REHABILITATION TECHNIQUES FOR SPORTS MEDICINE AND ATHLETIC TRAINING WILLIAM E. PRENTICE Restoring Range of Motion and Improving Flexibility.

REHABILITATION TECHNIQUES FOR SPORTS MEDICINE AND ATHLETIC

TRAINING

WILLIAM E. PRENTICE

Restoring Range of Motion and Improving Flexibility

Introduction

Loss of motion occurs after injury Due to pain, swelling, muscle guarding or spasm

Shortening of connective tissue and muscle Loss of neuromuscular control

Restoring normal range of motion is one of primary goals of rehabilitation program

Flexibility Ability to move a joint through a full, non-restricted,

pain free range of motion Dependent on combination of joint range of motion and

muscle flexibility

Introduction

Joint range of motion Limited by shape of articulating surface and capsular

and ligamentous structuresMuscle flexibility

Ability of musculotendinous unit to lengthen

Lack of flexibility in one joint can effect the entire kinetic chain

Importance of flexibility

Essential to normal daily living

Functional activities require relatively “normal” amounts of flexibility Some activities require more flexibility for superior

performance

Decreased flexibility creates uncoordinated/awkward movement patterns Result of loss of neuromuscular control

Importance of Flexibility

Generally accepted that flexibility is essential for improved performance Recent studies conflicting and inconclusive Stretching has shown to decrease performance

parameters Strength, endurance, power, joint position sense and

reaction times

Decrease incidence of injury Recent studies fail to find true cause and effect

relationship

Anatomic Factors that Limit Flexibility

Muscles, tendons and their surrounding fascial sheaths Stretching attempts to take advantage of highly elastic

properties of muscle Overtime it is possible to increase elasticity , or the length

a given muscle can be stretched

Connective tissue (ligaments and joint capsule) Become shortened and stiff during periods of

immobilization People can also be loose jointed from slack or increased

laxity in connective tissue Creates some instability

Anatomic Factors that Limit Flexibility

Bony structures Restrict end point in the range of motion

Good for stability After fracture excess calcium can develop which

interferes with normal range

Fat Excess fatty tissue can restrict range of motion

For example; excess abdominal fat can restrict trunk movement

Anatomic Factors that Limit Flexibility

Skin Inelastic scar tissue can develop after surgery or injury

Incapable of stretching with joint movement Overtime can improve elasticity to varying degrees through

stretching

Neural tissue Tightness develops in neural tissues from acute

compression, chronic repetitive microtrauma, muscle imbalances, joint dysfunctions, or poor posture Can create morphological changes in tissue that can cause pain Pain can cause muscle guarding and spasm Can eventually lad to neural fibrosis or scarring

Active and Passive Range of Motion

Active range of motion Dynamic flexibility Degree to which a joint can be moved by a muscle

contraction Not necessarily a good indicator of joint stiffness or

looseness because movement of joint has little resistance

Passive range of motion Static flexibility Degree to which a joint can be passively moved to end

points of range of motion No muscle contraction involved

Active and Passive ROM

Many situations in activity when muscle is forced beyond its normal active limits If muscle does not have elasticity to compensate,

injury to musculotendinous unit may occur

Assessment of ROM

Goniometers Large protractors w/ measurements in degrees Align arms of goniometer along longitudinal axis of 2

segments Reasonably accurate measurement of ROM Standardization of measurement techniques and

recording AROM & PROM have been developed Immobile arm is lined up along immobile segment Mobile arm is lined up along mobile segment

Neurophysiologic Basis of Stretching

Mechanoreceptors in muscle tell CNS what is happening within that muscle

2 of these are important in the stretch reflex

Muscle spindle and the Golgi tendon organ (GTO) Sensitive to changes in muscle length GTO also sensitive to change in muscle tension

Neurophysiologic Basis of Stretching

Muscle spindle initially sends sensory impulse to spinal cord which then sends a message back to muscle spindle causing the muscle to reflexively contract

If stretch last longer than 6 seconds, impulses from GTO begin to override muscle spindle • autogenic inhibition, or a reflex relaxation of the antagonist

muscle• Protective mechanism to allow stretch to avoid damage to

muscle fibers

Reciprocal inhibition• Contraction of agonist causes a reflex relaxation in the

antagonist muscle• Allows antagonist to stretch and protects from injury

Effects of stretching on physical and mechanical properties of muscle

Muscle and tendon composed of non contractile collagen and elastin fibers Collagen can withstand high tensile stress

Mechanical properties Elasticity: capability to recover normal length after

elongation Viscoelasticity: allows for slow return to normal length and

shape after deformation Plasticity: allows for permanent change or deformation

Physical Properties Creep response: ability of tissue to deform over time while a

constant load is imposed Greater the stretch the greater the noncontractile properties

contribute Lengthening of a muscle via stretching allows for viscoelastic

and plastic changes to occur in collagen and elastin

Effects of stretching on the kinetic chain

Muscle tightness has significant impact on neuromuscular control Effects normal length-tension relationships Compensations and adaptations occur that affect

neuromuscular efficiency through kinetic chain Reciprocal inhibition

For example: if psoas is tight or hyperactive the antagonist gluteus maximus can be inhibited due to decreased neural drive

The synergist, hamstrings (muscle that assist glut max); the stabilizers, erector spinae; and the neutralizers, piriformis become overactive• Creates abnormal joint stress and decreased neuromuscular

control during functional movement

Importance of increasing muscle temp. prior to stretching

Muscle temperature should be increased prior to stretching Positive effect of collagen and elastin components to

deform Capability of GTO to reflexively relax is enhanced

Can be achieved through low intensity warm up or through various therapeutic modalities However exercise is recommended over modalities If muscle guarding occurs cold therapy can also be

used prior to stretching

Stretching techniques

Agonist muscle: muscle that contracts to allow movement through a joint

Antagonist muscle: the muscle that is being stretched in response to contraction of agonist Balance between the agonist and antagonist is

necessary for normal, smooth, coordinated movement As well as reduce muscle strains secondary to muscular

imbalances Comprehension of this synergistic muscle action is

essential to understanding various stretching techniques

Ballistic stretching

Repetitive contractions of agonist used to produce quick stretches of antagonist Safety questioned because of risk of microtears in

musculotendinous unit Not recommended for sedentary individuals or those

recovering from muscle injury Most physical activities are dynamic and repetitive

contraction of agonist with eccentric resistance from antagonist occurs May be implemented in later stages of rehab during

reconditioning phase Progressive velocity flexibility program has been proposed

• Slow static to slow end range to slow full range to fast end range to fast full range

Static stretching

Extremely effective and widely used method of stretching Passively stretching antagonist or actively contracting

agonist to stretch antagonist to maximal position and holding for extended time Recommended to hold for 15 to 30 seconds is most

effective to increase flexibility Can be used early on in rehabilitation program

ATC, teammate, other assistive devices Best to do after muscle temperature is increased

May be more efficient to do after activity and not before

Proprioceptive Neuromuscular Facilitation (PNF)

First used by ATC’s rehabilitating neuromuscular disorders More recently used to increase flexibility 3 types of PNF stretching techniques

Contract relax: beneficial to athletes where ROM is limited by muscle tightness Athlete actively contracts agonist to point of limitation,

athlete then instructed to contract antagonist (muscle to be stretched) isotonically (through range of motion), athlete then relaxes as ATC passively moves part to point of limitation. Stretch is then repeated

Proprioceptive Neuromuscular Facilitation (PNF)

Hold relax: Similar to contract relax except antagonist goes through isometric contraction (contraction w/o movement) Hold for at least 6 seconds Can be used for agonist or antagonist

Slow reversal-hold-relax Begins with isotonic contraction of agonist, followed by

isometric contraction of antagonist During relax phase antagonist are relaxed while agonist

are contracting

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Dynamic stretching

Stretching through series of movement patters Progressive slow controlled movements to faster movements

Muscle activation of agonist and muscle stretching of antagonist Posture and form important Increases core and muscle temperature Increases neuromuscular control Increases balance Core stability Effective for increasing flexibility

Better way to stretch prior to activity• Shown to increase flexibility, decrease injury and increase force

and power output• Mimics sport activity, so more functional• Can initially cause some muscle soreness

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Comparing stretch techniques

All have been shown to increase flexibility PNF is capable of producing greater improvement in flexibility

Requires a partner Static

Has to be done often and held for extended periods of time Prior to exercise may decrease core and muscle temperature when

compared to dynamic stretching More appropriate in rehab and as a cool down method after

activity Dynamic

Research supports use prior to activity Ballistic

Can cause injury in untrained or already injured person Can maintain flexibility w/ stretching 1 day a week, but to

improve flexibility must perform 3-5 times/week

Pilates and Yoga

Pilates Extremely popular and widely used method Developed by Joseph Pilates prior to WWII Conditioning program that improves muscle control,

flexibility, coordination, strength and tone. Concentrated on body alignment, breathing, lengthening

of all muscles while building endurance and strength

Pilates and Yoga

Yoga Originated in India 6000 years ago Philosophy that most illness related to poor mental

attitude, posture and diet Aimed to unite body and mind through various body

postures and meditative breathing Start simple and progress to more complex movements Increase mobility and flexibility

Myofascial release stretching

Relieve soft tissue from abnormal grip of tight fascia (fibrous membrane that covers, supports and separates muscles, tendons, bones and organs) Localize restriction and move into direction of

restriction Releasing myofascial restrictions over large treatment

area can have significant impact on joint mobility Progression of superficial restrictions to deeper

restrictions Stretching techniques can be incorporated after

extensibility is improved in myofascia Can use foam rollers to assist with myofascial release

Other methods to restore ROM

MassageStrain-counter strainSoft tissue mobilizationGraston techniqueMassage

Benefits of ROM exercises

Inreased flexibilityIncreased mobilityIncreased blood flow to area

Facilitate tissue healing processDecreased swellingDecreased adhesion formationDecreased pain