Stretching for Impaired Mobility PDF

https://pixabay.com/en/gumby-pokey-toys-childhood-retro-1115930/ STRETCHING FOR IMPAIRED MOBILITY  Goals  Define terms related to mobility and stretching  Identify the appropriate response to immobilization and stretching  Determine the appropriate type, intensity...

https://pixabay.com/en/gumby-pokey-toys-childhood-retro-1115930/ STRETCHING FOR IMPAIRED MOBILITY  Goals  Define terms related to mobility and stretching  Identify the appropriate response to immobilization and stretching  Determine the appropriate type, intensity, duration, speed, frequency and mode of stretching for a given patient  Appropriately apply stretching as an intervention  Recognize the indications, precautions and contraindications for stretching  Select appropriate adjuncts to stretching interventions What is Stretching?  “…any therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility and ROM by elongating (lengthening) structures that have adaptively shortened and have become hypomobile over time.” - Kisner & Colby What Are We Stretching?  Flexibility reflects the extensibility of all tissues that cross and surround the joint  Muscles, tendons, ligaments  Connective Tissue surrounding musculature  Periarticular structures (e.g. joint capsule)  Nerves, blood vessels, skin, fascia  Allows for painfree functional movement Indications for Stretching  ROM is limited due to loss of soft tissue extensibility (e.g., adhesions, scar tissue formation, contractures)  Restricted motion that can lead to structural deformities  Muscle weakness and shortening of the opposing tissue  Component of a total health, wellness, and fitness program designed to prevent musculoskeletal injury  Impacts of Hypomobility Benefits of Stretching  Increase flexibility and ROM  General Fitness  Injury prevention and reduced soreness  Enhanced performance Properties of Soft Tissue Response to Immobilization and Stretch  Decreased extensibility of connective tissue (not contractile elements of muscle tissue) is the primary cause of restricted ROM.  Direction, velocity, intensity (magnitude), duration and frequency as well as tissue temperature affect the response of soft tissue  Most of our information about physiological responses to immobilization has been done on animals - therefore, the exact mechanism by which stretching produces an increase in human tissue extensibility is still unclear. Properties of Soft Tissue Response to Immobilization and Stretch  Elasticity  ability of soft tissue to return to its pre-stretch resting length immediately after a short duration stretch  Viscoelasticity  time dependent property that initially resists deformation (e.g. increased length) but with sustained stretch allows a change in length followed by a gradual return to pre-stretch length  Plasticity  tendency of soft tissue to assume a greater length after a sustained stretch ContracturesNoandpathology present but shortening decreased ROM. Improvement quickly with stretching  Myostatic CNS lesion or injury may result in  Adaptive shortening of spasticity or muscle spasms limit  Pseudomyost theROM musculo-tendinous through constant contracted atic state. Neuromuscular inhibition unit and other techniques may allowsoft for full ROM Contracture tissues that cross or temporarily  Intra-articular pathology is the root Arthrogenic surround the joint and cause with the connective tissue that periarticular crosses or attaches to a joint lacking  Result in and mobility significant limiting joint mobility  Fibrotic resistance to stretch and Contracture Fibrotic changes cause the limitation limitation of ROM in the mobility and likely cannot be and Irreversible reversed and it is difficult to achieve  Are named optimal tissue by the length evenaction of if ROM can Contracture thebeshortened improved because muscle normal tissue is replaced with fibrotic adhesions and (e.g., elbowscar flexion tissue. Stress Strain Curve Creep & Stress-Relaxation Changes That Impact Stress-Strain  Immobilization  Inactivity  Age  Corticosteriods  Injury  Additional conditions such as nutritional or hormonal imbalances Contraindications to Stretching  Bony block limiting motion  Recent fracture or insufficient bone union  Acute inflammation or infection  If it will disrupt the early healing process  Sharp, acute pain on joint movement or muscle elongation  Hematoma or other indication of tissue trauma  Hypermobility  Shortened soft tissues provide the necessary joint stability in the presence of abnormal structures or lack of neuromuscular control  Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform Precautions for Stretching  Use caution in the presence of osteoporosis, prolonged bed rest, prolonged use of steroids, the very old and the very young  Do not force a joint beyond its normal ROM  Progress the dosage (intensity, duration and frequency) gradually  Do not stretch edematous joint/tissue that is prone to injury  Do not overstretch weak muscles especially if they support joints (shoulder)  Do not overstretch…period Precaution – Overstretching  Overstretching can be detrimental and cause joint instability when the supporting structures of the joint, and strength of the muscles surrounding the joint are insufficient to provide joint stability during functional activities.  Overstretching can predispose a person to injury! Stretching As An Intervention http://www.geograph.org.uk/photo/2051573 Techniques to Increase Soft Tissue and Joint Mobility  Passive or Assisted Stretching (manual or mechanical)  Self-Stretching  Neuromuscular Facilitation & Inhibition (PNF)  Muscle Energy  Joint Mobilization/Manipulation  Neural Tissue Mobilization Determinants of Stretching  Alignment  Stabilization  Intensity of the stretch  Duration of the stretch  Speed of stretch  Frequency of stretch  Mode of stretch Alignment  Positioning so the stretch force is directed to the appropriate muscle group  Be sure to monitor the trunk and adjacent joints http://uacc.arizona.edu/sites/ default/files/injury_prevention.pdf Stabilization  Fixation of a site of attachment of the muscle as the stretch is applied to the other attachment  Commonly the proximal attachment is stabilized and the distal segment would be moved when manually stretched Self stretching often stabilizes the distal attachment (ie. On a chair or doorframe) and the proximal segment moves  Watch for substitutions! Intensity of Stretch  Magnitude of the stretch force applied should be LOW INTENSITY by a LOW LOAD  Low intensity stretching over long duration has improved ROM Decreased risk of tissue injury Improved comfort Elongation of dense connective tissue Duration of Stretch  In general, shorter duration needs increased reps  Static: a single cycle can range from 5 seconds to 5 minutes 30 second repetitions is the median duration in most literature Can be performed as a static progressive stretch  Cyclic (intermittent) stretching: short duration that is repeated, cycle lasting between 5 to 10 seconds Speed of Stretch  Speed of initial application of the stretch  Slowly applied stretch Encourages muscle relaxation and prevents injury Low velocity stretch is easier and safer for the therapist or patient to control  Ballistic stretching: rapid forceful intermittent stretching Not recommended for elderly, sedentary, or pt’s with pathology  High-velocity stretching: rapid low load stretch Static slow, short end-range slow, full-range Frequency of Stretch  Refers to the number of sessions per day and per week  Recommendation: 2 to 5 sessions per week  Daily frequency may range from 1 to 3 sessions  Allow for rest between sessions for healing and to minimize post exercise soreness  Must use clinical judgment and the response of the patient Mode of Stretch  Form the stretch is applied  Static  Ballistic  Cyclic  Degree of patient participation  Passive  Assisted  Active  Source of the stretch  Manual  Mechanical  Self Manual Stretch  Characteristics: external force provides pressure beyond the available ROM  Controlled, end-range, static, progressive  Hold 15-60 seconds through multiple reps  Effectiveness: research is inconclusive  Use: often in the early stages of stretching Self-Stretching  Characteristics: pt actively performs the activity to increase ROM  Effectiveness: must be carried out effectively and safely so pt education is key  30-60 second hold  Use: for HEP and long term self management  https:// jointactivesystem s.com/JAS-EZ- Systems/2/9/JAS- EZ-Elbow.aspx Mechanical Stretch  Characteristics: a device applies a low- intensity force over a prolonged period to create relatively permanent lengthening of soft tissue  Cuff weight/pulley system, adjustable orthotic devices  Effectiveness: must use the new range in order to maintain it  15- 30 minutes up to 8-10 hours  Serial casts are worn for days or weeks https:// theprintedstitchdotcom.wordpress.com/ 2010/08/04/serial-casting-complete/ PNF (Proprioceptive Neuromuscular Facilitation)Stretching Techniques  Active stretching utilizes active muscle contractions in the stretching  Requires voluntary control  Reciprocal inhibition  Types:  Hold-Relax or Contract-Relax  Agonist Contraction  Hold-Relax with Agonist Contraction Hold-Relax 1. The muscle to be stretched is lengthened to the end of range 2. The patient performs an isometric contraction (~5-10 sec) of the muscle against resistance. 3. With relaxation of the contraction, the therapist moves the limb into the new range, hold stretch for 10-15 seconds.  Examples: stretch of shortened pectoralis major muscles bilaterally in sitting; hamstring stretch in supine. Isometric contraction of the muscle to be lengthened (hamstring also Contract-Relax 1. The muscle to be stretched is lengthened to end of range 2. Patient performs a concentric contraction of the muscle to be lengthened, against resistance. 3. With relaxation of the contraction, the therapist stretches the limb into the new range. Hold for 10-15 sec and repeat. Repeat until no new range is gained. After a brief rest. Repeat.  Agonist Contraction (active stretching)  The “antagonist” refers to the tight muscle and the “agonist” refers to the muscle opposite the tight muscle. The patient performs a concentric contraction of the agonist holding for 6- 10 seconds. The patient then actively lengthens the antagonist.  Example: tight hip flexors-patient in prone performs a leg lift by concentrically contracting the hip extensors, hold for 6-10 sec, after a brief rest repeat Effectiveness of Agonist Contraction (AC)  In one study AC found to be as effective as static stretching  In another, one daily 30 second static stretch was 3 times as effective in increasing hamstring flexibility as six daily repetitions of AC or active stretching Effective with muscle guarding not with chronic contractures Useful when strong muscle contraction is painful Hold-Relax with Agonist Contraction or Slow Reversal Hold Relax 1. The muscle to be stretched is lengthened to end of range 2. the patient performs an isometric contraction of the tight muscle against resistance 5-10 seconds. 3. Then the patient is asked to relax the muscle and actively contract the opposite muscle. With relaxation, if able, the patient actively or with assistance stretches the muscle into the new range and holds the stretch 10-15 sec. Repeat until no new range is gained. Repeat after Preparation for Stretching  Select the best stretch given the pt and goals  Warm-up first  Positioning is key - Safety, Comfort, Access  Explain it and help with relaxation  When should you stretch? Before or active activity/sport? Application of Stretching  Move the extremity through the available range using proximal stabilization while mobilizing the distal segment  If a multi-joint muscle, stretch over 1 joint at a time  Can apply a gentle distraction  Apply low-load in the opposite direction to the line of pull of the range limiting muscle  Hold for 30-60 seconds or longer After the stretch  Perform AROM and/or strengthening  Make sure that the agonist and the antagonist strength is balanced Adjuncts to Stretching  Interventions that prepare tissues for stretching can enhance a stretching program  Heat (including warm-up)  Cold application Massage  Biofeedback  Joint Traction/Oscillation  Relaxation Techniques… Summary  What are we stretching?  Contraindications? Precautions?  Determinants of stretching?  Types of PNF stretching?  How long should you hold the stretch?  Reference and Reading Overview  Kisner, Carolyn, et al. Therapeutic Exercise: Foundations and Techniques, 8e. Available from: FADavis, (8th Edition). F. A. Davis Company, 2022.  Chapter 4: Stretching for Improved Mobility (pgs. 86-116) In class Demo 10SEP24  Short term positioning; draping, pillow placement  Pillow under back  Pillow under knee not being stretched Allows for posterior tilt of hip to reduce stress on hamstring Some people we don’t want that Hooklying is an option but if they’re guarding, you don’t want tense muscles, so you can get an even bigger bolster  Static progressive hamstring stretch Ask where pt is feeling it and what type of feeling Low load long duration is the best Build up to 30 seconds cyclic but the more the better  Ballistic stretching Didn’t demo, but it is for athletes This is not necessarily bouncing, it is probably more like what you call dynamic stretching