Mobility

Can be described by 2 parameters Ability of structure or segment of body to move or be moved to allow the presence of ROM for functional activities (functional ROM) It can also be defined as the ability of an individual to initiate control or sustained active movement of the body to perform simple to complex motor skills. (Functional Mobility)

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2.

Flexibility

Flexibility is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM. Muscle length in conjunction with joint integrity and the extensibility of periarticular soft tissues determine flexibility.

Dynamic flexibility Dynamic flexibility (active mobility) refers to the active ROM of a joint. This aspect of flexibility is dependent upon the degree to which a joint can be moved by a muscle contraction and the amount of tissue resistance met during the active movement.

Passive flexibility Passive flexibility( passive mobility) is the degree to which a joint can be passively moved through the available ROM dependent upon the extensibility of muscles and connective tissues that cross and surround a joint. Passive flexibility is a prerequisite for but does not ensure dynamic flexibility.

Hypo mobility
Hypo mobility refers to decreased mobility or restricted motion.
caused by 1 prolonged immobilization 2.sedentry life style 3.postural mal alignment 4.impaired muscle performance associated with disease condition 5.tissue trauma 6 congenital conditions or acquired deformity

Contracture

Contracture is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint, which results in significant resistance to passive or active stretch and limitation of ROM.

Shortness

Shortness is used to denote a partial loss of motion. In the clinical and fitness settings the term tightness, although a very non specific term, is frequently used to describe a mild restriction of motion.

Designation of Contractures by Location Contractures are described by identifying the action of the shortened muscle. If a patient has shortened elbow flexors and cannot fully extend the elbow, he or she is said to have as elbow flexion contracture.

Types of contractures One way to clarify what is meant by the term contracture is to describe contractures by the pathological changes in the different types of soft tissues involved.

1. Myostatic Contracture 2. Peseudomyostatic Contracture 3. Arthrogenic and Periarticular Contractures 4. Fibrotic Contracture and Irreversible Contracture

Myostatic Contracture In a myostatic (myogenic) contracture, although the musculotendinous unit has adaptively shortened and there is a significant loss of ROM, there is no specific muscle pathology present.

Peseudomyostatic Contracture
Impaired mobility and limited ROM may also be the result of hypertonicity(INCREESED TENSION OF MUSCLE), that is, spasticity or rigidity, associated with a central nervous system lesions such as a cerebral Vascular accident, a spinal cord injury, or a traumatic brain injury.

Arthrogenic and Periarticular Contractures An arthrogenic contracture is the result of intra -articular pathology. These changes may include adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation.

Fibrotic Contracture and Irreversible Contracture

Fibrous changes in the connective tissue of muscle and periarticular structures can cause adherence of these tissues and subsequent development of a fibrotic contracture. Although it is possible to stretch a fibrotic contracture and eventually increase ROM, it is often very difficult to re-establish optimal tissue length.

Stretching

Stretching is a general term used to describe any therapeutic maneuver to increase mobility of soft tissues and subsequently improve ROM by elongating (lengthening) structures that have adaptively shortened and have become hypo mobile over time.

Indications for use of Stretching

When ROM is limited because soft tissues have lost their extensibility as the result of adhesions, contractures, and scar tissue formation, causing functional limitations or disabilities. When restricted motion may lead to structural deformities other wise preventable. As a part of a total fitness program designed to prevent musculoskeletal injuries. Prior to an after vigorous exercise to potentially minimize post exercise muscle soreness.

Contraindications of Stretching
When a bony block limits joint motion. After a recent fracture before bony union is complete. Whenever there is evidence of an acute inflammatory or infectious process (heat and swelling) or when soft tissue healing could be disrupted in the tight tissues and surrounding region. Whenever there is sharp, acute pain with joint movement or muscle elongation. When a hematoma or other indication of tissue trauma is observed. When hyper mobility already exists. When contractures or shortened soft tissues are providing increased joint stability in lieu of normal structural stability or neuron muscular control. When contractures or shortened soft tissues are the basis for increased functional abilities, particularly in patients with paralysis or severe muscle weakness.

Interventions to Increase Mobility of Soft Tissues

There are many types of therapeutic interventions that are designed to improve the mobility of soft tissues and consequently increase ROM. Stretching and mobilization are general terms that describe any therapeutic maneuver that increase the extensibility of restricted soft tissues.

Overstretching and Hypermobility

Overstretching is a stretch well beyond the normal ROM of a joint and the surrounding soft tissues, resulting in Hypermobility (excessive mobility) Creating selective hypermobility by overstretching may be necessary for certain healthy individuals with normal strength and stability participating in sports that require extensive flexibility. Overstretching becomes detrimental and creates joint instability when the supporting structures of a joint and the strength of the muscles around a joint are insufficient and cannot hold a joint in a stable, functional position during activities. Instability of a joint often causes pain and may predispose a person to musculoskeletal injury.

TYPE OF STRETCHING

Static Stretching Static Progressive Stretching Cyclic (Intermittent) Stretching Ballistic Stretching

Static Stretching
Static stretching is the most common term used to describe a method by which soft tissues are lengthened just past the point is tissue resistance and then held in the lengthened position for as extended period of time with a sustained stretch force.

Static stretching has been linked to duration ranging from as few as 15 seconds to several minutes when a manual stretch or self-stretching procedure is employed.

Static stretching has been well accepted as a safer form of stretching than ballistic stretching for many years.

Static Progressive Stretching

Static Progressive Stretching is another term that describes how static stretch is applied for maximum effectiveness.

The shortened soft tissues are held in a comfortably lengthened position until a degree of relaxation is felt by the patient or therapist. Then the shortened tissues are incrementally lengthened even further and again held in the new end-range position for an additional duration of time.

Cyclic (Intermittent) Stretching

A relatively short-duration stretch force that is repeatedly but gradually applied, released, and then reapplied is described as cyclic (Intermittent) stretch.

Ballistic Stretching
A rapid forceful intermittent stretch, that is, a high-speed and high-intensity stretch, is commonly called Ballistic Stretching. It is characterized by the use of vigorous bouncing movements that create momentum to carry the body segment quickly through the ROM to stretch shortened structures. Ballistic stretching has been shown to increase ROM in young, healthy subjects, who participated in a conditioning program. It is, for the most part, not recommended. It is consistently contraindicated in elderly or sedentary individuals or patients with musculoskeletal pathology or chronic contractures because, The high-velocity, high-intensity movements are difficult to control. Tissues, weakened by immobilization or disuse, are easily injured. Dense connective tissue found in chronic contractures does not yield easily with rapid stretch; rather it becomes more brittle and tears more readily.

Determinants of Stretching Exercises

There are number of essential elements that determine the effectiveness of a stretching program. The elements of stretching, all of which are interrelated, include the alignment and stabilization of the body during stretching, intensity speed, duration frequency mode of stretch the integration of neuromuscular inhibition and functional activities into stretching procedures. The numerous variations and combination of thee elements provide the therapist with many options from which to choose when designing stretching exercises that are safe and effective and meet many patients needs, goals and capabilities.

Alignment
Proper alignment or positioning of the patient and the specific muscles and joints to be stretched is necessary for patient comfort and stability during stretching. Alignment influences the amount of tension present is soft tissue and consequently affects the range of motion available in joints. Alignment of the muscles and joints to be stretched as the alignment of the trunk and adjacent joints must all be considered.

Stabilization

To achieve an effective stretch of a specific muscle or muscle group and associated periarticular structures, it is imperative to stabilize (fixate) either the proximal or distal attachment site of the muscle-tendon unit being elongated.

Intensity of Stretch
The intensity of a stretch force is determinate by the load placed on soft tissue as it is being elongated. There is general agreement among clinicians and researches the stretching should be applied gently, that is, at a low intensity by means of a low load. Low intensity stretching in comparison to high-intensity stretching makes the stretching maneuver more comfortable for the patient and minimizes voluntary or involuntary muscle guarding so that the patient can either remain relaxed or assist with the stretching maneuver.

Duration of Stretch
The duration of a stretch refers to the period of time a stretch force is applied, and shortened tissues are held in a lengthened position. Duration most often refers to how long a single cycle of stretch is applied. If more than one repetition of stretch (stretch Cycle) occurs in a treatment session, the cumulative time of all the stretch cycles is also considered an aspect of duration. Terms such as, Static, sustained, maintained, and prolonged are all used to describe a long-duration stretch, whereas terms such as cyclic, intermittent or ballistic are used to characterized short duration stretch.

Speed of Stretch

Importance of a Slowly Applied Stretch To ensure optimal muscle relaxation and prevent injury to restricted tissues, the speed of stretch should be slow. The stretch force should be applied and released gradually.

Frequency of Stretch
Frequency of stretching refers to the number of bouts (sessions) per day or per week a patient carries out a stretching regimen. The recommended frequency of stretching is often based on the underlying cause of immobility, quality and the level of healing of tissues, chronicity and severity of a contracture, patients age, use of corticosteroids, and previous response to stretching. Since very few studies have attempted to determine the optimal frequency of stretching within a day or a week.

MODE OF STRETCH
The mode of stretch refers to the form of stretch or the manner in which stretching exercises are carried out.

Mode of stretch can be defined by who or what is applying the stretch force or whether or not the patient is actively participating in the stretching maneuver.

passive With assistance of patient Self(by patient)

Manual Mode Mechanical

MANUAL STRETCHING
A therapist or other trained practitioner or caregiver applies an external force to move the involved body segment slightly beyond the point of tissue resistance and available ROM. The therapist manually controls the site of stabilization as well as the direction, speed, intensity, and duration of stretch. Manual stretching usually employs a gentle, controlled, end-range, static, and progressive stretch held for about 30 to 60 seconds and then repeated for several or more cycles. Manual stretching is indicated in the early stages of a stretching program when a therapist may want to determine how a patient responds to carrying intensities or durations of stretch and when optimal stabilization is most critical.

Manual Stretching can be performed, (similar to ROM exe)

Passively With assistance from the patient Even independently by the patient

Manual stretching performed passively, also referred to as Passive Stretching, is the only choice if a patient lacks neuromuscular control of the body segment to be stretched

It is often to ask the patient to assist the therapist with the stretching maneuver, particularly if the patient is apprehensive and is having difficulty relaxing. If the patient concentrically contracts the muscle opposite the short muscle and assists with joint movement, the range limiting muscle will reflexively relax, making muscle elongation easier. Some clinicians refer to this as a form of neuromuscular inhibition, called agonist contraction; this approach to muscle relaxation and elongation Using procedures and hand placements similar to those described for self-ROM exercises, patient can also independently lengthen range-limiting muscles and periarticular tissues with manual stretching. As such, this form of stretch is usually referred to as Self-stretching.

SELF STRETCHING
Self-stretching (also referred as flexibility exercises or active stretching) is a type of stretching procedure that a patient can carry out independently after careful instruction and supervised practice. Self stretching enables a patient to maintain or increase the ROM gained as the result of direct intervention by a therapist.
This form of stretching is often an integral component of a home exercise program and is necessary for effective and efficient long-term self-management of many musculoskeletal and neuromuscular disorders

MECHANICAL STRETCHING
There are many ways to use equipment to stretch a contracture and increase joint ROM. The equipment can be as simple as a cuff weight or weight-pulley system or as sophisticated as some orthosis or automated stretching machines. These mechanical stretching devices either provide a constant load with variable displacement or constant displacement with variable loads

Mechanical stretching devices apply a very low-intensity stretch force (low-load) over a prolonged period of time to create plastic deformation (lengthening) of tissues.

It is often the responsibility of a therapist to recommend the type of stretching device that is most suitable or to teach a patient how to safely use the equipment and to monitor its use in the fabrication of serial casts or splints The stretch load, which can be applied with a cuff weight, is often as low as a few pounds

Some devices, such as the Joint Active Systems orthosis , allow the patient to control and adjust the load (stretch force) during the stretching session. With other devices , such as the Dynasplint , the load is preset prior to the application of the splint and the load remains constant while the splint sin in place.

The duration of mechanical stretch ranges from 15 to 30 minutes or as long as 8 to 10 hours at a time, depending on the type of device employed, the severity of impairment, and patient tolerance.

Some devices such as serial casts are worn for days or weeks at a time before being removed and then reapplied. Significantly longer durations of stretch are required for patients with chronic contractures as the result of neurologic or musculoskeletal disorders than healthy subjects with only mild hypomobility as the result of myostatic contractures.