generate power
Source: See Reference 2.
178 CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988
categorized as follows: static, ballistic,
couraged as the initial method of ponents. There is a greater risk of in-
and proprioceptive neuromuscular fa- stretching. This method involves rapid jury in using this technique if it is not
cilitation (PNF). Any method used changes in direction and velocity. This done properly, and communication be-
should be preceded by general warm- can lead to overstretch on the Golgi tween the participants is vital for pre-
up. The athlete wants to take advan- apparatus within the muscle and result venting injury.
in contraction of the muscle and strain.
tage of the increase in tissue elasticity Stretching should follow the com-
It must be realized, however, that most
that follows elevation of the core tem- pletion of any strenuous activity.
perature. The flexibility program mustathletic activities consist of a series of DeVries suggests that stretching exer-
be individualized for each athlete, and
ballistic movements. After the soft tis- cises held for two minutes or more
it is helpful for the physician to be-sues are prepared through general after strenuous activity were beneficial
come familiar with the demands of the warming up and static and PNF stretch- in reducing or eliminating muscle
patient's sport. Attention should be ing, ballistic stretching, if performed soreness.18 Muscle tightness usually
concentrated on the soft-tissue areas carefully can be included in the spe- follows activity and can last up to two
cific warm-up phase.
that will be under stress during the ac- to three days after the exercise period.
tivity. The particular flexibility exer- PNF flexibility techniques can pro- Stretching after the activity has been
cise should be designed to isolate andduce dramatic increases in range of shown by a number of authors to elim-
stretch the specific muscle group in- motion. If the athlete's activity re- inate this tightness.
volved. Any areas that have been in- quires great ranges of motion to per- There are a number of stretches in
jured need careful attention, but form the sport successfully, this tech- common use that should be dis-
stretching of all the principal musclenique is to be recommended. It is couraged because of the risk of injury
groups should be encouraged, as flex- more effective for increasing flexibil- that they entail. The athlete can be
ibility is specific to a joint.12 ity than are other techniques.16 Con- taught a safe stretch for the same area.
Static stretching should be pro- sider the ranges of joint motion re- Figures 6 to 8 present examples of in-
moted as the initial flexibility tech-quired by the following athletes: correct and correct techniques.
nique performed in the warm-up ballerina, gymnasts, ice-hockey goa-
period. Research by Moore and col- lie, and high jumper. Specific Wann-Up
leagues indicates that static stretching There are a number of different PNF
techniques, including hold-relax, anta-
produces less tension and resistance in In this phase of the warm-up, the
the soft tissue than do other tech- gonist-contraction-relax, and slow- emphasis is on rehearsing the specific
niques and may be less likely to result
reversal-hold-relax techniques. Figure movements that will be used in the
in injury."3 This technique can be 5 demonstrates the hold-relax tech- actual athletic activity, but keeping
adapted to any of the major muscle- nique.17 The muscle to be stretched is the intensity at a reduced level. This
tendon units. Figures 1-4 show ex- passively stretched by the partner. activity improves co-ordination and
amples. This technique can be done This movement is followed by a 3-6- balance and may reduce the chance of
unassisted. second isometric contraction of the injury. Rehearsals also increase mus-
Athletes performing static stretch-same muscle while the athlete uses the cle strength by enlarging neurological
ing should use slow controlled move- partner for resistance. The contraction recruitment and increasing muscular
ment. They should stretch the soft tis-
should build up to a maximal contrac- response time. This phase should in-
sue to the point of perceived tension tion. This movement is followed by a clude a short rest period of about 10
but not pain. The area being stretchedperiod of passive static stretch per- minutes. During this period the ath-
should be relaxed. The stretch posi- formed by the partner. lete may visualize the upcoming ac-
tion should be maintained for as long PNF techniques are ideal for athletes tivity and "psych up."
as possible, ideally about 30-60 sec- involved in team sports or those who
onds.14 Repetitions may be done as have a training partner. The disadvan- Psychological Aspects
long as the above principles are fol- tage is that the athlete must have a of Wann-Up
lowed. The effect of stretching may partner who is familiar with the tech- A number of coaches and sport sci-
last for up to three hours as long as nique and can provide enough resis- entists believe that the benefits of
the core temperature remains ele- tance to support the isometric compo- warm-up are related to its psychologi-
vated.15 nents and be careful enough to not cal aspects. Massey did a study that
Ballistic stretching is to be dis- overstretch the area for the static com- would suggest that psyching up is the
Figure 2 Static Stretch Figure 4
Static Stretch for Hip Abductors for Posterior Rotator Cuff Static Stretch for Low Back
CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988 179
most important component.'9 He hyp- tion of elite athletes for competition, race plan. She practices starts and then
notized athletes who had warmed up and the scientific aspects of this new returns to land and retreats to a quiet
to forget that they had done so, and application of psychology are begin- place where she uses mental imagery
he found no measurable improvement ning to be published. to "'psych up" for the event or goes
in their physical performance. Ma- through relaxation techniques to re-
lareki found that athletes who thought Specific Example lieve anxiety. Fifteen minutes before
they had warmed up performed bet- of a Warm-Up Routine the race begins, she is on the course
ter.20 Thus the warm-up period may doing short accelerations but at a low
be an important means for athletes to An athlete is to compete in the na- intensity to avoid any anaerobic activ-
decrease their anxiety levels. The area tional finals for canoe racing in the ity which would lead to lactic-acid
of sport psychology is becoming in- 1000-metre event. The athlete's warm- build-up in the muscles.
creasingly important in the prepara- up begins at the competition site,
where she starts by preparing and References
checking all of her equipment. Next 1. Kreiie V, Koch P. Warming-up as a pre-
Figure 5 she runs along side the course for five liminary to training and competitive sport.
PNF Stretch for Hamstrings minutes, working up a light to moder- Muscle and tendon injuries in athletes.
ate sweat. She is instructed to keep on Stuttgard: Georg Thieme Publishers, 1979;
her sweatsuit to maintain an elevated 76.
core temperature, and she begins to 2. Shellock FG. Physiological benefits of
stretch on dry land, concentrating on warm-up. Phys Sportsmed 1983;
static and PNF stretches for the low- 10:136-9.
back rotators and the rotator cuff of 3. Asmussen E, Boje 0. Body temperature
the shoulder. This exercise can be fol- and capacity for work. Acta Physiol Scand
lowed by ballistic stretches for the
4. Elam R. Warm-up and athletic perfor-
same areas, while the athlete goes mance: physiological analysis.
through a mental rehearsal of the event Strength aand Conditioning Assoc National
ahead. The athlete goes out on the 2:30.
water 75 minutes prior to race time and 5. Barnard RJ. The heart needs warm-up
paddles two to four kilometres, con- time. Phys Sportsmed 1976; 1:40.
centrating on the feel of the boat and 6. Astrand PO,
on correct alignment and technique. Work Physiology.Rodahl K. Textbook of
New York: McGraw
This period is followed by periods of Hill, 1977.
short sprints as she builds up accelera- 7. Levine M, Lombardo J, McNeely J, et
tion, progressing from half-speed to al. An analysis of individual stretching pro-
full speed. The event is rehearsed by grams of intercollegiate athletes. Phys
completing the 1000 metre distance in Sportsmed 1987; 3:130-9.
the appropriate lane, simulating the 8. Greipp JF. Swimmer's shoulder: the in-
Figure 6a Figure 7a
Improper Stretch for Low Back Improper Stretch for Quadriceps
Proper Stretch for Quadriceps
Proper Stretch for Low Back
180 CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988
fluence of flexibility and weight training.
Phys Sportsmed 1985; 8:92- 105.
9. Beaulieu JE. Stretching for all sports.
Pasadena: Athletic Press, 1980. College of Family Physicians of Canada
10. DeVries H. Prevention of muscle dis-
tress after exercise. Research Quarterly
1961; 32:177- 85.
11. Wiktorsson-Moller M, Oberg B, Ek-
strand J, et al. Effects of warming up, mas-
sage, and stretching on range of motion
and muscle strength in the lower extremity.
Amer JSport Med 1983; 4:249-53.
12. Harris M. Flexibility: review of the lit-
Annual Scientific Assembly
erature. Phys Ther 1969; 49:591-601.
13. Moore MA, Hutton RS. Electromyo-
graphic investigation of muscle stretching
Montreal, 15-18 May 1988
techniques. Medicine and Science in Sport
and Exercise 1980; 5:322-9.
14. Beaulieu JE. Developing a stretching
program. Phys Sportsmed 1981;
CALL FOR PAPERS
15. Hansen TO. Selected effects of stretch-
ing on flexibility. Master's Thesis Univer- A feature of the College's 1988 Annual Scientific
sity of California at Los Angeles, 1962. Assembly, to be held in Montreal, will be the
16. Holt LE, Travis RM, Okita T. Com- presentation of freestanding papers on a variety of
parative study of three stretching tech- topics. CFPC and AAFP members are invited to submit
niques. Perceptual and Motor Skills 1970;
31:611-6. abstracts of proposed papers, which will be judged by
17. Holt LE. Scientific Stretching for the Scientific Program Committee for possible
Sport (3-s) Dalhousie University, 1974. presentation.
18. DeVries H. Physiology of exercise for
physical education and athletics. Dubu- ABSTRACTS
que, Iowa: William C. Brown Co., 1974. Abstracts should include:
19. Massey BH, Johnson WR, Kramer GF. * a brief statement of thepurpose of the study;
Effect of warm-up exercise upon physical * a statement of the methods used;
performance using hypnosis to control the * a summary of the results, presented in sufficient detail
psychological variable. Research Quar-
terly 1961; 32:63-71. to support the conclusions;
20. Malareki I. Investigation on physiolog- * a statement of the conclusions reached. It is not
ical justification of so-called warming-up. satisfactory to state, "The results will be discussed", or
Acta Physiologica Poland 1954; 5:543-6. "Other data will be presented."
Figure 8a FORMAT
Improper Abductor Stretch Each speaker will have 10 minutes for presentation,
including 35 mm slides, if desired, plus five minutes
discussion time. Papers may cover any research, or any
clinical, political, economic, philosophical or historical
area of direct relevance to family medicine.
Abstracts will be considered only if submitted on
official abstract forms and accompanied by a completed
Figure 8b registration form for the Assembly, together with the
Proper Stretch for Hip Abductors registration fee. Forms and additional information are
Director of Administration
College of Family Physicians of Canada
4000 Leslie Street
Willowdale, Ont. M2K 2R9
Deadline for submission of abstracts: March 21, 1988
CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988 181