Therapeutic Exercise Chapter 4: Stretching For Impaired Mobility

Front 1

Mobility

Back 1

-ability of structures/segments of body to move or be moved to allow functional ROM

-ability of individual to initiate, control, or sustain active movements of the body to perform functional mobility

-associated with joint integrity and flexibility

Front 2

Hypomobility

Back 2

-restricted motion caused by adaptive shortening of soft tissues

-can lead to activity limitations and participation restrictions

Front 3

Common Causes of Hypomobility

Back 3

-prolonged immobilization of a body part

-sedentary lifestyle

-postural malalignment

-muscle imbalances

-impaired muscle performance

-tissue trauma resulting in inflammation/pain

-congenital/acquired deformities

Front 4

Stretching

Back 4

-any therapeutic maneuver designed to increase extensibility of soft tissues

-improves flexibility and ROM by elongating structures that have adaptively shortened over time

Front 5

Flexibility

Back 5

-ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM

-determined by muscle length, joint integrity, and extensibility of periarticular soft tissues

Front 6

Dynamic Flexibility

Back 6

-AKA active mobility/active ROM

-degree to which an active muscle contraction moves a body segment through available ROM

-dependent on the degree to which a joint can be moved by a muscle contraction and amount of tissue resistance met during active movement

Front 7

Passive Flexibility

Back 7

-AKA passive mobility/passive ROM

-degree to which a body segment can be passively moved through the available ROM

-dependent on extensibility of muscles and connective tissues that cross and surround a joint

Front 8

Contracture

Back 8

-adaptive shortening of muscle-tendon unit and other soft tissues that cross/surround a joint

-results in significant resistance to passive/active stretch and limitation of ROM

-may compromise functional abilities

-described by identifying the action of the shortened muscle

Front 9

Myostatic Contracture

Back 9

-no specific muscle pathology present

-musculotendinous unit has adaptively shortened

-significant loss of ROM

-can be resolved with stretching exercises

Front 10

Pseudomyostatic Contracture

Back 10

-impaired mobility and limited ROM

-may be result of hypertonicity

-associated with CNS lesion

-may also be caused by spasm or guarding

-resolved with neuromuscular inhibition

Front 11

Arthrogenic and Periarticular Contracture

Back 11

-result of intra-articular pathology

-changes may include adhesions, synovial proliferation, joint effusion, articular cartilage irregularities, or osteophyte formation

-connective tissues that cross or attach to a joint or joint capsule lose mobility

-restricts normal arthrokinematic motion

Front 12

Fibrotic Contracture and Irreversible Contracture

Back 12

-cannot be reversed

-normal tissue is replaced by adhesions, scar tissue, or heterotopic bone

-also occurs after long periods of immobilization

-difficult to regain optimal mobility

Front 13

Selective Stretching

Back 13

-applying stretching techniques selectively to some muscles and joints but allowing limitation of motion to develop in other muscles/joints

-keep in mind functional needs of patient

-used in SCI patients to build trunk stability, tenodesis in hand/wrist

Front 14

Overstretching and Hypermobility

Back 14

-stretch well beyond normal length of muscle and ROM

-results in excessive mobility

-creates joint instability

-may be necessary for some athletes

Front 15

Manual or Mechanical Stretching

Back 15

-external, end-range force applied with overpressure

-elongates shortened muscle-tendon unit

-can be active or passive depending on patient

Front 16

Self-Stretching

Back 16

any stretching carried out independently after instruction and supervision by a therapist

Front 17

Neuromuscular Facilitation and Inhibition Techniques

Back 17

-relax tension in shortened muscles prior to or during muscle elongation

-associated with PNF (hold-relax, contract-relax)

Front 18

Muscle Energy Techniques

Back 18

-AKA postisometric relaxation

-lengthen muscle/fascia and mobilize joint

-voluntary muscle contractions by patient in a controlled direction and intensity against a counterforce applied by practitioner

Front 19

Joint Mobilization/Manipulation

Back 19

-skilled manual therapy interventions specifically applied to joint structures

-modulate pain and treat joint impairments that limit ROM

Front 20

Soft Tissue Mobilization/Manipulation

Back 20

-improve muscle extensibility

-specific and progressive manual forces to effect change in myofascial structures that bind soft tissues and impair mobility

-Ex: STM, friction massage, myofascial release, acupressure, and trigger point therapy

Front 21

Neural Tissue Mobilization

Back 21

-AKA neuromeningeal mobilization

-reduce adhesions/scar tissue that form around meninges/nerve roots after trauma/surgery

Front 22

Indications for Use of Stretching

Back 22

-ROM is limited b/c soft tissues have lost extensibility

-adhesions, contractures, scar tissue

-structural deformities that are preventable

-muscle weakness/shortening of antagonist

-prevent/reduce risk of injury

-potentially reduce postexercise soreness

Front 23

Contraindications to Stretching

Back 23

-bony block limits joint motion

-recent fracture/incomplete bony union

-acute inflammation or infection

-sharp, acute pain with movement

-hematoma or tissue trauma

-hypermobility

-hypomobility provides necessary stability/neuromuscular control

Front 24

Potential Benefits and Outcomes of Stretching

Back 24

-increased flexibility and ROM

-general fitness

-injury prevention

-reduced postexercise muscle soreness

-enhanced performance

Front 25

Soft Tissue Response to Stretch

Back 25

-elasticity: ability of soft tissue to return to pre-stretch resting length directly after a short-duration stretch force has been remove

-viscoelasticity: initially resists deformation, but will allow change in length of tissue and then enable tissue to return to prestretch state

-plasticity: tendency to assume new/greater length after stretch force is removed

Front 26

Contractile Elements of Muscle

Back 26

-sarcomere is the contractile unit of the myofibril

-sarcomere gives a muscle its ability to contract and relax

Front 27

Response of Sarcomere to Stretch

Back 27

-filaments slide apart, leading to abrupt lengthening of sarcomeres (sarcomere give)

-when stretch force is released, sarcomeres return to normal resting length (elasticity)

Front 28

Response of Sarcomere to Immobilization

Back 28

-decreased contractile protein, fiber diameter, number of myofibrils, and capillary density leads to atrophy and weakness

-in shortened position, reduction in muscle length and number of sarcomeres (absorption)

-in lengthened position, number of sarcomeres increases and can be maintained if muscle is used on a regular basis

Front 29

Muscle Spindle

Back 29

-major sensory organ of muscle

-sensitive to quick and sustained stretch

-receive and convey info about changes in muscle length and velocity of length changes

-composed of afferent sensory fibers, efferent motor fibers, and intrafusal fibers

Front 30

Golgi Tendon Organ

Back 30

-monitors changes in tension of muscle-tendon units

-sensitive to even slight changes

-continuously monitors and adjusts force of active muscle contractions or tension in muscle during passive stretch

Front 31

Neurophysiological Response of Muscle to Stretch

Back 31

-increased tension in muscle being stretched

-inhibition in the muscle on the opposite side of the joint may occur

-a slowly applied, low-intensity, prolonged stretch is preferable

Front 32

Composition of Connective Tissue

Back 32

-collagen fibers: strength, stiffness, resist tensile deformation

-elastin fibers: provide extensibility

-reticulin fibers: provide tissue with bulk

-ground substance: reduces friction b/w fibers and transports nutrients

Front 33

Mechanical Behavior of Noncontractile Tissue

Back 33

-determined by proportion of collagen and elastin fibers and their structure

-tissue high in collagen fibers resist high tensile loads (tendons)

-tissue high in ground substance withstand greater compressive loads (cartilage)

-ligaments, joint capsules, and fasciae have a combo of both depending on stressors

Front 34

Stress

Back 34

-force (load) per unit area

-mechanical stress is the internal reaction or resistance to an external load

Front 35

Strain

Back 35

amount of deformation or lengthening that occurs when a load (or stretch force) is applied

Front 36

Tension

Back 36

-a force applied perpendicular to the cross-sectional area of the tissue in a direction away from the tissue

-Ex: stretching force

Front 37

Compression

Back 37

-a force applied perpendicular to the cross-sectional area of the tissue in a direction toward the tissue

-Ex: muscle contraction, loading of a joint during WB

Front 38

Shear

Back 38

a force applied parallel to the cross-sectional area of the tissue

Front 39

Stress-Strain Curve

Back 39

-used to interpret what is happening to connective tissue under stress loads

-toe region

-elastic range

-elastic limit

-plastic range

-ultimate strength

-failure

Front 40

Toe Region

Back 40

-considerable deformation w/o use of much force

-most functional activity normally occurs

Front 41

Elastic Range

Back 41

-strain is directly proportional to ability of tissue to resist force

-occurs when tissue is taken to end of ROM and gentle stretch is applied

-complete recovery from this deformation if stress is not maintained for any length of time

Front 42

Elastic Limit

Back 42

the point beyond which the tissue does not return to its original shape and size

Front 43

Plastic Range

Back 43

-range beyond elastic limit extending to point of rupture

-permanent deformation of tissue when released

-heat is released and absorbed in tissue

-rupturing of fibers results in increased length

Front 44

Ultimate Strength

Back 44

-greatest load the tissue can sustain

-increased strain w/o an increase in stress required

-necking: considerable weakening of tissue and it rapidly fails

-tissue could completely tear if stress is maintained

Front 45

Failure

Back 45

rupture of integrity of tissue

Front 46

Creep

Back 46

-load is applied for extended period of time, tissue elongates and doesn't return to original length

-low loads, usually in elastic range, and applied for long periods increase deformation of connective tissue

Front 47

Stress-Relaxation

Back 47

-after initial creep, decrease in force required to maintain that length

-tension in tissue decreases

-recovery versus permanent change in length is dependent on amount of deformation and length of time the deformation is maintained

Front 48

Effects of Immobilization on Collagen

Back 48

-weakening of tissue

-adhesion formation

-rate of return to normal tensile strength is slow

Front 49

Effects of Inactivity on Collagen

Back 49

-decrease in size and amount of collagen fibers

-weakening of tissue

Front 50

Effects of Age on Collagen

Back 50

-decrease in maximum tensile strength

-rate of adaptation to stress is slower

-increased tendency for overuse syndromes, fatigue, failures, and tears with stretching

Front 51

Effect of Corticosteroids on Collagen

Back 51

decrease in tensile strength

Front 52

Effects of Injury on Collagen

Back 52

-rupture of ligaments and tendons

-remodeling can take 3 weeks-12 months depending on size of tissue and magnitude of tear

Front 53

Other Conditions Affecting Collagen

Back 53

-nutritional deficiencies

-hormonal imbalances

-dialysis

Front 54

Determinants of Stretching Interventions

Back 54

-alignment and stabilization

-intensity of stretch

-duration of stretch

-speed of stretch

-frequency of stretch

-mode of stretch

Front 55

Alignment and Stabilization

Back 55

-positioning a limb or the body such that the stretch force is directed to the appropriate muscle group

-fixation of one site of attachment of the muscle as the stretch force is applied to the other bony attachment

Front 56

Intensity of Stretch

Back 56

magnitude (load) of stretch force applied

Front 57

Duration of Stretch

Back 57

length of time the stretch force is applied during a stretch cycle

Front 58

Speed of Stretch

Back 58

speed of initial application of the stretch force

Front 59

Frequency of Stretch

Back 59

number of stretching sessions per day/week

Front 60

Mode of Stretch

Back 60

-form or manner in which the stretch is applied (static, ballistic, cyclic)

-degree of patient participation (passive, assisted, active)

-source of stretch force (manual, mechanical, self)

Front 61

Proprioceptive Neuromuscular Facilitation Stretching

Back 61

-AKA active stretching/facilitative stretching

-inhibit or facilitate muscle activation

-increase likelihood that the muscle to be lengthened remains as relaxed as possible as it is stretched

-increase flexibility and ROM

Front 62

Types of PNF Stretching

Back 62

-hold-relax (HR) and contract-relax (CR)

-agonist contraction (AC)
-hold-relax with agonist contraction (HR-AC)

Front 63

Hold-Relax and Contract-Relax

Back 63

-muscle is first lengthened to point of tissue resistance or patient comfort

-patient performs pre-stretch, end-range, isometric contraction followed by relaxation

-limb is then passively moved into new range as muscle is elongated

Front 64

Agonist Contraction

Back 64

-refers to the muscle opposite the range-limiting target muscle

-patient concentrically contracts agonist and holds end-range position for several seconds

-movement is controlled by patient and is deliberate and slow

Front 65

Hold-Relax with Agonist Contraction

Back 65

-move the limb to the point that tissue resistance is felt

-have patient perform a resisted, prestretch, isometric contraction followed by relaxation

-immediately concentrically contract the muscle opposite the range-limiting muscle

Front 66

Importance of Strength and Muscle Endurance

Back 66

-low-load resistance to improve muscle performance as early as possible in a stretching program

-develop neuromuscular control and strength of agonist as well

-use recently gained ROM

Front 67

Use of Increased Mobility for Functional Activities

Back 67

-integrate functional activities into a stretching program to use gained ROM on a regular basis

-lends diversity and interest to a stretching program

Front 68

Guidelines for Application of Stretching

Back 68

-examination and evaluation of patient

-preparation for stretching: warm-up, explain procedure, clear area

-application of manual stretching

-after stretching: apply cold, have patient perform active ROM

Front 69

Precautions for Stretching

Back 69

-do not force a joint past normal ROM

-osteoporosis, prolonged bed rest, age, steroids

-recent fractures

-immobilization

-gradual progression

-edema

-weak muscles (especially postural muscles)

Front 70

Common Problems for Mass-Market Flexibility Programs

Back 70

-poorly balanced stretching activities

-insufficient warm-up

-ineffective stabilization

-ballistic stretching

-excessive intensity

-abnormal biomechanics

-insufficient information about age differences

Front 71

Relaxation Training

Back 71

-using methods of general relaxation (total body relaxation) which reduces muscle tension

-help patients relieve/reduce pain, muscle tension, anxiety/stress, and other impairments

Front 72

Examples of Relaxation Training

Back 72

-autogenic: conscious relaxation, meditation

-progressive: systematic, distal-to-proximal progression of voluntary contraction and relaxation of muscles

-awareness through movement: alter muscle imbalances and abnormal postural alignment

Front 73

Heat & Stretching

Back 73

-as temp increases, so does extensibility of contractile and non-contractile tissues

-warm-up: hot packs, paraffin, US, diathermy; low-intensity, active exercises also increase body temp

Front 74

Cold & Stretching

Back 74

-pre-stretch: decrease muscle tone, make muscle less sensitive

-post-stretch: decreases pain and muscle spasm

-cooling soft tissues in a lengthened position after stretching = more lasting increases in length and minimized soreness

Front 75

Massage & Stretching

Back 75

-helps relaxation

-increases circulation to muscles

-decreases muscle spasm

-increase mobility of shortened tissues

-break up adhesions

-increase mobility of scar tissue

Front 76

Biofeedback & Stretching

Back 76

-help a patient learn and practice the process of relaxation

-by reducing muscle tension, pain can be decreased and flexibility increased

Front 77

Joint Traction/Oscillation & Stretching

Back 77

inhibit joint pain and spasm of muscles around a joint