PTA215-Unit2-ROM and Stretching Flashcards
Identify 6-9 major goals of therapeutic exercise
To develop, improve, restore or maintain normal • Strength • Power • Endurance • Mobility/Flexibility • Stability • Relaxation • Balance • Coordination • Functional skills
discuss Normal Joint Mobility
- alignment of articulating surfaces
- looseness of joint capsule
- congruent joint surface
- arthrokinematics – roll and glide
discuss factors for Abnormal Joint Mobility
- Misalignment of articulating surfaces
- Tightness of joint capsule
- Degeneration of joint structures
discuss Normal Soft Tissue Mobility
- contractile tissue is muscle
- noncontractile tissue is tendon, ligament, cartilage, fascia, skin (scars), adipose
- muscle, tendon, ligament, and capsular
- the ability of the body to move freely without restriction and with control during functional activities.
describe decreased soft tissue mobility
- hypomobility - adaptive shortening
- loss of ROM
discuss 8 factors for Decreased Soft Tissue Mobility
- Prolonged immobilization
- Restricted mobility
- Connective tissue or neuromuscular disease
- Tissue pathology due to trauma
- Paralysis, tonal abnormalities, muscle imbalances
- Postural malalignment with muscle imbalances
- Postural misalignment: congenital or acquired (Sedentary lifestyle and habitual faulty or asymmetrical postures)
define Range Of Motion
- Range of Motion is a basic technique used for the examination of movement and for initiating movement into a program of therapeutic intervention.
- ROM is the full motion possible between any two bones
- Amount of angular motion allowed at the joint between any two boney levers
describe 6 factors which may affect ROM
- Systemic disease
- Joint disease
- Neurological disease
- Muscular disease
- Surgical or traumatic insults
- Inactivity or immobilization for any reason
define Functional Excursion
The distance a muscle is capable of shortening after it has been elongated to its maximum
describe Active Insufficiency
- When a two-joint muscle is as contracted as can be
* Ex. Biceps brachii flexes elbow, supinates forearm, and flexes shoulder all at once – cannot contract any more
describe Passive Insufficiency
- When a two-joint muscle is as elongated as can be
* Ex. Biceps brachii is in passive insufficiency when elbow extended, shoulder extended, forearm pronated
explain Active ROM
- Movement of a segment within the unrestricted ROM that is produced by active contraction of the muscles crossing that joint
- Patient moves segment without assistance
explain Active-Assistive ROM
- Movement of a segment within unrestricted ROM that is produced by active contraction of the muscles crossing that joint AND with assistance from outside force because Prime Movers can’t do it alone
- Assistance provided manually or mechanically
explain Passive ROM
- Movement of a segment within the unrestricted ROM that is produced entirely by external force
- Little to no voluntary muscle contraction
- External force from gravity, a machine or another individual
- Not the same as Passive Stretching
list 3 indications for Passive ROM exercises
- Patient is comatose
- Patient is paralyzed
- Patient has doctor’s orders
list indications for AAROM/AROM
If it isn’t one of the three indications for Passive, then it will be Active-Assistive or Active
list 12 goals for all ROM exercises
- Maintain joint and soft tissue integrity
- Maintain elasticity of muscle
- Help maintain patient awareness of movement
- Minimize formation of contractures
- Assist circulation
- Assist healing process after surgery or injury
- Facilitate synovial fluid movement
- Decrease/inhibit pain
- Assess joint limitations, joint stability or soft tissue extensibility
- Demonstrate desired motion for active exercise
- Prepare patient for stretching
- Relax the patient
list 7 additional goals for AAROM and AROM
- Maintain elasticity and contractility of muscles
- Receive sensory feedback from muscles
- Be stimulus for bone and joint tissue integrity (wolff’s law)
- Increase circulation; prevent thrombus
- Increase strength in very weak muscles
- Develop coordination and motor skill
- Improve cardiovascular and respiratory response (aerobic conditioning)
explain the/list 4 limitations of PROM exercises
- Difficult when patient is conscious and muscles are innervated
- Will not prevent muscle atrophy
- Will not increase strength or endurance
- Not as effective as A/AROM in increasing circulation
explain the/list 2 limitations of AAROM/AROM exercises
- No increase or maintenance of strength for strong muscles
* Develops skill/coordination in only the movement pattern used
list precautions for ROM exercise
- Therapist must stay within the range, speed and tolerance of the patient during acute recovery
- Therapist must be aware of signs of too much or wrong motion – increased pain and/or inflammation
- Therapist must be aware of other signs of too much motion – resting pain, fatigue, increased weakness, spasm lasting beyond 24 hours
list the 3 contraindications for ROM exercise
- When it is disruptive to healing (acute tears, fractures, surgery)
- Additional trauma is contraindicated (p53)
- When cardiovascular system is unstable and exercise would endanger the patient’s life
explain CPM operation
- Passive motion performed by a mechanical device that moves a joint slowly and continuously through a controlled ROM
- The devices are used for many conditions
explain CPM application
• Align patient’s joint w/ machine joint • Secure limb in device with straps • Set beginning and end ranges • Sample Knee Protocol: – May begin in arc of 20-30 degrees – May progress 10-15 degrees/day – Rate of movement: 45 secs to 2 mins/cycle – Duration: Varies from 1hr TID to 24 hrs/day
identify 5 diagnoses/conditions for which CPM is indicated
• Joint effusions • Contractures • Intra-articular fractures • To decrease post-op complications • To increase recovery rate and ROM after certain surgeries, such as: o TKA o ACL repair o Rotator cuff repair
list the 8 Beneficial Effects of CPM
- Prevents degrading effects of immobilization
- Prevents development of adhesions and contractures and thus joint stiffness
- Provides a stimulating effect on the healing of tendons and ligaments
- Provides a quicker return of ROM
- Enhances healing of incisions over the moving joint
- Increases synovial fluid lubrication of the joint and thus increases the rate of intra-articular cartilage healing and regeneration
- Decreases postoperative pain
- Decreases joint effusion and edema
list 5 categories that lead to need for Stretching
- Prolonged immobilization
- Restricted mobility
- Connective tissue or neuromuscular disease
- Tissue pathology due to trauma
- Postural malalignment with muscle imbalances
define Stretching
- Therapeutic maneuver designed to lengthen pathologically shortened soft tissue that have become hypomobile
- To increase ROM and extensibility (to improve flexibility)
discuss Passive Stretching
- If the patient is as relaxed as possible, it’s called passive stretching
- A form of static stretching in which an external force exerts upon the limb to move it into the new position
- Passive stretching resistance is normally achieved through the force of gravity on the limb or on the body weighing down on it.
- Is can also be achieved with the help of a partner, stretch bands, or mechanical device
define Flexibility
- The ability to move a single joint or a series of joints smoothly and easily through an unrestricted, pain-free ROM
- depends on extensibilty of muscle and connective tissue
define/discuss Extensibility
- the ability to expand or stretch
- muscle cells shorten when contracting, but can stretch beyond resting length with relaxed
- flexibilty depends on extensibilty
- property of muscles which cross joints to relax, lengthen, and yield to a stretch force
discuss Active Inhibition
- Reflexively relax the muscle for stretch (not the connective tissue)
- Muscle must be normally innervated and under voluntary control
- Not as effective if severe muscle weakness, spasticity, paralysis
- The tight muscle is the antagonist, opposing muscle is the agonist
- The enemy is the antagonist, the antagonist is the tight muscle
define Overstretch
- A stretch well beyond the normal length of muscle and ROM of a joint and the surrounding soft tissues
- Results in hypermobility (excessive mobility)
identify Positive Overstretch
Creating selective hypermobility for certain healthy individuals with normal strength and stability and who participate in sports that require extensive flexibility
identify Negative Overstretch
- Becomes detrimental when joint instability is created
- When the supporting structures of a joint and the strength of the muscles around a joint are insufficient and cannot hold a joint in a stable, functional position during activities.
- Instability of a joint often causes pain and may predispose a person to musculoskeletal injury
define Contracture
- an almost complete loss of function to decreased ROM
- adaptive shortening of the muscle-tendon unit and the other soft tissue that cross or surround the the joint resulting in resistance to passive or active stretch or ROM
identify 5 Types of Contractures
- Myostatic
- Pseudomyostatic
- Adhesion
- Arthrogenic/Periarticular
- Irreversible/Fibrotic
discuss Myostatic Contracture
- (myogenic) musculotendinous unit has adaptively shortend and there is significant loss of ROM, but no pathology
- Can be resolved with stretching exercises
discuss Pseudomyostatic Contracture
- Results from hypertonicity due to CNS lesion spasm, muscle guarding, pain
- The result of hypertonicity (spasticity or rigidity) associated with CNS lesion, such as CVA or SCI or TBI.
- Muscle spasm or guarding and pain
- Muscles appear to be in constant state of contraction, but if neuromuscular inhibition procedures to reduce muscle tension temporarily are applied, full passive elongation is possible
discuss Adhesion Contracture
- Collagen fibers bond & adhere to each other in a disorganized manner
- Scar tissue adhesion – collagen laid down randomly between normal tissue
discuss Arthrogenic/Periarticular Contracture
• Tightening of connective tissue within the joint capsule
• Result of intra-articular pathology
• May include
o adhesions,
o synovial proliferation,
o joint effusion,
o irregularities in articular cartilage,
o osteophyte formation
• Develops when connective tissues that cross or attach to a joint or the joint capsule lose mobility
• Thus restricting normal arthrokinematic motion
discuss Irreversible/Fibrotic Contracture
- Soft tissue replaced by bone or fibrotic tissue
- Fibrous changes in the connective tissue of muscle and periarticular structures can cause adherence of these tissues and subsequent development of a fibrotic contracture
- Although it is possible to stretch a fibrotic contracture and eventually increase ROM, it is often difficult to re-establish optimal tissue length
- Permanent loss of extensibility of soft tissues that cannot be reverse by nonsurgical intervention may occur when normal muscle tissue and organized connective tissue are replaced with a large amount of relatively nonextensible fibrotic adhesion and scar tissue, or even heterotopic bone
- Changes can occur after lon periods of immobilization of tissues in shortened position or after tissue trauma and the subsequent inflammatory response
- The longer a fibrotic contracture exists or the greater the replacement of normal muscle and connective tissue with nonextensible adhesions and scar tissue or bone, the more difficult it becomes to regain optimal mobility of soft tissues and the more likely it is that the contracture will become irreversible
discuss Ballistic Stretching
- A rapid, forceful intermittent stretch
- A high-speed and high-intensity stretch
- Characterized by the use of quick, bouncing movements that create momentum to carry the body segment through the ROM to stretch shortened structures
- Not recommended for elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures
- Tissues, weakened by immobilization or disease, are easily injured
- Dense connective tissue found in chronic contractures does not yield easily with high-intensity, short-duration stretch
- May be appropriate for highly trained athlete who requires significant dynamic flexibility
discuss the 6 General Principles of Manual Passive Stretching
- Warm up muscles first
- Patient must be relaxed
- External force applied with attention/control of direction, speed, intensity, duration
- Push beyond available ROM
- Apply for 15-30 seconds, repeat several times
- Slow maintained stretch is best to avoid stretch reflex and increased tension
discuss the 2ish General Principles of Prolonged Mechanical Passive Stretching
• Low intensity (5-15 lbs or 10-15% of body weight) static stretch as long as possible o To increase comfort o Allows remodeling of collagen fibers • Applied via: o Serial casting o Dynamic splints o Pt positioning o Weighted traction
discuss active inhibition Hold-Relax
- Autogenic inhibition: tension in the tight muscle stimulates the golgi tendon organ which inhibits the motor neuron to this muscle and facilitates motor neuron to the opposing muscle
- The tight (antagonist) muscle is contracted isometrically against resistance for 10 seconds (or more)
- Then relax
- Then IMMEDIATELY passively stretched
- Repeat
discuss active inhibition Contract-Relax
- Autogenic inhibition: tension in the tight muscle stimulates the golgi tendon organ which inhibits the motor neuron to this muscle and facilitates motor neuron to the opposing muscle
- Same as Hold-relax, but allows movement in rotation only if moving in a diagonal pattern
discuss active inhibition Agonist-Contraction
- Reciprocal inhibition: during facilitation of contracting the agonist muscle you get inhibition of the antagonist, which makes antagonist easier to stretch
- Muscle opposite the tight muscle (the agonist) contracts concentrically against minimal resistance
discuss active inhibition Hold-Relax-with-Agonist-Contraction
- Autogenic inhibition, then Reciprocal inhibition
- Isometric contraction of antagonist against resistance
- Then relax
- Then immediate voluntary concentric contraction of agonist against slight resistance
- Then relax and increase ROM
name the contractile unit of the muscle
sarcomere
-give the muscle its ability to contract and relax
name the 2 filaments in the sarcomere
actin (thin)
myosin (thick)
name 3 contraindications to CPM
- non-stable fracture site
- excessive edema
- patient intolerance
list 6 devices one can utilize for Self-ROM exercises
- other extremity
- wand, dowel or rod
- rolling ball
- strap or towel
- bicycle or UE ergometer
- powder board with skate
name one precaution for Self-ROM exercise
Do not compromise patient’s body mechanics
name one thing to remember about evidence regarding CPM
many studies show quicker initial gains in ROM, but they equalize by three months
connective tissue strength: tendons
- strongest to tensile loads
- have parallel fibers
connective tissue strength: skin
- weakest to tensile loads
- random organization of fibers
connective tissue strength: ligaments, capsules, fasciae
- varied due to fiber orientation and cross-sectional area
skin and scars
connective tissue:
- skin is normally mobile, but maybe become tight if scar tissue develops, leads to limited motion
- scars are denser connective tissue which does not yield to stretch due to crossbonding of collagen fibers
list 4 indications for Stretching
- limited ROM due to contracture, adhesion, scar tissue
- limitations which may lead to structural deformities
- contracture which interfered with functional ADL or nursing care
- opposing muscle weakness with tightness
list 4 goals for Stretching
- overall: regain or establish normal or functional ROM of joint and mobility of tissue that surrounds the joint
- prevent irreversible contractures
- increase flexibility of body part along with strengthening
- prevent or minimize risk of musculotendinous injuries due to physical activities or sport
discuss Selective Stretching
- stretch some muscles and allow adaptive shortening in others
- done to increase function and stability in certain disabilities
- ex. decreased length of back extensors & hamstrings in SCI pt will increase stability in long sit
- ex. maintaining wrist flexibility with hypomobility in long finger flexor will allow grip in pt with quadriplegia (keep the tenodesis)
list 7 precautions for Stretching
- do NOT passively force a joint beyond normal ROM
- carefully protect newly united fractures
- use extra caution in patients with or suspected osteoporosis
- avoid rigorous stretching after long periods of immobilization
- it was too much force used if joint pain or muscle soreness lasts more than 24 hours
- avoid stretching edematous tissue
- avoid overstretching weak muscles
list 7 contraindications to Stretching
- a bony block limits joint motion
- after recent fracture
- acute inflammation or infection
- sharp or acute pain with movement or stretch
- hematoma or other tissue trauma
- contracture provides stability or strength
- contractures improve functional abilities
describe autogenic inhibition
- the Golgi Tendon Organ synapses on the interneuron
- the interneuron is inhibitory
- it inhibits the alpha neuron —————————-
- makes it harder for the muscle to contract AKA relax
- sense too much tension, send relax signal
- ## is a protective thing
describe reciprocal inhibition
- reciprocal - going back and forth
- as faciliate the flexor, send impulse to extensor to relax
- relax the antagonist
which stretch technique is the sneaky one?
agonist contraction
