Musculoskeletal Physiotherapy PDF

Musculoskeletal physiotherapy Stretching Elongate the contractile and noncontractile components, in order to place the myotendinous structure in maximum external path. *max distance between origin and insertion Classification of stretching 1. According to structure Global: group of muscles/muscle...

Musculoskeletal physiotherapy Stretching Elongate the contractile and noncontractile components, in order to place the myotendinous structure in maximum external path. *max distance between origin and insertion Classification of stretching 1. According to structure Global: group of muscles/muscle chain - Prophylactic/maintenance purposes. for example, when we want to change posture. Analytic (muscle/bundle): only one muscle - Most used for therapeutic purposes. Example of global vs analytic ● ● Hamstrings: Flexion of the hip and extension of the knee Isolate biceps femoris: Flexion of the hip, medial rotation and extension of the knee 2. According to form of realization ● ● ● Dynamic Static passive, active, (in)active tension Proprioceptive neuromuscular facilitation - Hold - relax (HR) Contract - relax (C-R) Contract relax - against contract Dynamic stretching ● Active or ballistic ○ Active: full ROM ○ Ballistic: rapid or bouncing at end ROM ● Easy, soft rhythmic, repetitive For increasing dynamic flexibility (must be informed after static stretching) *we are actually referring to extensibility Dynamic flexibility: degree to which an active muscle contraction moves through ROM ● Always must be performed after static/passive stretching *because passive stretches inhibit myotatic reflex ● Exclusive for sports Definition of terms: ● Extensibility: lengthening or elongation of skeletal muscle ● Flexibility: natural freedom of movement for joints ● Elasticity: ability of deformable structures to return to the original position after removing external forces that deformed it. Dynamic stretching inconveniences/contraindications: ● Fast stretching → little adaptation of soft tissue ● can provoke myotatic reflex *tonic contraction of the muscle in response to its own stretching ● Increase risk of injury (ballistic) *if static is not done previously ● Energy cost Inverse myotatic reflex: autogenic inhibition, in prolonged stretching of 3-5 minutes. You lose the myotatic reflex Static stretching - passive, active A specific position is held with the muscle on tension to a point of a stretching sensation and repeated. Slow, progressive → tightness (sensation) Position must be held until tightness or tension disappears *the tension is the myotatic reflex NO: myotatic reflex, rupture, pain Increase in local metabolism + intramuscular circulation Mostly used for therapeutic purposes Trophism vs. tone Trophism: not only muscle, but the whole structure. Tone: muscle tone. Contracture, stretching 1. Passive static force of traction is an external force External forces: - PT - Gravity - Self-placement - instrumental (pulleys) More analytic / specific 2. Active static stretch: contracting antagonist muscle Force of traction is an internal force: antagonist contraction. Tension of conjunctive structures Fixed points Connection groups/muscle chains ⇩ Antagonist contraction Neurophysiological concepts Reciprocal inhibition - Normal response in contraction of muscles. What prevents agonists and antagonists from contracting/relaxing at the same time. Soft muscle contraction of an agonist muscle - provokes relaxation (inhibition) of the antagonist muscle group - inhibits the stretch (myotatic reflex) When one muscle is activated, antagonist is reflexively inhibited. To do this, muscles that oppose the muscle being stretched is voluntarily contracted. 3. Static stretch (in) active tension For tendons!! where there is NO inflammation and is necessary to reorganize the fibers - Problem in organization of collagen fibers - Degeneration of collagen fibers/they lose the parallel-ness F traction = internal force→ agonist contraction For lower and upper limbs, not in muscles of the trunk Steps: 1. 2. 3. 4. Place muscle in pre-elongation (below submaximal/not maximum) Hold & Isometric contraction of agonist (that we want to stretch) 4-6s Hold and maintain, don’t increase stretch Repeat 3-5 times. Summary: Passive Active Inactive tension Myotendinous complex Myotendinous complex Only tendinous tissue Muscular local activity none Internal Antagonist contraction Internal Agonist contraction Secondary phenomena none Structure involved 🙂 Muscle maintenance and warming 🙁 Stiffness & muscle fatigue Learning Easy to learn Longer 🙂 Muscle maintenance and warming 🙁 Stiffness & muscle fatigue Longer learning and concentration Demands more knowledge of body & concentration Specificity Neurological phenomena More ability to be analytic Less analytic in extremities than in trunk More analytic in extremities than trunk none Reciprocal inhibition none Mechanical properties Maximum elongation and intratisular tension Less traction efforts with less maximum elongation and optimal intratisular tensión Elongation and intratisular tension less intenses than in passives. Proprioceptive Neuromuscular facilitation For increasing extensibility of the muscle To enhance active and passive range of motion. 1. Hold-relax technique Neurological silence* Often used if amplitude of movement is very limited / muscle is too stiff Repeated 3-5 times until maximum elongation is reached. Post isometric stretching Neurological silence: *right after isometric, 2-4 seconds in which neuromuscular system enters a refractory state wherein its possible to perform a passive elongation without opposition from myotatic reflex. *another way to inhibit myotatic reflex. Steps: 1. Maximum elongation state, hold 2. Isometric contraction of agonist 4-6” *to stimulate neurological silence 3. Increase stretch passively to new maximum elongation 2. Contract - relax technique *reciprocal inhibition Same as hold relax but contraction is antagonist muscle. Used when ROM is limited and painful contraction Repeated 3-5 times / until max elongation is reached. Steps: 1. Maximum elongation state, hold 2. Isometric contraction of antagonist 4-6” *to stimulate neurological silence 3. Increase stretch passively to new maximum elongation 3. Contract relax *neurological silence and reciprocal inhibition. Used if the patient cannot relax the muscle. If the myotatic reflex is very strong. Repeated 3-5 times / until max elongation is reached. Steps: 1. Maximum elongation state, hold 2. Isometric contraction of agonist 4-6” 3. Increase stretch actively, through concentric contraction of antagonist muscle to new maximum elongation position isometric contraction of agonist. - This activates neurological silence First 2 passively look for maximum elongation Last is actively look for maximum elongation. For the three techniques, Always begin in maximum elongation position. Or else you won’t increase extensibility If you ask for isometric contraction in PNF → must be submaximal! The same efficacy as with maximal contractions but more comfortable and lower risk for injury. Inverse myotatic reflex / autogenic inhibition: “inhibitory pulse sent to the muscle inducing relaxation thereof, removing excess of tightness when exist an excessive stress on the tendon (by lengthening or contraction there)” Nomenclature of stretching Type + structure Ex: - analytic passive static stretch of pectoralis minor Global dynamic stretch of the hamstring muscle Mechanical actions of stretching - If we apply an external force to the myotendinous unit → elongation - Elongation: external force > internal force - When lengthening is over, both forces are balanced. - In stretching, not all muscles will be stretched equally Central part is stretched more than in tendons Curve of tension-deformation Force deformation curve of a muscle 1st phase: elastic phase. - Resting until 1st resistance - If stopping during this phase, no deformation. 2nd phase: plastic phase Modification of muscle architecture - Disorganization molecular phase; if stopping here, not long lasting deformation - Clear deformation phase: if stopping, long lasting 3rd phase: rupture phase - As ruptures appear, effort to increase length reduces Goals of stretching 1. Improve/maintain extensibility 2. Relaxation Factors in maintaining and improving extensibility - Intensity of traction Velocity from resting to stretch / progression in application How long stretch is maintained for Location of force Temp of structures Age Intensity - To maintain extensibility: 1st tension feeling between phases 1& 2 To increase extensibility: work in clear deformation phase To relax muscle: between phases 1 and 2 - Aim: inhibit myotatic reflex Velocity - Maintain extensibility: not important Increase extensibility: slow ** to inhibit myotatic reflex → if stretching fast: activate myotatic reflex Time: - Maintain extensibility: not important Increase extensibility: important to stay longer (10 seconds → 1minute) Relax muscle: important to maintain *at least 30 secs Location of force: - To maintain extensibility: focus on fibers - Increase extensibility: include tendons Relax muscle: focus on fibers Temperature: - Maintain extensibility: not important Increase extensibility: need to heat up times before To relax the muscle: need to increase local temperature of the muscle For cramps: static active stretching by Contract the antagonist How long to maintain a stretch? - Variability from 10 to 1 minute - Relax: >30 seconds EMG obtained (>30 sec) Better to spread out stretching sessions. More important is total duration of stretch For prevention: include in warm up (15-30s) For static stretching: If static stretching is applied and is maintained > 45 seconds → reduce explosive muscle performance *not so applicable to marathon runners Ideal: 15-30 seconds for preventive effects. Persistence of elongation: Immediate effectiveness depends on factors mentioned above. 2 hours → 2 or 3 days. Long term: 1x a week. Contradiction of the reserve of extensibility Patients with more limited extensibility will have a greater capacity to increase extensibility. Elongation mechanisms: capacity to elongate depends on: ● Mechanical - Altering geometric structure of sarcomeres - Sarcomere changes in length / deforms but does not change volume. Can increase up to 50% its length Liberation of slip planes between tissues (skin, subcutaneous tissue, fascia) Repeated stretching provokes Internal frictions → increase tissue temperature, dilation of tissues and increase viscoelasticity ● Liquid & vascular factors. - Repetitive traction → myotendinous flattening → decrease concentration of intramuscular liquids → comes back to soak/absorb Stretching facilitates circulatory drainage => Increase internal temperature => evacuation of stagnant liquids. If a muscle is compressed, the concentration of intratissular liquids increase ● Nervous factors Inverse myotatic reflex → long lasting stretch Reflex inhibition of the stretched muscle If you stretch for prolonged periods → inverse myotatic reflex. Improves body image = body proprioception Being able to feel the position of the joints/tension. Stretching techniques must be chosen based on activities After explosive physical activities, avoid doing anything (stretching, massage, etc). After explosive workout - Aerobic - self stretching - shower - if more tension in circulatory drainage, cold water - PT. Indications and contraindications Mechanical indications - Maintain extensibility Increase range of motion Increase performance Orientation of collagen fibers → cicatrization injury Increase of tissular temperature → could we use it for warming? Circulatory improvement by compression among muscle masses Neurophysiological indications - Induce the inverse myotatic reflex → muscle cramp Rupture of the vicious cycle Improvement of propriocepion Not all pain will produce contractures or tension Increase amount of sarcomeres with long term stretching Therapeutic indications - Spasticity (but take precautions) Myotendinous retraction Post-immobilization syndromes Non-functional scars Respiratory disease (?) Contraindications - Acute / recent injuries like muscle tears Ultrasound would be needed to see whether stretching can be applied or not - Instabilities / dislocations Acute lumbalgia Acute neuralgia - - Inflammation of peripheral nerve (absolutely contraindicated) Stretching may provoke immediate relief but the evolution would be worse. hyperlaxity Take precaution; there may be limitations in range of motion Acute inflammation: absolute contraindication. Severe pain Fragile skin grafts Recent muscle tear Acute neuralgia Vascular fragility Recent capsuloligamentous injury Hypermobility Rules and principles 1. 2. 3. 4. 5. 6. Respect joint physiology Respect joint amplitudes Previous warm up Preparatory stage. Further gradual tension Respect times of stretching T4 = T1 + T2 + T3 Total time of stretching = time of rest before next stretching techniques Rules of application 1. Place muscle in maximum external path 2. muscle physiological actions through joints 3. Final touch → one single joint Don’t increase range of motion in 2 joints at the same time. You will stretch the muscle of the joint of the last joint you move. 4. Single joint muscles are the most complex. 5. Adjacent joints = maximum efficiency Put the joints around the muscle in the best position 6. Rotation component - rotating will increase tension in a transversal way. 7. Fixed and moving point 8. Increase intensity across transversal mobilization. 9. If defensive contraction appears (myotatic reflex) →use neurological silence.