4 Stretching exercise.pdf

Stretching exercise DR. MEEYOUNG KIM THERAPEUTIC EXERCISE PHYSIOTHERAPY DEPT. UNIVERSITY OF SHARJAH Contents  Definition of Terms Associated with Mobility and Stretching  Indications, Contraindications, and Potential Outcomes of Stretching Exercises  Properties of Soft Tissue: Response to...

Stretching exercise DR. MEEYOUNG KIM THERAPEUTIC EXERCISE PHYSIOTHERAPY DEPT. UNIVERSITY OF SHARJAH Contents  Definition of Terms Associated with Mobility and Stretching  Indications, Contraindications, and Potential Outcomes of Stretching Exercises  Properties of Soft Tissue: Response to Immobilization and Stretch  Application of Manual Stretching  Types of stretching  PNF (Proprioceptive Neuromuscular Facilitation) Stretching Techniques Definition of Terms Associated with Mobility and Stretching  Definition Stretching Mobility  a general term used to describe  The ability of structures or any therapeutic maneuver segments of the body to move designed to increase the or be moved to allow the extensibility of soft tissues, presence of range of motion for thereby improving flexibility and functional activities (functional ROM by elongating ROM). (lengthening) structures that have adaptively shortened and  Functional mobility: The ability of have become hypomobile over an individual to initiate, control, time. or sustain active movements of the body to perform simple to complex motor skills.  Definition Hypomobility  Decreased mobility or restricted motion.  Contributing factors: Prolonged immobilization by: Extrinsic Casts and splints Intrinsic: Pain Joint inflammation and effusion Muscle or tendon disorders Skin disorders Vascular disorders Sedentary lifestyle Paralysis Postural mal-alignment: congenital or acquired Contracture  The adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint  Resulting in significant resistance to passive or active stretch and limitation of ROM, which may compromise functional abilities.  Irreversible E.g. Wrist flexion contracture  Definition 5 Types of Contracture  1. Myostatic contracture - Adaptive shortening of muscle, usually caused by immobilization and without tissue pa thology.  2. Pseudomyostatic contracture - Impaired mobility and limited ROM from  hypertonicity (i.e., spasticity or rigidity) associated with a central nervous system lesion  or Muscle spasm or guarding and pain  3. Arthrogenic contracture - the result of intra-articular pathology (adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation)  Definition 5 Types of Contracture – cont’d  Periarticular contracture develops when connective tissues that cross or attach to a joint or the joint capsule lose mobility, thus restricting normal arthrokinematic motion.  Fibrotic contracture - a large amount of relatively nonextensible, fibrotic adhesions and scar tissue. can occur after long periods of immobilization of tissues in a shortened position or after tissue trauma and the subsequent inflammatory response. Solution is only surgical replacement Indications, Contraindications, and Potential Outcomes of Stretching Exercises Indications for Stretching ROM is limited because soft tissues have lost their extensibility as the result of adhesions, contractures, and scar tissue formation, causing activity limitations (functional limitations) or participation restrictions (disabilities). Restricted motion may lead to structural deformities that are otherwise preventable. Muscle weakness and shortening of opposing tissue have led to limited ROM. May be a component of a total fitness or sport-specific conditioning program designed to prevent or reduce the risk of musculoskeletal injuries. May be used prior to and after vigorous exercise to potentially reduce postexercise muscle soreness. Contraindications A bony block limits joint motion. There was a recent fracture, and bony union is incomplete. There is evidence of an acute inflammatory or infectious process (heat and swelling), or soft tissue healing could be disrupted in the restricted tissues and surrounding region. There is sharp, acute pain with joint movement or muscle elongation. A hematoma or other indication of tissue trauma is observed. Hypermobility already exists. Shortened soft tissues provide necessary joint stability in lieu of normal structural stability or neuromuscular control. Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible. Potential Benefits and Outcomes of Stretching  Increased Flexibility and ROM  General Fitness  Injury prevention and reduced postexercise muscle soreness.  Enhanced performance. Properties of Soft Tissue: Response to Immobilization and Stretch  contractile units of muscle, the sarcomeres, into the plastic ROM progressively leads to increased soft tissue length due to an increased number of sarcomeres in series.  Non-contractile units of muscle are tendon, ligaments, joint capsule, and fascia which all consist of collagen and elastin fibers. Mechanical Response of the Contractile Unit to Stretch  Tendency of muscle to return to its resting length after short-term stretch is called elasticity. If longer lasting or more permanent (viscoelastic or plastic) length increases are to occur. Mechanical Response of the Contractile Unit to Immobilization  If a muscle is immobilized for a prolonged period -> decay of contractile protein in muscle, decreases in muscle fiber diameter, the number of myofibrils, and intramuscular capillary density -> muscle atrophy and weakness (decreased force generating capacity of muscle)  The longer the duration of immobilization, the greater is the atrophy of muscle and loss of functional strength. Atrophy can begin within as little as a few days to a week. Immobilization in a shortened position  For several weeks  reduction in the length of the muscle, fibers, and the number of sarcomeres as the result of sarcomere absorption.  A muscle immobilized in a shortened position atrophies and weakens at a faster rate than if it is held in a lengthened position over time.  Increased proportion of fibrous tissue and subcutaneous fat Immobilization in a lengthened position  It may gain in muscle length (indirectly identified by increases in joint ROM) following the use of serial casts  Sarcomere number addition occurs to maintain the greatest functional overlap of actin and myosin filaments in the muscle The adaptation of the contractile units of muscle (an increase or decrease in the number of sarcomeres) to prolonged positioning in either lengthened or shortened positions is transient, lasting only 3 to 5 week. Mechanical Properties of Noncontractile Soft Tissue  Collagen fibers  are responsible for the strength and stiffness of tissue and resist tensile deformation.  In tendons, parallel and can resist the greatest tensile load. They transmit forces to the bone created by the muscle.  In skin, collagen fibers are random and weakest in resisting tension.  In ligaments, joint capsules, and fasciae, the collagen fibers vary between the two extremes, and they resist multidirectional forces. Mechanical Principles for Stretching Connective Tissue  Connective tissue deformation (stretch) requires breaking of collagen bonds and realignment of the fibers for there to be permanent elongation or increased flexibility.  Healing and adaptive remodeling time allow the tissue to respond to repetitive and sustained loads. Otherwise, a breakdown of tissue (failure) occurs -> inflammation from the micro ruptures is excessive, additional scar tissue, which could become more restrictive. Application of Manual Stretching Procedures  Apply a low-intensity stretch in a slow, sustained manner.  Remember, the direction of the stretching movement is directly opposite the line of pull of the range-limiting muscle.  Take the hypomobile soft tissues to the point of firm tissue resistance and then move just beyond that point.  The force must be enough to place tension on soft tissue structures but not so great as to cause pain or injure the structures.  The patient should experience a pulling sensation, but not pain, in the structures being stretched. When stretching adhesions of a tendon within its sheath, the patient may experience a “stinging” sensation. Application of Manual Stretching Procedures (Cont’d) Consider incorporating a prestretch, isometric contraction of the range-limiting muscle (the hold-relax procedure) theoretically designed to relax the muscle reflexively prior to stretching it. To avoid joint compression during the stretching procedure, apply gentle (grade I) distraction to the moving joint. Maintain the stretched position for 30 seconds or longer. repeat the sequence several times. Non-Thrust Sustained Joint-Play Techniques Grade I (loosen). Small-amplitude distraction  is applied when no stress is placed on the capsule.  Grade II (tighten). Enough distraction or glide is applied to tighten the tissues around the joint.  Grade III (stretch). A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures.  Speed of Stretch Importance of a Slowly Applied Stretch  Muscle spindle  A slowly applied stretch is less likely to increase tensile stresses on connective tissues or to activate the stretch reflex.  Ia fibers of the muscle spindle are sensitive to the velocity of muscle lengthening. Types of stretching  Static stretching  Cyclic/Intermittent stretching  Ballistic stretching  Proprioceptive neuromuscular facilitation stretching (PNF stretching)  Manual stretching  Mechanical stretching  Self-stretching  Passive stretching  Active stretching  Duration of Stretch Static Stretching  a commonly used method of stretching  soft tissues are elongated just past the point of tissue resistance and then held in the lengthened position with a sustained stretch force.  =sustained, maintained, or prolonged stretching.  The duration of static stretch is predetermined prior to stretching or is based on the patient’s tolerance and response during the stretching procedure.  an effective form of stretching to increase flexibility and ROM  a safer form of stretching than ballistic stretching (tension in muscle during static stretching is approximately half)  Duration of Stretch Static Progressive Stretching  Shortened soft tissues are held in a comfortably lengthened position until a degree of relaxation is felt by the patient or therapist.  Then the shortened tissues are incrementally lengthened even further  Again, held in the new end-range position for an additional duration of time.  Duration of Stretch Cyclic (Intermittent) Stretching  A relatively short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied.  With cyclic stretching, the end-range stretch force is applied at a slow velocity, in a controlled manner, and at relatively low-intensity. (not synonymous with ballistic stretching, hold 5 to 10 sec)  Speed of Stretch Ballistic Stretching  A rapid, forceful intermittent stretch—that is, a high-speed and high- intensity stretch  quick, bouncing movements that create momentum to carry the body segment through the ROM  not recommended for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures  Speed of Stretch High-Velocity Stretching in Conditioning Programs and Advanced-Phase Rehabilitation  a highly trained athlete involved in a sport, such as gymnastics, that requires significant dynamic flexibility  a young, active patient in the final phase of rehabilitation  prior to beginning plyometric training or simulated, sport-specific exercises or drills Proprioceptive Neuromuscular Facilitation Stretching Techniques  PNF Stretching  referred to as active stretching or facilitative stretching  underlying mechanisms of PNF stretching  reflexive relaxation occurs during the stretching maneuvers, as the result of autogenic or reciprocal inhibition.  Current idea: more complex mechanisms of sensorimotor processing, viscoelastic adaptation of the muscle-tendon unit and changes in a patient’s tolerance to the stretching maneuver  PNF stretching yields greater gains in ROM than static stretching  PNF Stretching Autogenic inhibition  PNF Stretching Reciprocal inhibition  PNF stretching Types of PNF Stretching Hold-relax (HR) or https://www.youtube.com/watch?v=V31lkMrSk5U Contract-relax (CR) https://www.youtube.com/watch?v=gJHxJEd-BWE -Answer which is using isometric and isotonic contraction? -Which neuromuscular inhibition used? Agonist contraction (AC) Hold-relax with agonist contraction (HR-AC) https://www.youtube.com/watch?v=53_EqT678oI&t=3s  PNF stretching Hold-Relax and Contract-Relax  to make passive elongation of muscles more comfortable for a patient than manual passive stretching. A commonly held assumption is that neuromuscular relaxation  PNF stretching Hold-relax Putting a muscle in a stretched position (also called a passive stretch) and holding for a few to 10 seconds. Contracting the muscle isometrically, such as pushing gently against the stretch without actually moving. This is when the reflex is triggered and there is a “6- to 10-second window of opportunity for a beyond ‘normal’ stretch,” Relaxing the stretch, then stretching again, 10sec. This second stretch should be deeper than the first  PNF Stretching Contract-relax  almost identical to hold-relax, except that instead of contracting the muscle without moving, the muscle is contracted while moving. This is sometimes called isotonic stretching.  For example, in a hamstring stretch, this could mean a trainer provides resistance as an athlete contracts the muscle and pushes the leg down to the floor.  PNF stretching Agonist Contraction  The “agonist” refers to the muscle opposite the range-limiting target muscle.  AC procedure  the patient concentrically contracts the muscle opposite the range- limiting muscle and then holds the end-range position for at least several seconds.  the shortening contraction is performed without the addition of resistance.  After a brief rest period, the patient repeats  For example, if the hip flexors are the range-limiting target muscle group, the patient performs end-range, prone leg lifts by contracting the hip extensors concentrically  PNF Stretching AC technique especially effective when: significant muscle guarding restricts muscle lengthening and joint movement and is less effective in reducing chronic contractures. a patient cannot generate a strong, pain-free contraction of the range- limiting muscle, during the HR and CR procedures. for initiating neuromuscular control in the newly gained range to re-establish dynamic flexibility. But least effective if a patient has close to normal flexibility.  PNF stretching Hold-Relax with Agonist Contraction  also referred to as the CR-AC procedure or slow reversal hold-relax technique  HR-AC procedure:  move the limb to the point that tissue resistance is felt in the range-limiting target muscle;  then have the patient perform a resisted, prestretch isometric contraction of the range- limiting muscle  followed by voluntary relaxation  an immediate concentric contraction of the muscle opposite the range-limiting muscle. Any questions?