Range of Motion and Flexibility
Day 3
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Discuss ROM
Describe the differences in ROM and flexibility
Discuss stretching principles
List indications, contraindications and precautions for
stretching
Discuss effects of prolonged immobilization
Describe different modes of stretching
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ROM- The full motion possible between two bones

Flexibility- extensibility of soft tissues that cross or
surround joints- muscles, tendons, fascia, joint
capsules, ligaments, nerves, blood vessels
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Hypomobility- shortening of soft tissues
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Contracture- adaptive shortening of the muscletendon unit and other soft tissues that cross or
surround a joint that results in limitation of ROM
 Benefits
of ROM exercises
◦ ROM activities are administered to
maintain joint and soft tissue mobility
to minimize loss of tissue flexibility and
contracture formation
Concorde Career College
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Passive ROM = PROM
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Active assistive ROM = AAROM
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Active ROM = AROM
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Resisted ROM = RROM
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Movement of a segment within the unrestricted
ROM that is produced entirely by an external force.
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No voluntary muscle contraction
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Force may be from gravity, a machine, another
individual or another part of the individual’s own
body
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Movement of a segment within the
unrestricted ROM that is produced by active
contraction of the muscles crossing that joint
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A type of AROM in which assistance is
provided manually or mechanically by an
outside force because the prime mover
muscles need assistance to complete the
motion.
 Indications
◦ Acute, inflamed tissue
◦ When a patient is not able to or
supposed to move a segment of their
body
 Contraindications
◦ When motion is disruptive to the
healing process
Decrease complications of immobilization
 Minimize the effects of the formation of
contractures
 Assist circulation and vascular dynamics
 Decrease or inhibit pain
 Assist with the healing process
 Help maintain the patient’s awareness of
movement
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INDICATIONS
◦ ROM deficiencies
due to shortened
tissues (scar tissue
and adhesions)
◦ Contractures &
structural
deformities
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CONTRAINDICATIONS
◦ Recent fractures
◦ Joint infection
◦ Acute inflammation
◦ Extreme pain
◦ When tightness
contributes to an area’s
stability
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Indications
◦ Arthritis, contractures, Intra-articular fractures
◦ Improves recovery rate and ROM after surgical
procedures *
◦ Provides stimulating effect on the healing of tendons
and ligaments
◦ Enhances healing of incisions over the moving joint
◦ Increases synovial fluid lubrication of the joint
◦ Decreases post-operative pain
 Precautions
◦ Excessive post-operative bleeding
◦ Some patients may require increased
analgesic intervention
•
Active Insufficiency- A muscle can shorten no more
•
Passive Insufficiency- A muscle is fully elongated
•
Functional Excursion- the distance a muscle is capable
of shortening after it has been elongated to its
maximum
 Multi-joint
muscles normally function in the
midportion of their functional excursion, where ideal
length-tension relations exist
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Elasticity: ability to return to normal length
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Viscosity: resistance to change from outside force
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Viscoelasticity: resistance to change, ability to
return to former state
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Plasticity: allows permanent change
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All present simultaneously
 Collagen
fibers are responsible
for the strength and stiffness of
tissue and resist tensile
deformation
 Collagen
 Elastin
 Reticulin
 Ground
substance
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Collagen:
◦ Tendons and ligaments mostly Type I collagen
◦ Provides tissue with strength and stiffness
◦ Collagen is 5x stronger than elastin
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Elastin:
◦ Provides structure with extensibility
◦ Withstand elongation stress and are able to return
to original length
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Reticulin:
◦ Type III collagen
◦ Provides bulk
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Ground substance:
◦ Organic gel that reduces friction between collagen
and elastin- contains proteoglycans and
glycoproteins
◦ Transports nutrients and metabolites
◦ May help prevent excessive cross-linking between
fibers by maintaining space between fibers
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Loose irregular (areolar) connective tissue
◦ Ex: fascia
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Dense regular connective tissue
◦ Ex: tendons and ligaments
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Dense irregular connective tissue
◦ Ex: joint capsules, aponeuroses expansions
of tendons, and bone periosteum
 CT
naturally shortens as part of its
reorganization process.
 Normal
motion maintains CT length.
 Rapid
changes can occur in CT with
immobilization.
 The
longer the immobilization, the more
profound and lasting its effects
A
decrease in ground substance leads to an increase
in collagen cross-links.
 Fiber meshwork becomes hard, dense, and less
supple.
 New collagen formation encourages new cross-link
formation.
 Wound contraction reduces range of motion.
 Changes seen within 1 week of immobilization
 Produces structural weakness and loss of mobility
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Collagen fibers bind to other structures and
limit tissue mobility.
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The structure becomes weaker.
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The end result is loss of range of motion.
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Clinical changes:
 Reduction in muscle fiber size, # of
myofibrils & oxidative capacity
 Weakness, atrophy and  endurance
 Delayed reflex response
 Loss of normal neural feedback system
(proprioception)
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Cartilage becomes thinner
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Necrosis can occur if constant pressure between
joint surfaces is maintained during immobilization
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Contracture of a joint can occur (Irreversible
damage)
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 Fibrofatty tissue in joint cavity that becomes scar
tissue
[ligaments, joint capsule, fascia, tendons,
synovial membranes]
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Connective tissue becomes thick and fibrotic
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Tissue mobility is reduced.
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Clinical result is  range of motion.
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Enhancement of recovery:
◦ Prevention of abnormal collagen cross-link
formation and increase of fluid content in the
extracellular matrix of CT
◦ On muscle
◦ On articular cartilage
◦ On periarticular CT
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ROM is limited because soft tissues have lost
their extensibility as the result of adhesions,
contractures, and scar tissue formation,
causing functional limitation or disability
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Restricted motion may lead to structural
deformities that are otherwise preventable
 Con’t
Muscle weakness and shortening of opposing
tissue
 May be used as part of a total fitness program
designed to prevent musculoskeletal injuries
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May be used prior to and after vigorous
exercise potentially to minimize post exercise
muscle soreness
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Presence of a bony block limiting joint motion
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A recent fracture & bony union is incomplete
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Evidence of an acute inflammatory or infection
process
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If soft tissue healing could be disrupted
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If there is sharp, acute pain with joint movement
con’t
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A hematoma or other indication of tissue trauma is
observed
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Hypermobility already exists
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Shortened soft tissues provide necessary joint stability
in lieu of normal structural stability or neuromuscular
control
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Shortened soft tissues enable a patient with paralysis
or severe muscle weakness to perform specific
functional skills otherwise not possible
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Force deformation: force applied to maintain a
change of length or other tissue deformation
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Creep: When a load is applied for an extended
period of time the tissue elongates, resulting in
permanent deformation
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Stress-relaxation: Force is applied while length is
held constant- after initial creep there is a decrease
in the force required to maintain that length, and the
tension in the tissue decreases
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Cyclic loading: Repetitive loading of tissue increases
heat production and may cause failure below the
yield point
◦ Examples- stress fractures and overuse syndrome
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Hysteresis: repetitive stretches heat tissue to 
viscosity, which increases length
Fatigue failure: the point at which structural failure
causes tissue failure.
Structural fatigue occurs when the structure is
loaded repeatedly below the failure point until the
cumulative stress results in failure.
◦ Tendinopathy
◦ Stress fractures
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Amount of collagen and elastin in the
structure
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Amount of force applied
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Amount of time the force is applied
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Tissue’s temperature
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Types of stress are defined by the load or force that
changes the shape or form: tension, compression, and
shear.
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Strain is the amount of deformation that occurs when
a stress is applied.
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Hooke’s law: The stress applied to a body to deform it
is proportional to the strain. This law is illustrated by
the stress-strain curve (see figure 5.4)
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Tissue width
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Tissue slack length
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Tissue microstructure and orientation of
structure to the forces applied
Muscle spindles
◦ Composed of intrafusal fibers and nerve fibers in
CT sheath
◦ Sensitive to changes in muscle length
◦ Two types of intrafusal fibers
 Nuclear bag
 Nuclear chain
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Nuclear bag (indicated by “B” in figure 5.8)
◦ Are sensitive to stretch velocity
◦ Have enlarged centers with 2-3 nuclei per nuclei per row
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Nuclear chain (indicated by “C” in figure 5.8)
◦ Are shorter, thin
◦ Have nuclei in single file
Figure 5.8 Muscle Spindle and Golgi
Tendon Organ
Ib afferent fibers:
 Are at musculotendinous junction
 Less sensitive to stretch
 More sensitive to contraction
 Perform autogenic muscle inhibition
 Activate antagonist
GTO—a protective mechanism
 If stretch applied quickly, muscle contracts
(muscle spindle)
 If stretch applied slowly, GTO fires to inhibit
contraction of agonist
 Contraction of antagonist inhibits agonist
contraction.
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Autogenic Inhibition: Stimulation of a muscle
that causes neurologic relaxation
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Reciprocal Inhibition: Neurologic mechanism
that inhibits the antagonist muscle as the
agonist muscle (the prime mover) moves a
limb through the ROM.
Concorde Career College
Alignment and Stabilization
 Intensity
 Duration
 Speed
 Frequency
 Mode
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Active
 Passive
 Proprioceptive neuromuscular facilitation
(PNF)
 Ballistic
 With assistive devices: weights, theraband
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Hold-relax
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Contract-relax
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(Slow reversal-hold-relax)
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Hold-relax with agonist contraction
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Elbow Contracture in a Dynamic Stretch Splint.
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Dyna-splint – for a knee flexion contracture
Depends on the tissues involved
 Stage of healing
 Patient’s motivation
 Time and resources available
 Other factors of the injury
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Measurements usually based on 180° system
 For accuracy of measure and performance:
◦ Apply goniometer correctly
◦ Maintain arm and axis positions
◦ Recheck position of goniometer and patient
before recording
 Watch for substitution by patient (who will try
to do his or her best for you).
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
Histological changes:
  ATP (adenosine triphosphate), ADP
(adenosine diphosphate), CP (creatine
phosphate), and creatine glycogen
  Lactic acid production,  Mitochondrial
production
  Fibrous and fatty tissue in muscle
  Intramuscular capillary density
Cont- Clinical Changes