Wk 2 Stretching and Active Inhibition technique (stu) PDF

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Wk 2 Stretching and Active Inhibition technique (stu)...

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Stretching and Active Inhibition techniques The term mobility can be described based on two different by interrelated parameters. It is often defined as the ability of structures or segments of the body to move or be moved to allow the presence of range of motion for functional activities (fx ROM). It can also be defined as the ability of an individual to initiate, control, or sustain active movements of the body to perform simple to complex motor skills (fx mobility) Factors include:  Prolonged immobilization of a body segment  Sedentary lifestyle  Postural malalignment and muscle imbalances  Impaired muscle performance (weakness) associated  Tissue trauma resulting in inflammation and pain  Congenital or acquired deformities Hypomobility can be due to a pathological process such as contractures and can lead to FX limitations and disability in a person’s life. Flexibility: Is the ability to rotate a single joint or series of joints smoothly through an unrestricted, pain-free ROM. Dynamic Flexibility: aka Active ROM / Active mobility, is dependent on the degree a mm can move a jt thru ROM and the degree of tissue restriction during motion. Passive Flexibility: aka Passive ROM/passive mobility is the ability for a joint to be passively rotated through its available ROM. The amount an external force can move a segment through. It is a prerequisite to AROM though it does not ensure it. What are contractures? Hypomobility can range from mild muscle shortening to irreversible contractures. Contractures are adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM. To assist in identifying a contracture they describe the action (i.e. elbow flexion contracture) Designation of contracture by location -Identify the action of the muscle to the joint it affects. (Bicep = elbow flexor contracture)

Stretching and Active Inhibition techniques Contracture vs. contraction: contractions can release, contractures can’t on their own. Types of Contractures Myostatic contracture: Musculotendinous unit has adaptively shortened and there is a significant loss of ROM, there is no specific muscle pathology present. Myostatic contracture can be resolved quickly with active, passive, stretching (heat, knead, stretch) Pseudomystatic Contracture: Impaired mobility and limited ROM may also be the result of hypertonicity or spasticity associated with a Central Nervous System injury (i.e., stroke or spinal cord injury). The muscle guarding and pain may cause a pseudomyostatic contracture. The involved muscle seems to be in a constant state of contraction decreasing passive ROM. Pseudomystatic contractures respond well to inhibition techniques. (stimulate and contract the opposite muscle to get the affected muscle to relax) (PIR, PNF type2 AC) Arthrogenic and Periarticular contractures Arthrogenic contractures are a result of intra-articular pathology. These changes may include adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation. A periarticular contracture develops when connective tissue that crosses or attach to a joint or the joint capsule loss mobility, therefore decreasing ROM. Fibrotic Contracture and irreversible contracture Are fibrous changes in the connective tissue of muscle and periarticular structures can cause adhesion of these tissues and subsequent development of a fibrotic contracture. Although you can stretch a fibrotic contracture and eventually increase ROM, it is often difficult to reestablish optimal tissue length. Permanent loss of extensibility of soft tissues that cannot be reversed by nonsurgical intervention may occur when normal muscle tissue and connective tissue are replaced with a fibrotic adhesions and scar tissue or even heterotopic bone. Stretching Just as strengthening and endurance exercises are essential intervention to improve impaired muscle performance or prevent injury, when restricted mobility adversely affects function and increases the risk of injury, stretching interventions become an integral component of the clients rehab program.

Stretching and Active Inhibition techniques Stretching is a general term used to describe any therapeutic maneuver designed to increase the extensibility of soft tissue, (contractile and noncontractile components of muscle- tendon units and periarticular structures) thereby improving flexibility by elongating structures that have adaptively shortened and have become hypomobile over time. Techniques to increase mobility of soft tissue Manual or Mechanical/Passive or assisted Stretch When a trained practitioner or caregiver applies an external force to the segment, taking it slightly beyond tissue resistance. Usually held for 15 to 60 seconds and repeated for at least several reps. Passive stretch A sustained end-range stretch, applied with overpressure. Move a restricted joint just past the available ROM. If the client assists in moving the joint through a greater range it is called assisted stretching Mechanical: Using equipment (weight-pulley system, automated stretching machines) to apply low-intensity force. These loads provided by mechanical stretching should be low intensity and applied for extended periods of time (research describes times ranging from 15-30 minutes to if 8-10 hours at a time) Self-stretching: (active stretch/flexibility exercises) Usually held for 15 to 60 seconds and repeated for at least several reps.  Another form of self-stretching is, Low-intensity active stretching aka dynamic ROM: using repeated, short-duration, end-range active mm contraction of the antagonist mm Neuromuscular Facilitation and Inhibition Techniques (PNF) Proprioceptive neuromuscular facilitation/ Active inhibition techniques. Used to Relax tension in shortened muscles reflexively or reciprocal inhibition during muscle elongation. Also referred to as active stretching or facilitative stretching. It integrates active muscle contractions into stretching maneuvers to facilitate or inhibit muscle activation and to increase the likelihood that the muscle to be lengthened remains as relaxed as possible as it is stretched. Types of PNF 1. PNF type 1 aka Contract Relax (previously Hold-relax)

Stretching and Active Inhibition techniques *How      

to perform* Start by warming up the muscle (heat/petrissage) Stretch affected muscle for 30sec Then contract affected muscle(s) isometrically for 10sec Ask the client to take a deep breath and exhale, therapist bring client to new range and hold for 30sec Repeat isometric contractions 5-10 seconds Repeat set 3-5 times

2. PNF type 2 aka Agonist contract 3. PNF type 3 aka Contract-relax-contract

Muscle Energy Techniques Lengthen muscle and fascia and to mobilize joints. The procedures employ voluntary muscle contractions by the client in a precisely controlled direction and intensity against a counterforce applied by the therapist. ALSO called post isometric relaxation Joint Mobilization Are manual therapy techniques specifically applied to joint structures and are used to stretch capsular restrictions or reposition a subluxed joint. Soft tissue mobilization and manipulation Are designed to improve tissue mobility by mobilizing and manipulation connective tissue that binds soft tissues. I.E Slow deep stroking to effect change in the myofascial structures that can bind soft tissues an impair mobility techniques include friction massage, Myofascial release, acupressure, and TP therapy or ischemic compression. Neural Tissue Mobilization Are techniques used to improve or restore nerve tissue mobility, after trauma or surgical procedures where there is nerve involvement adhesions or scar tissue may form around the meninges and nerve roots or at the site of injury at the plexus or peripheral nerves. After tests to determine neural tissue mobility are conducted, the neural pathways are mobilized.  For the most part, decreased extensibility of connective tissue, not the contractile elements of muscle tissue, is the primary cause of restricted ROM.

Stretching and Active Inhibition techniques Indication for use of Stretching  ROM is Limited because soft tissues have lost their extensibility as the result of adhesion, contractures, and scar tissue formation, causing FX limitations or disabilities  Restricted motion may lead to structural deformities that are otherwise preventable  There is muscle weakness and shortening of opposing tissue  Maybe used as part of a total fitness program designed to prevent injuries and enhance performance  Maybe used prior to and after vigorous exercise to minimize DOMS  CI’s to Stretching  A bony block limits joint motion  There was a recent fracture,  There is evidence of an acute inflammatory or infection process or soft tissue healing could be disrupted  There is sharp, acute pain with joint movement or muscle elongation  A hematoma  Hypermobility already exists  Shortened soft tissue enable a client with paralysis or severe muscle weakness to perform specific FX skills/or Stability Precautions:  ROM is different in everyone; don’t go beyond someone’s normal ROM  Be cautious of clients with Osteoporosis, prolonged bed rest, Age or steroids  Ensure safety of healing fractures.  Avoid vigorous stretching of tissue previously immobilized  Progress the dosage gradually (intensity, duration, and frequency) if the client feels joint pain or mm soreness lasting more than 24hr; too much force has been used Overstretching & Hypermobility: Is a stretch well beyond the normal length of mm and ROM, which results in hypermobility. Important in dance and gymnastics, in other populations, detrimental instability occurs. Determinants of Stretching Interventions  Alignment  Stabilization  Intensity of stretch  Duration 30secs. X3, 3 x / day. (9 times in total)

Stretching and Active Inhibition techniques  Speed of stretch  Frequency of stretch  Mode of stretch (static, ballistic, cyclic) (active, passive, assisted) A therapist has many options from which to choose when designing a stretching program that are safe an effective and meet the clients need, functional goals, and capabilities Broad categories of stretching exercises: Manual & mechanical or self-stretching, passive, assisted, active; which fall under the following 4 broad categories Static, Cyclic stretching, ballistic stretching, PNF) Cyclic (intermittent) stretching: Short duration stretch force that is repeatedly, but gradually applied, released, and then reapplied. Each cycle of cyclic stretch is held for 5 to 10 seconds no real consensus on the optimal number of reps of cyclic stretching during a treatment session. Rather, determination is often based on the client’s response to stretching. Ballistic Stretching: A quick forceful intermittent stretch that is, high speed and high-intensity. Characterized by quick bouncing movement; which can cause greater trauma to stretched tissues and greater residual muscle soreness than static stretching. (usually advanced-phase rehab ie. a gymnast. Dynamic stretching: Uses controlled movement to stretch muscle groups. It is similar to ballistic stretch in that it moves the joint through its ROM, but it is at a low velocities and intensities. It is widely emerging as a viable replacement for static stretching prior to athletic activities.  Regardless of the Mode of stretching it should be preceded by either low-intensity active exercise or therapeutic heat to warm the tissue that are to be lengthened. Considerations for selecting appropriate mode of stretching  Based upon assessment, what is impairing mobility  Is there pain or inflammation present  How long has hypomobility been present  What is the stage of healing  If performed, How did the patient respond to previous stretching  Are there underlying pathologies  Can the patient participant, also consider age, ability to follow instruction

Stretching and Active Inhibition techniques Preparation for stretching  Review the goals and desired outcomes of the stretching program  Discuss negative effect (risk and side effects) That they should experience a pulling sensation but stop if they feel pain. Inform the patient that postexercise mm soreness may be felt and last no more than 24hrs. When stretching adhesions the client may describe a “stinging” sensation as adhesion are mobilized.  Select the stretching techniques that will be most effective and efficient  Warm up the soft tissues to be stretched by local heat or by active, low intensity exercise  Have the client assume a comfortable, stable position  Explain the procedure make sure they understand  Demonstrate  Explain important to be as relaxed as possible, no bouncing  Explain how long to hold stretch for, sets, reps, and frequency  Do they have any questions  Suggest active ROM  Apply cold to the soft tissues that have been stretched and allow these structures to cool in a lengthened position. Cold may minimize poststretch muscle soreness that can result of microtruama during stretching. Application of Manual Stretching Procedures  Position the limb at tissue resistance point  Carefully grasp the areas on either side of the joint (prox, dist of jt)  Firmly stabilize the proximal segment and move the distal segment  Multi-joint muscles, stabilize anything, incorporate stretches over one joint at a time and then all joints together.  Consider PNF techniques  Consider applying grade 1 distraction to minimize jt compression  Stretching rule: slow and low (Speed and intensity)  Hold for a minimum of 30 seconds  Slowly release the stretch, maintaining the position for repetition  If pt doesn’t tolerate prolonged stretches, increase number and decrease duration  Consider fascial / cross fiber techniques during stretch. The effect of Stretching When soft tissue is stretched, elastic, visoelastic, or plastic changes occur.

Stretching and Active Inhibition techniques

Elasticity Is the ability of soft tissue to return to its prestretch resting length directly after a short-duration stretch force has been removed. Viscoelasticity Is a time-dependent property of soft tissue that initially resists deformation, such as a change in length, of the tissue when a stretch force is first applied. If a stretch force is sustained, viscoelasticty allows a change in the length of the tissue and then enables the tissue to return gradually to its prestretch state after the stretch force has been removed. Plasticity Is the tendency of soft tissue to assume a new and greater length after the stretch force has been removed. Both contractile and non contractile tissue have elastic and plastic qualities; however only connective tissues, have viscoelastic properties. Mechanical Properties of contractile tissue The contractile elements of muscle give it the characteristics of contractility and irritability. The noncontractile connective tissue in and around muscle has the same properties as all connective tissue, including the ability to resist deforming forces. Connective tissue Endomysium = acts as a harness of a muscle it is the innermost layer that separates individual muscle fibers and myofibrils Perimysium= encases fiber bundles Epimysium= which is the fascial sheath around the entire muscle It is the connective tissue make up in muscle that is the primary source hypomobility. When contractures develop, adhesions in and between collagen fibers resist and restrict movement. Contractile components of muscle A individual muscle are composed of many muscle fibers that lie in parallel with one another. A single muscle fiber is made up of many myofibrils. Each myofibril is composed of even smaller structures called sarcomeres A sarcomere is the contractile unit of the myofibril and is composed of overlapping myofilaments of actin and myosin that form cross-bridges

Stretching and Active Inhibition techniques Therefore a sarcomere gives a muscle its ability to contract and relax. So when a motor unit stimulates a muscle to contract, the actin-myosin filaments slide together and the muscle shortens.  Muscle contraction is the activation of tension-generating sites within muscle fibers. In physiology, muscle contraction does not necessarily mean muscle shortening because muscle tension can be produced without changes in muscle length such as holding a heavy book or a dumbbell at the same position. Response to Stretch When a muscle is stretched, the elongated force is transmitted to the muscle fibers via connective tissue (endomysium and perimysium). Initial lengthening occurs in the connective tissue after a point, there is mechanical change influenced by neural and biochemical changes leading to filaments sliding apart followed by an abrupt lengthening of the sarcomeres or (sarcomere give). When the stretch force is released, the individual sarcomeres return to their resting length. (elastic) Response to Immobilization and remobilization If a muscle is immobilized for a prolonged period of time as . This results in decay of contractile protein in the immobilized muscle, a decrease in muscle fiber diameter, decrease in the number of myofibrils, and a decrease in intramuscular capillary density, the outcome of which is muscle atrophy and weakness. (Begin in days to weeks) Subsequently, an increase in fibrous and fatty tissue in muscle also occurs. On another note the composition of muscle affects its response to immobilization, with atrophy occurring more quickly and extensively in postural (tonic or slow-twitch) fibers. Then phasic (fast-twitch) fibers. Immobilization in a shortened position Usually following a muscle tear or tendon rupture, there is a reduction in the length of the muscle and its fibers and in the number of sarcomeres (sarcomeres absorptions). It has suggested that a muscle immobilized in a shortened position atrophies and weakens faster than in a lengthened position. Subsequently immobilization in a lengthened position it adapts by increasing the number of sarcomeres called myofibrillogenesis (permanent plastic) In either case the adaptation of increase or decrease in the number of sarcomeres to prolonged positioning usually lasts 3 to 5 weeks if the muscle resumes its pre-immobilization usage.

Stretching and Active Inhibition techniques

Neurophysiological properties of contractile tissue The neurophysiological properties of the muscle-tendon unit also influence a muscle’s response to stretch. In particular the two sensory organs the muscle spindle and the golgi tendon organ which are mechanoreceptors that convey information to the CNS about what is occurring in a muscle-tendon unit. Muscle spindle It’s the major sensory organ of muscle and is sensitive to quick and sustained (tonic) stretch. Its main function is to receive and convey changes in the length of a muscle and the velocity the length changes. They are small encapsulated receptors composed of afferent sensory fiber, efferent motor fiber ending, intrafusal fiber. There are 2 types of intrafusal fiber: nuclear bag fibers and nuclear chain fibers Primary (type Ia fiber) afferent endings, which arise from nuclear bag fibers sense and cause muscle to respond to both quick and sustained (tonic) stretch Secondary (type II) afferents from the nuclear chain fibers are sensitive only to tonic stretch. Golgi Tendon Organ Is a sensory organ located near the musculotendinous junctions of extrafusal muscle fibers. The function of a GTO is to monitor changes in tension of muscle-tendon units. These encapsulated nerve ending are woven among collagen strands of a tendon and transmit sensory information via IB fibers. When tension develops in a muscle, the GTO fires, inhibits alpha motoneuron activity, and decreases tension in the muscle-tendon unit being stretched. Mechanical properties of Noncontractile soft Tissue Ligaments, tendon, joint capsules, fasciae, noncontractile tissue in muscle. When these tissues restrict ROM and require stretching, it is important to understand how they respond to the intensity and duration of stretch and to understand the only way to increase the extensibility of connective tissue is to remodel...