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