PTA 1005 Therapeutic Exercise - Stretching for Impaired Mobility Part 2 PDF

P TA 1 0 0 5 THERAPEUTIC EXERCISE S T R E T C H I N G F O R I M PA I R E D M O B I L I T Y PA R T 2 ©Stanbridge University 2022 1 ROAD MAP Stretching part 2: By the end of this section the student should be able to: Understand the stress strain curve and its clinical rele...

P TA 1 0 0 5 THERAPEUTIC EXERCISE S T R E T C H I N G F O R I M PA I R E D M O B I L I T Y PA R T 2 ©Stanbridge University 2022 1 ROAD MAP Stretching part 2: By the end of this section the student should be able to: Understand the stress strain curve and its clinical relevance Summarize the properties of soft tissue and their response to stretch Understand how changes in collagen tissue affect the stress strain curve State the indications, precautions and contraindications of stretching Be able to state and describe the determinants of stretching Describe how to properly apply stretching and when to perform that technique within a session State the adjuncts to stretching Be able to appropriately apply or teach stretches assigned in lab ©Stanbridge University 2022 2 OUTLINE Properties of Soft Adjuncts to Tissue: Response to Stretching Immobilization and Interventions Stretch Stretching Indications Precautions for & Contraindications Stretching Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 3  STRESS STRAIN CURVE: WHAT IS IT? An illustration of the mechanical strength of structures Used to interpret what is happening to connective tissue under stress loads When a tensile force is applied to a structure it elongates Curve illustrates the strength properties, stiffness and amount of energy that can be stored before FAILURE ©Stanbridge University 2022 4 STRESS AND STRAIN Stress: force per unit area Mechanical Stress: internal resistance to external LOAD Strain: amount of deformation or lengthening that occurs when a load (stress) or stretch force is applied ©Stanbridge University 2022 5  KINDS OF STRESS 1. Tension: Force applied perpendicular to the cross-sectional area of tissue in a direction AWAY from the tissue (i.e., stretching, muscle contraction) 2. Compression: Force applied perpendicular to the CSA of tissue in a direction TOWARD the tissue  i.e. pushing two ends of a joint together, wrapping an ace bandage around a limb 3. Shear: Force applied PARALLEL to CSA of tissue  ie. Rubbing across skin ©Stanbridge University 2022 6  STRESS STRAIN CURVE DEFINITIONS Elasticity: ability of soft tissue to return to its pre-stretch resting length after a short duration stretch has been removed (non-contractile and contractile) Viscoelasticity: TIME-dependent property of soft tissue that initially resists deformation (non-contractile) Plasticity: tendency of soft tissue to assume a new and greater length after stretch has been removed (non-contractile and contractile) ©Stanbridge University 2022 7 STRESS STRAIN CURVE DEFINITIONS Toe region: Area with Considerable deformation without the use of much force wavy collagen fibers align and straighten- most FUNCTIONAL ACTIVITY occur in this region Kisner & Colby 7th edition, figure 4.3 ©Stanbridge University 2022 8  STRESS STRAIN CURVE DEFINITIONS Elastic range: tissue is taken to the end of the ROM; tissue returns to original size when load is released if stress is not maintained Kisner & Colby 7th edition, figure 4.3 think “Elastic Band” 9 ©Stanbridge University 2022 STRESS STRAIN CURVE DEFINITIONS Elastic Limit: point beyond which tissue does not return to its original shape and size Plastic Range: range where there is permanent deformation when stress is released Kisner & Colby 7th edition, figure 4.3 ©Stanbridge University 2022 10 STRESS STRAIN CURVE DEFINITIONS Plastic Range: Micro-failure of the bonds b/w the collagen fibrils and eventually the whole fibers Heat (energy) is released and absorbed into surrounding tissue Individual fibers do not stretch, but instead rupture, leading to increased length →this is what occurs during stretching procedure ©Stanbridge University 2022 11 STRESS STRAIN CURVE DEFINITIONS Ultimate Strength: greatest load (Stress) a tissue can sustain -top of curve before necking Necking: weakening of tissue leading to rapid failure of the tissue Structural stiffness: Slope of the linear part of the curve (elastic range) Kisner & Colby 7th edition, figure 4.3 – tissues with more stiffness higher (steeper) slope ©Stanbridge University 2022 12 STRESS- STRAIN CURVE: CLINICAL RELEVANCE Be aware of the tissue feel when manually stretching a patient to avoid unnecessary injury Move slowly so you can observe changes in tissue tension & communicate with patient regarding intensity of the stretch they are feeling (light vs. medium vs. strong pulling sensation) Goal: MODERATE stretch sensation ©Stanbridge University 2022 13 STRESS- STRAIN CURVE: CLINICAL RELEVANCE Grading of Ligament Injuries (Sprains): Grade I: Micro failure: rupture of few fibers in the lower part of the plastic range Grade II: Macro failure: rupture of a greater # of fibers resulting in a partial tear further into the plastic range (will see area of failure on imaging) Grade III: Complete rupture or tissue failure ©Stanbridge University 2022 14 CONNECTIVE TISSUE RESPONSE TO LOAD Creep: when load is applied for an extended period, the tissue elongates and does not return to its original length www.memegenerator.net ©Stanbridge University 2022 15 CONNECTIVE TISSUE RESPONSE TO LOAD CREEP Constant load (stress) applied over time results in increased tissue length (plastic range) until equilibrium is reached Kisner & Colby 7th edition, figure 4.4 ©Stanbridge University 2022 16 CONNECTIVE TISSUE RESPONSE TO LOAD STRESS-RELAXATION Underlying principle in prolonged passive stretching When a stress applied to the tissue to stretch a tissue and the length is kept constant, after the initial creep there is a decrease in force required to maintain that length and tension in the tissue decreases ©Stanbridge University 2022 17 HOW ARE THE 2 DIFFERENT? Creep Stress Relaxation Constant STRESS Constant STRAIN Results in Results in (plastic) STRAIN STRESS ©Stanbridge University 2022 18 REVIEW What are the different components of the stress strain curve? Where in the stress strain curve do permanent changes occur? ©Stanbridge University 2022 19 CONNECTIVE TISSUE: RESPONSE TO LOAD Cycle loading and connective tissue fatigue: repetitive loading of tissue increases heat production and may cause failure below yield point Greater load applied, fewer # of cycles need for failure (i.e. stress fractures, overuse syndromes) Clinical relevance for stretching apply repetitive (cyclical) loads at SUBMAXIMAL level on successive days or every other day Allow for recovery ©Stanbridge University 2022 20 CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE 1) Immobilization 2) Inactivity/decreased activity 3) Age 4) Medications: ex. corticosteroids 5) Injury ©Stanbridge University 2022 21 CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE Immobilization: Weakening of tissue due to collagen turnover and weak bonding b/w the new, non-stressed fibers Adhesion formation: -greater crosslinking between disorganized collagen fibers -decreased effectiveness of ground substance in maintaining space and lubrication b/w fibers http://oregonmassageandwellnessclinic.com ©Stanbridge University 2022 22 CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE Inactivity/Decreased Activity: Weakening of tissue due to decrease in size and amount of collagen fibers (atrophy, fatty infiltrates) Physical activity has a beneficial effect on strength of connective tissue (hypertrophy) Recovery takes up to 5 months with regular cyclic loading (without re-injury) ©Stanbridge University 2022 23  CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE Age: - Decrease in maximum tensile strength and elastic modulus - Rate of adaptation to stress is slower Increased tendency for overuse syndromes, fatigue failure, tears with stretching ©Stanbridge University 2022 24  CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE Corticosteroid injections: Decreased tensile strength of collagen Fibrocyte death next to the injection side up to 15 weeks Results in an increased risk of injury Must educate the patient regarding reduced loading Progress therapeutic interventions more slowly ©Stanbridge University 2022 25  CHANGES IN COLLAGEN AFFECTING STRESS-STRAIN RESPONSE Injury: Excessive tensile loading can lead to rupture of ligaments and tendons Initial healing is with type III collagen: structurally weaker than the mature type I collagen Previous injury decreases the structural stiffness of a tissue 3 weeks→1 year to fully remodel to stronger type I collagen ©Stanbridge University 2022 26 OUTLINE Properties of Soft Adjuncts to Tissue: Response to Stretching Immobilization and Interventions Stretch Stretching Indications Precautions for & Contraindications Stretching Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 27 STRETCHING INDICATIONS 1) Soft tissues have lost their extensibility 2) Restricted motion that may lead to structural deformities 3) Muscle weakness and shortening of opposing tissue has lead to limited ROM 4) Prevention of future injuries in a training or wellness program 5) Prior to and after vigorous exercise- reduce post exercise muscle soreness or enhance muscle performance Behm et al. 2016 Appl. Physiol. Nutr. Metab. Behm at al found that stretching does not prevent injuries and is not best if performed prior to vigorous exercise ©Stanbridge University 2022 28 CONTRAINDICATIONS TO STRETCHING Bony block/end feel Incomplete bony union (fracture) Acute inflammation (disrupt healing tissue) Infection Hematoma/tissue trauma Hypermobility already exists Shortened soft tissues provide joint stability in lieu of neuromuscular or structural stability Shortened soft tissues allow someone with paralysis or severe muscle weakness to perform special functional skills ©Stanbridge University 2022 29 OUTLINE Properties of Soft Tissue: Response to Adjuncts to Stretching Immobilization and Interventions Stretch Stretching Indications, Precautions for Contraindications and Stretching Potential Outcomes Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 30 ***MOTION VS STRETCHING*** Perform a stretch to increase glenohumeral External Rotation (motion) –Move the same direction as the motion stated –Move into external rotation Perform a stretch to increase the flexibility of the External Rotators (muscle) –Move the opposite direction of the muscle’s action –Move into internal rotation ©Stanbridge University 2022 31 ACTIVITY: What motion is being performed or increased in this photo? What muscle group is being stretched? Name 2 of those muscles Review the origin and insertion of those muscles ©Stanbridge University 2022 32 ACTIVITY: What motion is being performed or increased in this photo? What muscle group is being stretched? Name 2 of those muscles Review the origin and insertion of those muscles ©Stanbridge University 2022 33 ACTIVITY: What motion is being performed or increased in this photo? What muscle group is being stretched? Name 2 of those muscles Review the origin and insertion of those muscles ©Stanbridge University 2022 34 DETERMINANTS, TYPES, AND EFFECTIVENESS OF STRETCHING INTERVENTIONS Alignment and stabilization Intensity of stretch Duration of stretch Speed of stretch Mode of stretch PNF Stretching Techniques Dynamic stretching Integration of function into stretching ©Stanbridge University 2022 35 ALIGNMENT & STABILIZATION For a stretch to be effective the following must be addressed: Alignment of segment being stretched: consider position of trunk and adjacent joints Stabilization of one segment: fixate proximal or distal attachment site of tissue being stretched – influences amount of stress placed on soft tissues and affects ROM available in the joints ©Stanbridge University 2022 36 ALIGNMENT & STABILIZATION: EXAMPLE RECTUS FEMORIS STRETCH Option B is correct Avoid anterior pelvic tilt, excessive Posterior lumbar extension, hip abduction Pelvic tilt Keep belly button pulled in to avoid excessive lumbar extension(recruit TrA) ©Stanbridge University 2022 37  DURATION OF STRETCH Traditional Manual and self static stretches: 3 x 30” (program standard) May be cumulative- minimum total stretch time needs to add up to a minimum of 60 seconds Hold time may need to be adjusted consider patient response ©Stanbridge University 2022 38  DURATION OF STRETCH Low load, long duration stretch (LLLD) – Other name: Prolonged passive stretch (PPS) – Best when the capsule/joint is limiting the motion – Build up time slowly to a total of 6 hours a day (or the length of time needed to see the change) – Begin with 6 x 5’ a day at 30 minutes and increase slowly to 60 minutes – Goal: 6 sessions a day x 10 min/each session = total of 60 minutes – Mechanical stretch- Performed with weights, positioning, bands – Dynamic splint: device with springs to increase stretch load up to 8-10 hours/day ©Stanbridge University 2022 39  INTENSITY OF STRETCH: Traditional static stretches: Moderate discomfort More comfortable Minimizes muscle guarding Decreased muscle spindle activity Mode: manual or self stretch LLLD stretching: Little discomfort or low intensity stretch Typically not felt immediately but after several minutes of stretching May be sore for up to 10 minutes after removing the stretch ©Stanbridge University 2022 40 WHAT KIND OF END FEEL MIGHT YOU EXPERIENCE IF THE JOINT CAPSULE IS LIMITING THE MOTION? ©Stanbridge University 2022 41 DURATION OF STRETCH Static: Soft tissues are elongated just past the point of tissue resistance and held there for a period – Static progressive- increased stretch force over time Cyclic: Short duration force that is applied, released, then reapplied (5-10 sec at a time) – Not synonymous with ballistic stretching because the stretch is slowly applied ©Stanbridge University 2022 42  SPEED OF STRETCH Goal: Slow and controlled Gradually increase force Remember muscle spindle is sensitive to velocity of muscle length changes Ballistic Stretching- fast, forceful intermittent stretch- ie. dancers and gymnasts Unsafe for the average individual ©Stanbridge University 2022 43 FREQUENCY OF STRETCH Refers to the number of bouts of stretching per day or week 2x-5x/week (program standard) Based on: -underlying cause of impaired mobility -quality and level of healing tissue -chronicity and severity of contracture -age -tissue response -previous use of corticosteroids ©Stanbridge University 2022 44  MODE OF STRETCH Who/What is applying the stretch force: – Therapist = manual – Caregiver = manual – Mechanical: weight, serial cast, splint – Self: static vs. active stretching Active: repeated short duration end range active muscle contractions of the muscle opposite the shortened muscle i.e. supine hamstring stretch ©Stanbridge University 2022 45 MODE OF STRETCH Self Stretch Source of stretch force: weight of upper body as patient bends forward ©Stanbridge University 2022 46 MODE OF STRETCH Mechanical Stretch Source of stretch force: cuff weight ©Stanbridge University 2022 47 MODE OF STRETCH Mechanical Stretch Source of stretch force: JAS orthosis providing static progressive stretch The brace has adjustable springs in the mechanism to slowly increase stretch over time ©Stanbridge University 2022 48  INTEGRATION WITH FUNCTION www.spineandsport.org After the stretch, ensure the patient uses to new ROM Emphasize development of neuromuscular control and strength of the agonis Low load resistance exercises or functional AROM into new range x 10 reps ©Stanbridge University 2022 49 REVIEW What direction would you move the wrist to increase flexion? What direction would you move the wrist to increase the flexibility of the flexors? List and describe the various determinants of stretching? ©Stanbridge University 2022 50 PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION STRETCHING TECHNIQUES Active stretching or facilitative stretching keep the stretched muscle as relaxed as possible Utilizes- reflexive relaxation as the result of autogenic or reciprocal inhibition Self-induced, inhibitory, negative feedback lengthening reaction (Golgi tendon activation) that is protective in nature ©Stanbridge University 2022 51 PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION STRETCHING TECHNIQUES Contract Relax (CR), slow reversal- neuro class Agonist Contraction (AC) See Lab handouts for details: – Hold Relax (HR) – Hold Relax with Agonist Contraction (HR-AC) or Hold Relax Active – Because of the voluntary active component with PNF stretching, these techniques cannot be used with diagnoses of spasticity and/or paralysis – More appropriate for when contractile tissue limits motion ©Stanbridge University 2022 52 WHAT KIND OF ABNORMAL END FEEL MIGHT YOU EXPERIENCE IF THE CONTRACTILE TISSUE IS LIMITING THE MOTION? ©Stanbridge University 2022 53  PNF STRETCHING TECHNIQUES Agonist Contraction = Active Stretching “Agonist”= muscle opposite the range limiting target muscle “Antagonist”= range limiting (tight) muscle Examples: 1. Short hip flexors: contract hip extensors 2. Short elbow flexors: contract elbow extensors 3. Short hamstrings: contract quadriceps ©Stanbridge University 2022 54 ANOTHER WAY TO SAY IT: The AGONIST is the muscle that acts in the direction of motion you are trying to increase The ANTAGONIST is the muscle that when tight limits the motion you are trying to achieve Example: ✓ Tight hip flexors limit hip extension ✓ The hip flexors are the antagonist to hip extension ✓ And the hip extensors are agonists to hip extension ©Stanbridge University 2022 55 PNF STRETCHING TECHNIQUES Multiple joint muscles- maximally move one joint first then the next joint Example: Biceps brachii- 1) extend elbow 2) pronate forearm then 3) extend glenohumeral joint ©Stanbridge University 2022 56 DYNAMIC STRETCHING: Defined as controlled movement through the AROM for each joint It Is proposed that dynamic stretching can enhance performance Positive effect on performance increased with dynamic stretches > 90 seconds Best used as a warm-up ©Stanbridge University 2022 57 RESEARCH UPDATE ©Stanbridge University 2022 58 ACSM GUIDELINES STRETCHING GARBER ET AL., MEDICINE AND SCIENCE IN SPORTS AND EXERCISE, 2011 ✓Mode: Active or passive stretching ✓Duration: 10-30 sec min, older populations 30-60 sec PNF 20-75% max contraction for 3-6 sec hold ✓Reps: Attain 60 sec of stretching time per flexibility exercise ✓examples: 2x 30 sec or 4 x 15sec ✓Frequency: ≥2-3 days/week ✓Timing: When muscle temp is elevated after light to mod cardiovascular activity ©Stanbridge University 2022 59 OUTLINE Properties of Soft Tissue: Response to Adjuncts to Stretching Immobilization and Interventions Stretch Stretching Indications, Precautions for Contraindications and Stretching Potential Outcomes Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 60 PROCEDURAL GUIDELINES: APPLICATION OF STRETCHING Examination and evaluation of the patient Preparation for stretching Application of manual stretching procedures After stretching utilize the new functional ROM actively ©Stanbridge University 2022 61 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Examination and Evaluation of Patient: -Cause of ROM limitations? -What structures are involved? -Irritability of tissues? -Stage of Healing? -What is the strength of the muscles? -What are the goals? ©Stanbridge University 2022 62 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Preparation for Stretching: -Obtain consent -Select appropriate technique -Warm up tissue -Position appropriately -Free area from restrictions (i.e. clothing) -Explain/educate/demonstrate **Double check for contraindications to stretching** ©Stanbridge University 2022 63 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Manual Stretching: Use firm grasp, appropriate stabilization Single Joint Stretches first → multi-joint (move one joint at a time) Grade I distraction- do not compress the joint Move slowly to point of tissue resistance Low intensity, slow, controlled, sustained stretch x 30 sec ©Stanbridge University 2022 64 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Manual Stretching, continued Hold until tissue tension decreases (allow for creep and stress relaxation) → stretch further Gradually release tension Assess Response/Tolerance: Repeat/Change ©Stanbridge University 2022 65 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Manual stretching, continued: Watch/feel for signs that patient is relaxed: Decreased muscle tension Lowered heart and respiratory rates Constricted pupils Little or no body movement Flat affect Jaws and hands relaxed; not clenched ©Stanbridge University 2022 66 STRETCHING INTERVENTIONS: GUIDELINES/APPLICATION Post- Stretching: Perform AROM, strengthen, use functional movement patterns Ice in elongated position if appropriate ©Stanbridge University 2022 67 OUTLINE Properties of Soft Tissue: Response to Adjuncts to Stretching Immobilization and Interventions Stretch Stretching Indications, Precautions for Contraindications and Stretching Potential Outcomes Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 68 GENERAL STRETCHING PRECAUTIONS 1. Do not force a joint beyond it’s normal ROM 2. Use caution with patient’s suspected or known to have osteoporosis 3. Avoid vigorous stretching of tissue that has recently been immobilized 4. Progress dosage gradually 5. Avoid stretching edematous/swollen tissue 6. Avoid overstretching weak tissue ©Stanbridge University 2022 69 SPECIAL PRECAUTIONS FOR MASS- MARKET FLEXIBILITY PROGRAMS Nonselective or poorly balanced stretching activities Insufficient warm-up Ineffective stabilization Ballistic stretching Excessive intensity “no pain, no gain” Abnormal biomechanics Limited attention to age related differences (elderly, growth spurts) Educate your patients, stay up-to-date on current exercise trends ©Stanbridge University 2022 70 OUTLINE Properties of Soft Tissue: Response to Adjuncts to Stretching Immobilization and Interventions Stretch Stretching Indications, Precautions for Contraindications and Stretching Potential Outcomes Procedural Guidelines Determinants and for Application of Types of Stretching Stretching Exercises Interventions ©Stanbridge University 2022 71  ADJUNCTS TO STRETCHING Heat: increases extensibility of tissues, less guarding (HP, paraffin, US, active exercise, shortwave diathermy) – Decreases the amount of intensity of stretch required to make a plastic change Cold: used to decrease muscle tone (spasticity) and icing tissue in a lengthened position Massage: increase circulation, decrease spasms, break up adhesions, improve scar mobility, cause creep and stress-relaxation Relaxation training ©Stanbridge University 2022 72 ADJUNCTS TO STRETCHING Biofeedback: visual, auditory -monitor and learn to reduce amount of tension in muscles, HR, BP -helps patient get sense of what muscle relaxation is -decrease muscle tension → decrease pain, increase flexibility Joint traction or oscillation: inhibit joint pain and muscle spasm surrounding a joint example: pendulums ©Stanbridge University 2022 73 REVIEW What stages of tissue healing for stretch vs the various ROM options? What do you always do after a stretch? What tissue are you stretching? When in the treatment session would you stretch? ©Stanbridge University 2022 74  REFERENCES Cynthia Holzman Weppler and S. Peter Magnusson, Increasing muscle extensibility: A matter of increasing length or modifying sensation? Phys Ther. 2010; 90: 438-449 David G Behm, Anthony J. Blazevich, Anthony D. Kay and Malachy McHugh, Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: systematic review. Appl. Physiol. Nutr. Metab. 2016; 41:1-11 Carol Ewing Garber, Ph D, Bryan Blissmer, Ph D, Michael R Deschenes, Ph D, Barry A Franklin Ph D, Michael Lamonte, Ph D, I-Min Lee MD ScD, David Neiman Ph D, David Swain Ph D. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise, 2011; 1334-1359 ©Stanbridge University 2022 75 THERAPEUTIC EXERCISE P TA 1 0 0 5 PERIPHERAL JOINT M O B I L I Z AT I O N ©Stanbridge University 2022 76 ROAD MAP By the end of the section the student should be able to: State and define the basic mobilization and movement terms Describe basic concepts of joint motion including types of motion, passive angular stretching vs joint glide stretching and other accessory motions Describe indications, precautions and contraindications of joint mobilization Describe the grade of joint mobilization along with what grade is appropriate for each stage ©Stanbridge University 2022 77 JOINT MOBILIZATION Definition: Manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit ROM by specifically addressing the altered mechanics of the joint ©Stanbridge University 2022 78  JOINT MOBILIZATIONS Specifically addresses the capsular restrictions By replicating normal joint mechanics while minimizing abnormal compressive stresses on the articular cartilage in the joint Best performed in the open pack position ©Stanbridge University 2022 79 DEFINITION OF TERMS You are responsible for the following terms: – Mobilization/Manipulation – High velocity thrust – Self-mobilization (auto-mobilization) – Mobilization with movement (MWM) – Physiologic movements – Accessory movements – Manipulation under anesthesia – Muscle energy ©Stanbridge University 2022 80  MOBILIZATION/MANIPULATION Passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes. Can be performed at various intensities and speeds: i.e. small amplitude force at fast velocity or large amplitude force at slow velocity, etc. Grade I → Grade V ©Stanbridge University 2022 81 DEFINITIONS Physiologic Movements: movements the patient can do voluntarily example: traditional movements such as flexion, abduction, rotation Accessory movements: movements in the joint and surrounding tissue necessary for movement but the patient cannot actively perform them ©Stanbridge University 2022 82 HIGH VELOCITY THRUST High velocity, short amplitude manipulation technique (Grade V) Goal: alter positional relationships, snap adhesions, or stimulate joint receptors Performed at end of the pathological limit of the joint: end of available ROM where there is a restriction www.spine-health.com ©Stanbridge University 2022 83 SELF MOBILIZATION Self stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule www.hiptrac.com www.researchgate.net ©Stanbridge University 2022 84  MOBILIZATION WITH MOVEMENT (MWM) Therapist applies a sustained accessory mobilization with Patient performing a physiologic movement (AROM) to end range Overpressure is then delivered without pain as a barrier Corrects joint tracking if there is a positional fault ©Stanbridge University 2022 85 MOBILIZATION WITH MOVEMENT (MWM): GOAL: PILL P- Pain free I- Instant result LL- Long Lasting if not: therapist must change the direction of the accessory glide they are performing ©Stanbridge University 2022 86 MOBILIZATION WITH MOVEMENT (MWM) https://youtu.be/lhgI2d7VA7A ©Stanbridge University 2022 87 MANIPULATION UNDER ANESTHESIA (MUA) Procedure used to restore full ROM by breaking adhesions around a joint while the patient is anesthetized Technique: rapid thrust or passive stretch using physiological or accessory movements Utilized when conservative care is not restoring ROM Common joints: Knee, shoulders ©Stanbridge University 2022 88 MANIPULATION UNDER ANESTHESIA (MUA) Watch only if you are comfortable https://youtu.be/RaVGTTGiicg ©Stanbridge University 2022 89 MUSCLE ENERGY TECHNIQUE Use active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory motion Therapist provides Stabilization to a segment, gives a command for an isometric contraction of the muscles Examples: Sacroiliac Joint MET, C/S, L/S ©Stanbridge University 2022 90 MUSCLE ENERGY TECHNIQUE https://youtu.be/yT8Oyi6vnHk ©Stanbridge University 2022 91  PHYSIOLOGICAL MOVEMENTS OSTEOkinematics- motions of the bones are described as: Flexion Abduction Rotation Movements the patient can do voluntarily ©Stanbridge University 2022 92 ACCESSORY MOTIONS ARTHROkinematics- motions of the joints are described as rolling sliding and spinning Movements in the joint and surrounding tissues that are necessary for normal ROM but cannot be actively performed by the patient Other accessory motions: compression and distraction ©Stanbridge University 2022 93 ACCESSORY MOVEMENTS variable combination of rolling and sliding, or spinning Joint Play Movement between two joint surfaces “give” of the joint capsule Necessary for normal joint function joint play is assessed to determine if a joint capsule is tight, and a joint mobilization is needed ©Stanbridge University 2022 94 TYPES OF ARTHROKINEMATIC MOTION: GLIDE Direction in which sliding occurs depends on whether the joint surface is concave or convex If the moving surface is CONVEX: gliding is in the OPPOSITE direction of the angular movement of the bone Ex. Femur on acetabulum ©Stanbridge University 2022 95 TYPES OF ARTHROKINEMATIC MOTION: GLIDE If the moving surface is CONCAVE: gliding is in the SAME direction as the angular movement (roll) of the bone Ex. Acetabulum on femur ©Stanbridge University 2022 96 TYPES OF ARTHROKINEMATIC MOTION: COMBINED ROLLING/SLIDING Joint mobilization techniques use the GLIDING component of the joint motion to restore joint play and reverse joint hypomobility ©Stanbridge University 2022 97 CONCAVE-CONVEX RULE …Is the theoretical basis for determining the direction of the mobilizing force when joint gliding (mobilization) techniques are used. Direction of the Joint Mobilization depends on the shape of the boney surface you are moving: Concave: mobilization is in SAME direction as the physiological motion you are trying to improve Convex: mobilization is in the OPPOSITE direction as the physiological motion ©Stanbridge University 2022 98 REVIEW Name and describe the various types of mobilization/manipulation techniques What is the difference between osteo and arthrokinematics What are the joint motions that combined can create normal osteokinematic motion ©Stanbridge University 2022 99 CLINICAL APPLICATION ARTHROKIEMATICS: OSTEOKINEMATICS: Accessory Movements Physiologic movements Ex: Roll, glide, spin Ex: Flexion, extension Treatment: Treatment: JOINT MOBILIZATIONS STRETCHING ©Stanbridge University 2022 100 PASSIVE STATIC STRETCHING VS. JOINT MOBILIZATION Osteokinematic stretching of a joint with a tight joint capsule can cause increased pain or joint trauma due to: The straight lever magnifies the force at the joint The force causes compression of the joint surfaces in the direction of the rolling bone ©Stanbridge University 2022 101 STRETCHING VS. JOINT MOBILIZATION Joint glide/mobilization technique is SAFER and MORE SELECTIVE: (osteo vs arthrokinematic motions) Force is applied close to the joint surface and controlled by the therapist at an intensity compatible with the pathology Direction of the force replicates the gliding component of the joint mechanics; does not compress the cartilage Amplitude of motion is small yet specific to the restricted or adherent portion of the capsule or ligament ©Stanbridge University 2022 102 OTHER ACCESSORY MOTIONS THAT AFFECT THE JOINT 1. Compression 2. Long Axis Traction 3. Joint Distraction ©Stanbridge University 2022 103 ARTHROKINEMATICS KINESIOLOGY REVIEW Roll, spin, and glide must occur together to allow for normal movement © 2011 by F. A. Davis Company ©Stanbridge University 2022 104 COMPRESSION Decrease in joint space between two bony partners 1. Occurs in extremities and spinal joints during weight bearing 2. Occurs when muscles contract providing stability to the joints ©Stanbridge University 2022 105 COMPRESSION DURING ARTHROKINEMATICS: Occurs as one bone ROLLS over the other on the same side to which the bone is spinning © 2011 by F. A. Davis Company ©Stanbridge University 2022 D COMPRESSION Normal intermittent compressive loads help maintain cartilage health through synovial fluid movement Abnormally high compressive loads articular cartilage changes & deterioration ©Stanbridge University 2022 107 TRACTION & DISTRACTION Distraction: separation, or pulling Traction: pulling along the long axis apart of joint surfaces; also called: of the bone -joint traction -joint separation Kisner & Colby 7th edition ©Stanbridge University 2022 108  B: Distraction of the A: Traction (Long GH joint: separation axis) to the GH of the GH joint at joint: caudal right angle to the gliding of the glenoid fossa joint surface Kisner & Colby 7th edition ©Stanbridge University 2022 109 WHY IS PROPER JOINT MOBILITY NECESSARY? Loss of joint mobility causes: Decreases synovial fluid movement Decreased extensibility and tensile strength of the articular and peri-articular tissues Afferent nerve impulses from joint receptors are affected → decrease in proprioceptive feedback that can affect the balance/muscle response ©Stanbridge University 2022 110 INDICATIONS FOR JOINT MOBILIZATION 1) Pain, muscle guarding, and spasm 2) Reversible joint hypomobility 3) Positional faults/subluxations 4) Progressive limitation 5) Functional immobility ©Stanbridge University 2022 111 INDICATIONS FOR JOINT MOBILIZATION PAIN, MUSCLE GUARDING, SPASM Small amplitude oscillatory and distraction movements are used to: Neurophysiological effects: Stimulate mechanoreceptors that may inhibit the transmission of nociceptive stimuli (Inhibit Pain) Mechanical effects: Helps maintain nutrient exchange, prevent painful and degenerating effects of fluid stasis when a joint is swollen, painful, and cannot move through the ROM ©Stanbridge University 2022 112 INDICATIONS FOR JOINT MOBILIZATION: REVERSIBLE JOINT HYPOMOBILITY Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically Elongation of hypomobile capsular or ligamentous connective tissue through progressively vigorous joint play stretching techniques ©Stanbridge University 2022 113 INDICATIONS FOR JOINT MOBILIZATION: POSITIONAL FAULTS/SUBLUXATIONS Faulty tracking of the joint surfaces resulting in pain or limited motion Causes: trauma, immobility, muscle imbalances Can use: MWM techniques High velocity thrusts ©Stanbridge University 2022 114 INDICATIONS FOR JOINT MOBILIZATION: PROGRESSIVE LIMITATION Diseases that progressively limit movement can be treated with joint play techniques to: Maintain available ROM Retard progressive mechanical restrictions ©Stanbridge University 2022 115 INDICATIONS FOR JOINT MOBILIZATION: FUNCTIONAL IMMOBILITY When a patient cannot functionally move a joint for a period, the joint can be treated with a non stretch gliding technique or distraction technique (Grade I or II): Maintain available joint play Prevent degenerating and restricting effects of immobility ©Stanbridge University 2022 116 SELF TREATMENTS: www.HEP2go.com Seated knee joint Traction Elbow joint Distraction ©Stanbridge University 2022 117  CONTRAINDICATIONS TO JOINT MOBILIZATION Hypermobility: no joint mobilization involving https://movingprayer.wordpress.com stretching techniques (i.e. necrosis of ligaments, capsule, hypermobility syndromes, etc.) Joint effusion: don’t stretch (passively or through joint mobilization) a swollen joint because capsule is already on stretch gentle oscillations may help decrease pain and improve fluid flow while maintaining joint play ©Stanbridge University 2022 118 CONTRAINDICATIONS TO JOINT MOBILIZATION Presence of Inflammation: Stretching usually increases pain and muscle guarding Further tissue damage ©Stanbridge University 2022 119 PRECAUTIONS TO JOINT MOBILIZATION: USE EXTREME CARE WITH…. Malignancy Bone disease Unhealed fracture (depends on fracture site and stabilization provided) Excessive pain Hypermobility in associated joints: stabilize properly so mobilization force isn’t transmitted to associated joints ©Stanbridge University 2022 120 PRECAUTIONS TO JOINT MOBILIZATION: USE EXTREME CARE WITH…. Total Joint Replacements: implant design may self-limit available ROM and therefore mobilization may be inappropriate (read op report and available range measured during operation) Newly formed or weakened connective tissue i.e. no forceful techniques immediately after injury, surgery, or with disuse, certain medications ©Stanbridge University 2022 121 PRECAUTIONS TO JOINT MOBILIZATION: USE EXTREME CARE WITH…. Systemic Connective Tissue Diseases where disease weakens the connective tissue i.e. rheumatoid arthritis: no forceful techniques→ can result in ruptured tissue and instability Elderly individuals with weakened connective tissue and diminished circulation (may use gentle techniques) ©Stanbridge University 2022 122 REVIEW Why do we need normal joint mobility? What key characteristics differ between joint mobilization and osteokinematic stretching? List the indications, precautions and contraindications of joint mobilization. ©Stanbridge University 2022 123 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Examination and evaluation: what determines the plan of care? – Quality of pain – Capsular restriction – Subluxation or dislocation ©Stanbridge University 2022 124 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Examination and evaluation: Quality of Pain Pain BEFORE tissue limitation: No stretch, pain limiting techniques Pain at SAME TIME as tissue limitation: gentle stretch Pain AFTER tissue limitation: more aggressive stretch ©Stanbridge University 2022 125 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES ARE THERE CAPSULAR RESTRICTION?? Look in evaluation documentation for: Passive ROM limited in a capsular pattern Firm capsular end feel documented when overpressure is applied to the tissues limiting the motion Decreased joint play documented with mobility testing ©Stanbridge University 2022 126  PROCEDURES FOR APPLYING PASSIVE JOINT TECHNIQUES Examination and Evaluation for history of SUBLUXATION or DISLOCATION Proceed with caution (Grade I and II okay) DO NOT STRETCH in the direction of HYPERMOBILITY May be appropriate for high thrust technique- Not in PTAs scope of Practice ©Stanbridge University 2022 127 GRADES AND DOSAGES OF MOBILIZATIONS Maitland- Non-Thrust Oscillation Kaltenborn- Non-Thrust Sustained Techniques techniques Grades I→III Grades I→ IV ©Stanbridge University 2022 128 SUSTAINED VS OSCILLATORY Both Maitland and Kaltenborn: Grades I and II are Low intensity and DO NOT create a stretch Grades III and IV oscillations and Grade III sustained are similar in intensity and create a stretch ©Stanbridge University 2022 129 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Maitland Grades or Dosages of Movement: OSCILLATIONS Grade I: small amplitude rhythmic oscillations performed at the beginning of the range; rapid oscillations like manual vibrations Grade II: large amplitude rhythmic oscillations performed within the range, but NOT reaching the limit; 2-3 per second for 1-2 minutes Grades I, II: for treating joints limited by pain or muscle guarding: stimulate mechanoreceptors that block nociceptive pathways; synovial fluid movement ©Stanbridge University 2022 130 JOINT MOBILIZATIONS I- IV ©Stanbridge University 2022 131 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Grades or Dosages of Movement: OSCILLATIONS Grade III: large amplitude rhythmic oscillations performed up to the limit of the available motion and are stressed into the tissue resistance; 2- 3/second for 1-2 minutes Grade IV: small amplitude rhythmic oscillations performed at the limit of the available motion and stressed into the tissue resistance; rapid oscillations like manual vibration Grades III, IV are STRETCHING maneuvers ©Stanbridge University 2022 132 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Kaltenborn Grades or Dosages of Movement: SUSTAINED Techniques Joint techniques that separate (distract) or glide/translate (slide) the joint surfaces Rate of application is slow and SUSTAINED for several seconds followed by partial relaxation and then repeated ©Stanbridge University 2022 133 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Grade I (Loosen)- Small amplitude distraction with NO stress on the capsule (within slack zone) Grade II (Tighten)- Enough distraction or glide is applied to tighten the tissues around the joint (slack zone to transition zone) Grade III (Stretch)- A large enough amplitude distraction or glide is applied to stretch the joint capsule and periarticular tissues (Push through transition zone) ©Stanbridge University 2022 134 KALTENBORN SUSTAINED GRADES ©Stanbridge University 2022 135 OSCILLATING & SUSTAINED PRESCRIPTION BASED ON TREATMENT GOALS Controlling pain in acute and subacute phases of healing: Grade I or II Oscillation or Sustained Decreased Functional Range (due to loss of joint play) in subacute and Chronic phases of tissue healing: arguments in research over whether Grade III sustained, Grade II-IV oscillation or Grade III MWM are better Maintain available range, any phase of tissue healing: Grade II oscillating or sustained techniques ©Stanbridge University 2022 136 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Positioning and Stabilization: Position patient such that they can RELAX STABILIZE one joint partner (usually proximal) Assess joint play and apply treatment in RESTING POSITION for that joint (position where greatest capsular laxity is possible) Progression if trying to increase joint play (Grade III, IV): bring joint near the end of the available ROM before applying mobilization technique ©Stanbridge University 2022 137 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Treatment Force and Direction of Movement Treatment force: applied as close to the opposing joint surface as possible using as large of a contact surface as possible Treatment plane: plane is on the concave bony partner; is the plane perpendicular to a line running from the axis of rotation to the middle of the concave articular surface ©Stanbridge University 2022 138 JOINT MOBILIZATION APPLICATION Glides: parallel to the T.P Distraction: perpendicular to T.P. Treatment plane (T.P.): lies in the concave surface; is at right angle to a line drawn from the AOR to the center of the concave surface. ©Stanbridge University 2022 139 PROCEDURES FOR APPLYING JOINT MOBILIZATION TECHNIQUES Treatment Force and Direction of Movement Direction of movement is either: 1) Parallel to treatment plane: used for gliding techniques; direction of glided determined by concave/convex 2) Perpendicular to the treatment plane: used for distraction techniques where entire bone is moved so the joint surfaces are separated 3) Usually Combined ©Stanbridge University 2022 140 SUGGESTED SEQUENCE OF TREATMENT 1. Warm the tissue (active warm up, hot pack, etc.) 2. Relax the muscles: hold-relax inhibition technique, Grade I-II joint oscillations 3. Joint mobilization stretches (address faulty Arthrokinematics) 4. Passive stretching (address faulty Osteokinematics) 5. Patient actively uses new range (Functional activity) 6. Maintain new range: HEP- self stretches, self mobilization techniques, active resistive ROM, functional use of body segments in new range ©Stanbridge University 2022 141 PERIPHERAL JOINT MOBILIZATION TECHNIQUES Will be TAUGHT AND PRACTICED in PTA 1008 Orthopedic Interventions ©Stanbridge University 2022 142 JOINT MOBILIZATION- SUPPORTIVE EVIDENCE I C/S leans more to specific mobilization and L/S leans more to non-specific mobilization. Slaven et al. Journal of Manual & Manipulative Therapy, 2013 II There is no difference in outcomes for thrust vs non-thrust techniques in patients who met the clinical prediction rule for spinal manipulation. Learman et al. Physiother Can, 2014 A Clinician should consider using thrust manipulative procedures with L/S spine mobility deficits and acute low back pain and back related buttock or thigh pain. Delitto et al. Low Back Pain: Clinical Practice Guidelines, 2012 ©Stanbridge University 2022 143  JOINT MOBILIZATION- SUPPORTIVE EVIDENCE A Clinicians should consider using cervical manipulation/mobilization procedures in conjunction with exercise to reduce neck pain and headache. Childs et al. Neck Pain: Clinical Practice Guidelines, 2008 C Kelley et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis: Clinical Practice Guidelines, 2014 A Martin et al., Heel Pain- Plantar Fasciitis: Clinical Practice Guidelines Revision 2014, 2014 B Cibulka et al., Hip Pain and Mobility Deficits- Hip Osteoarthritis, 2009 ©Stanbridge University 2022 144 REVIEW What are the various non thrust oscillation and sustained grades and how are each defined? What stages of tissue healing are appropriate for each grade listed? ©Stanbridge University 2022 145 REVIEW By the end of the section the student should be able to: State and define the basic mobilization and movement terms. Describe basic concepts of joint motion including types of motion, passive angular stretching vs joint glide stretching and other accessory motions. Describe indications, precautions and contraindications of joint mobilization. Describe the grade of joint mobilization along with what grade is appropriate for each stage. ©Stanbridge University 2022 146