Chapter 4 Stretching for Improved Mobility
Contraindications for Stretching:
- Bony Block - Non-Union Fracture - Acute Inflammation or Infection - Sharp or Acute Pain With Elongation - Hematoma or Tissue Trauma - Hypermobility - Hypomobility Provides Stability or Neuro-muscular Control
Changes in Collagen Affecting Stress-Strain Response - Effects of injury
- Follows a predictable healing pattern - Formation of type III collagen bridging injury site - Progression to type I collagen - Remodeling begins about 3 weeks post-injury and continues for several months to a year
Pseudomyostatic Contracture
- Impaired mobility and limited ROM may also be the result of Hypertonicity (spasticity or rigidity) - Associated with Central Nervous System Lesion (cerebrovascular accident, spinal cord injury, TBI) - Muscle spasms or guarding and pain may also cause contracture - In both states the involved muscles appear to be in a constant state of contraction
Potential Benefits and Outcomes for Stretching Exercises:
- Increased Flexibility and ROM - General Fitness - Other Potential Benefits Injury prevention Reduced post-exercise soreness Enhanced performance
Arthrogenic and Perarticular Contracture:
- Result of intra-articular pathology - Adhesion, synovial proliferation, joint effusion, irregularities in articular cartilage, Develop when connective tissues that cross or attach to a joint or joint capsule lose mobility
Changes in Collagen Affecting Stress-Strain Response -Effects of immobilization
- causes collagen turnover and weak bonding between the new, nonstressed fibers - rate of return is slow
Changes in Collagen Affecting Stress-Strain Response - Effects of corticosteroids
- decreased collagen synthesis and organization - necrosis - fibrocyte death with delayed reappearance up to 15 weeks
Changes in Collagen Affecting Stress-Strain Response -Effects of inactivity (decrease of normal activity)
- decreases the size and amount of collagen fibers resulting in weakness - recovery takes about 5 months
Fibrotic and Irreversible Contracture:
- fibrous changes in the connnective tissue and perarticular structures - Permanent loss of soft tissue extensibility that cannot be reversed by nonsurgical intervention may occur When normal muscle and organized connective tissue are replaced with a large amount of non extensible fibrotic adhesion's, scar tissue. - the longer a fibrotic contracture exists or more extensive the tissue replacement the more difficult it becomes to regain optimal mobility
Myostatic Contracture:
- musculotendinous unit has adaptively shortened and significant loss of ROM - There is no specific muscle pathology present - can be resolved in a relatively short time with stretching
proteoglycans and glycoproteins:
- reduce friction between fibers - transport nutrients and metabolites within tissue - maintain space between fibers to help prevent excessive cross-linking
Indications for stretching:
1. Adhesions, Contractures, Scar Tissue Limit ROM 2. Potential for Structural Deformity d/t Limited ROM 3. Muscle Weakness, Shortening of Muscles 4. Part of a Total Fitness Program 5. Pre and Post Vigorous Exercise
Designation of contractures by location:
1. Are described as the side of the joint that has the tissue tightness; if tightness is on the flexion side of the joint axis, it is called a flexion contracture 2. Flexion contracture means, the extensors need stretched
Summary of Mechanical Principles for Stretching Connective Tissue
1. Permanent changes in tissue length or flexibility requires breaking of collagen bonds and realignment of the fibers 2. If healing and remodeling time is not allowed, a breakdown of tissue (failure) occurs as in over use syndromes and stress fractures 3. Individual is to use any newly gained range to allow remodeling of tissue and to train the muscle to control the new range
There are 4 categories of stretching Exercises:
1. Static 2. cyclic 3. Ballistic 4. PNF Principles
Factors leading to Hypomobility include:
1. prolonged immobilization of a body segment 2. sedentary lifestyle 3. Postural malalignment with muscle length alterations 4. impaired muscle performance (weakness) associated with musculosketal or neuromuscular disorders 5. tissue trauma resulting in inflammation and pain 6. congenital or acquired deformities
Ballistic Stretching,
A rapid, forceful intermittent stretch-- that is, a high velocity and high intensity stretch. - Although both ballistic and static stretching can improve flexibility equally, ballistic is thought to cause greater trauma to stretched tissues and greater residual muscle soreness - Should not be used with elderly or sedentary individuals or patients with musculoskeletal pathology
Dynamic Flexibility:
Active ROM, is the extent to which an active muscle contraction can rotate a joint through its available ROM
Changes in Collagen Affecting Stress-Strain Response - Effects of age
Aging decreases the maximum tensile strength and stiffness of tissue, and the rate of adaptation to loading is slower - there is an increased tendency for overuse syndrome, fatigue failures, and tears with stretching
Determinants and Types of Stretching Exercises - Alignment
Alignment- positioning a limb or the body such that the stretch force is directed to the appropriate muscle - effective stretching requires maximizing the distance between the origin and insertion, alignment that compromises this requirement
Overstretching
Is a stretch well beyound the normal length of the muscle and ROM (hypermobility) - for Sports
Determinants and Types of Stretching Exercises - Duration of stretch
Length of time the stretch force is applied during a stretch cycle -Static, sustained, maintained and prolonged are used to describe a long duration stretch - cyclic, intermittent, or ballistic are used for short-duration stretch
Static Stretches should be held for:
Longer than 90 Seconds
Determinants and Types of Stretching Exercises - Intensity of stretch
Magnitude of the stretch force applied - stretching should be applied at a low intensity by means of a low load
Determinants and Types of Stretching Exercises - Mode of stretch
Manner in which stretch force is applied (static, ballistic, cyclic), degree of patient participation (passive, assisted, or active) or the source of the stretch force (manual, mechanical, or self)
Determinants and Types of Stretching Exercises - Frequency of stretch
Number of stretching sessions per day or per week
Passive Flexibility:
Passive ROM, is the extent to which a joint can be passively rotated through its available ROM and depends on the extensibility of soft tissues that cross and surround a joint
Muscle Energy Techniques:
Procedures employ voluntary muscle contractions by the patient in a precisely controlled direction and intensity against a counterforce applied by the practintioner
Determinants and Types of Stretching Exercises - Speed of Stretch
Rate of initial application of the stretch force - A stretch force should be applied and released at a slow rate is less likely to increase tensile stresses on connective tissues, making it safer
What is Hypomobility
Refers to decreased mobility or restricted motion at a single joint or series of joints.
Determinants and Types of Stretching Exercises - Stabilization
Stabilization- fixation of a bony segment that has an attachment of the muscle to be stretched Manual stretching the proximal attachment is stabilized Self stretching the distal attachment is stablized
Cyclic (intermittent) Stretching
Stretch force that is repeatedly but gradually applied applied, released, and the reapplied multiple times during a single treatment session - cyclic loading has been shown to increase flexibility as effectively or more effectively than static stretching
Static Progressive Stretching
The shortened soft tissues are held in a comfortably lengthened position until a degree of relaxation is felt by patient or therapist. - the shortened tissues are incrementally lengthened even further and again held in the new range.
Selective Stretching:
Whereby the overall function of a patient may be improved by applying stretching techniques to some muscles and joints while allowing motion limitations to develop in other muscles or joints. - is usually typical in patients with permanent paralysis - SCI to thoracic and cervical lesions, stretching of the hamstrings and moderate hypomobility is allowed to delvelop in the extensors of the low back. Allows for trunk mobility
Soft Tissue Mobilization
application of specific and progressive manual forces using sustained manual pressure or slow, deep stroking - designed to improve tissue mobility by manipulating connective tissue that binds soft tissue
Collagen fibers:
are responsible for the strength and stiffness of tissue and resist tensile deformation
Contracture is most often defined as:
as an almost complete loss of Motion
Connective tissue is composed of:
collagen, elastin , reticulin, proteoglycans and glycoproteins
What is the primary cause of restricted mobility in healthy or patients after injury, disease, or surgery:
decreased extensibility of connective tissue
Contractile tissues have what properties:
elastic and plastic qualities
Non contractile Tissues have what properties:
elastic, plastic, and viscoelastic
Static Stretching
is commonly used method of stretching in which soft tissues are elongated just beyond the point of tissue resistance and then held in the lengthened position with a sustained stretch force over a period of time - considered safer than ballistic stretching
Contracture:
is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a join, resulting in significant resistance to passive or active stretch and limited ROM
Tightness is:
is described as restricted motion due to adaptive shortening of soft tissue, mild muscle shortening
Plasticity properties are:
is the tendency of soft tissue to assume a new and greater length after a stretch force is removed
Assisted stretching
patient assists in moving the joint through a greater range
Elastin fibers:
provide extensibility
Reticulin fibers:
provide tissue with bulk
Joint Mobilization
skilled manual therapy interventions specifically applied to joint structures by the clinician to modulate pain and treat joint impairments that limit ROM
Elastic properties are:
stretched soft tissue is elastic if it returns to its prestretched resting length directly after a short duration stretch
Flexibility is:
the ability to rotate a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM - muscle length, joint integrity and periarticular soft tissue extensibility all interact to determine flexibility
Shortness is:
used to denote partial loss of motions
Viscoelasticity properties are:
viscoelastic tissue initially resists deformation, but will slowly lengthen if the force is sustained. - will slowly return to prestretched form
Passive Stretching
when patient is as relaxed as possible during stretched