Transcript Restoring Range of Motion and Improving Flexibility

Restoring Range of Motion
and Improving Flexibility
Importance of Flexibility
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Important Goal: Restore or improve to normal pre-injury
range of motion
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With injury there is generally some degree of lost range
of motion
Due to pain, swelling, muscle guarding, &/or inactivity
resulting in tissue shortening
 Need to encourage stretching exercises
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Restricted range of motion can impact performance &
result in uncoordinated motion
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Essential for successful physical performance & injury
prevention
Flexibility
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Ability of neuromuscular system to allow
for efficient movement of a joint or series
of joint through a full, non-restricted pain
free range of motion
Anatomic Factors Impacting Flexibility
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Muscles
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Connective Tissue
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Increasing flexibility relies on the elastic properties of muscle
 Length can be changed over time
Ligaments & joint capsules, while possessing some elastic
properties, can lose their elasticity during periods of disuse &
immobilization
Bony Structures
Can limit end point range
 Bony prominences can also stop movements at normal end
points in the range
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Fat
Can act as a wedge between lever arms
 Restricts movement wherever it is found
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Skin
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Injury or surgical procedure may alter skin – variable in elasticity
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Skin adheres to underlying tissue
Neural tissue
Develops tightness as a result of compression, chronic repetitive
microtrauma, muscle imbalances, joint dysfunction or
morphological adaptations due to posture
 Could stimulate nociceptors & pain
 Cause muscle guarding & spasm to protect irritated neural
structures
 Neural fibrosis ultimately results causing decreased elasticity &
restricted motion
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Except for bone structure, age & gender all other
flexibility limiting factors can be modified & altered
to increase range of motion
Soft Tissue Properties that Affect
Immobilization & Elongation
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Responses that affect soft tissue during
stretching
 Velocity,
intensity, frequency & duration of
stretch force
 Temperature of tissues
Elasticity – ability of soft tissue to return
to its resting length after passive stretch
 Plasticity – tendency of soft tissue to
assume a new & greater length after
stretch force has been removed
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Soft Tissue Properties that Affect
Immobilization & Elongation
Contractile tissue: gives muscle
characteristics of contractility & irritability
 Noncontractile tissue: has same properties
as all CT, including ability to resist
deforming forces as well as viscoelasticity
 CT structures of muscle-tendon unit
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 Epimysium
– enveloping fascial sheath
 Perimysium – encases bundles of fasciculi
 Endomysium – innermost layer that separates
individual m. fibers & myofibrils
CT Structures of Muscle-tendon Unit
Muscle Anatomy
Made up of many muscle fibers that lie parallel
with one another
 Single fiber – made up of many myofibrils
 Myofibrils - composed of sarcomeres
 Sarcomere – contractile unit of the myofibril
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Gives muscle ability to contract & relax
 Composed of overlapping myofilaments of Actin &
Myosin (form cross-bridges)
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 Motor
unit stimulated = m. contraction -actin-myosin
filaments slide together & the muscle actively
shortens
 Muscle relaxes = cross-bridges slide apart slightly &
the muscle returns to its resting length
Muscle
Anatomy
Muscle
Structure
Myofilament
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Interlocking Mesh
Structure
A myofilament shows several
distinct bands
Each band has been given a
special letter
The lightest (least electron
dense) band is the “I band”
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Consists primarily of actin
In the center of the “I band” is
the “Z-line”, an electron
dense line
The wide, dark band is the “A
band”
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Consists primarily of myosin
In the middle of the “A band” is
the “M line”, another dense
line
Myofilament
Sliding
Noncontractile Tissue
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Made up of:
Collagen – resist tensile deformation & are responsible for
strength & stiffness of tissue, elongates quickly under light loads
 Elastin - extensibility
 Reticulin fibers – bulk
 Ground substance – proteoglycans (PGs) & glycoproteins;
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PGs hydrate matrix, stabilize collagen network, resist compressive forces;
Glycoproteins provide linkage between matrix components & between cells
& matrix opponents
Mechanical behavior is determined by proportion of collagen
& elastin fibers & structural orientation of the fibers
High collagen, low PGs – resist high tensile loads
 High collagen content tissue = greater stability (tendons)
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Active & Passive Range of Motion
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Active range of motion (AROM)
Dynamic flexibility
 Joint movement via muscle contraction
 Ability to move a joint with little resistance
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Passive range of motion (PROM)
Static flexibility
 Motion of joint to end points without muscle contraction
 Critical in injury prevention
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Muscles can be forced to stretch beyond “normal” limits
Without elasticity it is likely that the musculotendinous unit will be injured
During athletic activity
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Must be able to move through unrestricted range
Must have elasticity for additional stretch encountered during
activity
Measuring Range of Motion
Essential to assess improvement during
rehabilitation
 Goniometer
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Utilizes alignment of two arms parallel to
longitudinal axis of two segments involved in
motion
Relatively accurate tool
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Ensures accuracy standardize techniques & methods of
recording AROM & PROM
Agonist vs. Antagonist Muscles
Joints are capable of multiple movements
 Example:
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Quadriceps will extend knee with contraction
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Quads (muscle producing movement) = agonist
Hamstrings will stretch during knee extension
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Hamstrings undergoing stretch = antagonist
Agonist & antagonist work together to produce
smooth coordinated movements
 Muscles that work together function synergistically
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What is another pair of agonist/antagonist muscles?
Stretching Techniques
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Ballistic
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Static stretching
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Stretch to point of discomfort & holding at that point
for period of time
Proprioceptive Neuromuscular Facilitation (PNF)
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Bouncing movement in which repetitive contractions
of agonist work to stretch antagonist muscle
Involves alternating contractions & stretches
Myofascial & neural tissue stretching
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Enhances neuromuscular system’s ability to control
movement
Ballistic Stretching
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Need to be careful when performing this
stretch
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Possible soreness due to uncontrolled forces
within muscle created by bouncing
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May result in tissue damage
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Should be incorporated into a program to allow
body to adapt & reduce likelihood of injury
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Incorporate into later stages of rehabilitation
Static Stretching
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Passively stretching given antagonist
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6-8 second hold in maximal position of stretch
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Go to point of discomfort & back off slightly
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Hold for 15-30 seconds (do this 3-4 times)
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Can be accomplished utilizing agonist
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Controlled movement, less chance of injury
Proprioceptive Neuromuscular
Facilitation
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Three techniques that combine alternating
isometric or isotonic contractions & relaxation
of both agonist & antagonists
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Slow-reversal-hold-relax
Contract-relax
Hold-relax
Hold Relax (HR)
Isometric contraction of antagonist followed by concentric
contraction of agonist with light pressure
 Facilitates stretch of antagonist
 Effective with muscle tension on one side of joint
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Contract Relax (CR)
Moves body passively into agonist pattern
 Athlete instructed to contract antagonist isotonically against
resistance
 Athlete then relaxes & allow athletic trainer to push body further
(passively) into agonist pattern
 Utilized when flexibility is limited due to muscle tightness
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Slow Reversal-Hold-Relax (SRHR)
Isotonic contraction of agonist
 Follow with isometric contraction of antagonist
 During relax phase antagonist is relaxed while
agonist contracts in agonist pattern
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Results in stretch of antagonist
Useful to stretch antagonist
Comparing Stretching Techniques
Ballistic stretching is recommended for athletes
engaged in dynamic activity
 Static stretching most widely used
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Safe & effective
PNF techniques
Capable of producing dramatic increases in ROM
 Limitation – partner is required
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Maintaining flexibility
Can decrease considerable after only 2 weeks
 Should be engaged in at least once per week
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Specific Stretching Exercises
Stretching Neural Structures
Requires
differentiation
between
musculotendinous &
neural tightness
 Assess movements
that create tension in
neural structures
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May cause numbness
& tingling
 Straight-leg raise
example
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Myofascial Release Stretching
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Techniques used to relieve abnormally tight
fascia
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Myofascial restrictions are unpredictable & may occur
in different planes & directions
Requires specialized training & in depth
understanding of fascial system
 Fascia
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Connective tissue that runs throughout the body &
establishes interconnectedness of body
 If altered or injured can result in localized response
at focal point of injury or away from injury site
 Responds to gentle pressure
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Sometimes called: Soft-tissue Mobilization
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Treatment
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Localize restriction
Considerably more subjective component & relies
heavily on clinician’s experience
Focuses on large treatment area
Work superficial to deep
Joint mobilizations may follow
Tissue stretching & elongation as well as
strengthening should follow
Postural re-training may also be required
Dramatic results may occur
Treatment should be done at least 3 times per week
Perform manually or via foam roller
Neurophysiological Basis of
Stretching
Stretch Reflex
Muscle is placed on stretch – muscle spindle
 Muscle spindles fire relaying info. to spinal cord
 Spinal cord relays message to golgi tendon &
increases tension
 After 6 seconds, golgi tendon organ (GTO) relays
signal for muscle tension to decrease
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 Cause
reflex relaxation
 Prevents injury - protective mechanism
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Ballistic stretching does not allow this overriding
response by GTO
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With static stretching GTO’s are able to
override impulses from muscle spindle
following initial reflex resistance
 Allows
injury
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muscle to remain stretched without
PNF benefits greatly from these
principles
 With
slow-reversal hold technique, maximal
contraction of muscle stimulates GTO reflex
relaxation before stretch applied
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Autogenic inhibition
Relaxation of antagonist during contraction
 During relaxation phase, antagonist is placed
under stretch but assisted by agonist
contraction to pull further into stretch
 GTO is protective mechanism that inhibits
tension in the muscle
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Reciprocal inhibition
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Isotonic contraction of an agonist muscle elicits
a reflex relaxation of antagonist muscle group (protect against injury)
Effect of Stretching on Physical &
Mechanical Properties of Muscle
Physical lengthening of muscle occurs due to
reflex relaxation
 Contractile & non-contractile elements of muscle
dictate capability of deformation & recovery
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Both resist deformation
 Deformation is dependent on degree of stretch &
velocity
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 Non-contractile
– limit degree
 Contractile – limit velocity
 Greater stretch = more non-contractile components
contribute
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Stretches sustained long enough
(autogenic inhibition) result in viscoelastic
& plastic changes in collagen & elastin
 Viscoelastic
changes allow slow deformation
& imperfect recovery (not permanent)
 Plastic changes result in permanent changes
in length
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Greater velocity = greater chance for
exceeding tissue capacity (viscoelastic &
plastic)
Effects of Stretching On Kinetic Chain
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Joint hypomobility causes:
Faulty posture
 Muscular imbalance
 Abnormal neuromuscular control
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Alteration in arthrokinematics
Change in muscle tension to reduce translation
 Alters degrees of tension & activation in synergist,
stabilizers & neutralizers
 Compensatory response
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Muscle Tightness & Hypertonicity
Impact on length-tension
relationships
 Alters force couples &
arthrokinematics
 Impacts normal force
couple relationships &
creates kinetic chain
reaction
 Impacts synergistic
function of kinetic chain
 Causes abnormal joint &
tissue stresses, neural
compromise &
vascular/lymphatic stasis
 Alters recruitment
strategies & stabilization
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Alters neuromuscular
efficiency impacting
activation/firing sequence
Additionally altered joint
function & stress response
Can causes reciprocal
inhibition
Increases muscle spindle
activity
May impart inhibitory
response (decreased
neuromuscular control)
Result = synergistic
dominance – synergist
compensatory action for
weak & inhibited muscle
Importance of Warm-up Prior to
Stretching
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Intramuscular temperature should be increased
prior to stretching
Positive effect on ability of collagen & elastin to
deform
Enhances reflexive relaxation associated with
golgi tendon organs
Optimal temperature 39oC/103oF
To increase = low intensity, warm-up type
exercise or modalities
Exercise should be primary means of warm-up
Environment - Heat vs. Cold
Flexibility vs. Strength
Co-exist
 Muscle bound
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Negative connotation
 Loss of motion
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Encourage full pain free movements during
rehabilitation
 Strength training will provide individual with
ability to develop dynamic flexibility through full
range of motion
 Develop more powerful & coordinated
movements
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Guidelines & Precautions for
Stretching
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Warm-up
Overload or stretch beyond
normal range
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Not to point of pain
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Stretch to point of resistance
Increases in range will be
specific to muscle being
stretched
Use caution when stretching
around painful joints
Avoid overstretching ligaments
& capsules
Exercise caution with low back
& neck stretches
Stretch from seated position to
reduce stress on back
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Continue normal breathing
while stretching
For improvements in ROM,
utilize static & PNF stretching
techniques
Ballistic stretching should be
used by those who possess
flexibility & are accustomed to
it
Ballistic stretching should follow
period of static stretching
Stretching should be performed
a minimum of 3 times per week
For maximum gains stretching
5-6 times per week is ideal