Restoring Range of Motion and Improving Flexibility

1. Restoring Range of Motion and Improving Flexibility Rehabilitation Techniques for Sports medicine and athletic training William e. prentice

2. Introduction • Loss of motion occurs after injury • Due to pain, swelling, muscle guarding or spasm • Shortening of connective tissue and muscle • Loss of neuromuscular control • Restoring normal range of motion is one of primary goals of rehabilitation program • Flexibility • Ability to move a joint through a full, non-restricted, pain free range of motion • Dependent on combination of joint range of motion and muscle flexibility

3. Introduction • Joint range of motion • Limited by shape of articulating surface and capsular and ligamentous structures • Muscle flexibility • Ability of musculotendinous unit to lengthen • Lack of flexibility in one joint can effect the entire kinetic chain

4. Importance of flexibility • Essential to normal daily living • Functional activities require relatively “normal” amounts of flexibility • Some activities require more flexibility for superior performance • Decreased flexibility creates uncoordinated/awkward movement patterns • Result of loss of neuromuscular control

5. Importance of Flexibility • Generally accepted that flexibility is essential for improved performance • Recent studies conflicting and inconclusive • Stretching has shown to decrease performance parameters • Strength, endurance, power, joint position sense and reaction times • Decrease incidence of injury • Recent studies fail to find true cause and effect relationship

6. Anatomic Factors that Limit Flexibility • Muscles, tendons and their surrounding fascial sheaths • Stretching attempts to take advantage of highly elastic properties of muscle • Overtime it is possible to increase elasticity , or the length a given muscle can be stretched • Connective tissue (ligaments and joint capsule) • Become shortened and stiff during periods of immobilization • People can also be loose jointed from slack or increased laxity in connective tissue • Creates some instability

7. Anatomic Factors that Limit Flexibility • Bony structures • Restrict end point in the range of motion • Good for stability • After fracture excess calcium can develop which interferes with normal range • Fat • Excess fatty tissue can restrict range of motion • For example; excess abdominal fat can restrict trunk movement

8. Anatomic Factors that Limit Flexibility • Skin • Inelastic scar tissue can develop after surgery or injury • Incapable of stretching with joint movement • Overtime can improve elasticity to varying degrees through stretching • Neural tissue • Tightness develops in neural tissues from acute compression, chronic repetitive microtrauma, muscle imbalances, joint dysfunctions, or poor posture • Can create morphological changes in tissue that can cause pain • Pain can cause muscle guarding and spasm • Can eventually lad to neural fibrosis or scarring

9. Active and Passive Range of Motion • Active range of motion • Dynamic flexibility • Degree to which a joint can be moved by a muscle contraction • Not necessarily a good indicator of joint stiffness or looseness because movement of joint has little resistance • Passive range of motion • Static flexibility • Degree to which a joint can be passively moved to end points of range of motion • No muscle contraction involved

10. Active and Passive ROM • Many situations in activity when muscle is forced beyond its normal active limits • If muscle does not have elasticity to compensate, injury to musculotendinous unit may occur

11. Assessment of ROM • Goniometers • Large protractors w/ measurements in degrees • Align arms of goniometer along longitudinal axis of 2 segments • Reasonably accurate measurement of ROM • Standardization of measurement techniques and recording AROM & PROM have been developed • Immobile arm is lined up along immobile segment • Mobile arm is lined up along mobile segment

12. Neurophysiologic Basis of Stretching • Mechanoreceptors in muscle tell CNS what is happening within that muscle • 2 of these are important in the stretch reflex • Muscle spindle and the Golgi tendon organ (GTO) • Sensitive to changes in muscle length • GTO also sensitive to change in muscle tension

13. Neurophysiologic Basis of Stretching • Muscle spindle initially sends sensory impulse to spinal cord which then sends a message back to muscle spindle causing the muscle to reflexively contract • If stretch last longer than 6 seconds, impulses from GTO begin to override muscle spindle • autogenic inhibition, or a reflex relaxation of the antagonist muscle • Protective mechanism to allow stretch to avoid damage to muscle fibers • Reciprocal inhibition • Contraction of agonist causes a reflex relaxation in the antagonist muscle • Allows antagonist to stretch and protects from injury

14. Effects of stretching on physical and mechanical properties of muscle • Muscle and tendon composed of non contractile collagen and elastin fibers • Collagen can withstand high tensile stress • Mechanical properties • Elasticity: capability to recover normal length after elongation • Viscoelasticity: allows for slow return to normal length and shape after deformation • Plasticity: allows for permanent change or deformation • Physical Properties • Creep response: ability of tissue to deform over time while a constant load is imposed • Greater the stretch the greater the noncontractile properties contribute • Lengthening of a muscle via stretching allows for viscoelastic and plastic changes to occur in collagen and elastin

15. Effects of stretching on the kinetic chain • Muscle tightness has significant impact on neuromuscular control • Effects normal length-tension relationships • Compensations and adaptations occur that affect neuromuscular efficiency through kinetic chain • Reciprocal inhibition • For example: if psoas is tight or hyperactive the antagonist gluteus maximus can be inhibited due to decreased neural drive • The synergist, hamstrings (muscle that assist glut max); the stabilizers, erector spinae; and the neutralizers, piriformis become overactive • Creates abnormal joint stress and decreased neuromuscular control during functional movement

16. Importance of increasing muscle temp. prior to stretching • Muscle temperature should be increased prior to stretching • Positive effect of collagen and elastin components to deform • Capability of GTO to reflexively relax is enhanced • Can be achieved through low intensity warm up or through various therapeutic modalities • However exercise is recommended over modalities • If muscle guarding occurs cold therapy can also be used prior to stretching

17. Stretching techniques • Agonist muscle: muscle that contracts to allow movement through a joint • Antagonist muscle: the muscle that is being stretched in response to contraction of agonist • Balance between the agonist and antagonist is necessary for normal, smooth, coordinated movement • As well as reduce muscle strains secondary to muscular imbalances • Comprehension of this synergistic muscle action is essential to understanding various stretching techniques

18. Ballistic stretching • Repetitive contractions of agonist used to produce quick stretches of antagonist • Safety questioned because of risk of microtears in musculotendinous unit • Not recommended for sedentary individuals or those recovering from muscle injury • Most physical activities are dynamic and repetitive contraction of agonist with eccentric resistance from antagonist occurs • May be implemented in later stages of rehab during reconditioning phase • Progressive velocity flexibility program has been proposed • Slow static to slow end range to slow full range to fast end range to fast full range

19. Static stretching • Extremely effective and widely used method of stretching • Passively stretching antagonist or actively contracting agonist to stretch antagonist to maximal position and holding for extended time • Recommended to hold for 15 to 30 seconds is most effective to increase flexibility • Can be used early on in rehabilitation program • ATC, teammate, other assistive devices • Best to do after muscle temperature is increased • May be more efficient to do after activity and not before

22. Proprioceptive Neuromuscular Facilitation (PNF) • First used by ATC’s rehabilitating neuromuscular disorders • More recently used to increase flexibility • 3 types of PNF stretching techniques • Contract relax: beneficial to athletes where ROM is limited by muscle tightness • Athlete actively contracts agonist to point of limitation, athlete then instructed to contract antagonist (muscle to be stretched) isotonically (through range of motion), athlete then relaxes as ATC passively moves part to point of limitation. Stretch is then repeated

23. Proprioceptive Neuromuscular Facilitation (PNF) • Hold relax: Similar to contract relax except antagonist goes through isometric contraction (contraction w/o movement) • Hold for at least 6 seconds • Can be used for agonist or antagonist • Slow reversal-hold-relax • Begins with isotonic contraction of agonist, followed by isometric contraction of antagonist • During relax phase antagonist are relaxed while agonist are contracting • ..\..\..\..\Downloads\url2.htm

24. Dynamic stretching • Stretching through series of movement patters • Progressive slow controlled movements to faster movements • Muscle activation of agonist and muscle stretching of antagonist • Posture and form important • Increases core and muscle temperature • Increases neuromuscular control • Increases balance • Core stability • Effective for increasing flexibility • Better way to stretch prior to activity • Shown to increase flexibility, decrease injury and increase force and power output • Mimics sport activity, so more functional • Can initially cause some muscle soreness

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26. Comparing stretch techniques • All have been shown to increase flexibility • PNF is capable of producing greater improvement in flexibility • Requires a partner • Static • Has to be done often and held for extended periods of time • Prior to exercise may decrease core and muscle temperature when compared to dynamic stretching • More appropriate in rehab and as a cool down method after activity • Dynamic • Research supports use prior to activity • Ballistic • Can cause injury in untrained or already injured person • Can maintain flexibility w/ stretching 1 day a week, but to improve flexibility must perform 3-5 times/week

27. Pilates and Yoga • Pilates • Extremely popular and widely used method • Developed by Joseph Pilates prior to WWII • Conditioning program that improves muscle control, flexibility, coordination, strength and tone. • Concentrated on body alignment, breathing, lengthening of all muscles while building endurance and strength

29. Pilates and Yoga • Yoga • Originated in India 6000 years ago • Philosophy that most illness related to poor mental attitude, posture and diet • Aimed to unite body and mind through various body postures and meditative breathing • Start simple and progress to more complex movements • Increase mobility and flexibility

32. Myofascial release stretching • Relieve soft tissue from abnormal grip of tight fascia (fibrous membrane that covers, supports and separates muscles, tendons, bones and organs) • Localize restriction and move into direction of restriction • Releasing myofascial restrictions over large treatment area can have significant impact on joint mobility • Progression of superficial restrictions to deeper restrictions • Stretching techniques can be incorporated after extensibility is improved in myofascia • Can use foam rollers to assist with myofascial release

34. Other methods to restore ROM Massage Strain-counter strain Soft tissue mobilization Graston technique Massage

35. Benefits of ROM exercises • Inreased flexibility • Increased mobility • Increased blood flow to area • Facilitate tissue healing process • Decreased swelling • Decreased adhesion formation • Decreased pain