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Ch. 3 Ortho

Flexibility & Stretching (PNF)

Definition of Contracture An adaptive shortening of muscle (all soft tissues) (true contracture = 0 tightness, 0 tone)Position held so long the muscle changes to accommodate.
Definition of Golgi Tendon Organs (GTO's) Located @ musculotendinous junction activated by excessive or prolonged stretch & muscle contraction. GTO's (+) send message to Spinal cord then to muscle to relax
Definition of Stress The amount of tension or load placed on tissues.
Definition of Muscle spindles The excitatory fibers in muscle activated by rapid changes in muscle length. Stretch quick (message) to spinal cord (message) to muscle contraction. Ex. Deep Tendon Reflex (DTR)
Definition of Strain The proportional degree of elongation during stress.
Definition of Viscoelasticity The return after change in length, return is slow & force was of longer duration (like molasses)
Definition of Elasticity The ability to return to its original shape post (after) force is removed (change in length or shape). Short duration. Ex. MFR, stretch
Definition of Recovery The ability of tissues to return to their previous resting state.
Definition of Flexibility The ability of a muscle to relax and yield to a stretch force.
Does flexibility ever diminish? Yes, it will diminish over time if tissues are not stretched or exercised using regular and proper stretching regimens.
What are the mechanoreceptors responsible for the contractile responses? Muscle spindles & Golgi tendon organs are the mechanoreceptors responsible for the contractile responses.
True or False - A warmed muscle will be able to contract more forcefully & relax more slowly, thereby enhancing work production for those muscles used? False - A warmed muscle will be able to contract more forcefully & relax more QUICKLY, thereby enhancing work production for those muscles used.
What are the benefits of a general body warm up? 1)Blood flow to working muscles is increased. 2)Temperature in working muscles is increased. 3)Cardiovascular response to sudden, dynamic exercise is improved. 4)Breakdown of oxyhemoglobin for the delivery of oxygen to the working muscles is increased.
True or False - The warm-up should be intense enough to cause an increase in body temperature, but not so intense as to cause injury. False - The warm-up should be intense enough to cause an increase in body temperature, but not so intense as to cause FATIGUE.
Static Stretch A fully elongated muscle & holding that position. Decreased chance of injury; easy & practical. Anyone can do this unless they are not allowed to move. Most common stretch.
Ballistic Stretching Dynamic, high velocity, activity related (for athletes) stretch.
What happens when a muscle spindle is stretched? When a muscle is stretched, the spindles send messages to the spinal cord, which in turn send signals to muscle to contract. Ex. tapping the patellar tendon reflex
Disadvantages of PNF stretching 1)More time consuming 2)Requires skillful application by trained professionals to be effective 3)May lead to mild complaints of patient discomfort
Types of PNF Techniques Rhythmic Initiation, Repeated Contractions, Slow Reversal, Slow Reversal Hold, Alternating isometrics, Rhythmic Stabilization.
How many repetitions should a stretching exercise be repeated according to the American College of Sports Medicine? 3-5 times for each stretch
How many weeks of stretching are necessary to demonstrate significant increases in muscular flexibility? Approximately 6 weeks of stretching
How many times a week is stretching necessary to improve flexibility? At least 3 times a week
How many times a week is stretching necessary to maintain the flexibility gained during the program? At least 1 day per week
What is the appropriate intensity for static stretching? Stretch slowly & hold the position at low force levels. Communicated as pain-free or mild discomfort to the patient.
Name the proposed stretching benefits Enhanced flexibility, relief of muscular soreness, muscle relaxation, injury prevention & performance enhancement.
True or False - Both, before and after, stretching produced significant increases in ROM. True. Both, before and after, stretching produced significant increases in ROM.
What does the stretching of soft-tissue contractures involve? Involve muscle, capsule, tendon, ligament, bursa & skin
What is the time period for long-duration stretching? Stretching over a period of 20-60 minutes
Definition of Load The force sustained by the body. Ex. compression, tension, shear & torsion.
Definition of Mobility Movement of body segment = Functional ROM or Movement of the body (motor skills)= Functional Mobility (moving in space. *can use a position achieved like a 1/2 kneel for 90 degree angles
Joint mobility = ROM (measured by goniometer, tape measure, sit & reach test (functional skills)
Flexibility (all soft tissue) is? "Extensibility". Joint capsule = synovial joint; muscle, nerve, vessels, tendons, lymphatics, and *fascia*
Passive (PROM) vs Dynamic (AROM) P- no real muscle activity (sit & hold) D- patient actively participates (antagonist being used)
Position to measure ROM & Flexibility for Rectus Femoris Knee Flexion ROM - Supine. Flexibility - Prone (RF Rectus Femoris)
Position to measure ROM & Flexibility for DorsiFlexion ROM - Short Sit (gastroc jt). Flexibility - Long Sit
If joint range is higher than flexibility range, what is the issue? Flexibility is the issue
Definition of Hypomobility The prolonged mobilization (1 hr), Sedentary lifestyle, postural malalignment (body out of sync), muscle imbalances (tone, spasticity), trauma (pain inflammation), congenital & acquired deformities (lateral shift to cover injury)
True or False - In a joint, fluid does NOT compress True - In a joint, fluid does NOT compress
Definition of Myostatic (still muscle) A decrease in the number of sarcomeres (Ex. casting - still muscle) Can be improved in a short time.
Definition of Pseudomyostatic (false still muscle) Spasticity, rigidity. Not because of loss of sarcomeres - can be fixed (CVA, TBI, SCI) increase in tone. Tone decreases ROM, if "relaxed" you have full ROM. (Tardeau Scale)
What in pseudomyostatic decreases ROM? ROM is decreased by tone. If relaxed you have full ROM.
Modified Ashworth Scale - subjective 0 - not high tone, 1 - full PROM, 1+ - catch & release, 2 - Clonus (10 seconds or less), 3 - Clonus (more than 10 seconds) High Tone
What is Clonus A reflex that does not turn off, just keeps going. Upper Motor Lesion identifier.
Tardeau Scale (2 dimensions)- is subjective The faster you move the limb the higher (more) tone the body kicks in. - Upper Motor Lesion diagnostic tool
What is an Arthrogenic contracture (intra-articular pathologies) A contracture with meniscus in the joint and is fixed surgically.
What is a Peri-articular contracture (intra-articular pathologies) A contracture involving the medial or lateral collateral ligament
What is a Fibrotic Contracture A contracture with adherence of tissue (stick together), difficult to recover ROM. Irreversible w/o surgery. From trauma, inflammation or scaring
What is an Irreversible Contracture A contracture that is irreversible w/o surgery, from trauma, inflammation or scaring (scar adheres to the tissue)
Definition of Plasticity It assumes greater length after force is removed
Describe Static Progressive Stretching Stretch till slight resistance, push into it, hold, relax, push into it again.
Why heat tissue pre-stretch? It decreases the chance of injury, ease & practical, goals - increase movement, increase flexibility, decrease contracture.
Dynamic, High Velocity, Activity related & specificity are words that are used to describe? Describe Ballistic stretching
Who's lifestyle benefits from Ballistic Stretching? Athletes, like sprinters or hurdlers, lifestyles benefit
Per research, is static or ballistic stretching better? Static stretching is better than ballistic stretching for all people because the GTO’s relax.
Per research, how long should a stretch be held and how many reps should be done? Manual or self, held for 30 seconds & 1 or more reps are all that is needed.
Describe static progressive stretching An increased stretch as the muscle relaxes (use of dynamic orthoses - dynasplints/ wear 2-3hrs 3-4 times per day). It is better than static because there is more relaxation.
Describe Cyclic (Intermittent) Stretch Short duration, repeatedly & gradually applied stretch, release & then reapplied stretch. Multiple reps (slow & low intensity). Various times recommendations; 5 sets hold for 6 seconds. More comfortable than static.
Name the stretch parameters Alignment, stabilization, intensity of stretch, duration of stretch, speed of stretch, frequency of stretch & mode of stretch
(Theory) Proprioceptive Neuromuscular Facilitation (PNF) An active or facilitated stretch. Uses communication between muscle system and nervous system for specific results.
Inhibitory Stretch Lean into muscle; sustained icing or stretch
Describe Hold-Relax (HR) or Contract-Relax Move body part to end range, Isometric (not max. 0 Valsalva's) contraction (5-10 sec) of tight muscle then stretch.
Isometric = Hold
Max contraction = Max Relaxation
Describe Hold-Relax-Agonist-Contract (HR-AC) Move body to end ROM; resisted, pre-stretch isometric; relax, immediate contraction of the muscle opposite the tight muscle & hold (hold 10sec, relax, stretch 10sec, back off, repeat) - Hold, relax, pull, back off, repeat
Static Stretching Strategy Fully elongated muscle; hold position for 10-60 seconds, rest 5 seconds, repeat w/increased stretch. 5-15 reps ~10reps
Static Stretching Strategy limitations Home Exercise Program is a limitation; 6 weeks to show a significant change.
Static Stretching Goals Increased movement & flexion; decreased contracture
Words not to use in SOAP for Static Stretch Maintain & prevent in book not goals to be used in SOAP
Contraindicated for Static Stretch Osteoporosis contraindicated
Ballistic Stretching requirement MUST warm up; increase blood flow, body temp, cardiovascular response, decrease soft tissue damage with activity (for athletes)
Difference between slow & quick stretches Slow stretch = mm relaxation; quick stretch = mm contraction (tearing)
What is the best stretch for a first timer in pain? Cyclic (Intermittent) stretching is best because it's more comfortable than static stretching
Define the stretching parameter: Alignment Positioning of the limb or body so the stretch force is directed to the appropriate group
Define the stretching parameter: Stabilization What you are using; table, hand, etc...
Define the stretching parameter: Intensity (load) of stretch The kind of stress (force) we put on the patient
Define the stretching parameter: Duration of stretch The length of time the stretch is held
Define the stretching parameter: Speed of stretch Slow or quick initial stretch force
Define the stretching parameter: Frequency of stretch How many sessions they stretch per day or per week
Define the stretching parameter: Mode of stretch The manor in which the stretch is applied: (static, ballistic, or cyclic); degree of patient participation (passive, assisted, or active); source of stretch force (self, manual or mechanical).
The Thomas test is for? Testing the length of hip flexors; if tightness, it identifies what muscle by doing the motion of that muscle.
What are the muscles tested in the Thomas Test? Iliopsoas, Rectus Femoris, TFL, Sartorius
Ballistic Stretching strategy “Bounce” @ end ROM. Increased risk of tissue damage & narrow patient range benefits.
Action & length test for Iliopsoas Action: Hip Flexion; Length test:hip extension with knee in extension
Action & length test for Rectus Femoris Action: hip flexion & knee extension; Length test: Hip extension & knee flexion
Action & length test for TFL Action: Hip flexion, Abduction & internal rotation & knee extension; Length test: Hip extension, adduction & medial rotation, & knee flexion
Action & length test for Sartorius Action: Hip flexion, abduction & external rotation, & knee flexion; Length test: hip extension, adduction, & internal rotation, & knee extension
Describe the Thomas test Patient seated @end of table w/legs off table. Have patient bring one knee up toward their chest and wrap arms around their thigh while the PT assists them into lying back on the table.
In the Thomas Test, what should the patient NOT do & why? The patient should not bring both legs up toward their chest because it allows for excessive posterior tilt which results in apparent (not actual) hip flexor shortness.
Would you check or try and loosen hamstring tightness on an 11-14 year old child? No, hamstring tightness is normal for children of that age.
What do the motions for D1 Flexion resemble? Shave your face; feed yourself
What do the motions for D1 Extension resemble? Push the dog away
What do the motions for D2 Flexion resemble? Cheerleader V
What do the motions for D2 Extension resemble? Hand in opposite pocket or put your sword away
What PNF pattern do we use to put on a sweater? D2 Flexion, cheerleader V
If a patient is more spastic, what can you do to relax them when doing PNF? Use a quiet voice to help them relax
Is PNF a strengthening or testing activity? Strengthening activity NOT a testing activity
What is the highest level of function for PNF? Rotation
Approximation A gentle compression of joint surfaces by means of manual compression or weight bearing stimulates co-contraction. (Co-contraction, stability technique)
What should the patient do when your doing a single pattern PNF? Watch your hand at all times for visual input
Define PNF An approach to therapeutic exercise that combines functionally based diagonal patterns of movement with techniques of neuromuscular facilitation to evoke motor responses & to improve neuromuscular control & function.
Who developed PNF? Developed during the 1940's & 50's by Kabat, Knott & Voss.
What did the work of Kabat, Knott & Voss integrate? The analysis of movement during functional activities with then current theories of motor development, control, & learning & principles of neurophysiology as the foundations of their approach to exercise & rehabilitation.
What can PNF techniques be used for? To develop muscular strength & endurance; facilitate stability, mobility, neuromuscular control & coordinated movements; and lay a foundation for the restoration of function.
When are PNF techniques useful in rehabilitation? Early phases of tissue healing when isometric techniques are appropriate to the final phase of rehabilitation when high-speed diagonal movements can be performed against maximum resistance.
What are the "hallmarks" of the PNF approach? The use of diagonal patterns & the application of sensory cues - specifically proprioceptive, cutaneous, visual, & auditory stimuli - to elicit or augment motor responses.
What is embedded in the philosophy & approach to PNF exercise? The stronger muscle groups of diagonal pattern facilitate the responsiveness of the weaker muscle group.
How are PNF patterns identified? They are named by the position of the shoulder or hip when the diagonal pattern has been completed. (proximal pivot points)
What is the most prominent feature of PNF? The interaction between patient and therapist provides the greatest amount and variety of sensory input, particularly in the early stages of re-establishing neuromuscular control.
Define Manual Contact How and where the therapists hands are placed on the patient.
In manual contact, where are the therapists hands placed, whenever possible? The agonist muscle group or their tendinous intersections.
Why does the PT put their hands on the agonist muscle group or the tendentious intersections? It allows the PT to cue the patient in the desired direction of movement.
Define Maximal Resistance The greatest amount of resistance possible that still allows the patient to move smoothly & without pain through the available range during a dynamic concentric contraction.
What is the position & movement of the PT during PNF? The PT remains positioned and alined along the diagonal planes of movement with shoulders and trunk facing in the direction of the moving limb.
Define Stretch Stimulus The placing of the body segment in positions that lengthen the muscles that are to contract during the diagonal pattern.
What is the importance of Rotation in PNF? Rotation elongates the muscle fibers & spindles of the agonist muscles of a given pattern & increases the excitably & responsiveness of those muscles.
What is the stretch stimulus "Rotation" described as in PNF? "Winding up the part" or "Taking up the slack"
Define Stretch Reflex A rapid stretch just past the point of tension to an already elongated agonist muscle.
Why use a Stretch Reflex? It will further stimulate an agonist muscle contraction or direct a patients attention to a weak component of a pattern.
What is a precaution of the stretch reflex? Not advisable during the early stages of soft tissue healing after injury or surgery. It is also inappropriate with acute or active arthritic conditions.
Define Normal Timing a "sequence" of distal to proximal, coordinated muscle contractions occurs during the diagonal patterns. THE DISTAL COMPONENT MOTIONS SHOULD BE COMPLETED HALFWAY THROUGH THE PATTERN.
What does correct sequencing of movements promote? Neuromuscular control & coordinated movements.
Define Traction The slight separation of joint surfaces theoretically to inhibit pain & facilitate movement during execution of movement patterns.
When is traction most often applied? Applied during flexion (anti-gravity) patterns.
Define Verbal Commands Auditory commands given to enhance motor output.
What is varied to help maintain patients attention during PNF? The tone & volume are varied
Define Visual Cues The patient is asked to follow the movement of a limb to further enhance control of movement throughout the ROM.
What does the PT ask the patient to do during PNF to enhance control of movement throughout the ROM? Follow the movement of a limb (visual cues)
By mid-range, what position should the patients arm be in? The arm should be in neutral rotation.
Why do we use PNF? To stimulate weak muscles & enhance movement or stability.
What are the specific techniques of PNF/ Rhythmic Initiation, Repeated Contractions, Slow Reversal, Slow Reversal Hold, Alternating Isometrics & Rhythmic Stabilization
Define Rhythmic Initiation After the patient voluntarily relaxes, the PT moves the patients limb "passively" through the "available range" of the desired movement pattern several times so the patient becomes familiar with the sequence of movements within the pattern.
Why use Rhythmic Initiation To promote the ability to initiate a movement pattern.
In Rhythmic Initiation, why does the PT move the patients through the pattern several times passively? Helps the patient understand the "rate" the movement is to occur.
Practicing assisted or active movements (without resistance) helps the patient what? Learn the movement pattern
Define Repeated Contractions Dynamic contractions initiated with repeated quick stretches followed by resistance. They are applied at any point in the ROM to strengthen a weak agonist component of a diagonal pattern.
Define Slow Reversal Dynamic concentric contraction of a stronger agonist pattern immediately followed by a dynamic concentric contraction of the weaker antagonist pattern. *No voluntary relaxation between patterns*
What does slow reversal promote? Rapid, reciprocal action of agonists & antagonists
Define Slow Reversal Hold Adds an isometric contraction at the end of the range of a pattern to enhance end-rang holding of a weakened muscle.
Define Alternating Isometrics manual resistance applied in a single plane on one side of a body segment & then on the other. The patient is asked to "hold" the position as resistance is applied alternately from one direction to another. (hands on one side then on the other)
Why use alternating isometrics? To improve strength and stability of the postural muscles of the trunk or proximal stabilizing muscles of the shoulder girdle & hip.
Should joint movement occur with Alternating Isometrics? No joint movement should occur.
What positions (OKC or CKC) should Alternating Isometrics be applied? Both OKC & CKC can be applied
True or False - Alternating Isometrics strengthens agonists and antagonists True - Alternating Isometrics strengthens agonists and antagonists
How can Alternating Isometrics be applied? It can be applied to one extremity, or both extremities simultaneously, or to the trunk.
Define Rhythmic Stabilization PT applies multidirectional resistance by placing manual contacts on opposite sides of the body & applying resistance simultaneously in opposite directions as the patient holds the selected position.
What is important regarding Rhythmic Stabilization? Multiple muscle groups around joints must contract, most importantly the rotators, to hold the position.
How is Rhythmic Stabilization used? It is used as a progression of alternating isometrics & is designed to promote stability through co-contraction of the proximal stabilizing musculature of the trunk , shoulder & pelvic girdle regions.
In what positions is Rhythmic Stabilization technique preformed? Preformed in weight bearing positions to incorporate joint approximation into the procedure, further facilitating co-contraction.
Chop Start in D1 Flexion
Lift Start in D2 Flexion
If you are feeding yourself what PNF pattern are you doing? D1 Flexion
What are the 2 PNF patterns that are the lowest levels of function? D1 Flexion (Chop ) & D2 Flexion (Lift)
What disease is Rhythmic Initiation technique good for? Parkinson's Disease
Is Rhythmic Initiation technique for mobility or Stability? Mobility (passive); familiar with sequence & rate of movement
Is Slow Reversal Hold technique for mobility or stability? Stability; concentric contractions in both directions
What is considered the highest level of skill? One extremity @ a time
The 1st & 2nd Trunk exercises are considered? Primitive or simplistic
When doing PNF patterns with patients, you must cross what? The mid-line
Difference in Tardieu scale & Modified Ashworth Scale (MAS) The Tardieu Scale differentiates contracture from spasticity whereas the MAS is for grading spasticity only.
Is Slow Reversal technique for mobility or stability? Mobility; rapid reciprocal action of agonists & antagonists
Is Rhythmic Stabilization technique for mobility or stability? Stability; multi-directional in weight bearing positions to incorporate joint approximation. Most important rotators contract.
Is Alternating isometrics technique for mobility or stability? Stability; isometrically strengthens agonists & antagonists without joint movement
Is Repeated Contractions technique for mobility or stability? Mobility; quick stretches followed by resistance, applied at any point in ROM, to strengthen weak agonists component of a diagonal pattern
Created by: srussel