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Mobility as it relates to functional ROM is associated with _____ as well as _______
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Ther.Ex.Stretching
| Question | Answer |
|---|---|
| mobility | ability of structures or segments of the body to be moved to allow the presence of ROM for functional activities; the ability of an individual to initiate, control, or sustain active movements of the body to perform simple to complex motor skills |
| Mobility as it relates to functional ROM is associated with _____ as well as _______ | joint integrity as well as flexibility |
| Functional Mobility Requirements | sufficient mobility of soft tissues, ROM of joints, adequate levels of muscle strength, endurance, and neuromuscular control |
| Hypomobility | decreased mobility or restricted motion |
| What can cause hypomobility? | adaptive shortening of soft tissues |
| Hypomobility can occur due to what 6 things? | prolonged immobilization of a body segment ( fracture, surgery), sedentary lifestyle, postural malalignment and muscle imbalances, weakness, tissue trauma (inflammation and pain, and congenital or aquired deformities) |
| What can hypomobility lead to? | functional limitations and disability |
| Impaired Mobility | any therapeutic maneuver designed to increase the extensibility of soft tissues (improves flexibility by elongating hypomobile structures that have adaptively shortened over time) |
| What must be done on a regular basis to allow the ROM gains to remain permanent? | must be complemented with an appropriate level of strength and endurance exercise program done on a regular basis |
| Flexibility | ability to move a single joint or series of joints smoothly and easily thorugh an unrestricted, pain-free ROM |
| Dynamic flexibility | also referred to as "AROM," the degree to which an active muscle contraction moves a body segment through the available ROM of a joint |
| Passive flexibility | "PROM", is the degree to which a joint can be passively moved through the available ROM, it is a PREREQUISITE for but does not ensure dynamic flexibility |
| Contracture | adaptive shortening of the muscle-tendon unit and other soft tissues that surround a joint |
| What does a contracture result in? | significant resistance to passive or active stretching and limitation to motion and may cause functional limitations |
| How does Kendall define contracture? | an almost complete loss of motion, whereas shortness is used to denote partial loss of motion |
| How does Hertling and Kessler definte contracture? | muscle tightness to denote adaptive shortening of the contractile and noncontractile elements of muscle |
| Contracture vs. Contraction | Contracture: muscle shortening (involuntary); Contraction: a diff. form of muscle shortening (voluntary) |
| What different types of contractures are there? | Myostatic, Pseudomyostatic, Arthrogenic, Fibrotic/Irreversible |
| Myostatic contractures | musculotendinous unit has SHORTENED BUT CAN BE RESOLVED in a short time with stretching, no specific muscle pathology present |
| Pseudomyostatic Contracture | hypertonicity associated with a central nervous system lesion or w/ spasm, guarding or pain, muscles appear to be in a CONSTANT STATE OF CONTRACTION, thus excessive resistance to passive stretch |
| Arthrogenic contractures | result of an intra-articular pathology, within the joint, develop when connective tissues that cross or attach to a joint lose mobility, osteophytes, bone spurs |
| Fibrotic/Irreversible Contractures | fibrous changes in the connective tissue of muscle and periarticular structures cause adherence of these tissues, normalreplaced with large amount of nonextensible tissue, adhesions, scar tissue or heterotopic bone (bone that grows where it shouldnt |
| Who and why do we stretch? | ROM is limited because extensibility is lost, restricted motion may lead to structural deformities, muscle weakness and shortening of opposing tissue, prevent musculoskeletal injuries, minimizes soreness |
| Who and why wouldn't we stretch? (look at slide 23) | bony block limits motion, recent fracture and union is incomplete, evidence of an acute inflammatory or infectious process or soft tissue healing could be disrupted, shart, acute pain with joint movement, hemotoma present, existing hypermobility |
| Selective stretching | patient's function may improve by stretching some muscles and joints while allowing limitations to develop in other muscles |
| List interventions to increase mobility | manual/mechanical/passive or assisted stretching, self-stretching, PNF, muscle energy techniques, joint mobilization/manipulation techniques, soft tissue mobilization/manipulation, neural tissue mobilization |
| Manual of Mechanical/Passive or Assisted Stretching | sustained or intermittent external, end-range stretch force applied with overpressure manual contact or mechanical device, moves restricted joint just past the available ROM (have to reach plastic phase so permanent changes can be made) |
| In manual or mechanical/passive or assisted stretching: if patient is relazed it's ____ stretching and if patient assists it's ____ | if patient is relaxed - passive stretching if patient assists - assisted stretching |
| self stretching | any stretching exercise carried out independently, often used interchangeably with flexiblity exercises |
| Neuromuscular Facilitation and Inhibition Techniques (PNF) | purported to relax tension in shortened muscles reflexively prior to or during muscle elongation |
| Muscle Energy Techniques (also referred to as "post-isometric relaxation") | designed to lengthen muscle and fascia andto mobilize joints (anterior tilt/posterior tilt), employ voluntary muscle contractions by the pt. in a precise, controlled direction and intensity against a counterforce applied by the practitioner |
| Joint mobilization/manipulation techniques | specfically applied to joint structures and are used to stretch capsular restrictions or reposition a subluxed or dislocated joint |
| Soft tissue mobilization/manipulation | techniques are designed to improve muscle extensibility and involve application of specific and progressive manual forces |
| List examples of soft tissue mobilization/manipulation techniques | myofascial release, friction massage, acupressure, trigger point therapy, ASTM |
| Neural Tissue Mobilization | Adverse neural tissue tension (can lead to pain or other neurological symptoms), and nerve glides |
| What is the primary cause of restricted ROM in both healthy individuals and patient's with impaired mobility as the result of injury, disease, or surgery? | decreased extensibility of connective tissue |
| What factors affect the responses of the various types of soft tissue? | stretches, direction, velocity, intensity, duration, and frequency of stretch |
| What are some soft tissue properties? | elasticity, viscoelasticity, and plasticity |
| Elasticity | ability of soft tissue to return to its pre-stretch resting length after a stretch force is removed |
| Viscoelasticity | time dependent, initially resists when stretch is 1st applied, but when sustained, length changes and then tissue is able to gradually return to pre-stretch state (think taffyor pizza dough) |
| Plasticity | tendency of soft tissue to assume a new or greater length afte the stretch force is removed, until you get into this phase, you aren't going to be able to gain true ROM |
| Both contractile and non-contractile tissues have elastic and plastic qualities: however, only connective tissue, not contractile elements of muscle, have ________. | viscoelastic properties |
| Contractile Elements: Individual muscles composed of many ______. Single muscle fiber made up of many ______. In turn, _____ make up the myofibril. Sarcomere composed of overlapping myofilaments of ____ and _____. Lie _____ to eachother. | Individual muscles compoes of many muscle fibers. Single muscle fiber made up of many myofibrils. In turn, sarcomeres make up the myofibril. Sarcomere composed of overlapping myofilaments of actin and myosin. Lie parallel to eachother. |
| The sarcomere is what gives the muscle its ability to ____ and _____. | contract and relax. |
| What acts as a harness to a muscle? | non contractile tissues |
| What makes up the harness? | endoymsium (seperates fibers and myofibrils), perimysium (encases fiber burrelles), and epimysium (enveloping fascial sheath around the entire muscle) |
| What is the primary source of resistance to passive elongation? | noncontractile elements |
| Where is the stretch force transmitted to when a muscle is stretched and elongates? | muscle fibers via connective tissue (endomysium and perimysium) |
| For plastic, or long-term, changes to occur what must happen during a stretch? | stretch must be maintained for extended period of time |
| What does atrophy occur more rapidly? | tonic slow-twitch muscles (postural muscles first) |
| What occurs when immobilization occurs in a shortened position? | reduction in muscle length and its fibers, and numbers of sarcomeres, muscles immobilized in shortened position atrophy at a faster rate, length-tension curve shifts to the left |
| What are some factors to keep in mind during immobilization in a lengthened position? | adapts by increasing # of sarcomeres, exact time frame for stretched muscle to becomes a longer muscle is unknown, adaptations may be short lived if muscle resumes pre-immobilization use, important to use full ROM during activities |
| What is the major sensory organ of muscle and what is it composed of? | muscle spindle, composed of intrafusal muscle fibers that are bundled together and lie parallel to an extrafusal muscle fiber |
| Muscle spindle | velocity of the stretch |
| What does the muscle spindle primarily detect? | changes in length of muscle and the velocity o those changes |
| What does the Primary, Type IA respond to in a muscle spindle? What does Type II respond to? | Type IA cause muscle to respond to both quick and tonic (sustained) stretch and Type II, are sensitiveonly to tonic stretch |
| Muscle spindle is not activated with ____. | static stretch |
| What is the function of the Golgi Tendon Organ (GTO)? | monitor changes in tension of muscle-tendon unites |
| Transmit sensory info. viz Ib fibers which are sensitive to even slight changes of tension on a muscle-tendon unit as the result of _____of a muscle or with ______ during normal movement. | Sensitive to even slight changes of tension on a muscle-tendon unit as the result of passive stretch of a muscle or with active muscle contractions during normal movement. |
| What does the GTO do when it fires in a muscle? | inhibits alpha motoneuron activity and decrease tension in the muscle-tendon being stretched |
| The GTO has been shown to have a low threshold for firing to allow what? | to allow for continuous monitoring and adjust forces of active muscle contractions |
| Inhibition | state of decreased neuronal activity and altered synaptic potential, which reflexively deminishes the capacity of a muscle to contract |
| What are two forms of inhibition? | autogenic and reciprocal |
| Autogenic inhibition | relaxation that occurs in the smae muscle experiencing increased tension |
| How is autogenic inhibition accomplished? | by actively contracting a muscle immediately before a passive stretch of the same muscle |
| What is autogenic inhibition the basis of? | PNF Contract- relax technique |
| Reciprocal Inhibition | relaxation occurs in the muscle opposing the muscle experiencing the increased tension |
| Howis reciprocal inhibition accomplished? | by simultaneously contracting the muscle opposing the muscle being passively stretched |
| What is reciprocal inhibition the basis of? | PNF Hold-Relax technique |
| What are 3 types of fibers in connective tissue? | collagen, elastin & Reticulin, and nonfibrous ground substance |
| What is collagen responsible for? | strength and stiffness of tissue and resist tensile deformation |
| Organization of collagen fibers is related to the _____. | the function of the tissue |
| What do tissues with greater proportion of collagen provide? | provide greater stability |
| What makes up Type I collagen? | tendons and ligaments and it is highly resistant to tension |
| What do elastin fibers provide? | extensibility |
| Extensibility | ability to return to original length after stretch |
| Tissues with increased elastin have greater ____. | flexibility |
| What do reticulin fibers provide? | tissue with bulk |
| What makes up ground substance? | proteoglycans and glycoproteins |
| What does ground substance's function? | hydrate the matrix, stabilize the collagen network and RESIST COMPRESSIVE FORCES |
| What is ground substance the most important in? | cartilage and intervertebral discs |
| What does ground substance do? | reduce friction, transports nutrients and prevents cross linking from occurring |
| What is the mechanical behavior of noncontractile tissue determined by? | determined by proportion of collagen and elastin fibers and by the structural orientation of the fibers |
| What influences mechanical properties? | proportion of proteoglycans |
| What is high collagen, low PGs designed to do? | resist high tensile loads |
| What is higher PGs concentration able to do? | withstand greater compressive loads |
| In mechanical behavior of noncontractile tissue, collagen is the structural element that does what? | absorbs most ofthe tensile stress |
| When tensile forces are applied the maximum elongation of collagen is ____, while elastin may _______ and return to its original configuration. | less than 10% lengthen 150% |
| Collagen alignment reflects tensile forces- tendon: collagen fibers are ____ and can resist greatest tensile load. Skin: collagen fibers are ____ in resisting tension. Ligaments, joint capsules and fascia: ______ and resist multidirectional forces. | parallel; random and weakest; vary between the above 2 extremes |
| Ligaments that resist major joint stresses have a more ______ orientation. | parallel |
| LOOK AT STRESS-STRAIN CURVE (SLIDE 66) | |
| What are 3 kinds of stress depicted on the stress-strain curve? | tension:force applied perpendicular to the cross-sectional area in a direction away from the tissue; compression:force applied perpendicular to the cross-sectional area in a direction toward the tissue; Shear:forceappliedparalleltothe cross-sectional ar |
| What does the toe region of the stress-strain curve include? | considerable deformation without much force, range where most functional activity normally occurs, and every day functional activities, for example: reaching up in a cabinet |
| What happens during the elastic range? | strain is directly proportional to ability of tissue to resist the force, occurs when gentle stretch is applied, complete recovery from this deformation and tissue returns to its original size and shape when load is released, and its a gentle stretch |
| What do you reach the elastic limit in the stress-strain curve? | point beyond which the tissue does not return to its original shape and size |
| When do you reach the plastic range in the stress-strain curve? | tissue strained in this range has permanent deformation when the stress is released, sequential failure between collagen fibers and eventually collagen fibers, rupturing of these fibers is what increases length of muscle |
| When do you know you've reached the ultimate strength on the stress-strain curve? | greatest load tissue can sustain, increased deformation without an increase in stress, REGION OF NECKING, end feels are important in this phase, complete rupture can occur at this point even with the smallest loads |
| What does structural stiffness indicate? | indicates there is less elastic deformation with greater stress |
| What are two things that have greater stiffness? | contractures and scar tissue |
| Creep | when a load is applied for an extended period of time the tissue elongates (deforms) |
| What is creep related to? | viscosity of the tissue |
| Is creep time dependent? | yes |
| When does deformation during creep depend on? | depends on amount of force and rate at which force is applied |
| When dealing with connective tissue what does repetitive loading of tissue cause? | increases heat production and may cause failure below the yield point |
| What is needed for failure in connective tissue responses? | greater load applied the fewer number of cycles |
| What are 2 examples of cyclic loading and connective tissue fatigue? | stress fractures and overuse syndromes |
| What are some changes in collagen affecting stress-strain response due to immobilization? | weakening of tissue, adhesion formation (scar tissue), rate of return to normal tensile strength is slow (300 days) |
| What are some effects of inactivity on collagen? | decrease in size and amount of collagen fibers, result in weakening of tissue, proportional increase in the predominance of elastin fibers, recovery takes about 5 months of regular cyclic loading ` |
| What are some effects that age has on changes in collagen? | decrease in maximum tensile strength, rate of adaptation to stress is slower, increased tendency for overuse syndromes, fatigue failures, and tears with stretching |
| What are some effects that corticosteroids have on changes in collagen? | decrease in tensile strength, fibrocyte death next to injection site, reappearance can take up to 15 weeks |
| What are some effects of injury on collagen? | excessive tensile loading can lead to rupture of ligaments and tendons, healing begins with newly synthesized type III collagen (will remodel to type I, this is what takes 300 days) |
| What is a stretching intervention? | alignment: positioning of limb or body such that the stretch force is directed to the appropriate muscle group (LOOK AT EXAMPLE OF SLIDE 80) |
| How do you stabilize joints during stretching? | fixation of one site of attachment of the muscle as the stretch force is applied to the other bony attachment (ex. PROM: locking the hip as he is stretching the quad) |
| How much intensity shouldbe applied during stretching? | stretching should be applied with low load, low intensity - results in optimal rates of ROM increases by getting into the "plastic" area - also been shown to elongate dense connective tissue more effectively (contractures) |
| How long should a single bout of stretching be held? | 15-30 seconds clinically |
| How long does Cirpriani think a stretch should be held? | hamstring stretches: 2 x 30 seconds just as effective as 6 x 10 seconds |
| How long does Robers and Wilson think a stretch should be held? | hamstrings: over 5 weeks 3 x 15 seconds daily yielded greater gains in ROM than 9 x 5 second stretches |
| To ensure the optimal muscle relaxation what speed must a stretch occur? | speed should be slow, with force applied gradually |
| Which fibers are sensitive to velocity of stretch? | Ia |
| What are the 5 categories of stretching? | static stretching, ballistic stretching, dynamic stretching, cyclic stretching, PNF |
| What can stretching exercises and methods increase? | muscle extensibility and joint ROM |
| Static Stretching | a method of stretching in which the muscle and connective tissue being stretched are held in a stationary position at their greatest possible length for some period (15-30 seconds) |
| Static stretching advantages | using less force overall, decreasing danger of exceeding tissue extensibility limits, lower energy requirements, lower likelihood of muscle soreness, increases resistance to stretch and facilitateGTOdecreasing contractile elements resistancetodeformation |
| Ballistic Stretching | rapid, forceful intermittent stretch-high speed and high intensity stretch |
| What is ballistic stretching initiated by? | active contraction of the muscles antagonistic to the muscles and connective tissue being stretched- appear to be jerky in nature |
| When doing a ballistic stretch, what has a greater chance of occurring? | greater chance of muscle soreness and injury likely |
| Dynamic Stretching | similar to ballistic stretching in that it utilizes speed of movmeent, but dynamic avoids bouncing and includes movements specific to sport or movement pattern |
| What does dynamic stretching involve? | flexbility during sport-specific movements |
| Who most commonly uses dynamic stretching? | athletes |
| What do nerves prefer: dynamic stretching or static stretching? | dynamic stretching |
| Cyclic stretching | relatively short duration stretch that is repeatedly, but gradually applied, released and then reapplied |
| How does cyclic stretching differ from static stretching? | duration that each stretch is applied (hold 5 to 10 seconds, again some controversy as to whether this is really static stretching) |
| What was PNF usually developed as a part of? | neuromuscular rehabilitation program to relax muscles with increased tone/activity |
| How is PNF stretching usually performed? | with a partner and involved passive and active muscle actions |
| It is believed that there is less resistance to elongation by the contractile elements of the muscles when the muscle fibers are? | reflexively inhibited through autogenic or reciprocal inhibition |
| Inhibition techniques are designed to relax only the ___________, not the ____________. | inhibition techniques are designed to relax only the contractile structures, not the connective tissue |
| What are 3 types of PNF techniques? | hold- relax (HR), contract-relax (CR), and hold-relax with agonist contraction (HR-AC) |
| PNF: agonist contraction definition | the 'agonist' refers to the muscle opposite the range-limiting muscle. Antagonist therefore refers to the range limiting muscle. |
| What is an example of PNF agonist contraction? | tight hamstrings, agonist = quds, antagonist = hamstring Think of it as the short/tight muscle (antagonist) preventing full movement of the prime mover (agonist) |
| Hold-Relax (Hamstrings) | begins with passive stretch held 10 seconds in mild discomfort, then partner instructs "hold and on't let me move the leg", athlete holds isometric contraction 6 seconds, and then passive stretch is held for 30 seconds, RECIPROCAL INHIBITION |
| Contract-Relax (Hamstrings) | Begins with passive stretch held at mild discomfort 10 seconds, athlete then extends hip against resistance from partner, athlets then relaxes and passive hip flexion stretch is applied and held for 30 seconds, AUTOGENIC INHIBITION |
| Hold-Relax with agonist contraction | same hold-relax during first 2 phases, during 3rd phase, a concentric action of the agonist is used in addition to the passive stretch to add to the stretch force, following isometric hold, athlete flexes the hip, moving into new ROM,RECIPROCAL INHIBITION |
| What are the acute effects of stretching? | immediate, short term results, result of elongating the elastic component of musculotendious unit, effects of routine stretching |
| What are the chronic effects of stretching? | long term results of prolonged stretching, result of ading sarcomeres |
| Which stretching technique is the best? | no consensus |
| What is important to keep in mind with muscle/joints immobilized in a shortened position when stretching and strengthening? | -weak due to adaptive shortening, additionally opposing muscle group weakened (lengthened/overstretched), initially more important to gain strength in muscle group opposite muscle being stretched, strengthen stretched muscle when ROM approaches functional |
| What is the most effective way to achieve PERMANENT increases in ROM and reducing functional limitation? | incorporating functional activities |
| What range do you need to keep movements in? | pain-free range |
| Overstretching | a stretch beyond the normal length of a muscle, joint and soft tissues |
| What is caused by hypermobility? | by traumatic injury can lead to true instability- GH joint anterior/inferior dislocation can result in recurrent dislocation |
| When should hypermobility be treated? | associated with instability, producing symptoms elsewhere |
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