STRETCHING AND STABILIZATION
FOR IMPAIRED JOINT MOBILITY
PTH5416
Threapeutic Exercise
Spring 2023
Week 2
This Photo by Unknown Author is licensed under CC
BY-SA-NC
OBJECTIVES:
• Identify interventions to address impaired ROM/joint mobility
• Define stretching as a therapeutic intervention for PT plan of care
• Describe indications, contraindications, precautions to stretching exercise
• Understand and apply principles and considerations to stretching exercise
• Understand and demonstrate stabilization exercise as treatment intervention for
hypermobile joints
• Demonstrate neural tension techniques for impaired neural mobility
CONTINUUM OF MOBILITY
Degree of mobility occurs along a continuum
Hypomobility-----------ROM-------------Hypermobility
Impairment
Strengthen
Impairment
Limited mobility
in new
Excessive mobility
Shortened tissue
range
Lack of stability
Intervention:
Intervention:
Stretching
Stabilization Exercise
INTERVENTIONS FOR MOBILITY
• Range of Motion (ROM)-maintain ROM
• Stretching (limitation in muscle, soft tissue structures)
• Joint Mobilization (limitation in joint capsule)
• Soft Tissue Mobilization (STM)-(integument, fascia) used as an adjunct
• Neuromobilization-(impairment in neural movement)
• Stabilization (relative flexibility, hypermobility)
JOINT MOBILITY IMPAIRMENTS:
THERAPEUTIC INTERVENTIONS
• Joint HYPOmobility
•
•
• STRETCHING
Manual
Self-Stretching
PNF
External-Continuous Passive Motion Machine (CPM), Splint, Casting, etc
• JOINT MOBILIZATION
• Manual
• Self-Mobilization
• SOFT TISSUE MOBILIZATION—adjuncts to manual stretching
• Friction massage, myofascial release, acupressure, trigger point therapy
• NEURAL TISSUE MOBILIZATION
• Gliding
• Flossing
STRETCHING:
DEFINITION AND PURPOSE
• Any therapeutic maneuver designed to
increase soft tissue extensibility and
subsequently improve flexibility and ROM
by elongating (lengthening) structures that
have adaptively shortened and have
become hypomobile
STRETCHING: GOALS
> Increase ROM and Flexibility
> To increase: Mobility of soft tissues
> Extensibility of the muscle-tendon unit and
the periarticular connective tissue
> Function-general fitness, recreation, workplace, sports activities
> Physical performance
> To decrease:
> Resistance to elongation (decrease stiffness) in a muscle-tendon unit or
other connective tissue
(Goal dependent)
> Pain- from tissues with poor flexibility
> Risk of injury and post muscle soreness
> Promote alignment of structures-prevent injury
STRETCHING: INDICATIONS
• ROM limited
• Restricted motion
• Muscle weakness and shortening of opposing tissue à limited ROM
• Component of total fitness/sport specific conditioning program to reduce risk
of injury
• Prior to or after vigorous exercise
STRETCHING: PRECAUTIONS
> Normal ROM varies among individuals
> women, older adults
> Progress dosage gradually-minimize soft tissue trauma/muscle soreness
> Should only feel transitory feeling of tenderness
> M. Soreness lasting >24 hours->inflammatory response
> Osteoporosis
> Prolonged bed rest
> Prolonged use of steroids
> Newly united fractures
> Tissue where there is edema is more susceptible to injury
> Avoid overstretching weak muscles (especially those that support body weight
against gravity)
STRETCHING: CONTRAINDICATIONS
> Bony block
> Recent fracture/bony union incomplete
> Evidence of an acute inflammatory or infectious process or if soft tissue
healing might be disrupted
> Sharp, acute pain with joint movement or muscle elongation
> Hematoma or other tissue trauma
> Hypermobility
> Hypomobility that provides stability or neuromuscular control
> (consideration for chronic disability)
STRETCHING: CONSIDERATIONS
Develop balance in length and strength to reduce risk of imbalances
Stage of healing
Positional-using gravity or position to exert passive motion/stretch through
range
Use of equipment
Can use concurrent with other interventions
Inhibition/facilitation techniques (PNF)
Relaxation training
Massage
Biofeedback
Joint traction/oscillation
STRETCHING: PARAMETERS
• Posture/Alignment –positioning so stretch force is directed to appropriate muscle group
• Position for comfort/relaxation
• Properly align for most effective stretch
• Stabilization-fixation of bony segment that has an attachment of the muscle to be stretched
• Provide stabilization for body segments above and below proximal and distal attachment of m. group
to be stretched
STRETCHING: GUIDELINES
Pre-stretch-Warm tissue before stretching (active ROM, modality)
Increases blood flow and facilitates extensibility of tissue
Speed of stretch
Apply and release stretch force slowly
Apply low intensity, prolonged stretch force - promotes comfort
minimizes muscle guarding, soft tissue damage, residual
muscle soreness
Low load, long duration static stretch (manual, mechanical, selfstretch) is safest form and yields most change (Chronic, fibrotic
contractures)
Follow stretching activities: with daily activities/exercises that use new
ROM, active contraction of the antagonist
EFFECTS OF STRETCHING
> Acute effects
> Immediate, short-term results
> Result of elongating the elastic component of the
musculotendinous unit
> Chronic effects
> Long-term results
> Result of adding sarcomeres
Techniques based on the immediate goal
STRETCHING: DOSING
• Dosing
• Intensity-tensile load placed on soft tissue to elongate
• Clinicians/researchers agree that stretching should be applied at low intensity by low load
• More comfortable
• Minimizes muscle guarding (pt able to stay more relaxed)
• Optimal improvement
• Minimizes risk of injury
• Duration-refers to single cycle of stretch (one repetition is stretch cycle)
• Total elongation time (total duration of stretch)-cumulative time of all stretch cycles
• Ideal combination of stretch cycle and number of reps not known
• Applied in context w/ intensity, frequency, mode
• Long duration-static, sustained, maintained, prolonged
• Short duration- cyclic, intermittent, ballistic
STRETCHING: DOSING (CONT’D)
• Frequency-number of sessions per day/week
• Optimal based on
• Cause of immobility
• Tissue healing
• Chronicity/severity of contracture
• Contextual factors
• Age
• Use of steroids
• Previous response to stretching
• Mode of stretch-how stretch is applied
• Many modes-based on CDM of clinician (see box 4.6 in text)
STRETCHING: 4 CATEGORIES
> Static
> Ballistic
> Dynamic
> Proprioceptive Neuromuscular Facilitation (PNF)Techniques
STATIC STRETCHING
> Definition: A method of stretching in which the muscles and connective
tissue being stretched are held in a stationary position at their greatest
possible length for some time period
> Advantages:
> Uses less overall force
> Decreases the danger of exceeding the tissue extensibility limits
> Lower energy requirements
> Lower likelihood of muscle soreness
STATIC STRETCHING TECHNIQUES
MANUAL OR SELF STRETCHING
> Position patient to allow complete relaxation of the muscle
to be stretched
> Take the limb to the point at which a gentle stretching sensation is felt
(Incorporate pt education to help pt know difference between pain and
stretching).
-30 seconds minimum, up to 60 seconds. (can do reps of shorter duration that add up
to 30-60 sec if longer duration not tolerated well)
-Stretch cycle >60 sec has no additional benefit
-Other research suggests that it is the total time perday that
the stretch is performed that is significant
> Proper limb alignment ensures proper tissues being stretched
> Check in with patient to assess effective stretch, observe non-verbals
MANUAL STRETCHING
• Perform PROM
• At point you feel slight resistance, move into slightly more range and hold
position 30-60 seconds
• Check in with patient
• What they are feeling-might be uncomfortable but shouldn’t be painful
• Where they are feeling stretch
• Encourage deep breathing w/counting
BALLISTIC STRETCHING
> Uses quick movements that impose a rapid change in the length of muscle or
connective tissue
> Takes the muscle to the end of its range and applies a
rapid oscillating or “ballistic” stretch at end range
Technique→move limb until a gentle stretch is felt,
then gently “bounce” at end range
> Most appropriate for young, healthy pt ie athletes
> Not recommended for elderly, sedentary, pt w/ musculoskeletal pathology,
chronic contractures
> Increased chance of muscle soreness and injury
> Less tissue extensibility w/ chronic contracture, disuse, immobilization
DYNAMIC STRETCHING
> The limb is repeatedly taken through a ROM actively by the participant
> The primary mover takes the limb through a ROM while the antagonist muscle
relaxes and elongates
> Takes the structure to the limits of the range but does not hold this position
> Alternative for those who cannot tolerate holding a static stretch or who
will be participating in activities requiring power or explosive speed ie
gymnast
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION
(PNF) STRETCHING
> Based on
> Reciprocal and autogenic inhibition to induce relaxation promoting muscle elongation
>
Neurophysiologic concept of stretch activation
> Techniques:
> Contract-Relax (CR)-Maximal contraction in rotation
> Hold-Relax (HR)-Maximal isometric contraction
> Can achieve relaxation where muscle spasm accompanied by pain
> Agonist contraction (AC) can be included (CRAC, HRAC)
> Widely used
STRETCHING AND JOINT CONTRACTURES
> Contractures are usually the result of prolonged immobilization or
surgery
> Require low-torque, long-duration stretching for best results
> Stretching can be applied manually but can be tiring
Other methods
STRETCHING AND JOINT CONTRACTURES
STRETCHING AND JOINT CONTRACTURES
STRETCHING AND JOINT CONTRACTURES
> External devices used for providing prolonged stretch
Casting
Commercial dynamic splinting systems (Dynasplint)
STRETCHING AND JOINT
CONTRACTURES
STRETCHING: MANUAL
• Patient should be in a
comfortable, relaxed position
• Communicate with patient
throughout!
• Should feel a “pulling sensation” but no
pain
• STABILIZE proximal
segment/move distal segment
• Stretching movement should be
directly opposite the line of pull
of muscle being stretched
• Move extremity SLOWLY
to just past the point of
tissue resistance
• Hold stretch for 30-60
seconds
• Can be shorter bouts that add
up to 30-60 seconds if not
tolerated well
• Gently release stretch
• Repeat several times
STRETCHING: SELF-STRETCHING
• Patient performing stretch independently
• MUST first give instruction and supervised practice
to ensure pt can perform correctly and safely
• Patient must stabilize!
• Move distal segment while stabilizing proximal segment
• Distal attachment fixed, body weight used as source of
stretch
PRACTICE
KNOW YOUR ANATOMY
STRETCHING TO INCREASE JOINT ROM
KNOW NORMAL ROM
STRETCHING TO INCREASE MUSCLE LENGTH
KNOW ORIGIN/INSERTION
CONSIDER LINE OF MUSCLE
P R AC T I C E / A P P L I C AT I O N
YO U R PAT I E N T H A S A H I G H S T R E S S J O B A N D C O M E S TO S E E YO U F O R
N E C K PA I N . YO U E X A M I N E T H E PAT I E N T A N D F I N D L I M I TAT I O N S I N
N E C K RO M I N L AT E R A L S I D E B E N D I N G TO T H E L > R A S W E L L A S
I N C R E A S E D M U S C L E TO N E I N T H E U P P E R T R A P E Z I U S M U S C L E .
W H AT I S T H E I M PA I R M E N T ?
W H AT I N T E RV E N T I O N WO U L D YO U C H O O S E ?
A P P LY T H E I N T E RV E N T I O N O N YO U R PA RT N E R
INTERVENTIONS FOR MOBILITY
• Range of Motion (ROM)-maintain ROM
• Stretching (limitation in muscle, soft tissue structures)
• Joint Mobilization (limitation in joint capsule)
• Soft Tissue Mobilization (STM)-(integument, fascia) used as an adjunct
• Neuromobilization-(impairment in neural movement)
• Stabilization (relative flexibility, hypermobility)
JOINT MOBILIZATION TO INCREASE MOBILITY
> Joint mobilization is an integral component of a mobility program when capsular
restriction is a key finding
> The primary indication for joint mobilization is a joint restriction
resulting in a limitation in AROM and PROM at the joint
> Increases joint play or joint motion between joint surfaces
> The use of mobilization/manipulation requires an understanding of the normal joint
architecture, arthrokinematics, and specific pathology to determine which interventions
are appropriate
JOINT MOBILIZATION
> Assessment and treatment are similar
> Performing the mobilization closer to the end range h a s proven more
effective in increasing motion than performing mobilizations in mid-range
> Follow joint mobilization with an exercise or activity that uses the newly
gained range
JOINT MOBILIZATION
GRADES OF OSCILLATIONS (MAITLAND)
> Grade I
> Small amplitude movement at the beginning of the range (pain and spasm)
> Grade II
> Large amplitude movement within the midrange of the movement (pain and
spasm)
> Grade III
> Large amplitude movement at the end of the range (into restriction)
> Grade IV
> Small amplitude movement at end range when tissue resistance (not pain) is limiting
> Grade V
> Small amplitude, quick thrust manipulation at end range
SELF-MOBILIZATION
Joint mobilization
Soft-tissue mobilization
Neural mobilization
Promotes more rapid recovery, self-efficacy
SELF-MOBILIZATION
SELF-MOBILIZATION
SELF MOBILIZATION
JOINT MOBILITY IMPAIRMENTS:
THERAPEUTIC INTERVENTIONS (CONT’D)
• Joint HYPERmobility
•
STABILIZATION
• Manual
• Closed Chain/Open Chain
• PNF Techniques
• Rhythmic Stabilization (RS), Alternating Isometrics (AI)
• Ballistic Exercises
• Equipment• body blade, stability balls (dynamic stabilization)
• External adjuncts-may be used initially
• bracing, taping
JOINT HYPERMOBILITY
THERAPEUTIC EXERCISE INTERVENTION
STABILIZATION EXERCISES
> Dynamic activities that attempt to limit and control excessive movement
> (Also use to build strength in new ROM)
> Uses isometric co-contraction
> Uses manual or body weight resistance if permissible
> Activities include
> Strengthening exercises in the shortened range for hypermobile segments
> Postural training to ensure movement through a controlled range
> Patient education
> Should be chosen based on the direction in which the segment is susceptible to excessive
motion
METHODS OF TRAINING:
BODYWEIGHT
ØOpen chain exercise/Closed chain exercise-can be used for mobility/
muscle performance goals
o Closed chain exercise = activities where the distal segment is fixed on a rigid
or semi-rigid surface
• Squats, lunges, step-ups, push-ups
o Open chain exercise = activities where the distal segment is free
• SLR, resistive knee extension, biceps curl
STABILIZATION EXERCISES:
CLOSED-CHAIN EXERCISE
> Rationale – promote stability to the joint
Muscular co-contraction
Decreased shear forces
Increased joint compression-sensory input
> Squats, lunges, step-ups, push-ups
STABILIZATION EXERCISES: OPEN-CHAIN STABILIZATION
STABILIZATION EXERCISES:
OPEN-CHAIN STABILIZATION
> PNF techniques
Rhythmic stabilization-can be used to stabilize where there is
Hypermobility at joint
Decreased muscular support around joint/position-build postural control
Alternating isometrics-can be used to stabilize
Hypermobility at joint
To bias muscles in plane of movement-build postural control
SPINE STABILIZATION
> Difficult to categorize
Not a true closed or open system
> Program
Initiate in supine – abdominal bracing
Progress to sitting and standing
Add upper or lower extremity movement
Add unstable surface
STABILIZATION EXERCISES: BALLISTIC EXERCISES
> Produces co-contraction about a joint through triphasic muscle activation
> Results in synchronous activation of agonists and antagonist
> Quick movements through small distances
STABILIZATION EXERCISES:
BALLISTIC EXERCISES
BODY BLADE
Bodyblade uses vibration and the power of inertia to rapidly contract your muscles
up to 270 times per minute, stimulate your nervous system, and transform your
body. Bodyblade will build your body from the center out to develop stability
https://www.youtube.com/watch?v=ZbBXJej5ttM (to 3:37 min)
APPLICATION:
Your patient came to see you for shoulder pain. You measure ROM and determine
there is a mobility impairment in the shoulder with hypermobility in shoulder
extension and decreased strength in shoulder flexion.
What impairment is noted?
What intervention is appropriate?
Each partner should develop one intervention
QUESTIONS?????
• Readings (listed on syllabus) before Friday lab
• Read and practice neural tension positions
• Practice together in labà follow Lab worksheet (do not need to turn in)
• Coming Up:
• Quiz #1 Due February 5 (Open Friday 2/3 at 8am. Due Sunday 2/5 at 11:59pm)
• Open Book