Therapeutic Exercise I Chapter 4

1. Therapeutic Exercise IChapter 4 Stretching for Impaired Mobility

2. Selective Stretching • Mobility • Functional Mobility • Flexibility • Contractures • Overstretching • Tightness • Selective Stretching ROM needs vary among individuals

3. Stretching as an integral component to rehab • The supervising PT will determine what structures are restricted and what type of stretches to be implemented • Designed to increase the extensibility of soft tissues • Includes: manual, self, and mechanical stretching • There must be a balance between mobility and stability for MAXIMUM FUNCTION

4. Hypomobility • Prolonged immobilization • Sedentary lifestyle • Postural malalignment & muscle imbalances • Impaired muscle performance (weakness) associated with musculoskeletal or neuromuscular disorders • Tissue trauma resulting in inflammation & pain • Congenital or acquired deformities

5. Types of Contractures • Myostatic Contractures • Pseudomyostatic Contractures • Arthrogenic and Periarticular Contractures • Fibrotic Contracture and Irreversible Contracture

6. Goals of Stretching • Increased flexibility & ROM • General Fitness – warm up & cool down • Prevention/reduction of soft tissue injuries • Decreased post exercise soreness • Enhanced performance

7. Properties of Soft Tissue • Elasticity- the ability of soft tissue to its pre-stretch resting length directly after a short-duration stretch force has been removed • Viscoelasticity- Time dependent property of soft tissue that initially resists deformation, such as change in length, of the tissue when a stretch is first applied. But if the stretch is sustained…it allows a change in the length of the tissue and then enables the tissue to return gradually to its pre-stretched state after the stretch force has been removed • Plasticity- is the tendency of soft tissue to assume a new and greater length after the stretch force has been removed Muscles (contractile and non-contractile) have both elastic and plastic qualities; however, only the connective tissues have viscoelastic qualities

8. Mechanical Properties of Contractile Tissue • When contractures develop, adhesions in and between collagen fibers resist and restrict movement • If a muscle is immobilized for a prolonged period of time, the outcome is atrophy or weakness….which can result in an increase in fibrous and fatty tissue in the muscle, and disorganizes collagen • Atrophy can occur in days/weeks and duration plays a major part in the severity of the atrophy

9. Neurophysiological Properties of Contractile Tissue • Muscle Spindles – changes in length & velocity of length changes • Golgi Tendon Organs – changes in tension; • Autogenic inhibition • Reciprocal inhibition

10. Mechanical Properties of Non-Contractile Soft Tissue • Non-contractile soft tissue comes in various types of connective tissue: ligaments, tendons, joint capsule, fascia, non-contractile tissue in muscles, and skin (adhesions) • Creep can occur- amount of deformation will depend on the severity of the position and the period of time in the position i.e.: significant thoracic kyphosis

11. Non-contractile Tissue • Only way to increase extensibility is to remodel its basic structure • Collagen – strength & stiffness; resists tensile deformation • Elastin – provides extensibility • Reticulin – provides tissue bulk • PG’s & GP’s – reduce friction, transports nutrients, maintains space between fibers

12. Stress Strain Curve • Toe Region • Elastic Range • Elastic Limit • Plastic Range • Failure

13. Determinants of Stretching Interventions • Alignment • Stabilization • Intensity • Duration • Speed • Frequency • Mode

14. Mode (types) of Stretching • Manual • Self • Mechanical • PNF

15. Types of Proprioceptive Neuromuscular Facilitation (PNF) Stretching Techniques • Hold Relax (HR) or Contract Relax (CR) • Agonist Contraction • Hold-Relax with Antagonist Contraction (HR-AC)

16. Stabilize Proximal versus Distal • When being stretched by the supervising PT/PTA it is common for them to stabilize the proximal attachment and move the distal attachment • When performing a self-stretch often the distal attachment is stabilized as the proximal segment moves • Duration of Stretch-30 second stretch has been identified as the median time frame • Types of stretching: static (static progressive stretching), cyclic (intermittent), ballistic (rapid force)

17. Adjuncts to Stretching Interventions • Relaxation Training (autogenic training, progressive relaxation, awareness through movement) • Heat (warming of the tissue) – see article • Exercise • Massage (warming of the tissue with a manual technique) • Biofeedback (audio or visual awareness) • Joint traction or oscillation (any joint mobilization techniques to be done by the PT only) • Ice should be used after stretching-preferred in a lengthened

18. Indications • Limited ROM – adhesions, contractures, scar tissue formation • Structural deformities caused by restricted motion • Muscle weakness & shortening of opposing muscle groups • Total fitness/sports conditioning • Warm up & cool down to decrease soreness

19. Contraindications • Bony block • Fracture/incomplete union • Acute inflammation/infection • Sharp acute pain with movement • Hematoma • Hypermobility • Shortened soft tissue necessary for function • Shortened soft tissue providing joint stability

20. Break for Lab with Lecture on UE Stretching Techniques in Anatomical Planes of Motion (If time permits may review LE’s)