Active Care - Exam 1 Part 2: Mobility and Soft Tissue Treatments

What is the AROM ability of a joint to move through a given range of motion under neurological control of a given joint and surrounding soft tissue?

Mobility

What is the PROM of a given joint and surrounding tissue?

Flexibility

What is the ability to get a certain angle (ROM) but not to be able to use that angle (ROM) in daily life, needing to work on motor control to give a person the ability to actively express ROM and flexibility that they already possess?

Useless Flexibility

(Great passive but can't express the active)

What can cause reduced ROM from an active tension? (3)

1) Nervous system tone

2) Contracture

3) Guarding of a muscle (protective & stability function)

What can cause reduced ROM from a passive tension? (3)

1) Muscle viscoelasticity

2) Fascia

3) Nerve (time)

When we have joint hypermobility, the brain senses instability in the _________ stabilizing system through __________ feedback from joint structures. The body then responds by creating stability through ___________ stabilization system and creating _________ muscle tone

Passive stabilizing system

Afferent feedback

Active stabilizing system

Increased muscle tone

What is the relationship between flexibility and injuries?

Very flexible & NOT flexible have higher rates of injuires

(U-shaped curve)

Are tight or flexible muscles more prone to soft tissue injuries? Joint related injuries?

Soft Tissue = Tight muscles

Joint Related = Flexible muscles

Are tight or flexible muscles are more prone to DOMS and store and release energy better?

Tight muscles

As we age, flexibility will decrease, with a reduction of ____% per decade from 20-49 years old?

10% reduction per decade

What most likely causes the feeling of muscle tightness?

Sensitivity that comes from nervous system and sometimes inflammation (fascia and neurological)

Tightness = shortening / unpleasant sensation

What are 4 reasons why we experience tightness and stiffness?

1) Prolonged posture leading to ISCHEMIA

2) Lack of movement leading to ADAPTATION to imposed demands

3) Weakness leading to OVERLOAD

4) Stress/diet/sleep/emotions leading to SENSITIZATION

How does neuromuscular dysfunction lead to tightness and restricted ROM?

Nervous system dysfunction leads to what presents as tight/immobile tissues

-- nothing is physically wrong w/ the tissues

What are the 3 different types of treatments that are optimal for neuromuscular dysfunction?

1) Muscle activation stretching protocols (PNF, MET)

2) End range activation techniques (CARS, PAILs, lift offs)

3) General movement or specific motor control exercises

What specific types of treatments do physically remodeled/shortened tissues require?

Stretching/loading of tissues to end range that are sustained for 2+ minutes for 8+ weeks to remodel tissues

What holds cells and tissues together?

Fascia

What does fascia communicate and remodel in response to?

Mechanical loads such as compression, tension, strains

Movement depends on afferent feedback, and the brain is reliant on proprioceptive feedback to determine motor (efferent output). What major structure(s) in teh body provide a significant amount of afferent feedback necessary for allowing proper movement expression?

Sensory perception begins at articulations by the internal innervation of joint capsules, therefore, perception of load/force is perceived by JOINTS first

Why is performing an adjustment BEFORE active care exercises recommended?

Allows short window of neurological inhibition of muscles which allows active/movement-based intervention to be more effective

What are 5 indications of stretching?

1) Restricted motion leads to structural deformities (preventable)

2) Muscle weakness & shortening of opposing tissue

3) May be used as part of a total fitness program (MSK injury)

4) Prior vigorous exercise to minimize soreness

5) ROM limited due to loss of extensibility (adhesions, contractions, scar tissue formation)

What are 8 contraindications of stretching?

1) Bony block (limits motion)

2) Fracture (nonunion; incomplete)

3) Acute inflammatory or infectious process

4) Soft tissue healing

5) Sharp acute pain w/ JT movement

6) Hematoma or other tissue trauma

7) Shortened soft tissue provide support/enable functional skills in lieu of neuromuscular control

8) Hypermobility

Stretching will target nervous system tone and fascial structure (endomysium, perimysium, epimysium) to affect change in what?

Nervous system through facilitation or inhibition of neuromuscular tone, fascial tension/contraction, and viscoelasticity

How long do the effects of stretching endure?

5-30 minutes

Which important factor or parameters is most important to moidfy in order to counter the short-term effects of stretching?

Load & Time

If you stretch for ______s, then you plateau faster at 6-7 weeks. If you stretch for _______s, then you plateau at 10 weeks.

30s

15s

What 3 things cause acute increase in ROM seen with static stretching?

1) Analgesic response

2) Inhibited nervous system tone

3) Short term increase in flexibility of muscles

In _____s stretches, the viscoelasticity of muscle increased until the 4th rep, showing that this is sufficient to increase ROM in most healthy people. This increase in ROM can be gained through ___-___ reps for most people.

30s stretch

3-4 reps

During what timeframe of stretching does majority of the increase in ROM occur?

The first 15s of the 30s

NOTE: no more than 120 s

What is the ideal duration a stretch should be held?

15-30s

NOTE: Remember, most occurs in first 15s, after 4th 30s stretch there is no gains

What is the ideal frequency for stretching? How long (days/weeks) should someone be consistent w/ a stretching routine for optimal outcomes?

Multiple times per day

6-10 weeks

What is the ideal number of repetitions a stretch should be performed for maximal benefit?

3-4 sets (15-30s)

NOTE: adherence and consistency necessary to accomplish long term improvement as fascia and load leads to fibroblast activity

What is the primary factor for increasing tendon flexibility, and how long do you need to stretch a tendon to see length improvements?

Gentle stretch for up to 10 minutes

What is stretching causing an acute inhibition of maximal force produced by the muscles?

Stretch induced strength loss

What activities is primarily impacted by stretch induced strength loss?

Activities of slow velocities (deadlift or bench press)

What minimizes the stretch induced strength loss?

Maximal contraction of muscle prior to static stretch

With the effect stretching has on economy of movement and perceived exertion for steady state endurance training such as running, the results should encourage runners to insert ___________ during warm-up to optimize the running energy cost, _________ the perception of effort, and make training enjoyable?

Insert stretching during warm-up

Reduce perception of effort

What is the difference between static stretching and strength training for increase ROM?

NO difference in ROM gain

-- any movement routine will provide increased flexiblilty and mobility if performed through full ranges of motion and performed regularly

What are the 3 causes of DOMS (Delayed Onset Muscle Soreness)?

1) Neural feedback (stretched & elongated, muscle spindle stretch leads to pain)

2) Free radical (produced/released from mitochondria)

3) Swelling (relates back to pressure around nerve endings)

What are the 4 different categories of stretching techniques?

1) Static

2) Dynamic (active or ballistic)

3) Muscle energy technique (PIR & RI)

4) PNF (contract-relax, hold-relax, CRAC)

What type of stretching is passive and "relaxing", slow and constant, and if done by self can use bands or stretch snaps?

Static Stretching

What is the underlying reasoning behind the push against while performing ballistic stretching?

Makes more active by moving yourself into an end range stretch position

-- dedicated effort on the part of the stretcher to use force to hold or extend the ROM

Why does ballistic stretching have an increased risk of injury, difficult control of momentum, and is not indicated for injury recovery?

Does not result in sustained increase in ROM, so doesn't allow muscles to adjust and relax to stretched position or for neurological system to adapt to new end range position

What type of stretching is controlled movement through a full range, starting slow then picking up speed and increased ROM, using sport or task specific stretches, preparing and "warming up" the body for specific demands/tasks, and may be beneficial for improving performance, especially in sports?

Active Dynamic stretching

What is the concept of patient management where all humans have untapped existing potential, with each session directed to total human not just a specific probelm (integrated), a focus on and reinforcement task that the patient can do (positive) that helps the patient achieve highest level of function as well as motor control and learning principles that move at patients pace to allow for body to adapt?

Proprioceptive Neuromuscular Facilitation (PNF)

What are the 3 GOALS for PNF inhibitor techniques? (The PNF basics for inhibition)

1) Motor control

2) Inhibition & decreased excitability of motor units

3) Reduction in spasticity and hypertonicity

What are the 3 PNF inhibitory techniques?

1) Hold relax

2) Contract relax

3) Contract relax agonist contract (CRAC)

What PNF stretching technique is the contraction of the antagonist simultaneously to inhibition the action of the agonist?

Reciprocal inhibition / Sherringtons Law

What anatomy is involved with Reciprocal inhibition / Sherringtons Law?

Muscle Spindles

What 2 techniques use the idea of Reciprocal inhibition?

1) CRAC

2) Reciprocal inhibition MET (muscle energy technique)

Which PNF stretching techniques utilize post contraction inhibition? (6)

1) Hold relax

2) Contract relax

3) CRAC

4) PIR

5) MET

6) PFS

Which stretching technique is for 15s the muscle is stretched, the patient contracts for 6 s and Dr matches resistance to make isometric contraction, with 20% of the contraction, then relax and the muscle is moved to its new motion barrier and held for another 15s, repeating this 2-4 times?

Hold-Relax technique (PNF inhibitory technique)

Which stretching technique is where the Dr finds a point of tension, passive stretch of 15s, then isometrically contract muscle for 6s, then patient concentrically contracts the muscle being strewed when Dr does light resistance until neutral resting is reached, then go to a new barrier and hold for 15s, repeating 2-4 times?

Contract Relax technique (PNF inhibitory technique)

Which stretching technique is where the Dr finds a point of tension, passive stretch of 15s, then isometrically contract muscle for 6s, then patient concentrically contracts the reciprocal muscle when Dr does light resistance until neutral resting is reached, then go to a new barrier and hold for 15s, repeating 2-4 times?

Contract Relax Antagonist (CRAC)

-- NOTE: same as contract relax but use RECPIROCAL INHIBITION

What is stretching involving voluntary contraction of a muscle in precise and controlled direction with variations in intensity, using the muscles own energy in the form of isometric contraction to relax the muscle via autogenic or recipricol inhibition and lengthen the muscle?

Muscle Energy Technique (MET)

Why should we incorporate stretching with chiropractic care? (3)

1) Smooth adjustment

2) Helps hold adjustment longer

3) Better short term and long term adjustments

What senses the increase in tension when muscle contracts or stretches, so when the muscle contracts its activated and responds by INHIBITING the contraction (reflex inhibition) and contracting the opposing (antagonist) muscle group?

Golgi Tendon Organ

What role do Golgi Tendon Organs and Muscle Spindles play in protecting muscles, tendons, and joints?

GTO = cx of same muscle = inhibition (relax) same muscle

Muscle Spindle / Sherrington Law = cx of opposite muscle inhibits actions of muscles being stretched

Post contraction inhibition (PIR) involves proprioceptor?

Golgi Tendon Organs

What is where the GTO between the muscle belly and tendons senses an increase in tension when the muscle contracts or stretches, where the GTO inhibits contraction of already stretched muscles for PROTECTION?

Autogenic inhibition

How is autogenic inhibition used during stretching?

Contraction of stretched muscle followed by further stretching of same muscle

(brief contraction = increased relaxation = stretch muscle further)

Which MET technique uses autogenic inhibition?

PIR

What stretch is submax (10-20%) contraction of the target muscle, performed away from the barrier?

Post-isometric relaxation (PIR)

How long is the initial PIR stretch held? What percent of contraction of the target muscle is asked to be performed? How many cycles/reps?

5-10s

10-20%

2-4x

What is the relaxation of muscles on one side of a joint to accommodate contraction on the other side of the joint, where muscle spindles located within the muscle belly and stretch along the muscle are activated causing that reflexive contraction in the agonist muscle (stretch reflex) and relaxation in antagonist muscle?

Reciprocal inhibition (Sherrington's Law)

Reciprocal inhibition (Sherrington's Law) involves what proprioceptor?

Muscle spindles

How is reciprocal inhibition used during stretching?

Contraction of one muscle followed by stretching of the opposite muscle

What is isometric action of opposing (shortened) muscles, with muscle taken to resistance an dpatient isometrically contracting antagonist muscles?

Reciprocal Inhibition MET stretch

How long is the initial IR stretch held? What percent of contraction of the target muscle is asked to be performed? How many cycles/reps?

Initial = 10-15s (or 5-10?)

10-20% effort

Repeat 2-4x

What stretch is holding the muscle midway between neutral and point of tension with a contraction of maximum or near maximum effort (Max contraction at mid range) for 10 seconds, relax, hold stretch for 15, rest for 20-30, and repeat 3-5 times?

Post-Facilitation Stretch (PFS)

What stretch is no longer than 2 s, all target muscles to optimally lengthen w/o triggering protective stretch mechanism, where the patient initiates voluntary movement towards end range and the Dr applies gradual tension of no more than 1 lb of pressure to stretch, the patient contracts the antagonist for 1-2s once the barrier is reached, you stretch for no more than 2s at end range, return to strating position, release 15-20 reps for 1-2 sets?

Active Isolated Stretching (AIS)

What is the application of typical elements of game playing into exercise/stretching?

Gamification

What 3 constraints can be modified using dynamic systems theory (DST)?

1) Environment

2) Task

3) Individual

What type of cue is preferred more in gamification? Why?

External cues

-- makes patient think and do more (Primary driver!)

For gamification, which is an internal cue and which is an external cue?

A) Imagine a large window between you knees

B) Squeeze your glutes

A = External cue (imagine)

B = Internal cue (direct)

Which of the following is considered a goal of evidence-inspired active care?

A. Build resiliency and capacity through load management

B. create dependency on provider treatment

C. promote pain avoidance

D. promote short-term relief

A. build resiliency and capacity through load management

Which of the following describes how the human body can be considered in terms of interrelated links or segments?

A. motor control

B. upper crossed syndrome

C. kinetic chain

D. length-tension relationship

E. Joint centration

C. kinetic chain

According to the joint by joint approach, which joint is most prone to mobility restrictions?

A. knee

B. thoracic spine

C. lumbar spine

D. scapula

E. elbow

B. thoracic spine

How many minutes per week of moderate intensity aerobic training are recommended?

A. 90

B. 100

C. 120

D. 150

E. 160

F. 180

D. 150

NOTE: resistance is 2 days

Why does incorporating a movement assessment lead to better diagnostics and better outcomes?

A. helps measure body parts more effectively

B. reduces need for physical examination

C. helps find the cause and explain the source

D. reduces the need for imaging

C. helps find the cause and explain the source

Utilizing the "Three R's" of active care, which of the following is an example of reinforce technique?

A. endurance training

B. adjustment

C. PNF stretching technique

D. lumbar roll

E. strengthening exercise

D. lumbar roll

NOTE: E = retrain

According to the 4x4 matrix, what position is considered least difficult?

A. standing

B. supported

C. stacked

D. suspended

E. seated

B. supported

According to the 4x4 matrix, which demand or challenge is considered most difficult?

A. demonstrate

B. feedback

C. capacity

D. capacity with feedback

C. capacity

NOTE: remember anything w/ feedback is assisting us a little bit

According to the 4x4 matrix, which progression would be most appropriate to increase the difficulty of a 2x2 exercise?

A. 1x1

B. 2x1

C. 2x3

D. 3x1

E. 4x1

F. 4x4

D. 3x1

Which of the following is a likely explanation for why individuals commonly experience tightness/stiffness?

A. frequent postural changes

B. weakness leading to overload

C. desensitized to stressful stimuli

D. hypertrophy from training

E. magnesium deficiency

B. weakness leading to overload

Tissue dysfunction involving physically remodeled (shortened) tissues typically takes _____ or more weeks to develop?

A. 2

B. 4

C. 6

D. 8

E. 10

F. 12

D. 8

Due to the short-term effects of stretching, which parameter is likely most important to increase?

A. intensity of stretching

B. frequency of strething

C. duration of stretching

D. type of stretching

E. time of day performing stretching

B. frequency of stretching

Which PNF technique utilizes reciprocal inhibition through concentric contraction of the antagonist (opposite) of the muscle being stretched ?

A. contract relax (CR)

B. hold relax (HR)

C. Post-isometric relaxation (PIR)

D. contract relax antagonist contract (CRAC)

E. post-facilitation stretch (PFS)

D. contract relax antagonist contract (CRAC)

NOTE: only two that utilize opposite is RI and CRAC

Individuals with tighter muscles are more prone to:

A. delayed onset muscle soreness

B. joint-related injuries

C. muscular atrophy

D. neurological disorders

E. muscular amnesia

A. Delayed onset muscle soreness (DOMS)

NOTE: cross off all the other stuff we didn't talk about in lecture, so down to joint or DOMS

Post-isometric relaxation (PIR) and reciprocal inhibition (RI) are both forms of which technique?

A. IASTM (instrument assisted soft tissue mobilization)

B. PNF (proprioceptive neuromuscular facilitation)

C. MET (muscle energy technique)

D. PFS

E. TRT (torque release technique)

C. MET (muscle energy technique)

Which of the following utilizes muscle spindles to facilitate increase relaxation and is also known as Sherrington's law?

A. Reciprocal inhibition

B. Autogenic inhibition

C. post-isometric relaxation

D. Trigger point release (Nimmo)

E. Active isolated stretching (AIS)

A. Reciprocal inhibition

During muscle energy technique (MET) stretching, what percentage of isometric contraction are we asking form the patient?

A. 0%

B. 20%

C. 40%

D. 50%

E. 80%

F. 100%

B. 20%

What is the best way to minimize stretch induced strength loss?

A. abstain from strength training

B. max contraction of muscle prior to static stretch

C. max contraction of muscle following static stretch

D. submaximal contraction just prior to heavy lift

E. submaximal contraction following heavy lift

B. max contraction of muscle prior to static stretch

T/F: The most efficient method of incorporating stretching into patient care is for the doctor to apply a gentle passive stretch following each adjustment

FALSE