Restoring Range of Motion and Improving Flexibility

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Restoring Range of Motion and Improving
Flexibility
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Importance of Flexibility

• Important Goal Restore or improve to normal
  pre-injury range of motion
• 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
• Restricted range of motion can impact performance
  result in uncoordinated motion
• Essential for successful physical performance
  injury prevention

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Flexibility

• 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

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Anatomic Factors Impacting Flexibility

• Muscles
• Increasing flexibility relies on the elastic
  properties of muscle
• Length can be changed over time
• Connective Tissue
• 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
• Fat
• Can act as a wedge between lever arms
• Restricts movement wherever it is found

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• Skin
• Injury or surgical procedure may alter skin
  variable in elasticity
• 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
• Except for bone structure, age gender all other
  flexibility limiting factors can be modified
  altered to increase range of motion

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Soft Tissue Properties that Affect Immobilization
Elongation

• 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
• Epimysium enveloping fascial sheath
• Perimysium encases bundles of fasciculi
• Endomysium innermost layer that separates
  individual m. fibers myofibrils

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CT Structures of Muscle-tendon Unit
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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
• Gives muscle ability to contract relax
• Composed of overlapping myofilaments of Actin
  Myosin (form cross-bridges)
• 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

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Muscle Anatomy
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Muscle Structure
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Myofilament

• 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
• 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
• Consists primarily of myosin
• In the middle of the A band is the M line,
  another dense line

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Myofilament Sliding
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Noncontractile Tissue

• 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
• 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

• Active range of motion (AROM)
• Dynamic flexibility
• Joint movement via muscle contraction
• Ability to move a joint with little resistance
• Passive range of motion (PROM)
• Static flexibility
• Motion of joint to end points without muscle
  contraction
• Critical in injury prevention
• Muscles can be forced to stretch beyond normal
  limits
• Without elasticity it is likely that the
  musculotendinous unit will be injured
• During athletic activity
• Must be able to move through unrestricted range
• Must have elasticity for additional stretch
  encountered during activity

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Measuring Range of Motion

• Essential to assess improvement during
  rehabilitation
• Goniometer
• Utilizes alignment of two arms parallel to
  longitudinal axis of two segments involved in
  motion
• Relatively accurate tool
• Ensures accuracy standardize techniques methods
  of recording AROM PROM

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Agonist vs. Antagonist Muscles

• Joints are capable of multiple movements
• Example
• Quadriceps will extend knee with contraction
• Quads (muscle producing movement) agonist
• Hamstrings will stretch during knee extension
• Hamstrings undergoing stretch antagonist
• Agonist antagonist work together to produce
  smooth coordinated movements
• Muscles that work together function
  synergistically
• What is another pair of agonist/antagonist
  muscles?

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Stretching Techniques

• Ballistic
• Bouncing movement in which repetitive
  contractions of agonist work to stretch
  antagonist muscle
• Static stretching
• Stretch to point of discomfort holding at that
  point for period of time
• Proprioceptive Neuromuscular Facilitation (PNF)
• Involves alternating contractions stretches
• Myofascial neural tissue stretching
• Enhances neuromuscular systems ability to
  control movement

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Ballistic Stretching

• Need to be careful when performing this stretch
• Possible soreness due to uncontrolled forces
  within muscle created by bouncing
• May result in tissue damage
• Should be incorporated into a program to allow
  body to adapt reduce likelihood of injury
• Incorporate into later stages of rehabilitation

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Static Stretching

• Passively stretching given antagonist
• 6-8 second hold in maximal position of stretch
• Go to point of discomfort back off slightly
• Hold for 15-30 seconds (do this 3-4 times)
• Can be accomplished utilizing agonist
• Controlled movement, less chance of injury

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Proprioceptive Neuromuscular Facilitation

• Three techniques that combine alternating
  isometric or isotonic contractions relaxation
  of both agonist antagonists
• 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
• 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
• Results in stretch of antagonist
• Useful to stretch antagonist

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Comparing Stretching Techniques

• Ballistic stretching is recommended for athletes
  engaged in dynamic activity
• Static stretching most widely used
• Safe effective
• PNF techniques
• Capable of producing dramatic increases in ROM
• Limitation partner is required
• 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
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Stretching Neural Structures

• Requires differentiation between musculotendinous
  neural tightness
• Assess movements that create tension in neural
  structures
• May cause numbness tingling
• Straight-leg raise example

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Myofascial Release Stretching

• Techniques used to relieve abnormally tight
  fascia
• Myofascial restrictions are unpredictable may
  occur in different planes directions
• Requires specialized training in depth
  understanding of fascial system
• Fascia
• 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
• Treatment
• Localize restriction
• Considerably more subjective component relies
  heavily on clinicians 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

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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
• Cause reflex relaxation
• Prevents injury - protective mechanism
• Ballistic stretching does not allow this
  overriding response by GTO

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• With static stretching GTOs are able to override
  impulses from muscle spindle following initial
  reflex resistance
• Allows muscle to remain stretched without injury
• 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
• Reciprocal inhibition
• Isotonic contraction of an agonist muscle elicits
  a reflex relaxation of antagonist muscle group -
  (protect against injury)

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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
• Both resist deformation
• Deformation is dependent on degree of stretch
  velocity
• 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
• Greater velocity greater chance for exceeding
  tissue capacity (viscoelastic plastic)

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Effects of Stretching On Kinetic Chain

• Joint hypomobility causes
• Faulty posture
• Muscular imbalance
• Abnormal neuromuscular control
• 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

• 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

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Importance of Warm-up Prior to Stretching

• 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

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Flexibility vs. Strength

• Co-exist
• Muscle bound
• Negative connotation
• Loss of motion
• 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

• Warm-up
• Overload or stretch beyond normal range
• Not to point of pain
• 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

• 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