Range of Motion & Stretching Flashcards
Mobility
ability of a body segment to move or be moved
Exercises that might be prescribed to maintain mobility or address mobility impairments
ROM or stretching exercises
2 types of mobility
joint mobility
functional mobility
Joint mobility
capacity of a joint to be moved or influenced by the structure and integrity of the joint surface along with soft tissue characteristics
arthrokinematic motion: motion occurring at joint surfaces
Functional mobility
ability to initiate and execute motor tasks to move in one’s environment
What influences functional mobility?
the patient, task and environment
Range of motion (ROM)
amount of motion a segment moves
2 ways ROM can be assessed
visual assessment or objectively measured using a goniometer or inclinometer
Available ROM
amount of motion a person demonstrates
3 categories of available ROM
normal, impaired or functional
Normal ROM
ability of a body segment to move or be moved through the full amount of motion at a particular joint
generally accepted values for the full amount of ROM at a particular joint
What are normal values of ROM based on?
the average amount of ROM in a healthy population
Impaired, decreased, limited or restricted ROM
less than normal range of motion
Functional ROM
ability of a body segment to move or be moved through an adequate range of motion needed for functional activities
Flexibility
ability to move a single joint or a series of joints through an unrestricted, pain-free ROM
Flexibility is influenced by what 2 factors?
extensibility of soft tissue(s) that surround or cross the joints
joint integrity
The amount of flexibility a patient needs depends on…
the functional activity
What must support flexibility in order to have optimal function?
strength, endurance and neuromuscular control
2 types of flexibility
dynamic flexibility
passive flexibility
Dynamic flexibility
another term for AROM
the extent active muscle contraction can cause a body segment to move through its ROM
Passive flexibility
another term for PROM
the extent a bony segment can be moved passively through its available ROM
What is required in order to have good active flexibility?
good passive flexibility
BUT having good passive flexibility does not ensure good active flexibility
2 main joint mobility deficits
hypermobility and hypermobility
Hypomobility
restricted or limited motion at a single joint or series of joints
Hypermobility
ability to move a joint beyond the normal ROM
excessive motion at a single or series of joints
Beighton criteria
general tool to measure joint looseness (laxity) or hypermobility
What is the classification of a contracture?
a joint hypomobility deficit
Contracture
loss of full PROM due to joint, muscle or other soft tissue limitations or alterations
loss of PROM ranges from minimal, severe or complete where two bones are fused together
there is no definite point where the loss of PROM is considered a contracture
Contraction
neuromuscular process that leads to tension development in muscles due to the interaction of actin and myosin (proteins)
3 ways contractures are named
by the action of the shortened muscle
by the motion caused by the shortened tissue(s)
motion opposite to the motion limited
What does the type of contracture influence?
whether ROM or stretching is needed
the parameters of exercise
Myostatic contracture
musculotendinous (MT) unit is shortened causing a significant loss of ROM
there is NO muscle pathology
Pseudomyostatic contracture
muscles appear to be constantly contracted due to a CNS lesion or response to pain/injury
Arthrogenic contracture
due to a joint pathology
Periarticular contracture
decreased extensibility of ligaments or the joint capsule
Fibrotic contracture
connective tissue changes (excessive deposition of ECM components, collagen)
may result in a permanent loss of extensibility
ROM as a therapeutic exercise
planned, structured and repetitive movement of a segment within an unrestricted pattern
Planned
designed in advance
Structured
activity has an organization, pattern or parameters
Repetitive
activity is done more than once
When ROM is used as a therapeutic exercise, how should patients move within the unrestricted pattern?
only move until the point of tissue resistance and NOT beyond (that would be stretching)
patients should not feel any tension, pull or stretch
3 types of ROM
PROM, AROM and AAROM
PROM
movement of a body segment within an unrestricted pattern or ROM that is produced entirely by an external force
little to no muscle activity because the external force should produce all of the movement
assess AFTER AROM
AROM
movement of a body segment within an unrestricted pattern or ROM that is produced entirely by the contraction of muscles that cross the joint
assess BEFORE PROM
AAROM
movement of a body segment within an unrestricted pattern or ROM that is produced by both the contraction of muscles AND an external force
Indications of PROM
patient has a health condition where active motion might negatively affect the healing process (when acute inflammation is present or in the event of contractile tissue repair)
patient is not able to actively move a body segment (not enough strength or force)
patient has poor understanding of the desired movement pattern (can be used as a method of education)
Goals of PROM
maintain joint mobility and soft tissue extensibility
maintain movement awareness
minimize and prevent contractures
assist blood circulation, vascular dynamics and synovial fluid movement
minimize pain
Limitations of PROM
does not prevent muscle trophy or increase muscle strength/endurance because there is little to no muscle activity
does not assist circulation as well as movements with muscle contraction (AROM or AAROM)
The methods of performing PROM as an intervention are based on what?
who or what provides the external force
Therapist or caregiver generated PROM
external force is provided by another person
Patient/self generated PROM
patient provides the force themselves with an uninvolved body part or via a piece of equipment
Gravity PROM
gravity provides the external force
Machine PROM
a CPM (constant passive motion) machine provides the external force
Indications of AROM and AAROM
patient is able to contract muscles and move the body segment with or without assistance
contraction of muscles is NOT contraindicated
to improve muscle performance in patients who are weak due to active muscle contraction
aerobic conditioning and warm-ups
relieve stress from sustained posture
When should AROM be used vs AAROM?
AROM: patients who are weak, but can move through the desired ROM
AAROM: patients who are weak, but cannot move through the desired ROM
Is AROM/AAROM or PROM better for assisting vascular dynamics?
AROM/AAROM
Goals of AROM/AAROM
same as PROM, BUT it assists vascular dynamics better than PROM
prevent thrombus formation
develop motor skills and coordination
prevent disuse atrophy of soft tissues due to active muscle contraction
Limitations of AROM/AAROM
only develops skills in the patterns used
does not improve or maintain strength in muscles with normal strength
The methods of performing AAROM as an intervention are based on what?
who or what provides assistance
Therapist or caregiver assisted AAROM
therapist or caregivers assists AROM
Patient or self assisted AAROM
patient assists the AROM themselves
What is the difference between therapist/caregiver generated PROM and therapist/caregiver generated AAROM?
in AAROM, the patient is allowed actively contract their muscles and is instructed to use the involved segment as much as possible and the external force is provided as much as needed to move the limb through the desired ROM
in PROM, there is NO muscle contraction and the external force produces all of the movement
Device AAROM
a device assists the AROM
When should ROM not be performed as an intervention?
if the patient is experiencing a life-threatening condition (once managed, ROM may be initiated with close monitoring)
if motion would be detrimental to the healing process (protective or controlled motion might aid the healing process)
if motion puts that at risk for injury or re-injury
if the patient experiences muscle guarding
if the patient experiences increased effusion or inflammation
Protective or controlled motion
minimize the physical stress applied to healing tissues by limiting the type of ROM, the specific ROM performed and the amount of ROM to protect the healing process
Why is complete immobilization avoided?
due to its negative effects: contractures, adhesions, decreased circulation, edema and decreased flow of synovial fluid within the joint(s), causing poor nutrition
BUT after surgery, too much motion may be detrimental to the healing process (use protective and controlled motion)
Stretching
application of a force at the end of the available ROM causing soft tissues to elongate just beyond the point of resistance
planned, structured and repetitive just like ROM
When is stretching prescribed by PTs?
when the restricted ROM is due to shortened tissues or when soft tissues have lost their extensibility
when restricted ROM may lead to structural deformities that are preventable
before/after vigorous exercise to educe muscle soreness
component of fitness
2 types of stretching
static
dynamic
Static stretching
elongating tissues just beyond the point of resistance and holding this stretch for a period of time
Dynamic stretching
actively moving the limb just beyond the point of resistance and it is performed several times in a controlled manner
How does static stretching impact physical performance immediately before activity?
does not improve or may even negatively impact physical performance before activity
How does dynamic stretching impact physical performance immediately before activity?
may improve physical performance before activity
When can both static and dynamic stretching have long-term benefits on physical performance?
if they are performed on a regular basis
Parameters of stretching
FITT Principle
volume, speed and mode
Frequency of stretching
number of sessions per day or per week
depends on the type or severity of contracture, the cause of motion loss and the stage of healing and tissue quality
Intensity of stretch
amount of force applied to a tissue
ORDINAL (numbers do not have real meaning, as it is related to a perception or feeling with the use of descriptors)
What is the difference between low intensity and high intensity stretching?
low: more effective, safe and comfortable
high: more soft tissue damage and worse post-exercise soreness (more recovery time)
4 types of stretching
passive
dynamic
ballistic
pre-contraction
Static stretching
elongating a tissue just beyond the point of resistance and holding the stretch for a period of time
2 types of static stretching
static-active
static-passive
Static-active stretching
elongating a tissue just beyond the point of resistance and holding the stretch for a period of time while the patient contracts muscles opposite to the short or stiff structures (what is being stretched)
Static-passive stretching
elongating a tissue just beyond the point of resistance and holding the stretch for a period of time using another body part, equipment or assistance from another person
Dynamic stretching
elongating a tissue just beyond the point of resistance and actively moving the body part in a controlled manner through the full ROM just beyond the point of tissue resistance at a slow velocity and then holding it for a (very) short period of time (a few seconds or less)
Ballistic stretching
elongating a tissue just beyond the point of resistance and then rapid, alternating movements or bouncing is performed at the end of the ROM
generally NOT recommended due to the risk of injury
Pre-contraction stretching
contraction of the muscle being stretched followed by stretching or contraction of muscles opposite to short or stiff muscles in order promote relaxation of muscle being stretched
3 types of pre-contraction stretching
proprioceptive neuromuscular facilitation and inhibition techniques
post-isometric relaxation
post-facilitation stretch
Duration of stretching
time a stretch force is applied and tissues are maintained in a lengthened position
Short duration stretching
60 seconds
Long duration stretching
minutes to hours
Relationship between the intensity and duration of stretching
low intensity, high duration
high intensity, low duration
Relationship between the intensity and frequency of stretching
low intensity, more frequency
high intensity, less frequency (to allow for tissue healing and prevent residual muscle soreness)
Duration of static-passive stretching
long duration
Duration of static-active stretching
short duration
Volume of stretching
total end range (elongation) time
includes the duration of stretch, number of reps and number of times per day
How do you increase volume?
by increasing the frequency and repetitions
Speed or velocity of stretching
rate at which a limb is moved or stretch force is applied
Slow stretch velocity
minimizes muscle activity, as less force is required to deform connective tissue
less likely to active muscle spindles and the muscle stretch reflex, causing tension and resistance to stretching
easier to control, making it safer (reduced risk of injury or soreness)
High stretch velocity
controversial (may be appropriate for highly trained individuals or high-demand athletes at the end of rehab)
progression should be done slowly (static, dynamic and then ballistic)
3 modes of stretching
manual
self-assisted
mechanical
Manual stretching
force is applied by the therapist or caregiver at the end of the ROM
Self-assisted stretching
force is applied independently by the patient
can be a part of either the treatment session or a HEP (home exercise program)
Mechanical stretching
force is applied by a device to stretch tissues
What are the indications of manual stretching?
when the therapist wants to determine how a patient responds to stretch intensities
when optimal stabilization is needed
when patient lacks the capacity to perform self-stretch either physically or cognitively
What is the benefit of including self-stretching in an HEP?
enables patients to maintain gains that result from interventions provided during the treatment session
can increase mobility and extensibility in between sessions
What must we educate patients on regarding self-stretching?
appropriate technique: alignment/position, stabilization and parameters of stretching
When should stretching be used with caution?
patients with poor bone health
patients with muscles and connective tissues that have been immobilized for an extended period of time due to poor tissue quality
What are the contraindications of stretching?
bony block
incomplete bony union after fracture
joint hypermobility (could lead to subluxation or dislocation)
acute inflammation
tissue trauma
intense sharp pain with movement
when there are shortened soft tissues needed for joint stability or functional tasks with paralysis or other neuromuscular conditions
Pre-stretching
warm-up to increase tissue temperature via low-intensity active exercise (walking for LE and AROM for UE)
superficial heat or deep-heating physical agents
can increase soft tissue extensibility and decrease stiffness in risk of complete tissue failure with stretching
Post-stretching
have the patient perform AROM/stretching exercises through the gained ROM
ensures adequate neuromuscular control and stability as flexibility increases
Purpose of joint mobilizations in addition to stretching
to reduce pain and promote relaxation prior to stretching
Purpose of soft tissue mobilization/massage in addition to stretching
to reduce pain, promote relaxation and reduce muscle tone prior to stretching
Purpose of cold application in addition to stretching
given prior to stretching to patients with spasticity to reduce tone and can reduce pain, therefore increasing pain tolerance
What precautions should be taken when applying cold?
caution should be taken when applying cold prior to stretching, especially in the early stages of healing (cold may decrease elasticity and increase stiffness, increasing the risk of trauma during stretching)
How can cold be used after stretching?
cold can be applied to soft tissues in the lengthened position after stretching, which may lead to improved maintenance in tissue length and less risk for post-stretching soreness
Parameters for ROM
type, pattern and dosage
What frequency of stretching exercises can improve ROM in healthy individuals?
2-3 times per week
What is considered the safest form of stretch and yields the most effective changes in tissues?
low intensity, long duration stretching
