1 FLEX-ABILITY: MUSCLE ENERGY- PNF STRETCHING Speaker: THERESA A. SCHMIDT, DPT,MS,OCS,LMT,CEAS This Photo by Unknown Author is licensed under CC BY-SA Provider Disclaimer • Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation. • There was no commercial support for this presentation. • The views expressed in this presentation are the views and opinions of the presenter. • Participants must use discretion when using the information contained in this presentation. Course Outline: Hour 1 • Flexibility • Stretching considerations • Neuromuscular reflexes • Reciprocal inhibition • Indications • Contraindications 3
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1
FLEX-ABILITY: MUSCLE ENERGY- PNF
STRETCHING
Speaker:
THERESA A. SCHMIDT, DPT,MS,OCS,LMT,CEAS
This Photo by Unknown Author is licensed under CC BY-SA
Provider Disclaimer
• Allied Health Education and the presenter of this webinar do not
have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be
discussed or displayed in this presentation.
• There was no commercial support for this presentation.
• The views expressed in this presentation are the views and
opinions of the presenter.
• Participants must use discretion when using the information
The ability to move through a range of motion (ROM) of a joint
or chain of joints
“Stretch-ability”
•What is normal ROM?
•Goniometry
•Flexibility screening
FLEXIBILITY NORMS
• What is normal ROM?
Standardized values are measured using:
• Goniometry*
• Flexibility screening
• Functional testing: performance-based: for work, sport or
physical activity demands
(*American Academy of Orthopedic Surgeons, goniometry chart, 1965)
4
NECK & T-L SPINE ROMJOINT MOTION NORMAL degrees
NECK FLEXION 45
EXTENSION 45
ROTATION 60
LATERAL FLEXION 45
TRUNK FLEXION 80 (4” from floor)
EXTENSION 25
ROTATION 45
LATERAL FLEXION 35
SHOULDER ROMJOINT MOTION NORMAL
degrees
SHOULDER FLEXION 180
EXTENSION 60
ABDUCTION 180
MEDIAL ROTATION
70
LATERAL ROTATION
90
ELBOW-FOREARM-WRIST ROMJOINT MOTION NORMAL degrees
ELBOW FLEXION 150
FOREARM PRONATION, SUPINATION
80
WRIST FLEXION 80
WRIST EXTENSION 70
WRIST RADIAL DEVIATION
20
WRIST ULNARDEVIATION
30
5
HIP ROMJOINT MOTION NORMAL degrees
HIP FLEXION 120
EXTENSION 30
ABDUCTION 45
ADDUCTION 30
ROTATION medial, lateral
45
KNEE- ANKLE ROM
JOINT MOTION NORMAL deg.
KNEE FLEXION 135
ANKLE DORSIFLEXION 20
ANKLE PLANTARFLEXION 50
ANKLE ANKLE INVERSION 35
ANKLE ANKLE EVERSION 15
HIP/KNEE/ANKLE STRAIGHT LEG RAISE
80
INTERVIEW
Discuss with client:
• Reason for seeking assistance: performance issues
• Personal needs and goals:
• Determine the need in order to set goals and
design an exercise program
6
INTERVIEW
Identify the need: impairment- be specific
• “Do you feel stiff?”• “Is it painful to move?”
• “Do certain motions feel tight or sore?”• “Is there a specific physical activity you are unable to perform or have trouble doing?”• List the intensity of the pain using the pain scale from 0-10:
10 is the worst pain imaginable, 0 is no pain
ASSESS- Measure
Goniometric normative reference values
• Norkin and White: Goniometry- Measurement of Joint
Motion
• Flexibility screening: functional tools in the ergonomic and
sports literature
(Resources: Journal of Biomechanics, Medicine and Science in Sports and Exercise,
Athletic Training, Journal of Strength and Conditioning)
DETERMINE GOALS
Educate client regarding the limitations
Get medical clearance for health issues
Decide what performance is desired or required for the
physical activity
Set measurable, objective goal using the assessment
tools
Determine a timeline for achievement, Document it
7
DESIGN A PROGRAM
Standard stretching uses positioning and an outside force or
gravity to place the joint(s) into an end range of motion
Normally a sensation of pulling or stretching discomfort is
observed
Avoid pain during stretching
STRETCING CONSIDERATIONS
• “No pain, no gain” - unnecessary muscle guarding,
protective spasm or even injury
• Keep intensity tolerable. Use Pain Scale, if above a 5/10, ease up on the force and range of stretch
• Begin with single joint stretches prior to moving into multiple joint stretches
PRECAUTIONS
• Injury warm-up prior to stretch to relax the area and
improve circulation
• Injured areas may need cooling after the stretch or workout for anti-inflammatory effects and pain reduction
• Progress gradually and gently with injury
• Never force the motion. If it does not move/ relax, try
something else!
8
PRECAUTIONS
• Once medical clearance is obtained, review the record
• Note contraindications, such as unhealed fracture,
bruising, open or sutured wounds, to be avoided unless you have special qualifications to treat (MD, PT, OT, etc.)
• Do not stretch areas of hypermobility, which may be due to environment, injury, overuse, genetic or hormonal
(pregnancy requires gentle motion, ligaments become lax)
STRETCHING TECHNIQUES
• Static stretch- holding the part still waiting for a period of
time for release of tension
• Dynamic stretch- involves adding motion and muscle contraction of agonist of antagonist muscles
• Ballistic stretch- includes a bouncing or jumping, usually high-velocity stretch, be cautious since this is only for
advanced sports and may tear muscle
FACILITATED STRETCH
• Rehab clinicians and trainers may employ neuromuscular
reflexes to improve the effectiveness of stretching and to
help clients to relax and enjoy the stretching process
• Using reflexes helps to minimize muscle guarding and
• STATE LIMITATION: Lateral flexion R is restricted
• NAME SHORT MUSCLES: Left quadratus lumborum,
erectors, obliques
• CONTRACT SHORT MUSCLES: resist L lateral flexion or L
hip hiking
• RELAX, STRETCH SHORT MUSCLES: extend into barrier
into R lateral flexion, bend over a pillow, ask client to hip hike
against your resistance (at ilium or pulling leg) No sudden or jerky motions!
• REPEAT 3-5 reps (avoid for joint replacements/instability)
CORRECT SOMATIC DYSFUNCTION
Abnormal Position: Anterior rotation R ilium:
•Low R ASIS, High L ASIS
•High R PSIS, Low L PSIS
Anterior Innominate Torsion, anterior rotation
If both true leg lengths are equal:
• Anterior Longer Lying, Anterior Shorter Sitting
• Anterior side leg may be externally rotated
• Lumbar spine is hyperextended
• Tight anterior hip flexors
• Typical complaint of pain in sustained standing or supine positions
35
Short Hip Flexors on anterior side
CORRECT SOMATIC DYSFUNCTION
Supine longsitting test:
Anterior is longer in lying, shorter in longsitting
Standing: anterior side leg is externally rotated, abducted
to functionally shorten it
Intervention:
• Contract: R hip extensors
• Contract: L hip flexors
Contract R Hip Extensors isometrically
36
Contract L Hip Flexors Isometrically
NOT recommended, may damage disc, psoas with strong contractions
Follow with Stabilization Exercise
Pelvic bridges
with knees flexed to work glutes
37
Follow with Stabilization
Exercise
Adductor and
abductor isometrics
using pillow and band
Interesting Cases
• 39 y/o female in car accident, auto rolled over 2x, she has whiplash and back strain. Unable to rotate her trunk to the left or to flex forward fully due to pain and stiffness. Her thoracic spine is locked in R rotation and extension
(in the position of ESR R)
• What can we do to help her to move?
MET TRUNK ROTATION
38
MET LUMBAR ESR R
How to Treat ESR R
• Need to go to barriers of flexion, sidebending and/or rotating to the left
• The opposite of her dysfunctional position
• Contract the short muscles, resist extension/SB/Rot R
• Passively move her into barriers of flexion/SB/Rot L
• More to it, this is a simplified model
• More courses on isolating a joint dysfunction, learn it in a live class!
MET LUMBAR NEUTRAL NLRRS
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MET IMPROVES ROM & STRENGTH
•Be gentle: Identify the limitation
•Position into restricted range
•Resist the tight muscle
•Rest, release, stretch into the range
•Follow with exercise and functional activity
•May need ice if sore post treatment
CLINICAL CASE STUDIES
• Identify a limitation of range of motion on your partner, or use a patient case
• Identify the short and/or weak muscles
•Position the joint for MET to increase ROM and strength
•Use active contraction to increase ROM and strength of the affected joint
•Design a functional activity to follow MET, include a home program
RESEARCH ON MET
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA
• RCT 50 people with ALBP received wither MET or MET+SCS strain
counterstrain 2x for 2 days
• Results: ODI Oswestry Disability Index, Roland Morris disability Q,
VAS pain, ROM all improved significantly, no difference between
groups
• No added benefit of SCS + MET
• (Patel, VD, et al, 2018)
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MET or Ischemic Compression IC for Shoulder Pain TPs
• RCT 60 patients with shoulder TPs in 2 groups: either IC or MET
• Outcomes: VAS pain, ROM
• Tx 6 wks.
• Results: MET had greater effect on ROM than IC
• IC more effective to reduce pain
• (Gupta 2018)
Case Studies
27 y/o athlete, female, injured R hamstring on last workout prepping for track season.
SLR 0-45 with pain 4/10, cannot run or jump, ambulates with shorter steps on R, difficulty driving car, cannot sit > 5 mins.
Can run after warmup but has pain to walk up to ¼ mile.
List 2 interventions to improve gait and range of motion
CLINICAL CASE STUDIES
• Identify a limitation of range of motion on your
partner, or use a patient case
• Identify the short and/or weak muscles
• Position the joint for MET to increase ROM and
strength
• Use active contraction to increase ROM and
strength of the affected joint
• Design a functional activity to follow MET, include
a home program
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COPYRIGHT THANKS
• Sam Barrow of Primal Pictures Ltd. provided copyright permission to use the anatomy pictures from the Primal Pictures. Ltd. DVD: Interactive Functional Anatomy,
Second Edition
www.primalpictures.com
• Primal Pictures Ltd. 4th Floor, Tennyson House, 159-165 Great Portland St.
London, W1W5PA, UK
124
To Comply with professional board and association standards, I
declare I do have a financial interest in products and or services
discussed in my presentation occurring in the last 12 months.
FLEX-ABILITY: MUSCLE ENERGY-
PNF STRETCHING
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