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Lecture 4: Stretching for Impaired Mobility

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Ashley Ambrosio

on 1 October 2015

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Transcript of Lecture 4: Stretching for Impaired Mobility

Stretching for Impaired Mobility
PTA 105 A
Chp. 4

Relaxation training
Progressive relaxation techniques

Gentle non fatiguing cycling, walking etc
US, diathermy..not so much…more for small areas



Jt traction and oscillations
Adjuncts to stretching interventions

Do not force a jt beyond its normal ROM please.

Be aware of age related changes in flexibility

Use caution with osteoporosis

Avoid vigorous stretching to tissue that has been immobilized for a long time. SLOW

Progress gradually

Don’t stretch swollen tissues

Avoid overstretching weak muscles
General precautions
Move extremity SLOWLY to the pt of restriction

Grasp proximal and distal to the jt in which motion occurs

Stabilize prox segment

Stretch muscle over 1 jt at a time if it’s a 2 jt muscle

To avoid compression, apply Gr I distraction

Apply low intensity stretch in slow, sustained manner.

The force is OPPOSITE the line of pull of the limited muscle

Maintain for 30 seconds

Gradually release

If pt does not tolerate sustained stretch, do slow gentle stretches. DON’T TRY TO REGAIN IT ALL AT ONCE!

Application of manual stretch

Integrates active muscle contraction into stretching

Only contractile elements will be relaxed

4 general techniques
Hold- relax
Agonist contraction
Hold-relax with agonist contraction
PNF Stretching Techniques
Form or manner in which stretching exercises are carried out.
Active stretching
Mode of Stretch

Alignment and Stabilization





Elements of Stretching Interventions
Passive vs. Assisted


Neuromuscular Inhibition Techniques, e.g. PNF, Muscle Energy techniques

Joint Mobilization/Manipulation

Soft Tissue Mobilization & Manipulation

Neural Tissue Mobilization
Interventions to Increase Soft Tissue Mobility
Bony block

Recent fracture has not yet healed

Evidence of acute inflammation or infection.

Sharp acute pain with joint movement or muscle elongation

Hypermobility already exists.

When contractures or shortened tissue might be providing support to increase joint stability.

When contractures or shortened tissue might be the basis for increased functional abilities.
Contraindications to Stretching

ROM limited because soft tissue has lost its extensibility as the result of adhesions, contractures and scar tissue formation, causing functional limitations or disabilities.

Restricted motion may lead to deformity.

Muscle weakness and shortening of opposing muscle tissue.

Part of a total fitness program.

Prior to or after vigorous exercise to potentially reduce muscle soreness.

Indications for Use of Stretching
Myostatic – Musculotendinous tissue shortened without muscle pathology present. Stretching techniques used to tx.

Pseudomyostatic – Caused by spasticity or rigidity associated with CNS lesions. Inhibition techniques result in full excursion of the muscle.

Arthrogenic or Periarticular – result of intraarticular pathology. Includes adhesions, irregularities in articular cartilage or osteophyte formation.

Fibrotic and irreversible contractures. Difficult to re-establish optimal length in the muscle tissue.
Cannot be reversed by non-surgical means.
Large amounts of adhesions and scar tissue buildup.

Changes on the Tissue Involved Describe the Type of Contracture
Restricted motion

Caused by adaptive shortening of soft tissues

May be caused by:
Prolonged immobilization
Sedentary lifestyle
Postural mal-alignment
Muscle imbalances
Impaired muscle performance
Tissue trauma
Congenital/acquired deformities



Types of contractures
Definitions of Terms Related to Mobility and Stretching
The ability of structures or segments of the body to move or be moved to allow the range of motion necessary for functional activities (functional ROM)

The ability to initiate, control, or sustain active movements of the body to perform simple to complex motor skills (functional mobility)

ROM needed for performing functional activities does not necessarily mean full or “normal” ROM
A general term used to describe any therapeutic maneuver designed to increase extensibility of soft tissue and subsequently improve flexibility/ROM by elongating (lengthening) structures that have adaptively shortened and become hypomobile over time.

Stretching Definition & Purpose

Review Goals w pt.

Chose most effective technique

Warm up

Use correct plane of motion for stretch

Give clear directions

No restrictive clothing

Tell pt to RELAX

Preparation for stretching
Permanent increases in ROM occur with integration into functional activities.

Emphasize the use of ADL’s to improve movement patterns and ROM
Integration of Function into Stretching

Variation of the hold-relax technique. Uses a pre-stretch isometric contraction of the range limiting muscle in a lengthened position followed by a concentric contraction of the muscle opposite the range-limiting muscle.
Hold Relax with Agonist Contraction

HR & CR used synonymously.

In classic PNF, contract relax occurs during the patterns.

Makes passive elongation of muscle more comfortable.
GTO stimulation – autogenic inhibition

Pre-stretch, end range, isometric contraction for 10 seconds.

Also used in muscle energy techniques to mobilize joints by overcoming restrictive barriers to specific joint motions.
Hold-Relax (HR)
Number of bouts or sessions per day or per week stretching regimen is carried out.

No research to support optimal numbers.
Frequency of Stretch
Slow – applied and released gradually.

Ballistic stretch –rapid forceful, intermittent stretch.

Difficult to control

Tissues easily injured if weak or diseased

Contractures do not yield with rapid stretch.

High-velocity stretch such as in Plyometric (jump training

Speed of Stretch
Refers to the time stretch force is applied (single cycle).

Research is inconclusive as to the ideal length of time or total time for stretching.

15, 30, 45, 60 or 2 minutes have all been effective at producing significant gains.

Static vs. Static- Progressive stretching

Duration of Stretch
Intensity determined by the load placed on soft tissue as it is being elongated.

Low intensity = low load

More comfortable, minimizes muscle guarding and danger of exposing possibly weakened tissue from immobilization to excessive loads.
Intensity of Stretch
Necessary for patient comfort and effectiveness.

Stabilization necessary to achieve effectiveness. Stabilize either the proximal or distal attachment site of the muscle-tendon unit being elongated.

E.g. when stretching the rectus femoris, knee flexion with hip extension and L spine in neutral.

Fixation can come from manual contacts, from body weight or firm surfaces.
Alignment & Stabilization
Going beyond normal ROM

Excessive mobility may be necessary for certain sporting activities.

Overstretching can become detrimental and creates joint instability
Over Stretching & Hypermobility
Adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint.

This results in significant resistance to passive or active stretch and limitation of ROM.

Described by identifying the action of the shortened muscle, e.g. elbow flexion contracture.
Ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM.

Dynamic vs. Passive or static flexibility
Prime mover (agonist) contracts opposite the range limiting muscle (antagonistic).

Concentrically contract the muscle opposite the muscle limiting range of motion.

Creates “reciprocal inhibition” of the antagonist.
Agonist Contraction (AC)
Overall function of a pt. May be improved by applying stretching selectively to some muscles or joints but allowing a limitation of motion to develop in other muscles or joints.

Stability of the trunk in SC pts. Is necessary for independent sitting. Lack trunk control, stretch hamstrings and allow moderate hypo-mobility to develop in the extensors of the low back,

Allows pt. to lean into shortened structures and will have stability in long sitting.
Selective Stretching
Static Stretching: tissues elongated just past the point of tissue resistance and held in the lengthened position with a sustained stretch force and held for a period of time
Also referred to as sustained, maintained or prolonged stretch
Safer and more effective than ballistic stretching (less tension created, non contractile tissue yields easier, less tissue trauma and post ex muscle soreness
Static Progressive Stretching: shortened soft tissues are held in a comfortably lengthened position until a degree of relaxation is felt by the pt or PT/PTA
Shortened tissues are incrementally lengthened even further and again held in the new end range position for additional duration of time
Involves continuous displacement of a limb by varying the stretch force
Ex: dynamic orthosis

After stretching
apply cold in lengthened position.
Do AROM and strengthening in newly gained ROM
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