1. Restoring Range of Motion and Improving Flexibility
Rehabilitation Techniques for Sports medicine and athletic training
William e. prentice

2. Introduction Loss of motion occurs after injury Flexibility
Due to pain, swelling, muscle guarding or spasm
Shortening of connective tissue and muscle
Loss of neuromuscular control
Restoring normal range of motion is one of primary goals of rehabilitation program
Flexibility
Ability to move a joint through a full, non-restricted, pain free range of motion
Dependent on combination of joint range of motion and muscle flexibility

3. Introduction Joint range of motion Muscle flexibility
Limited by shape of articulating surface and capsular and ligamentous structures
Muscle flexibility
Ability of musculotendinous unit to lengthen
Lack of flexibility in one joint can effect the entire kinetic chain

4. Importance of flexibility
Essential to normal daily living
Functional activities require relatively “normal” amounts of flexibility
Some activities require more flexibility for superior performance
Decreased flexibility creates uncoordinated/awkward movement patterns
Result of loss of neuromuscular control

5. Importance of Flexibility
Generally accepted that flexibility is essential for improved performance
Recent studies conflicting and inconclusive
Stretching has shown to decrease performance parameters
Strength, endurance, power, joint position sense and reaction times
Decrease incidence of injury
Recent studies fail to find true cause and effect relationship

6. Anatomic Factors that Limit Flexibility
Muscles, tendons and their surrounding fascial sheaths
Stretching attempts to take advantage of highly elastic properties of muscle
Overtime it is possible to increase elasticity , or the length a given muscle can be stretched
Connective tissue (ligaments and joint capsule)
Become shortened and stiff during periods of immobilization
People can also be loose jointed from slack or increased laxity in connective tissue
Creates some instability

7. Anatomic Factors that Limit Flexibility
Bony structures
Restrict end point in the range of motion
Good for stability
After fracture excess calcium can develop which interferes with normal range
Fat
Excess fatty tissue can restrict range of motion
For example; excess abdominal fat can restrict trunk movement

8. Anatomic Factors that Limit Flexibility
Skin
Inelastic scar tissue can develop after surgery or injury
Incapable of stretching with joint movement
Overtime can improve elasticity to varying degrees through stretching
Neural tissue
Tightness develops in neural tissues from acute compression, chronic repetitive microtrauma, muscle imbalances, joint dysfunctions, or poor posture
Can create morphological changes in tissue that can cause pain
Pain can cause muscle guarding and spasm
Can eventually lad to neural fibrosis or scarring

9. Active and Passive Range of Motion
Active range of motion
Dynamic flexibility
Degree to which a joint can be moved by a muscle contraction
Not necessarily a good indicator of joint stiffness or looseness because movement of joint has little resistance
Passive range of motion
Static flexibility
Degree to which a joint can be passively moved to end points of range of motion
No muscle contraction involved

10. Active and Passive ROM
Many situations in activity when muscle is forced beyond its normal active limits
If muscle does not have elasticity to compensate, injury to musculotendinous unit may occur

11. Assessment of ROM Goniometers
Large protractors w/ measurements in degrees
Align arms of goniometer along longitudinal axis of 2 segments
Reasonably accurate measurement of ROM
Standardization of measurement techniques and recording AROM & PROM have been developed
Immobile arm is lined up along immobile segment
Mobile arm is lined up along mobile segment

12. Neurophysiologic Basis of Stretching
Mechanoreceptors in muscle tell CNS what is happening within that muscle
2 of these are important in the stretch reflex
Muscle spindle and the Golgi tendon organ (GTO)
Sensitive to changes in muscle length
GTO also sensitive to change in muscle tension

13. Neurophysiologic Basis of Stretching
Muscle spindle initially sends sensory impulse to spinal cord which then sends a message back to muscle spindle causing the muscle to reflexively contract
If stretch last longer than 6 seconds, impulses from GTO begin to override muscle spindle
autogenic inhibition, or a reflex relaxation of the antagonist muscle
Protective mechanism to allow stretch to avoid damage to muscle fibers
Reciprocal inhibition
Contraction of agonist causes a reflex relaxation in the antagonist muscle
Allows antagonist to stretch and protects from injury

14. Effects of stretching on physical and mechanical properties of muscle
Muscle and tendon composed of non contractile collagen and elastin fibers
Collagen can withstand high tensile stress
Mechanical properties
Elasticity: capability to recover normal length after elongation
Viscoelasticity: allows for slow return to normal length and shape after deformation
Plasticity: allows for permanent change or deformation
Physical Properties
Creep response: ability of tissue to deform over time while a constant load is imposed
Greater the stretch the greater the noncontractile properties contribute
Lengthening of a muscle via stretching allows for viscoelastic and plastic changes to occur in collagen and elastin

15. Effects of stretching on the kinetic chain
Muscle tightness has significant impact on neuromuscular control
Effects normal length-tension relationships
Compensations and adaptations occur that affect neuromuscular efficiency through kinetic chain
Reciprocal inhibition
For example: if psoas is tight or hyperactive the antagonist gluteus maximus can be inhibited due to decreased neural drive
The synergist, hamstrings (muscle that assist glut max); the stabilizers, erector spinae; and the neutralizers, piriformis become overactive
Creates abnormal joint stress and decreased neuromuscular control during functional movement

16. Importance of increasing muscle temp. prior to stretching
Muscle temperature should be increased prior to stretching
Positive effect of collagen and elastin components to deform
Capability of GTO to reflexively relax is enhanced
Can be achieved through low intensity warm up or through various therapeutic modalities
However exercise is recommended over modalities
If muscle guarding occurs cold therapy can also be used prior to stretching

17. Stretching techniques
Agonist muscle: muscle that contracts to allow movement through a joint
Antagonist muscle: the muscle that is being stretched in response to contraction of agonist
Balance between the agonist and antagonist is necessary for normal, smooth, coordinated movement
As well as reduce muscle strains secondary to muscular imbalances
Comprehension of this synergistic muscle action is essential to understanding various stretching techniques

18. Ballistic stretching
Repetitive contractions of agonist used to produce quick stretches of antagonist
Safety questioned because of risk of microtears in musculotendinous unit
Not recommended for sedentary individuals or those recovering from muscle injury
Most physical activities are dynamic and repetitive contraction of agonist with eccentric resistance from antagonist occurs
May be implemented in later stages of rehab during reconditioning phase
Progressive velocity flexibility program has been proposed
Slow static to slow end range to slow full range to fast end range to fast full range

19. Static stretching
Extremely effective and widely used method of stretching
Passively stretching antagonist or actively contracting agonist to stretch antagonist to maximal position and holding for extended time
Recommended to hold for 15 to 30 seconds is most effective to increase flexibility
Can be used early on in rehabilitation program
ATC, teammate, other assistive devices
Best to do after muscle temperature is increased
May be more efficient to do after activity and not before

22. Proprioceptive Neuromuscular Facilitation (PNF)
First used by ATC’s rehabilitating neuromuscular disorders
More recently used to increase flexibility
3 types of PNF stretching techniques
Contract relax: beneficial to athletes where ROM is limited by muscle tightness
Athlete actively contracts agonist to point of limitation, athlete then instructed to contract antagonist (muscle to be stretched) isotonically (through range of motion), athlete then relaxes as ATC passively moves part to point of limitation. Stretch is then repeated

23. Proprioceptive Neuromuscular Facilitation (PNF)
Hold relax: Similar to contract relax except antagonist goes through isometric contraction (contraction w/o movement)
Hold for at least 6 seconds
Can be used for agonist or antagonist
Slow reversal-hold-relax
Begins with isotonic contraction of agonist, followed by isometric contraction of antagonist
During relax phase antagonist are relaxed while agonist are contracting
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24. Dynamic stretching Stretching through series of movement patters
Progressive slow controlled movements to faster movements
Muscle activation of agonist and muscle stretching of antagonist
Posture and form important
Increases core and muscle temperature
Increases neuromuscular control
Increases balance
Core stability
Effective for increasing flexibility
Better way to stretch prior to activity
Shown to increase flexibility, decrease injury and increase force and power output
Mimics sport activity, so more functional
Can initially cause some muscle soreness

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26. Comparing stretch techniques
All have been shown to increase flexibility
PNF is capable of producing greater improvement in flexibility
Requires a partner
Static
Has to be done often and held for extended periods of time
Prior to exercise may decrease core and muscle temperature when compared to dynamic stretching
More appropriate in rehab and as a cool down method after activity
Dynamic
Research supports use prior to activity
Ballistic
Can cause injury in untrained or already injured person
Can maintain flexibility w/ stretching 1 day a week, but to improve flexibility must perform 3-5 times/week

27. Pilates and Yoga Pilates Extremely popular and widely used method
Developed by Joseph Pilates prior to WWII
Conditioning program that improves muscle control, flexibility, coordination, strength and tone.
Concentrated on body alignment, breathing, lengthening of all muscles while building endurance and strength

29. Pilates and Yoga Yoga Originated in India 6000 years ago
Philosophy that most illness related to poor mental attitude, posture and diet
Aimed to unite body and mind through various body postures and meditative breathing
Start simple and progress to more complex movements
Increase mobility and flexibility

32. Myofascial release stretching
Relieve soft tissue from abnormal grip of tight fascia (fibrous membrane that covers, supports and separates muscles, tendons, bones and organs)
Localize restriction and move into direction of restriction
Releasing myofascial restrictions over large treatment area can have significant impact on joint mobility
Progression of superficial restrictions to deeper restrictions
Stretching techniques can be incorporated after extensibility is improved in myofascia
Can use foam rollers to assist with myofascial release

34. Other methods to restore ROM
Massage
Strain-counter strain
Soft tissue mobilization
Graston technique

35. Benefits of ROM exercises
Inreased flexibility
Increased mobility
Increased blood flow to area
Facilitate tissue healing process
Decreased swelling
Decreased adhesion formation
Decreased pain