Restoring Range of Restoring Range of Motion and Improving Motion and Improving

FlexibilityFlexibility

Importance of FlexibilityImportance of Flexibility Important Goal: Restore or improve to normal Important Goal: Restore or improve to normal

pre-injury range of motionpre-injury range of motion

With injury there is generally some degree of lost With injury there is generally some degree of lost range of motionrange of motion Due to pain, swelling, muscle guarding, &/or inactivity Due to pain, swelling, muscle guarding, &/or inactivity

resulting in tissue shorteningresulting in tissue shortening Need to encourage stretching exercisesNeed to encourage stretching exercises

Restricted range of motion can impact Restricted range of motion can impact performance & result in uncoordinated motionperformance & result in uncoordinated motion

Essential for successful physical performance & Essential for successful physical performance & injury preventioninjury prevention

Ability of neuromuscular system to Ability of neuromuscular system to allow for efficient movement of a allow for efficient movement of a joint or series of joint through a full, joint or series of joint through a full, non-restricted pain free range of non-restricted pain free range of motionmotion

FlexibilityFlexibility

Anatomic Factors Impacting Anatomic Factors Impacting FlexibilityFlexibility

MusclesMuscles Increasing flexibility relies on the elastic properties of Increasing flexibility relies on the elastic properties of

musclemuscleLength can be changed over timeLength can be changed over time

Connective TissueConnective Tissue Ligaments & joint capsules, while possessing some Ligaments & joint capsules, while possessing some

elastic properties, can lose their elasticity during elastic properties, can lose their elasticity during periods of disuse & immobilizationperiods of disuse & immobilization

Bony StructuresBony Structures Can limit end point rangeCan limit end point range Bony prominences can also stop movements at Bony prominences can also stop movements at

normal end points in the rangenormal end points in the range FatFat

Can act as a wedge between lever armsCan act as a wedge between lever arms Restricts movement wherever it is foundRestricts movement wherever it is found

SkinSkin Injury or surgical procedure may alter skin – variable in Injury or surgical procedure may alter skin – variable in

elasticityelasticity Skin adheres to underlying tissueSkin adheres to underlying tissue

Neural tissueNeural tissue Develops tightness as a result of compression, chronic Develops tightness as a result of compression, chronic

repetitive microtrauma, muscle imbalances, joint repetitive microtrauma, muscle imbalances, joint dysfunction or morphological adaptations due to posturedysfunction or morphological adaptations due to posture

Could stimulate nociceptors & pain Could stimulate nociceptors & pain Cause muscle guarding & spasm to protect irritated Cause muscle guarding & spasm to protect irritated

neural structuresneural structures Neural fibrosis ultimately results causing decreased Neural fibrosis ultimately results causing decreased

elasticity & restricted motionelasticity & restricted motion

Except for bone structure, age & gender all Except for bone structure, age & gender all other flexibility limiting factors can be other flexibility limiting factors can be modified & altered to increase range of motionmodified & altered to increase range of motion

Soft Tissue Properties that Soft Tissue Properties that Affect Immobilization & Affect Immobilization &

Elongation Elongation Responses that affect soft tissue during Responses that affect soft tissue during

stretchingstretchingVelocity, intensity, frequency & duration of Velocity, intensity, frequency & duration of

stretch forcestretch forceTemperature of tissuesTemperature of tissues

ElasticityElasticity – ability of soft tissue to – ability of soft tissue to return to its resting length after passive return to its resting length after passive stretchstretch

PlasticityPlasticity – tendency of soft tissue to – tendency of soft tissue to assume a new & greater length after assume a new & greater length after stretch force has been removedstretch force has been removed

Soft Tissue Properties that Affect Soft Tissue Properties that Affect Immobilization & ElongationImmobilization & Elongation

Contractile tissueContractile tissue: gives muscle : gives muscle characteristics of contractility & irritabilitycharacteristics of contractility & irritability

Noncontractile tissueNoncontractile tissue: has same : has same properties as all CT, including ability to properties as all CT, including ability to resist deforming forces as well as resist deforming forces as well as viscoelasticityviscoelasticity

CT structures of muscle-tendon unitCT structures of muscle-tendon unitEpimysiumEpimysium – enveloping fascial sheath – enveloping fascial sheath PerimysiumPerimysium – encases bundles of fasciculi – encases bundles of fasciculiEndomysiumEndomysium – innermost layer that separates – innermost layer that separates

individual m. fibers & myofibrilsindividual m. fibers & myofibrils

CT Structures of Muscle-tendon CT Structures of Muscle-tendon UnitUnit

Muscle AnatomyMuscle Anatomy Made up of many muscle fibers that lie Made up of many muscle fibers that lie

parallel with one anotherparallel with one another Single fiber – made up of many myofibrilsSingle fiber – made up of many myofibrils Myofibrils - composed of sarcomeres Myofibrils - composed of sarcomeres Sarcomere – contractile unit of the myofibril Sarcomere – contractile unit of the myofibril

Gives muscle ability to contract & relaxGives muscle ability to contract & relaxComposed of overlapping myofilaments of Composed of overlapping myofilaments of

Actin & Myosin (form cross-bridges)Actin & Myosin (form cross-bridges)Motor unit stimulated = m. contraction -actin-Motor unit stimulated = m. contraction -actin-

myosin filaments slide together & the muscle myosin filaments slide together & the muscle actively shortensactively shortens

Muscle relaxes = cross-bridges slide apart Muscle relaxes = cross-bridges slide apart slightly & the muscle returns to its resting lengthslightly & the muscle returns to its resting length

Muscle Muscle AnatomyAnatomy

Muscle Muscle StructureStructure

MyofilamentMyofilament Interlocking Mesh Interlocking Mesh

StructureStructure A myofilament shows A myofilament shows

several distinct bandsseveral distinct bands Each band has been given Each band has been given

a special lettera special letter

The lightest (least electron The lightest (least electron dense) band is the dense) band is the “I “I band”band” Consists primarily of actinConsists primarily of actin In the center of the “I band” In the center of the “I band”

is the is the “Z-line”,“Z-line”, an electron an electron dense line dense line

The wide, dark band is the The wide, dark band is the “A band”“A band” Consists primarily of myosin Consists primarily of myosin In the middle of the “A In the middle of the “A

band” is the band” is the “M line”,“M line”, another dense lineanother dense line

MyofilamenMyofilament Slidingt Sliding

Noncontractile TissueNoncontractile Tissue Made up of:Made up of:

CollagenCollagen – resist tensile deformation & are responsible for – resist tensile deformation & are responsible for strength & stiffness of tissue, elongates quickly under light strength & stiffness of tissue, elongates quickly under light loadsloads

ElastinElastin - extensibility - extensibility Reticulin fibersReticulin fibers – bulk – bulk Ground substanceGround substance – proteoglycans (PGs) & glycoproteins; – proteoglycans (PGs) & glycoproteins;

PGs hydrate matrix, stabilize collagen network, resist compressive PGs hydrate matrix, stabilize collagen network, resist compressive forces; forces;

Glycoproteins provide linkage between matrix components & between Glycoproteins provide linkage between matrix components & between cells & matrix opponentscells & matrix opponents

Mechanical behavior is determined by proportion of Mechanical behavior is determined by proportion of collagen & elastin fibers & structural orientation of the collagen & elastin fibers & structural orientation of the fibersfibers High collagen, low PGs – resist high tensile loadsHigh collagen, low PGs – resist high tensile loads High collagen content tissue = greater stability (tendons)High collagen content tissue = greater stability (tendons)

Active & Passive Range of Active & Passive Range of MotionMotion Active range of motion (AROM)Active range of motion (AROM)

Dynamic flexibilityDynamic flexibility Joint movement via muscle contractionJoint movement via muscle contraction Ability to move a joint with little resistanceAbility to move a joint with little resistance

Passive range of motion (PROM)Passive range of motion (PROM) Static flexibilityStatic flexibility Motion of joint to end points without muscle contractionMotion of joint to end points without muscle contraction Critical in injury preventionCritical in injury prevention

Muscles can be forced to stretch beyond “normal” limitsMuscles can be forced to stretch beyond “normal” limits Without elasticity it is likely that the musculotendinous unit will Without elasticity it is likely that the musculotendinous unit will

be injuredbe injured

During athletic activityDuring athletic activity Must be able to move through unrestricted rangeMust be able to move through unrestricted range Must have elasticity for additional stretch encountered Must have elasticity for additional stretch encountered

during activityduring activity

Measuring Range of MotionMeasuring Range of Motion

Essential to assess improvement during Essential to assess improvement during rehabilitationrehabilitation

Goniometer Goniometer Utilizes alignment of two arms parallel to Utilizes alignment of two arms parallel to

longitudinal axis of two segments involved in longitudinal axis of two segments involved in motionmotion

Relatively accurate toolRelatively accurate toolEnsures accuracy standardize techniques & Ensures accuracy standardize techniques &

methods of recording AROM & PROMmethods of recording AROM & PROM

Agonist vs. Antagonist Agonist vs. Antagonist MusclesMuscles

Joints are capable of multiple movementsJoints are capable of multiple movements Example:Example:

Quadriceps will extend knee with contractionQuadriceps will extend knee with contractionQuads (muscle producing movement) = agonistQuads (muscle producing movement) = agonist

Hamstrings will stretch during knee extensionHamstrings will stretch during knee extensionHamstrings undergoing stretch = antagonistHamstrings undergoing stretch = antagonist

Agonist & antagonist work together to produce Agonist & antagonist work together to produce smooth coordinated movementssmooth coordinated movements

Muscles that work together function Muscles that work together function synergisticallysynergistically

What is another pair of agonist/antagonist What is another pair of agonist/antagonist muscles?muscles?

Stretching TechniquesStretching Techniques BallisticBallistic

Bouncing movement in which repetitive Bouncing movement in which repetitive contractions of agonist work to stretch antagonist contractions of agonist work to stretch antagonist musclemuscle

Static stretchingStatic stretching Stretch to point of discomfort & holding at that Stretch to point of discomfort & holding at that

point for period of timepoint for period of time Proprioceptive Neuromuscular Facilitation (PNF)Proprioceptive Neuromuscular Facilitation (PNF)

Involves alternating contractions & stretchesInvolves alternating contractions & stretches Myofascial & neural tissue stretchingMyofascial & neural tissue stretching

Enhances neuromuscular system’s ability to Enhances neuromuscular system’s ability to control movementcontrol movement

Ballistic StretchingBallistic Stretching Need to be careful when performing this Need to be careful when performing this

stretchstretch

Possible soreness due to uncontrolled forces Possible soreness due to uncontrolled forces within muscle created by bouncingwithin muscle created by bouncingMay result in tissue damageMay result in tissue damage

Should be incorporated into a program to Should be incorporated into a program to allow body to adapt allow body to adapt && reduce likelihood of reduce likelihood of injuryinjury

Incorporate into later stages of rehabilitationIncorporate into later stages of rehabilitation

Static StretchingStatic Stretching Passively stretching given antagonistPassively stretching given antagonist

6-8 second hold in maximal position of 6-8 second hold in maximal position of stretchstretch

Go to point of discomfort & back off slightlyGo to point of discomfort & back off slightly

Hold for 15-30 seconds (do this 3-4 times)Hold for 15-30 seconds (do this 3-4 times)

Can be accomplished utilizing agonistCan be accomplished utilizing agonist

Controlled movement, less chance of injuryControlled movement, less chance of injury

Proprioceptive Neuromuscular Proprioceptive Neuromuscular FacilitationFacilitation

Three techniques that combine Three techniques that combine alternating isometric or isotonic alternating isometric or isotonic contractions & relaxation of both agonist contractions & relaxation of both agonist & antagonists& antagonists Slow-reversal-hold-relaxSlow-reversal-hold-relax Contract-relaxContract-relax Hold-relaxHold-relax

Hold Relax (HR)Hold Relax (HR) Isometric contraction of antagonist followed by Isometric contraction of antagonist followed by

concentric contraction of agonist with light concentric contraction of agonist with light pressurepressure

Facilitates stretch of antagonistFacilitates stretch of antagonist Effective with muscle tension on one side of jointEffective with muscle tension on one side of joint

Contract Relax (CR)Contract Relax (CR) Moves body passively into agonist patternMoves body passively into agonist pattern Athlete instructed to contract antagonist isotonically Athlete instructed to contract antagonist isotonically

against resistanceagainst resistance Athlete then relaxes & allow athletic trainer to push Athlete then relaxes & allow athletic trainer to push

body further (passively) into agonist patternbody further (passively) into agonist pattern Utilized when flexibility is limited due to muscle Utilized when flexibility is limited due to muscle

tightnesstightness

Slow Reversal-Hold-Relax (SRHR)Slow Reversal-Hold-Relax (SRHR) Isotonic contraction of agonistIsotonic contraction of agonistFollow with isometric contraction of Follow with isometric contraction of

antagonistantagonistDuring relax phase antagonist is relaxed During relax phase antagonist is relaxed

while agonist contracts in agonist patternwhile agonist contracts in agonist patternResults in stretch of antagonistResults in stretch of antagonist

Useful to stretch antagonistUseful to stretch antagonist

Comparing Stretching Comparing Stretching TechniquesTechniques

Ballistic stretching is recommended for Ballistic stretching is recommended for athletes engaged in dynamic activityathletes engaged in dynamic activity

Static stretching most widely usedStatic stretching most widely used Safe & effectiveSafe & effective

PNF techniquesPNF techniques Capable of producing dramatic increases in Capable of producing dramatic increases in

ROMROM Limitation – partner is requiredLimitation – partner is required

Maintaining flexibilityMaintaining flexibility Can decrease considerable after only 2 weeksCan decrease considerable after only 2 weeks Should be engaged in at least once per weekShould be engaged in at least once per week

Specific Stretching ExercisesSpecific Stretching Exercises

Stretching Neural StructuresStretching Neural Structures

Requires Requires differentiation differentiation between between musculotendinous musculotendinous & neural tightness& neural tightness

Assess movements Assess movements that create tension that create tension in neural structures in neural structures May cause May cause

numbness & numbness & tinglingtingling

Straight-leg raise Straight-leg raise exampleexample

Myofascial Release StretchingMyofascial Release Stretching Techniques used to relieve abnormally tight Techniques used to relieve abnormally tight

fasciafascia Myofascial restrictions are unpredictable & may Myofascial restrictions are unpredictable & may

occur in different planes & directionsoccur in different planes & directions Requires specialized training & in depth Requires specialized training & in depth

understanding of fascial systemunderstanding of fascial system FasciaFascia

Connective tissue that runs throughout the Connective tissue that runs throughout the body & establishes interconnectedness of bodybody & establishes interconnectedness of body

If altered or injured can result in localized If altered or injured can result in localized response at focal point of injury or away from response at focal point of injury or away from injury siteinjury site

Responds to gentle pressureResponds to gentle pressure

Sometimes called: Soft-tissue MobilizationSometimes called: Soft-tissue Mobilization

TreatmentTreatmentLocalize restrictionLocalize restrictionConsiderably more subjective component & Considerably more subjective component &

relies heavily on clinician’s experiencerelies heavily on clinician’s experienceFocuses on large treatment areaFocuses on large treatment areaWork superficial to deepWork superficial to deep Joint mobilizations may followJoint mobilizations may followTissue stretching & elongation as well as Tissue stretching & elongation as well as

strengthening should followstrengthening should followPostural re-training may also be requiredPostural re-training may also be requiredDramatic results may occurDramatic results may occurTreatment should be done at least 3 times per Treatment should be done at least 3 times per

weekweekPerform manually or via foam rollerPerform manually or via foam roller

Neurophysiological Basis of Neurophysiological Basis of StretchingStretching

Stretch ReflexStretch ReflexMuscle is placed on stretch – muscle spindleMuscle is placed on stretch – muscle spindleMuscle spindles fire relaying info. to spinal Muscle spindles fire relaying info. to spinal

cordcordSpinal cord relays message to golgi tendon Spinal cord relays message to golgi tendon

& increases tension& increases tensionAfter 6 seconds, golgi tendon organ (GTO) After 6 seconds, golgi tendon organ (GTO)

relays signal for muscle tension to decreaserelays signal for muscle tension to decreaseCause reflex relaxationCause reflex relaxationPrevents injury - protective mechanismPrevents injury - protective mechanism

Ballistic stretching does not allow this Ballistic stretching does not allow this overriding response by GTOoverriding response by GTO

With static stretching GTO’s are able With static stretching GTO’s are able to override impulses from muscle to override impulses from muscle spindle following initial reflex spindle following initial reflex resistanceresistanceAllows muscle to remain stretched Allows muscle to remain stretched

without injurywithout injury

PNF benefits greatly from these PNF benefits greatly from these principlesprinciplesWith slow-reversal hold technique, With slow-reversal hold technique,

maximal contraction of muscle stimulates maximal contraction of muscle stimulates GTO reflex relaxation before stretch GTO reflex relaxation before stretch appliedapplied

Autogenic inhibitionAutogenic inhibitionRelaxation of antagonist during contraction Relaxation of antagonist during contraction During relaxation phase, antagonist is During relaxation phase, antagonist is

placed under stretch but assisted by agonist placed under stretch but assisted by agonist contraction to pull further into stretchcontraction to pull further into stretch

GTO is protective mechanism that inhibits GTO is protective mechanism that inhibits tension in the muscletension in the muscle

Reciprocal inhibitionReciprocal inhibition Isotonic contraction of an agonist muscle Isotonic contraction of an agonist muscle

elicits a reflex relaxation of antagonist elicits a reflex relaxation of antagonist muscle group - (protect against injury)muscle group - (protect against injury)

Effect of Stretching on Physical Effect of Stretching on Physical & Mechanical Properties of & Mechanical Properties of

MuscleMuscle Physical lengthening of muscle occurs due Physical lengthening of muscle occurs due

to reflex relaxationto reflex relaxation Contractile & non-contractile elements of Contractile & non-contractile elements of

muscle dictate capability of deformation & muscle dictate capability of deformation & recoveryrecoveryBoth resist deformationBoth resist deformationDeformation is dependent on degree of stretch Deformation is dependent on degree of stretch

& velocity& velocityNon-contractile – limit degreeNon-contractile – limit degreeContractile – limit velocityContractile – limit velocityGreater stretch = more non-contractile Greater stretch = more non-contractile

components contributecomponents contribute

Stretches sustained long enough Stretches sustained long enough (autogenic inhibition) result in (autogenic inhibition) result in viscoelastic & plastic changes in viscoelastic & plastic changes in collagen & elastincollagen & elastinViscoelastic changes allow slow Viscoelastic changes allow slow

deformation & imperfect recovery (not deformation & imperfect recovery (not permanent)permanent)

Plastic changes result in permanent Plastic changes result in permanent changes in lengthchanges in length

Greater velocity = greater chance for Greater velocity = greater chance for exceeding tissue capacity (viscoelastic exceeding tissue capacity (viscoelastic & plastic)& plastic)

Effects of Stretching On Kinetic Effects of Stretching On Kinetic ChainChain

Joint hypomobility causes:Joint hypomobility causes: Faulty postureFaulty posture Muscular imbalanceMuscular imbalance Abnormal neuromuscular controlAbnormal neuromuscular control

Alteration in arthrokinematicsAlteration in arthrokinematics Change in muscle tension to reduce translationChange in muscle tension to reduce translation Alters degrees of tension & activation in Alters degrees of tension & activation in

synergist, stabilizers & neutralizerssynergist, stabilizers & neutralizers Compensatory responseCompensatory response

Muscle Tightness & Muscle Tightness & HypertonicityHypertonicity Impact on length-Impact on length-

tension relationshipstension relationships Alters force couples & Alters force couples &

arthrokinematicsarthrokinematics Impacts normal force Impacts normal force

couple relationships & couple relationships & creates kinetic chain creates kinetic chain reactionreaction

Impacts synergistic Impacts synergistic function of kinetic chainfunction of kinetic chain

Causes abnormal joint Causes abnormal joint & tissue stresses, & tissue stresses, neural compromise & neural compromise & vascular/lymphatic vascular/lymphatic stasisstasis

Alters recruitment Alters recruitment strategies & strategies & stabilizationstabilization

Alters neuromuscular Alters neuromuscular efficiency impacting efficiency impacting activation/firing activation/firing sequencesequence

Additionally altered joint Additionally altered joint function & stress function & stress responseresponse

Can causes reciprocal Can causes reciprocal inhibitioninhibition

Increases muscle spindle Increases muscle spindle activityactivity

May impart inhibitory May impart inhibitory response (decreased response (decreased neuromuscular control)neuromuscular control)

Result = Result = synergistic synergistic dominancedominance – synergist – synergist compensatory action for compensatory action for weak & inhibited muscleweak & inhibited muscle

Importance of Warm-up Prior to Importance of Warm-up Prior to StretchingStretching

Intramuscular temperature should be Intramuscular temperature should be increased prior to stretchingincreased prior to stretching

Positive effect on ability of collagen & elastin Positive effect on ability of collagen & elastin to deformto deform

Enhances reflexive relaxation associated with Enhances reflexive relaxation associated with golgi tendon organsgolgi tendon organs

Optimal temperature 39Optimal temperature 39ooC/103C/103ooFF To increase = low intensity, warm-up type To increase = low intensity, warm-up type

exercise or modalitiesexercise or modalities Exercise should be primary means of warm-Exercise should be primary means of warm-

upup Environment - Heat vs. ColdEnvironment - Heat vs. Cold

Flexibility vs. StrengthFlexibility vs. Strength Co-existCo-exist Muscle bound Muscle bound

Negative connotation Negative connotation Loss of motionLoss of motion

Encourage full pain free movements during Encourage full pain free movements during rehabilitationrehabilitation

Strength training will provide individual with Strength training will provide individual with ability to develop dynamic flexibility through ability to develop dynamic flexibility through full range of motionfull range of motion

Develop more powerful & coordinated Develop more powerful & coordinated movementsmovements

Guidelines & Precautions for Guidelines & Precautions for StretchingStretching

Warm-upWarm-up Overload or stretch beyond Overload or stretch beyond

normal range normal range Not to point of painNot to point of pain Stretch to point of Stretch to point of

resistanceresistance Increases in range will be Increases in range will be

specific to muscle being specific to muscle being stretchedstretched

Use caution when stretching Use caution when stretching around painful jointsaround painful joints

Avoid overstretching Avoid overstretching ligaments & capsulesligaments & capsules

Exercise caution with low Exercise caution with low back & neck stretchesback & neck stretches

Stretch from seated position Stretch from seated position to reduce stress on backto reduce stress on back

Continue normal breathing Continue normal breathing while stretchingwhile stretching

For improvements in ROM, For improvements in ROM, utilize static & PNF utilize static & PNF stretching techniquesstretching techniques

Ballistic stretching should be Ballistic stretching should be used by those who possess used by those who possess flexibility & are accustomed flexibility & are accustomed to itto it

Ballistic stretching should Ballistic stretching should follow period of static follow period of static stretchingstretching

Stretching should be Stretching should be performed a minimum of 3 performed a minimum of 3 times per weektimes per week

For maximum gains For maximum gains stretching 5-6 times per stretching 5-6 times per week is idealweek is ideal