Restoring ROM & Improving Flexibility Chapter 8. Importance of Flexibility Important Goal: Restore...
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Transcript of Restoring ROM & Improving Flexibility Chapter 8. Importance of Flexibility Important Goal: Restore...
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
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
Flexibility
Flexibility
Flexibility refers to the total range of motion (ROM) of a joint or group of joints.
The ability of a joint to move freely through the full range of motion.
It differs from person to person and from joint to joint.
What affects the extent of movement around a given joint?
Structural characteristics of the joint Mechanical properties of the connective tissues
Flexibility
The GOAL should be to optimize joint mobility while maintaining joint stability.
Primary FOCUS should be on the systematic, safe and effective application of the range of motion techniques used.
You should be able to communicate to the client WHY they should devote time to improving flexibility
It will enhance their program.
Flexibility
Keep the requirements of the activity in mind
A person’s activity level alone will not improve flexibility
Stretching exercises are essential if flexibility is to be maintained or increased
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
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
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
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
Benefits of Flexibility Training
Increases Range of Motion Reduction of lower back pain and injury Reduction in the incidence & severity of injuries Improved posture & muscle symmetry Delay in the onset of muscular fatigue Prevents or alleviates muscle soreness post
exercise Increases the level of certain skills & muscular
efficiency Picking something up off the floor
Promotes mental relaxation
Flexibility
It must be based upon the needs of the client.
Deliberate stretching should be done AFTER a general warm-up, but BEFORE the primary bout BUT….
It is dependant upon the activity to be performed.
Stair climbing vs. Basketball
General Warm Up
Full body rhythmic activities Low-moderate intensities ~ 5 minutes Increase core temp Should not lead to fatigue
Factors Affecting Flexibility
Joint Structure Age Gender Muscle & Connective Tissue Exercise History Temperature Resistance Training Pregnancy
Age & Gender
Young more flexible than older Females more flexible than men Youth become less flexible between ages
10-12 Childhood is the ideal time to start a
flexibility program Seniors lose flexibility due to inactivity
Muscle & Connective Tissue
Tendons, ligaments, fascia, joint capsules, skin
Elasticity – the ability to return to original resting length after passive stretch
Plasticity – the tendency to assume a new and greater length after passive stretch
Hyperlaxity – allows the joints to achieve a ROM that exceeds the normal range of motion
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
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
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?
Stretching Strategies
2 times per week, for 5 weeks, has been shown to improve flexibility
Varies depending upon the sport / activity General warm up for ~ 5 minutes Activity specific warm up ~ 10 minutes Post activity stretching ~ 5 minutes Hold each stretch for about 30 - 60
seconds Do 3 - 4 reps
Proprioceptors & Stretching
Muscle Spindles Within muscle Causes stretch reflex Muscle contracts when stretch too fast
Golgi Tendon Organs MT Junction Produces inverse stretch reflex Relaxes muscle when there is too much
tension
Types of Stretching
Static – slow & steady Ballistic - bouncing type movements Dynamic – avoids bouncing but includes
movements specific to the activity PNF – generally involves a 10 second
passive stretch followed by the specific technique: Hold-Relax Contract-Relax
Static Stretching
Most commonly used Safe & effective Muscle gradually stretched to the point of mild
tension If discomfort is felt, back off a little Does not activate the stretch reflex Beginners should hold the stretch for 15-20 s;
progress to 30 s Longer holds do not reap more rewards Significant improvements can occur Repeat 3-5 times
Ballistic Stretching
Rapid, jerky, uncontrolled movement Difficult to control the motion Higher risk of injury No longer considered acceptable however, is
appropriate for some activities Disadvantages:
Increased danger of exceeding the extensibility limits of involved tissues
Higher energy requirements Greater chance of causing muscle soreness Activation of the stretch reflex
Dynamic Stretching
Similar to ballistic but avoids bouncing Puts an emphasis on functionally based
movements Includes movements specific to the activity Example lunge walk Requires balance and coordination Clients may experience muscle soreness
initially
PNF Stretching
Widely accepted as an effective method for increasing range of motion
Performed with a partner Uses both passive movement & active muscle
action Technique:
Take the muscle into a static stretch while relaxing muscle
Hold stretch for 10 s, then contract muscle for 6 s with a strong isometric contraction against partner
Following a 1-2 s rest, repeat another 30 s passive stretch
Repeat
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
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
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
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
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
Sometimes called: Soft-tissue Mobilization
Treatment Localize restriction Considerably more subjective component & relies
heavily on clinician’s 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
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
With static stretching GTO’s 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
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)
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
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)
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
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
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
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
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
5-10 second stretch prepares muscles for activity, 30-60 second stretch increases flexibility.
Summary
Assess client’s flexibility to pinpoint strengths & weakness
Design program that stretches the specific muscles used by the client during activity
Warm up before stretching to increase temp Perform stretches daily Stretch all major muscle groups and opposing
groups
Summary
Focus on technique during the stretch Hold stretches for 30 seconds initially; later 60
seconds Do 4 reps each stretch for optimal gains Stretch to mild discomfort, not pain Keep breathing slow and rhythmical during
stretch Stretch muscles in different positions and
planes Stretch after primary bout