Flexibility and Endurance

what is hypermobility

excessive mobility or motion

what is hypomobility

decreased mobility or restricted motion

causes of hypermobility

- injury

- CT disorder (i.e. Ehlers Danlos Syndrome/EDS)

- overstretching beyond normal muscle length

effect of GHJ anterior displacement on chest musculature

tightens chest musculature

effect of GHJ anterior displacement on posterior shoulder musculature

weakens posterior shoulder musculature

effect of GHJ anterior displacement in posterior shoulder capsule

introduces tightness

things to consider when stretching with hypermobility

- cause of hypermobility

- does the hypomobility serve a purpose

when the cause of hypermobility is injury what should be avoided

stretching the injured/hypermobile tissue

when the cause of hypermobility is connective tissue disorder what should be avoided

stretching the ligament/joint capsule

when the cause of hypermobility is overstretching what should be avoided

stretching overstretched tissue

what does hypomobility help with in those with tight hamstrings

Provides support to knee joint that is not provided by noncontractile tissues

guidelines for stretching with hypermobility

- ensure a focused, specific stretch

- start with a manual stretch to provide more control

- have patient perform self stretch immediately after to ensure they can properly perform and feel stretch

causes of hypomobility

- sedentary lifestyle

- habitual faulty posture / asymmetrical movement

- paralysis

- tonal abnormality

- postural malalignment

- immobilization

types of postural malalignment

- congenital (i.e. scoliosis)

- acquired (i.e. injury)

contracture

adaptive shortening of muscle-tendon unit, noncontractile soft tissue resulting in resistance to stretch

how are contractures named

based on the action of the shortened muscle

i.e. elbow flexion contracture indicates an inability to extend the elbow due to shorted elbow flexors

how is a contraction different from a contracture

contraction is an active process and not pathological

myostatic contracture

- shortened muscle with no other pathology

- usually can be resolved relatively quick with stretching program

pseudomyostatic contracture

- results from hypertonicity (neurologic involvement) or protective guarding (active contraction)

- can be resolved with inhibitory effects

arthrogenic contracture

- intra-articular pathology (adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, osteophyte formation)

- some can be resolved as tissue heals but sometimes need surgical intervention

periarticular contracture

- CT that crosses or attaches to joint or joint capsule loses mobility and impairs arthrokinematics

- some can be resolved with prolonged stretching/mobility work but sometimes need surgical intervention

fibrotic contracture

- changes within the CT of muscle and periarticular changes result in adherence of these tissues

- can be changed but requires a lot of stretching/mobility work

irreversible contracture

- prolonged fibrotic changes proliferate enough that there is not enough tissue with extensibility to improve mobility

- almost always need surgical intervention

indications for stretching

- ROM limited due to reduced soft tissue extensibility, scar tissue, or contractures

- reduced ROM may lead to other issues

- muscle weakness and shortening of opposing tissues

contraindications for stretching

- bony blocks limits ROM

- recent fracture with incomplete bony union

- evidence of acute injury

- sharp, acute pain with movement

- hematoma or other indications of tissue trauma

immobilization rundown

- maintain soft issue approximation to facilitate tissue

- prevent movement to allow bone healing after fracture

- provide prolonged stretch

when do changes due to immobilization start to occur

within days to weeks

effect that immobilization in shortened position has on muscle

- reduced muscle length

- reduced number of sarcomeres in series (absorption)

- shift in length tension curve to the left that reduces overall muscle capacity to produce force

- reduced extensibility (increased fibrous and fatty tissue)

effect that immobilization in elongated position has on muscle

- designed to improve or limit reduction in mobility

- may increase number of sarcomeres in series (myofibrillogenesis)

ways to immobilize muscle in elongated position

- serial casting

- dynamic splinting after injury

effect of immobilization on non-contractile CT

- weakening of collage (no load to stress new fibers)

- adhesion formation (disorganized fibers and reduced lubrication)

- decreased size and number of collagen fibers

- increased predominance of elastin fibers

managing ROM after immobilization

- avoid high intensity, short burst stretching

- begin with static stretching before progressing to other types

- use soreness to guide progression

- promote physical activity (if patient is able)

indication of pain that lasts for >24 hours after stretching

intensity was too high --> reduce intensity at next session

effects of aging on collagen

- reduced elasticity

- reduced tensile strength

- slower rate of adaptation to stress

a strain is an injury to what structure

muscle

a sprain is an injury to what structure

ligament

grade 1 soft tissue injury

small tear

grade 2 soft tissue injury

moderate tear

grade 3 soft tissue injury

severe to complete tear

clinical signs of grade 1 soft tissue injury

- mild pain at time of injury or within first 24 hours

- mild swelling with local tenderness

- pain when tissue is stressed

clinical signs of grade 2 soft tissue injury

- moderate pain immediately - stop activity

- stress and palpation increase pain

- can have increased mobility

clinical signs of grade 3 soft tissue injury

- severe pain

- stress to tissue is usually painless

- may have instability

acute stage of recovery

- inflammatory response

- typically first 4-6 days

subacute stage of recovery

- phase of repair and healing

- typically days 14-21 after initial injury

- may last up to 6 weeks with tissues that have worse vascularization

chronic stage of recovery

- maturation and remodeling phase

- may last up to 6 months to a year

physiology of acute stage of recovery

- exudation of cells and solutes

- clot formation

- phagocytosis

- early fibroblastic activity

- new capillary beds form

symptoms present in acute stage of recovery

- inflammation (swelling, redness, heat)

- pain at rest

- loss of function

- movement is painful

treatment in acute stage of recovery

- patient education

- protection of injured tissue

- prevent adverse effects of immobilization via tissue specific movement and gentle passive movement

- passive range of motion

- muscle setting using gentle isometrics

- low grade joint mobilization

- massage

passive range of motion strategies

- ensure patient is relaxed

- proximal segment typically supported by table or chair

- distal segment typically supported by therapist

- begin with small ROM and slowly work toward limits of mobility (still not stretching)

physiology of subacute stage of recovery

- clot starts resolving

- more fibroblastic activity

- collagen formation

- granulation tissue develops

- immature collagen replaces clot

- myofibroblastic activity (shrinking of scar tissue)

- immature CT is thin, unorganized, and fragile

symptoms present in subacute stage of recovery

- reduced pain

- active movement begins

- patient typically feels better than they are (tissue is still fragile although pain is reduced)

- muscle weakness may be more prominent

treatment in subacute stage of recovery

- management of pain and inflammation

- initiate active exercise (AAROM, AROM, submaximal isometrics, muscular endurance training)

- initiate stretching (warm up, inhibition techniques, joint mobilization, stretching, massage, use new range)

physiology of chronic stage of recovery

- scar retraction from myofibroblastic activity

- collagen fibers thicken and reorient in response to stress

- improved balance between synthesis and reabsorption of collagen

- fibers will adhere if not stressed

- after a period of time the scar is adhered and will not respond to stretching

symptoms present in chronic stage of recovery

- little to no pain

- potentially limited ROM and/or reduced strength

treatment in chronic stage of recovery

- management of pain and inflammation

- initiate active exercise (AAROM, AROM, submaximal isometrics, muscular endurance training)

- initiate stretching (warm up, inhibition techniques, joint mobilization, stretching, massage, use new range)

physiology of chronic recurring pain

- persistent inflammation

- proliferation of fibroblasts

- increased collagen synthesis and degradation of mature collagen (predominance of new, immature collagen)

- weakened tissue

symptoms of chronic recurring pain

- persistent pain

- reduced ROM

- impaired strength

- swelling and warmth occasionally

treatment for chronic recurring pain

- activity modification to reduce stress on irritated tissue

- treatments that lightly stress tissue (can progress intensity as pain and inflammation decrease)

- develop a balance between strength and mobility

assessment of neurological pathologies and ROM

- positioning

- speed of movement

- gauge pain and mobility

- assess what tissue is limiting movement

(HIGHER/LOWER) speeds are more likely to trigger tone/spasticity

higher

(HIGH/LOW) speed allows contractile tissue to relax

low

ACSM recommendations for flexibility training in individuals with MS

frequency: 5-7 days/week, 1-2x/day

intensity: stretch to point of tightness or slight discomfort

time: 10-30 second hold, 2-4 repetitions

type: static

ACSM recommendations for flexibility training in individuals with SCI

frequency: daily

intensity: ensure discomfort is at most 2/10 on 0-10 VAS

time: 3-4 minute holds

type: active or passive static

ACSM recommendations for flexibility training in individuals with CVA

frequency: at least 2-3 days/week with daily being most effective

intensity: stretch to the point of tightness or slight discomfort

time: 10-30 second hold, 2-4 repetitions

type: static, dynamic, or PNF

ACSM recommendations for flexibility training in individuals with Parkinson's

frequency: at least 2-3 days/week with daily being most effective

intensity: stretch to the point of tightness or slight discomfort

time: 10-30 second hold, 2-4 repetitions, 30-60 min/week

type: slow, static stretches

low tone neurological pathology

- no neural drive to muscle

- no regular contractions to promote mobility of joint

- no stretching of antagonist musculature

- non-contractile tissue used for support more than in healthy individuals

high tone neurological pathology

- high neural drive to contractile tissue

- potential spasticity

- enter stretch slowly

- long hold times

- static or PNF techniques

resting HR is (ELEVATED/DECREASED) until puberty

elevated

smaller kids has (SMALLER/LARGER) stroke volume and cardiac output

smaller

pre-puberty differences in VO2max between males and females

no differences

BP is (HIGHER/LOWER) than adult levels until puberty

lower

young adult average resting HR

60-65 bpm

young adult average stroke volume

60-80 mL

stroke volume (INCREASES/DECREASES) with exercise

increases

young adult average resting cardiac output

5.6 L/min

cardiac output (INCREASES/DECREASES) with exercise

increases

VO2max differences exist between sexes in young adults except when expressed as a

ratio of lean mass

max HR (INCREASES/DECREASES) with age

decreases

stroke volume and cardiac output (INCREASE/DECREASE) with age

decrease

RBCs oxygen carrying capacity (INCREASES/DECREASES) with age

decreases

peripheral resistance (INCREASES/DECREASES) with age

increases

resting BP (INCREASES/DECREASES) with age

increases

resting respiratory rate (INCREASES/DECREASES) with age

increases

endurance considerations with aging

- need to be aware that bodies pre-puberty can bot be compared to adult numbers

- smaller kids have smaller cardiovascular capacity

- puberty begins bringing measures towards adult values

- lean mass is an equalizer for cardiovascular health metrics

- older adults start at an impaired state and have less capacity to increase cardiovascular response

how to adjust FITT-P based on age

- promote general physical activity in pediatric populations

- a lower activity intensity may achieve desired results in smaller pediatric patients

- start using similar dosing in post-puberty as you would for adults

- patients with higher levels of lean mass will have similar cardiovascular response and can handle similar intensities

- start at a lower intensity when working with older adults (unless they have previous training experience)

what is the most common area PTs will utilize pure cardiovascular endurance training methods

cardiac rehabilitation

phase 1 of cardiac rehab setting

inpatient

purpose of phase 1 of cardiac rehab

- progress from sitting to standing within 1-3 days

- provide orthostatic challenge to cardiovascular system

phase 2 of cardiac rehab setting

outpatient

purpose of phase 2 of cardiac rehab

- increase exercise capacity

- improve cardiovascular function

- circuit training may be beneficial as it allows more continuous work without fatigue associated with continuous walking

a symptoms limited stress test (submax) is performed how many weeks after discharge from hospital

2-12

phase 3 of cardiac rehab setting

outpatient

purpose of phase 3 of cardiac rehab

- improve overall fitness (or at least maintain)

- can begin recreational activities such as swimming, hiking, and jogging

- patient education on symptom management and gradual workload increase

HR response in phase 3 of cardiac rehab

resting and max HR decrease

RPE response in phase 3 of cardiac rehab

decreases during specific load

BP response in phase 3 of cardiac rehab

resting BP and BP at the end of a session both are decreased

ACSM recommendations for moderate cardiovascular training

frequency: at least 5 days/week

intensity: 40-59% of HR/VO2max

time: 30-60 min/day

type: regular, purposeful that involves major muscle groups and is rhythmic in nature

ACSM recommendations for vigorous cardiovascular training

frequency: at least 3 days/week

intensity: 60-89% HR/VO2max

time: 20-60 min/day

type: regular, purposeful that involves major muscle groups and is rhythmic in nature

ACSM recommendations for cardiovascular training in outpatient cardiac rehab

frequency: at least 3 days/week

intensity: 40-80% HRR/VO2max

time: 20-60 min/day

type: UE/LE ergometer, recumbent ergometer, recumbent stepper, etc.

the UE has a (HIGHER/LOWER) mechanical efficiency than the LE

lower