so welcome to the flexibility seminar we
have a 90 minutes of pact getting into a background of what flexibility is to
refresh us from some basic physiology concepts and then moving into a
particular reflex based technology for improving flexibility in the muscles and
fascial system known as muscle energy or PNF stretching and that's what we're
going to be digging into today hopefully you're in some comfortable loose
clothing and you may have a little space to stretch out a little bit later as we
go through our little webinar if you have questions about this topic after
today you have my contact information here on this slide
exercise resources is my company for continuing education and edgy size comm
has my connection information for both web and telephone numbers if you have
any questions or inquiries even after the program is over so a greetings once
again coming to you from New York and the challenge is how flexible are you
how flexible are the people that you're working with how many of you can
actually stand up bend forward and touch your toes without bending your knees or
as this guy here is going backwards that's a little extreme for some of us
we're looking to see what is normal flexibility and what are we looking to
restore and the clients were serving so take the challenge how would you like to
be this guy this is one of our Pocono llamas out there and he has excellent
flexibility but could you imagine he wouldn't have a good time if you didn't
so flexibility ability to move through a range of motion of a joint or a chain of
joints now we're all connected kinesthetically so we talked about
something called the kinetic chain all the joints in the body are completely
connected you can't really isolate them and just say oh well my knee is stiff
but what does it have to do with my ankle or my hip knees ankles and hips
are all connected so we have chains of joints throughout the body and our
flexibility or mobility range need to extend across those various joints so
essentially we're looking at stretch ability let's take a look at what normal
documented range of motion or flexibility is and that's typically
measured you know medically using goniometer II that fancy little
protractor with the two arms on it that tells one how many degrees a person has
moved through a range of motion there's also flexibility screening where
instead of looking at individual joint degrees of range of motion you look at
overall tests you can do something as simple as measure how far someone can
reach and their sit and reach tests for doing that so we'll just take a little
peek at some of the basics of flexibility and then go into how can we
manage helping people who've lost some of that flexibility that's now impairing
their performance so what is normal range of motion goniometer II of course
is one way to look at it and you will see here documented ranges of motions
using a goniometer from the american academy of orthopedic surgeons and these
are their standardized national normative reference values for range of
motion joint to joint there's oodles of flexibility screening information online
and I highly recommend even just using Google or Google Scholar to look up some
of that work many of the sports medicine journals biomechanics journals have
information physical therapy and athletic training journals of course
personal training journals have information on that as well but
functional testing is really the latest way to look at flexibility what is
required for an individual's performance what are they doing are they a runner
then they need to have particular flexibility especially about the ankles
the hips and the knees but remember that the torso rotation their arm swing needs
to be flexible as well if they're going to use everything they've got to win
that running race what kind of performance are they using to be a
secretary sitting at a desk don't need tremendous amount of flexibility for
that sometimes sitting too low of course will begin to impair someone's
performance as you know you don't use it you lose it so we need to see what is
the performance of the physical activity that we're looking
to have four goal for this particular client and if there's something in the
way of that physical performance related to poor flexibility so here's a little
bit of our measurements for neck and a middle lower back range of motion a
cervical spine of course forward bending flexion 45 degrees or chin to the chest
backward bending extension also 45 degrees rotation looking each way you
know driving a car you want to see who's passing you normal here 60 rates degrees
of range of motion lateral flexion bringing your ear to your shoulder 45
degrees and then looking at the trunk which is a combination of basically
below the neck to above the gluteal region and that would be trunk flexion
is 80 degrees of forward bending at the lumbosacral junction or average of
fingertip to the floor someone who is bending forward reaching for their toes
with the knees straight you should be able to reach at least four inches from
the floor trunk extension more measured from the low back where most of the
backward bending comes from 25 degrees rotation or twisting either way 45
degrees and core side bending or lateral flexion in is 35 degrees I'll show you
some of the muscles involved in neck flexion extension any of these pictures
of course that you see here are from primal pictures they're very nicely
animated anatomy if that interests you and they are bored with permission of
primal pictures you can see some of the muscles stretching in the extended neck
position sternocleidomastoid coming up in the front on the side on the right so
some of the longest coline muscles some of the scalene muscles in red on the
left side and the muscles that you see in green you're doing the contraction
there the muscles behind the neck perform any extension maneuver how about
the shoulder one of the very most common areas that people become stiff
particularly with rotator cuff injuries overuse injuries especially reaching
overhead and sometimes just the whole act of getting older sitting too much
not moving around enough tend to get very limited range of motion and
shoulder so you may test along with me for any of
these motions of course be careful if something is uncomfortable or painful
you should have that checked by your physician but go ahead and try some of
the motions along with me so you're moving and not just in it so a shoulder
flexion reach your arm all the way up overhead normal degrees of course is 180
should be able to bring your arm straight up in a line with your body
shoulder extension with your elbow straight reach back straight behind you
that should be about 60 degrees abduction that's moving your arms like a
jumping jack way up to the side over your head 180 degrees and then medial
rotation that's if you have your elbow bent and your hand in front of you pull
your hand toward your belly that's medial rotation or internal rotation
that's 70 degrees that's useful for pulling things towards your body I'm in
lateral or external rotation would be out to 90 degrees if your arm is at your
side your elbow is bent and make your forms like a door hinge and the doors
swinging open you're swinging your palm out away from your stomach that should
go out 90 degrees of lateral rotation it shows some of the rotator cuff muscles
and other muscles of the shoulder up at the top of the slide in the red you see
some of the deltoid muscles coming in here infraspinatus teres major
latissimus coming down and green so get a little review overlooked few of the
muscles while we're here elbow forearm wrist combination motions elbow bending
here at 150 degrees and of course extending would be zero so we left
extension out it goes just to a straight line forearm if you have your elbow bent
your arm at your side and you turn your palm up palm down
that's pronation supination so supination palm up degrees and then of
course palm down eighty degrees as well this flexion is bending the fingers
toward the palm wrist toward the palm risk flexion eighty degrees wrist
extension bending the palm away from the rest of the arm or fingers away from the
rest of the arm 70 degrees radial and ulnar deviation so
the ulna is the bone on the pinkie side and if you move your palm towards pinky
side that's going to be of course our deviation there should be 30 degrees of
mobility and then radial deviation moving the hand towards the thumb side
bending from the wrist that would be radial deviation 0 to 20 degrees and it
shows you some of the movement of elbow flexion extension of course it's
reflecting the elbow and have some of the biceps brachii allas muscles working
there in green the triceps stretching the muscles on the back of the arm and
Konya stretching during that elbow flexion and then muscles of the wrist
here as well the hand is shown with the wrist in extended position and the green
muscles lighting up some of the wrist extensors the red muscles stretching
here some of the wrist flexors for the hip range of motion another area that
tends to tighten up particularly over time or with overuse and under use
injuries so hip flexion if you're sitting and you just pull your knee up
toward your chest flexing your hip that should go about 120 degrees comfortably
a hip extension if you stand up for a moment stand up and reach one leg way
back behind you and point your toe back behind you
that would be hip extension which is normally 30 degrees of course when you
see our dancers they can flip their foot over the back of their head no problem
but you'll find that many so-called normal everyday people are little stiff
and hip flexors causing limited hip extension that comes into play quite a
bit when we watch people walking and running as well a hip abduction if
you're just standing in place hold on to something to maintain your balance
spread your leg up lifting it to the side that's abduction should be 0 to 45
degrees an adduction if you cross one leg in front of the
other or behind the other that's adduction 0 to 30 degrees and of
course the rotation if you're sitting in your chair and just want to try it sit
with your hips and knees at 90 degrees and the medial rotation or internal
rotation lift your foot up sideways away from your other foot lateral rotation
lift your foot up inwards as if you're sliding your heel off
your opposite shin that would be lateral rotation like when you go to cross your
leg to put a shoe or sock on that should be 45 degrees of lateral rotation people
get stiffed here and hip rotators imagine that trouble just getting their
shoes and socks on there's pictures some of the hip abductors adductors and which
are also rotators here take knee and ankle flexibility a range of motion your
knee should be able to bend or flex to 130 degrees you could try that just
sitting in your chair or standing bring your heel back so that your calf touches
the back of your thigh angle dorsiflexion easy to do in sitting just
pull your foot up bending it forward at the ankle and 20 degrees
plantar flexion point your toes away from you so bending the ankle down away
from your face zero to 50 degrees it's plantar flexion now if you turn your
feet inward turn the sole of your foot so that the two soles are facing each
other that would be inversion as you're at a
thirty-five degrees and then if you turn your feet out so that the soles are
facing away from your midline ankle aversion small range here at fifteen
degrees those motions are very helpful for getting people to walk carefully
across on little surfaces and adapt without falling and if you combine
motions what we typically see in the fitness industry and in therapy the
straight leg raise test when someone's laying on their back and lift this leg
straight up in the air like a rocket kicking there's a straight leg raise
that should be about eighty degrees most people consider that a test of hamstring
length so I show you here knee is in the flexed position of course stretching the
quadriceps muscles in the front and the hamstrings working through the back as
well as lower leg gastroc people will often forget that the gastroc muscle in
the posterior calf is also a flexor on the knee down at the ankle looking at
the plantar flexion okay dorsen plantar flexion so here the toes have pointed
down putting a stretch through tibialis anterior some of those dorsiflex your
muscles and of course the active muscle is posterior lee in green your gastroc
and soleus complex so now in someone's coming in to
to ask for a program designed to help with their flexibility what kind of
things you want to discuss with them to think about well why are you here what
seems to be the problem what gives you trouble
what kind of performance issues are they having so you want to ask them about
their personal needs what are their goals I'm working with the gentleman
right now who is preparing for the army and he wants to work in Special Forces
so he needs to do a certain very high level and demanding physical training
and he has very specific goals for these tests that he must pass or he's not
getting into those Special Forces so you need to know exactly what physical
performance are you looking to achieve what race you're looking to win what
load are you looking to lift so as specific as possible really guide you to
design a good program so decide what is it that they need and be specific maybe
you're seeing somebody who had a work injury and they're coming in for some
injury rehab do they feel stiff is something painful to move movement
should be comfortable sometimes it just feels stiff doesn't move easily does it
hurt not so much a problem that's pretty easy to handle by just teaching an
exercise program but if there's pain to move as well you need of course to have
some medical intervention to check with a physician to make sure about what they
don't have or perhaps that stiffness is so bad but the stiffness alone is
causing them pain and that's where our exercise programs and our muscle energy
comes in can be very very helpful to reduce some of the pain that people feel
associated with stretching and what motions in particular feel tight or sore
is there something they can do well gee now I'm seeing another gentleman who is
actually in the army and he had an in running injury and he's had some
iliotibial band tension where the band of tissue on the side of his thigh that
connects the hip to the knee through the tensor fasciae latae it was very very
tight giving him knee pain so we needed to do some stretching for the
– a lotta the glutes what couldn't he do he said well you know I can run really
fast for a short distance on my toes but I can't run any distance above a half
mile with a normal running gait so once he starts picking up his distance and
running mid foot the way he shouldn't be running for distance he's getting the
pain so we're trying to find out what specifically is giving you the trouble
when do you feel it the more precision the better ask him to lift the intensity
the pain oh you know when you stretch that in that direction how much does it
hurt they use the pain scale from zero to ten
imagine zero is no pain at all ten is the worst pain you can imagine oh you
know when I move my leg across like that that hurts at a seven out of ten so at
least you have some objective some objective measurement to put in with
what do they feel when they're being limited by this abnormal tension you can
always remesh II did the program I designed work to help reduce the pain
use the same scale before and after so you always need to assess first measure
know what the normative reference values are I've given you some other resources
here a great book on measuring joint mobility or motion by northing and white
and there's plenty of functional tools and literature some my favorites the
journal biomechanics particularly for ergonomic work and sports medicine and
science and sports and exercise Journal of strength and conditioning athletic
training journals of course the physical therapy journals are also great
resources for looking at these so decide your goals you know educate your client
are there certain limitations or things they need to be careful about so that
they could prevent injury maybe they need to take it easy from certain work
activities or limit certain sports activities until they are able to regain
their mobility so that they don't keep straining and causing other problems of
course you know medical issues need to be managed medically have them get
cleared and checked at their physician and decide what performance is actually
desirable and reasonable to tane so you want to make sure you have
reasonable objective goals to have a time line but once you work with people
a little bit you have an idea that hey you know they may need to do some daily
stretches before you start to see enough change in their flexibility that's
measurable that's significant so I'll typically have people doing some
daily stretches if they're mildly limited once or twice a day somebody
would say a frozen shoulder where it's just plain stuff they can't reach the
realm overhead I'm giving them programs stretching three to five times a day
depending on the severity of the problem you know sometimes more is merrier you
want to get them better faster sometimes they need a little more stretching so
determine your timeline is it a mild problem you may see changes within a
week or two that are objective and measurable more severe problem hey I
might want to see a few degrees maybe ten fifteen degrees each time they come
in see if it's made a change so document to keep keep a record we like to show
progress people love to see when they make an improvement so we're going to
design a program there's different types of stretching that we do now standard
stretching uses positioning and we impose an outside force either we're
pushing on our client to help them get to the range of motion or we give them a
stretch band the stretch rope and use that stretch rope to help you move
sometimes they're just moving against gravity and I like to make sure I tell
people that no pain no gain philosophy is not my way of doing things
you might feel some stretching discomfort but if there's a sharp pain
if that's reproducing that pain it stops you from doing things you're going too
far too much is not a good thing but they should feel that sense of
stretching that may be a little bit uncomfortable I usually use that pain
scale as a reference you know affect stretch hurts you more than a 5 out of
10 on the pain scale we talked about you might want to back off a little bit so
stretching considerations keep that intensity tolerable teach people how to
use the pain scale here to 10 very very easy to use and when you first begin
giving them some stretches to do don't go right away for the complex
multi-joint stretches give them some very simple
join stretches Oh their hamstrings are tight okay you can touch their toes it's
limiting their running stride okay maybe there's some things you need to look at
there with the hamstring for Chi is it tighter at their knee cuz that hamstring
crosses the knee or is it tighter at their hip hamstring courses the hip –
what is it muscle the ankle have to do with it
gasps Shawcross is the knee that could also be a problem so I might just give
them some knee extension stretches first working across the knee and then
gradually add the hip gradually add the ankle and you'll see that when we get to
some photographic illustrations later in this presentation
so keep it simple first now precautions of course what do you do before you
stretch what happens when people stretch cold not too comfortable right greater
chance of injury now very interesting I've seen a mixed evidence on warm-up or
exercise prior to stretching I've read studies that said yes a warm-up is
absolutely necessary to help with the stretching others say oh you can just
stretch cold and use that as a warm-up for exercise so the jury's still out in
the literature but I think if you consider it down to practical clinical
applications warm-ups in most situations help to get the blood flowing and it
makes it easier to move it also helps to unlink some of what we call those
collagen cross-linked little connection fibers within the fascial tissue the
tissue that holds everything together that covers every muscle every tendon
every ligament so having a warm up whether it's a moving warm up with some
very gentle exercises some people like to warm up with a hot shower or hot bath
some people warm up with a massage it's a little good so I'm a big fan of the
warm up first if someone has an area that's been strained or injured you have
to think about okay there may be an anti-inflammatory necessity after the
activity after the exercise or the stretching because you may have an
inflammatory response as the body's rebuilding from its injury first they
might be more sore some people are in rehab
you start stretching and you work in that area that they pull that they
injured or overused now we like to get an ice pack at the end it's ice pack on
10 or 15 minutes to that area let everything cool down again I think
there's a great preponderance of literature supporting the use of cooling
post activity of course more than 10 15 minutes not really necessary with a nice
little cool pack and progress gradually let them start to come back into their
normal activities gradually don't force anything if you force it you might break
it and then of course it's yours right you break it you got it
no but that's there's a problem I've seen even in the physical therapy field
many practitioners forcing motions so we won't rule will just make it move hey
try something else if the way you're trying to stretch maybe the position
you're in maybe your hand placement maybe the position the clients chosen to
be in it's just not the best for them so I'll simply try different hand positions
try to reposition their body in a way that's more relaxing for them of course
breathing is key having them work with some very gentle deep breathing
diaphragm breathing helps to relax the nervous system so it allows the muscles
to stretch more efficiently so that's something to keep in mind don't force it
work with the grieving so that they can relax through the stretch so of course
stop on the red signal all right more precautions if you have that medical
clearance if they have an injury of course review their records and see any
reasons why you want to avoid stretching now maybe somebody had attending repair
and a certain point depending on the tendon and the type of repair it might
be deleterious to start stretching you might actually tear that repair site so
you want to make sure you know is there anything that you need to avoid so check
with their physician if they're unhealed fracture was this person in an accident
is there bruising in that area in some situations particularly for muscles of
the thigh and the muscles around the upper arm around the humerus and the
femur those muscles the cause the hamstrings the biceps breakout
if you stretch them to forcibly after they've had some bruising from an injury
you could actually cause my new calcium deposits called heterotopic ossification
to form in the muscles that's like having little shards of glass growing in
your muscle excruciating ly painful that can happen as a result of someone
stretching too hard too much force too far in those specific areas of the body
so not uncommon there if you see that person's got some nice bruising you know
the black and blue around their hamstrings it's not time to go forcibly
stretching those hamstrings time to move gently through a range of motion so I
always like to go over just a couple of basic precautions obviously open wounds
or areas of sutures or surgical staples unless you're trained on how to work
with those you want to be staying away or refer to someone who is trained to
work with those areas okay all right sometimes people move too much they I
work with people who are runners I work with dancers I've worked with Broadway
dancers these people are very hyper mobile most dancers have lots of
mobility they have that body type of genetics that allowed them to move
through those ranges of motion so that hypermobility is normal for them but in
a person who didn't have that type of flexibility before that would be
deleterious so you need to see were you always this flexible or is this
something new for you some people become strained or sprained where the ligaments
become elongated that's called a sprain and they don't just bounce back to where
they were so the joints tend to become more relaxed we would say they're hyper
mobile or too flexible in a severe instance we could say that they're
unstable so someone's already moving beyond the so-called normal ranges of
motion that we talked about you want to be extra careful to see was their body
built that way were they always like that or existing hypermobility say post
pregnancy during pregnancy it's well known that there are certain hormones
that come out to help a female become more relaxed and her
preparing for delivery but that hypermobility could make the joints or
we need to make sure their muscles are very strong and maintain that strength
to hold it together until those hormones those relaxing hormones that make her
extra mobile are dying down in the system after the delivery so just be
aware something's moving too much already you probably don't want to
stretch beyond the normal range of motion unless that's their normal so you
need to find out what's going on with that
okay different kinds of stretching techniques you probably have a few of
your own favorites of how you like to stretch on a basic level there static
stretching where we typically hold the joint or hold that body part still and
some people hold it for two seconds some people hold it for two minutes I
actually downloaded a thousand articles from the internet looking at how long do
people typically hold stretches and what does the evidence say really works well
gee I got a headache because they all the evidence said different things which
is incredible but the preponderance of well-constructed research show that
anywhere between like 15 and 30 seconds was pretty optimal time to hold what we
call a static stretch we have dynamic stretches involving adding motion or
muscle contractions so they're not just sitting there holding position but we're
doing what we're doing today we're going to use the energy of a muscle
contraction to see if using that muscle contraction alters the flexibility or
alters the stretch ability so today is about dynamic stretching ballistic
stretching can also be used but this is something that is used only more highly
performing persons we add like a bouncing or jumping ok type of motion
tends to be a very high velocity a fast stretch and those ballistic or fast
stretches have a tendency to tear the muscle if the muscles not ready or if
you're too forceful so there's something you know to be thinking about with the
ballistic stretch is this an athlete that performs a great deal of jumping
activities fine if they are prepared for that train for that which is
gradual process then ballistic stretching may be appropriate at the
everyday Jo that comes in he pulled his rotator cuff at work he lifted too much
in the wrong direction he should have asked for help we're probably not doing
any ballistic stretching with him it doesn't mimic what he's doing in his
everyday functional performance okay so you have to really think about what's
this person's background those static and dynamic stretches are probably the
way to go so static stretch fifteen to thirty seconds the literature has shown
them to be very effective matter of fact some of the best studies from Journal of
orthopedic and sports physical therapy show that stretching for thirty Seconds
works as well to improve hamstring flexibility than stretching for sixty
Seconds so why wait I'm in your common heart we got places to go people to see
things to do so why wait longer if you saw that you had a good enough response
you had a nice increase of range of motion so and that's what much of the
literature says so you can do this on your own
give someone a home program with stretching activities to do they could
do it on their own or especially if someone has an injury or if they're
really sick having another person assist is tremendously helpful so those
ballistic stretches again we're bouncing or jerking if someone is doing high
level activities of course you want them to be prepared for this thinking about
some Air Force gentleman that I'm working with two Air Force gentleman
right now and one of them is part of the elite search and rescue so he needs to
jump out of a helicopter you could imagine the bouncing or jerking that his
body has to sustain when he's hitting the ground so he needs to do some
ballistic stretch to prepare for absorbing that impact so that's a very
specific type of thing we're not covering that today but just give you a
little example okay we don't want to be straining the muscles in our everyday
people but our high-performance people you need to know hey they you need to
perform these maneuvers for what they're doing at work or for recreation the body
needs to be ready with a gradual practice leading up from very gentle
ballistic stretching to a more high level
course over time okay dynamic stretch that's what today's about people have
all different names for this it'll drive you nuts
with those in pain neuromuscular re-education we actually have in
rehabilitation medicine there are building codes that we use for insurance
company and today's type of stretching we would use the billing code for
neuromuscular re-education so if you are one of those PT or ot people society
people that code for that on billing is nine seven one one two just a little FYI
they're a neuromuscular facilitation where you're going to be using reflexes
to activate or inhibit muscles in the physical therapy field years ago they
came up with the name PMS proprioceptive neuromuscular facilitation it's a
mouthful but it's basically the same as muscle energy terms muscle energy came
from the osteopathic field but they said let's use the energy of a muscle reflex
to inhibit or to activate to wake up muscles to get our intended response I'd
love if they just called it reflex therapy or reflex technique that's
essentially what we're doing here we're doing what's called facilitated stretch
tricking those reflexes into doing what we want them to do
now some people are stiff and they're uncomfortable you go to stretch them or
they go to stretch themselves and the body's fighting and sometimes you go to
stretch of court you feel fighting you a bit it's like well how do you turn off
the fight you do it easy facilitated stretching your muscle energy we're
going to use reflexes to trick the muscle into minimizing its guarding its
fight and also trick the muscle to minimize tension so that they don't have
so much pain you can see that clients achieve greater length with the
stretching what are the reflexes that we're dealing with this gets a little
heavier in the neural physiology realm so try to keep it simple for you
so neuromuscular reflexes the basics muscle spindle reflexes you know when
you go to get a medical exam the doctor says I'm going to check your reflexes
and they take out that little hammer and tap you in the knee and your foot
so of course that's our muscle spindle reflex what we call our monosynaptic
reflex the muscle you actually is getting a quick little stretch by the
tapping of the hammer stretching that tendon and of course that message goes
into the spinal cord says hey protect yourself from being torn you're
being stretched really fast the muscle contractions muscle spindle reflex
there's proprioceptive reflexes such as Golgi tendon organs we'll talk about the
little organs that live in attendance there's developmental reflexes anybody
out there have children anybody have little babies anyone ever played with a
baby I have when you go to grab the little baby's hand maybe they're 4 to 6
weeks old and you're just playing and you see I'll grab my finger and then you
can't take your finger away the baby automatically grabs whatever is put in
the palm well that's a primitive reflex or developmental reflex that's one
example if you've ever watched a young baby know couple months old turn his
head to one side he actually extends his arm sideways on
that same side that's a developmental reflex and
there's a whole host of these reflexes that help us learn how to get up and
walk and crawl and do all kinds of great things those reflexes still exist in
your body as an adult but they're hidden they're carefully hidden by the higher
centers of your brain some reflexes are positional so you actually have sensory
organs in your ears and in your joints telling you where you're moving in space
never get in a car and try to read a magazine and you start to get dizzy or
nauseous well that has to do with those positional reflexes vestibular reflexes
located in your inner ear some people easily get carsick or motion sick and
that has to do with the reflexes in their ears telling them where their
body's moving in space so there's a whole bunch of reflexes that we can use
to direct the body to do it what we wanted to do and that's the essence of
muscle energy we're going to use basic muscle spindle reflexes for our muscle
energy stretching let's take a look at those muscle spindle reflexes you might
have heard of the muscle spindle it's a little sensory receptor
detects changes in length of the muscle fiber it also checks how fast is the
muscle length changing so it's the change of length and this is what we
call a monosynaptic reflex arc so muscle spindle sense is a stretch it's the same
being stretched I feel the length changing I'm going to send a message to
the alpha motor neuron in the spinal cord the alpha motor neuron says hey
muscle contract protect yourself from being torn so that's a typical
monosynaptic reflex and it has two components and take a look at those it
has actually extra fees of fibers and intrafusal fibers within the muscle
spindle the extra fuel fibers say hey we're contracting protect yourself from
being torn from being stretched the interviews of fibers connect through the
gamma motor neuron and that's when a muscle sense is a stretch this is
checking not just how far is it being lengthened but how fast the speed of the
lengthening as you can imagine if you try to stretch your muscle too far too
quickly you're going to set off that intrafusal component and that's going to
be exquisitely sensitive to tell the muscle contract tighten up shorten up
protect yourself from being torn well there's a built-in sensitivity there's a
built-in threshold for excitation of these fibers of the muscle spindle and
we call that spindle bias the preset sensitivity to changes in muscle length
some people have a very high spindle bias and some people have very low
spindle bias some people very reactive even if you just start stretching them a
little we would say they haven't abnormally high or sensitive spindle
wise that's where you have trouble stretching and that your people have a
tendency to get injuries so we want to see can we alter the spindle bias using
the reflex of muscle energy using the reflex of muscle contraction so we'll
take a look at that as we go through so the spindle bias as the threshold for
stimulating the contraction of the muscle okay we can actually alter the
spindle bias with positioning if any of you have taken the position
release course learned a little bit about that now of course we can actually
position a muscle shorten it up quite a bit to reduce the abnormal sensitivity
of the muscle to stretch and reduce some of those painful areas within the muscle
as well give you a little review a little pop quiz on that one gold
detaining ordinance well we thought about muscle spindles before muscle
spindles live in the bellies of the muscles the Golgi tendon organs live in
the ends of the muscle the origin insertion or the attachments of the
muscle so say muscle contracts too hard too fast that pulls in its attachments
stretching the Golgi tendon organ GTO get the stretch it says hey I'm sending
a message into the one B's of the spinal cord and I'm turning off the alpha motor
neuron turning off protects the muscle from contracting so hard that it would
tear or vault its tendons from the bone so these GTO s keep firing and
inhibiting the muscle muscle has to have some activity to keep it strength if the
GTO is fire excessively you're going to find that muscles weak you can also use
GTO reflex to help stretch your muscle if you want to inhibit the contraction
if someone's fighting you during the stretch put some pressure or stretch on
the Golgi tendon organ by pressing on the tendon it's a little neat trick to
help them stretch a little bit more effectively so say I'm trying to stretch
a hamstring and those tendons attached down behind the back of the knee either
side don't push on the middle of the back of the knee because you have back
there of course your pup Willie lottery tibial nerve comes through but if you
push on the actual tendon if you feel little tendons they feel very stringy
behind your knee this couple in the back on the inside and the outside your
hamstrings if you put pressure on the 10 and while you're stretching you'll
activate that GTO and you'll make the stretching easier to do by relaxing the
muscle okay here's something that we'll be using quite a bit with muscle energy
reciprocal inhibition in the nervous system of course you have reflexes that
protect the muscles from being torn and then also activate the muscles for
activity so we're going to see their reflex for the laughing attraction of
single action muscle groups or paired opposing muscle groups think
flexors and extensors flexors say you're bringing your hand up to your face
that's flexing your elbow and of course stretching extensors on the back of the
elbow if you bring your hand up your face you're activating biceps break out
the muscles in the front of your forearm but bend your elbow the Popeye muscles
and of course as you're doing that you're stretching the triceps in the
back of the arm so those are paired agonist antagonist muscles they do
opposite activities agonists are synergist muscles work together so if
you're bending your elbow to bring your hand to your face we call that elbow
flexion the agonist the prime mover would be like biceps brachii alles
synergists okay what are their muscles are bending their brachioradialis might
also be helping not performing the main motion but acting as a helper that's a
synergist the triceps in this case is the antagonists or the opposing muscle
the opposite side of the humerus which performs the opposite motion so now we
just make sure we know agonist antagonist agonist is muscle performing
the military the antagonist is as opposing or opposite muscle by
reciprocal inhibition this reflex is set up so if the body knows when to turn on
and turn off muscles when to recruit muscles to do an activity so if your
flexors are firing I want to bring my hand to my face because I want to use
sandwich I'm flexing so the reflexes will reciprocally inhibit the extensors
the muscles in the back of my elbow making sure I don't extend or straighten
out my elbow when I'm trying to bend it so that reciprocal inhibition allows for
coordination and precision of movement another reflex that we'll use if muscle
energy is called post isometric relaxation some people call it PIR or
post isometric ambition now you notice this more if you were tired or you did a
lot of activity of a certain muscle and that muscle is too tired you just try to
contract it again like oh I'm really too tired to contract that muscle then I
have found enough that's something that happens even after
an isometric contraction after muscle contracts there's what we call a lengthy
period we used to call it the refractory period in exercise physiology it's used
up all the bio chemicals it helped to contract and it takes a little bit of
time a latency period to time duration in which the muscle will rebuild all
those nice chemicals that helped it to contract so it's a perfect time for
relaxation waste products has to be removed carbon dioxide that built up co2
is transported out oxygen o2 brought in by breathing right neurotransmitters
cross the membranes the actin and myosin filaments within the muscle have to
uncouple or unlink this is the perfect time to stretch the muscle after muscle
is finished contracting particularly isometrically
we have a window of opportunity within which we can stretch it that it can
contract harm against us and that's called that post isometric inhibition or
latency period or post isometric relaxation perfect time to get in there
and stretch that's quite a bit of what we use with muscle energy techniques or
PMF techniques same thing we're using the reflexes to trick the body into
letting us do what we wanted to do there hamstring wants to be tight and bend the
knee no we want it to straight now you want it to let go so they could stretch
out and straighten out their knee we want to use that reflex and trick the
body to allowing a more effective stretch or less painful stretch let's
fight from the muscle well we see in this picture just a quick example of the
muscle energy technique if I'm looking to stretch them hamstrings and I wanted
to work mostly across the hip joint you see I'm bending his knee up toward
his chest and say if that's as far as he went I allowed his knee to be flexed and
his hip is flexed I'm stretching the hamstrings where they crossed the back
of the hip so hamstrings come from the sit bones ischial tuberosity bones
supposed to be was sitting on your computer right now they attached down
behind the knee okay the posterior tibial and fibular
just below and behind the knee so here I'm stretching the upper hamstring or
what we call the proximal hamstring behind hip and flexing the hip to
stretch the knee extensors hip extensors let's look at the principles of how we
would use reflex to do just that now give you a little background or where
these reflex principles came from because they've been around for quite a
while neuromuscular facilitation or inhibition
concepts were first described by doctors Sherrington and Cabot dr.

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Fred Mitchell
is an osteopath at Michigan State University called using reflexes muscle
energy technique this is all the way back in the 50s physical therapists not
Voss we're writing at the same time as Mitchell describes as muscle ng they
were describing something they called PNF proprioceptive neuromuscular
facilitation others came along called new techniques post isometric relaxation
PIR active isolated stretching AI F Active Release Technique chiropractors
like to call it that they had little soft tissue work to the reflex
stretching technique and the list goes on and on I like to refer primarily to
what's out in the literature that shows that it works and that's going to be
under the terms the PMF and muscle energy or met technique the others are
the newer versions I've seen them represent in literature but mainly just
as case reports or we try this with a client and this was a result we had as
opposed to let's try this in a randomized clinical trial with a large
volume of clients and let's apply a standard statistical package to treat
the data in a methodological way and see how that works so that's we really want
to look more at their clinical trials so so many names muscle energy technique is
the osteopathic PMF from PT Active Release AR T for chiropractic active
isolated stretching see quite a bit of that in the athletic training journals
so lots of names for the same thing it's basically reflex technique
to allow the muscles to relax so that we can stretch them with less pain less
aggravation on the part of the patient less work for us which makes it very
nice want to see if we can use these reflexes to ultimately improve someone's
physical performance I'd like to take the definition of muscle energy from a

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Phil Bremen he wrote a book called principles of manual medicine it's a
very famous in the osteopathic field and he defines muscle energy or muscle
energy technique m ET as a quote manual medicine treatment using voluntary
contraction so there's the hint if the person can understand you they are not
likely to be able to give you a voluntary contraction now are they how
about someone who just doesn't have the ability maybe they have some spasticity
maybe they had a head injury and they're unable to control that muscle at will so
they don't have the ability to do a voluntary contraction well then
obviously this technique is not for them this is for people who can actually
follow some directions and give you at least a twitch contraction even a tiny
contraction is all you need to get some of these reflexes to work now I mention
on the force of the contraction required I have seen it listed in literature
anywhere from imagine the muscle contracting – you must use exactly five
pounds of force or this doesn't work and everything in between clinical
experience doing this for 30 years with physical therapists little force is all
you need you don't need a strong force but we're going to talk about what's in
the literature in terms of how you time this how much force do you use let's
take a look a little bit more into dr.

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Graiman's definition ok so it's a
hands-on manual medicine means the hands on treatment they're going to be
following on directions to give us a contraction and quote contracts the
muscle in precisely controlled direction at varying levels of intensity and I
love his terminology because precision is key so many people go into their
exercising training program and I watch them they are downright
sloppy it's a nightmare to see some of these people working out and wondering
why aren't they getting the results that they desire precision is key controlling
the motion is key and what about the intensity how do you know how much force
to use how do you know how long to hold so varying levels of intensity is very
important now way back when when I started at my first job I was at the VA
Veterans Administration Medical Center downtown Manhattan and I remember when I
went to PT school my teacher said oh you have to have the patient pushing you as
hard as you can and you have to really resist and push back and the first day
of work I got a new knee the bone crusher there she is look at the bone
crusher you are at me yesterday so there's something that you need to think
about you don't need to be forceful I learn that right away I use varying
levels of intensity and we're going to see that reflected here in a couple of
slides upcoming how much force to use and of course where are we applying this
force ok we're using a distinctly executed counter force and again
distinctly executed wonderful terminology on the part of that
agreement where do you place your hands when you're helping the client to
stretch where do you place your hands you place them over the joint to place
them above the joint below the joint when you're helping them to stretch do
you barge right in suddenly or do you gradually start to increase the pressure
of the stretch do you ramp up the force to increase the pressure gradually so
it's all about how you execute this moving to suddenly moving too abruptly
you can tear muscles I've known of therapists getting sued because it's
being too forceful too sudden too abrupt not thinking about not feeling the
response of the client on the table and that's something you want to pay acute
attention to so precision specificity what direction are you stretching do you
know do you know what muscles are responsible for limiting the flexibility
of that joint do you remember those muscles origins and insertions to
remember the muscles action do you remember the joint angle at which
its best to stress that muscle so Direction is important
duration much of the literature says fifteen to thirty seconds is pretty
adequate time to get a good increase of range of motion for holding your stretch
intensity well gee is this my high level athlete who's in the peak of fitness and
performing well or is this someone who's had a work injury who got out of shape
and just wasn't ready or maybe it was someone who had both issues that had a
work injury they're in great shape but now they're not able to perform so
they're starting to atrophy they're starting to tighten up and lose some of
that wonderful strength and flexibility they gained with their training you have
to look to see the intensity will be different based on that person's
condition how about the quality or type of stretching so you want to be very
precise with each of these we're going to take a look okay and that nice little
love falls up there upstate New York some stretching concepts types of
stretching and you have range of motion stretching basically could be passive so
the client is just kicking back and relaxing during the passive stretch
active assistive the client is helping with the stretch and you as the
practitioner or helping along as well or the client might be using some kind of
outside tool such as a strap or a belt to help them stretch or of course is
stretching machines as well that may be active assistant and of course after the
person is actively engaging and performing their own stretch without any
outside force all of these can be used as home programs as well so how about
passive stretching people love this I'll just lay here and you can stretch me
I'll just kick back and enjoy it that's pretty good stuff I'd love to get a good
stretch like this once in a while so the practitioner is doing the work nice part
about the passive stretch when we hold this over a period of time you get some
fascial relief if you attended our mild fascial course that we had in several
weeks ago we talked a little bit about releasing the connective tissue that
surrounds and invests all the muscles right
down to the cellular level the fascia so the past this stress is very nice for
that as well typically we hold this for a period of time with a passive stretch
again could be from seconds to minutes most of literature says 15 to 30 seconds
is effective in certain cases holding that minute and a half to two minutes
might be more effective depending upon do they have scar tissue or is it just
simple stiffness it makes a difference active assistive stretching okay here's
where we're helping them move through a range of motion very important if
they've had an injury very important if they don't know what direction to help
and you want to guide them now but make sure with this active assistant the
client or the patient is controlling how far you go so you're not just forcing
through their available range of motion they're able to control it and this
piece works well for people who are fighters or garters
now some people just like to be in control they're used to holding their
body a certain way or maybe years ago they got hurt by someone forcing them to
move a certain way they're just inherently protective where they guard
their emotions so unless they are controlling it they're not going to let
you move you've come across these people having it so that's where using the
active assistive stretch and the muscle energy stretch is especially helpful
they have some control of the motion and helps them to get through that range so
make sure they see the direction that you're expecting them to move and also
show them how much force to use if you're going to teach them for a home
program so I go through the hands-on techniques with clients first one-on-one
and then when I'm ready to give them their home program now I make sure I
watch them do it in front of me i watch to see how much force they use what
timing they wait you know how are they lined up mechanically in their body how
is our biomechanics I'm actually stretching the area that we're looking
to stretch now people tend to cheat don't they they tend to compensate I'm
looking for them to stretch their gastroc therefore it stalling out to the
side their knees bending their cheat and left and right so you need to watch
before you give them the whole make sure they know how to do it right
and then of course the more independently oriented active stretches
or clients can do it on their own they're in control of the whole
situation this you may find if someone is very limited in motion if they're
very stiff or if their body has been compensating for a long time for that
stiffness it's going to be tough for them to do this completely actively so
having some outside tools things to lean on could be very helpful so what are
indications when do you use stretching so here we're using reflexes to assist
the stretching if people have no substantial stiffness if they have pain
when they're moving and especially those people who just fight your stretches we
call that guarding the kind of resisting the motion these using the reflexes
tricks them into relaxing more and letting go
so of course indications they have limited range of motion for flexibility
they can't reach as far as they should when it's really common if they've come
out of a cast or a brace from an injury or even most people don't think of
immobilization the person doesn't have to be in a brace
or a cast to be immobilized they might have just stopped moving that body part
in their own because it hurt how many times have you seen somebody all my back
went out oh I pulled my neck and they still don't move very wrong because they
were so used to stiffening up to protect themselves from the pain once the pain
is gone they have that happen they didn't stop doing it so that
immobilization doesn't necessarily mean they were in a cast be aware that people
might have guarded because of pain which could even be long gone and then of
course if they had traumas injuries accidents that fibrosis or scars as you
could have set in and that's where you want to get some not just regular
stretching but some myofascial release stretching as well so some
contraindications again meaning it could be deleterious to do the stretches if
they have unhealed fractures open wounds no recent surgeries again a fee if you
are a medical practitioner and you're used to working with these things and
you know how to work around the kind of indications of course that's
fine but if not make sure medical clearance is obtained you don't want to
spread infections or rashes I had a client come in covered in poison ivy I
can't treat you today he's issued from head to toe he was high as a kite on
benadryl scratching you know I think you have a rash that's dressed in you today
was so funny we come back in a week when you're feeling better so I'm done
unknown diagnosis what about the purses you know everything's been stiffening up
and it's getting worse and worse and who knows maybe they have a certain disease
runs in their family maybe they have suffered an infection of some kind if
you don't know what their problem is coming from they need to get that
medical clearance I already mentioned the instability or hypermobility so you
don't want to stretch people beyond a normal range of motion unless that was
their say pre-injury normal that's different so contraction types is
keeping us on the same page here isometric contraction so I'm assuming
you're probably sitting in your seat here looking at the slide so if you're
sitting in your seat and this is comfortable for you bend your right
elbow put your left hand on top of your right forearm and bend your elbow but
don't let it move so you're trying to bend and flex the elbow holding tight s
isometric your biceps brachii uses muscles are keeping their same length
they're isometric in their contraction okay concentric now if you're bending
your right elbow and resisting with your left hand but allowing your hand to come
up to your face so allowing the movement to happen that's a concentric or we call
a positive contraction concentric the muscles shortening as is contracting
which is what it goes for living and it's actually doing what it's supposed
to do it's shortening as it goes so the joint is going through a range of motion
from the muscle contraction eccentric contraction or isolytic contraction kind
of a new term for that the muscle is lengthening what is trying to short just
reminder you may recall muscles can only do one thing for a living right so you
can only shorten they see like oh but that's not really doing anything that's
letting go so if a muscle lengthening it's because of an outside
force that's stronger than it is so Bend that elbow bend that right elbow put
some pressure on that form with your left hand so that you're trying to bend
the right elbow but you're making that arm straight now making it straight now
so you're losing you're not able to bend because the outside force is greater
that's you're eccentric or isolytic contraction anybody know which builds up
strength the fastest okay I say let close isometric is actually probably the
safest to work first in most situations like the eccentric or the lengthening
contraction is actually the one that will build strength the fastest but it's
also the one that makes the muscle most what tomorrow sore so something to think
about it it may build you up the quickest but it's going to make you more
sore so typically we don't use that from the get-go we use that after someone's
been on program for a bit or used to these activities usually start with
isometric move to concentric and finally each entry okay so isometrics muscle
length is on change is very easy to perform if you just try that on yourself
typically these are the strengthening contractions is it easiest to do less
likely to injure concentric is a shortening what we call positive
contraction very easy to do and that's our typical strength Adel let me give
you some bicep curls pick up these weights bend your elbow bend your elbow
concentric eccentric the muscles being elongated it's trying to shorten buts
losing yet you gave them too big a barbell for those elbow curls and bicep
curls and they can't curl that actually their elbow straightening out because
the weight is just dropping on them and that's called a negative contraction or
eccentric too much of those could be deleterious to the muscle could cause a
strain or pain so interesting guy named dr.

Leon shake towel he's done some
voluminous work publishing all kinds of information about muscles contractions
flexibility and in his description of muscle energy technique he says so what
do you do use muscle energy first I have to attend
by for what muscle is tight we would say the tight muscle is a short lesson well
muscle can't be stress very well so we're going to actually get in and
resist that short muscle at the barrier what's the barrier it's the end limit to
the range of motion oh I'm trying to reach my arm forward if you're thinking
about the elbow here try and reach my arm forward but I can't quite straighten
out my elbow ever since I was in a cast my elbow stayed a little bent there so
he'd say okay what muscles are short anybody know what muscles are short at
the elbow if you can't straighten it out so if I can't right now my elbow
thinking okay the biceps the class is available the brachialis brachioradialis
these are the short muscles so what are we going to do for muscle energy you're
going to ask the client to give you 20% or less effort in bending that elbow 20%
or less what we call maximum voluntary contraction that's effort or intensity
so we'll actually resist them I'll say you know I'm going to have you push
against you bend your elbow and resist them at the end of their arm they're the
distal radius and ulna give me 20% or less effort just bend that elbow a
little bit hold it hold it hold it and have them hold that isometric
contraction hold it still two or three seconds then I say relax okay relax and
let go as soon as we feel them letting go they're not pushing anymore as key to
weight to make sure they actually let go follow in a gradual stretch of that
short muscle so you gradually straightening out the elbow possibly for
them so they feel a stretch going through those elbow flexors that biceps
that brachialis that break your radials and then at that point once they let go
you're holding that stretch that's fifteen to thirty seconds one of the
reasons this works and this is all reflected in the literature from EMG or
electromyographic studies there's a 15 to 30 second latency period within which
the muscle has to recover from its previous isometric contraction even if
it was only a couple seconds long and that latency period allows the area to
be stretched more easily and it tends to be less painful to the patient so I
typically will repeat this technique or three to five repetitions
is this the short muscles of barriers so at the barre means I'm going to stretch
out their elbow as much as it goes within their tolerance I'm just going to
repeat that again within the tolerance of the client that they feel the stretch
but within the tolerance means it's not painful even if they're not telling you
it hurts if they're tightening up can't you tell is there fighting you could
look at the face you could feel their arm fighting you that means is too much
so I back off so I stay within their tolerance
okay contract short muscle bend your elbow going to contraction up biceps
good less than 20% of your effort not 100% less than 20% hold it hold it hold
it two or three seconds relax okay now I'm going to stretch you out and hold
them about that fifteen to thirty seconds and we'll do five repetitions
like that you should be able to see a measurable increase in the flexibility
using this muscle energy technique so it's a simple post isometric relaxation
you could also use other reflexes contracting the antagonist in this case
the elbow extensors to reciprocally inhibit the short flexor what we do okay
I want them to straighten out their elbow first I did from the last slide
bend your elbow hold it hold it hold it relax let me stretch you they stretch
now help me to stretch it help to straighten out your arm to have them
activate the triceps on the elbow extensor that's using reciprocal
inhibition inhibit the flexors get the extensors to work the other trick I
mentioned earlier press on the tendon of the muscle that's short so press on
those elbow flexor tendons at the elbow and as you put pressure on the 10 and
the GTO reflex inhibit the flexors let's you go through more movement how about
just asking the client visualize I want you to picture your arm straightening
out as straight as it could possibly be what about using the other side of the
body these reflexes across the body so they could contract the contralateral or
the opposite side of the body muscle to facilitate that same one so if I'm
looking to straighten out their elbow on the right are I'll say yeah really work
to straighten out your elbow on your left arm at the same time using that
extra effort gets another reflex to cross the body and
help you there's all different ways of helping what if you want to strengthen
with muscle energy well its increased strength you can activate the antagonist
or the lung muscle to go beyond the barrier into the weak range of motion so
what is that an tigress that's the triceps now straighten out your elbow
picture of being very straight you can also use automatic reflexes automatic
reflexes are like the ones when you get hit with a reflex hammer that you hit
the triceps with a reflex hammer you apply a quick stretch that makes it
contract right away so you want to wake up the triceps straight now if your arm
do a quick stretch tapping on the triceps can be helpful vibration can be
helpful if you want to activate the right triceps or right arm extension you
can tell they look to the right with great effort while you do your their arm
and exercise while you do your resistive exercise look in the direction that
you're trying to straighten out that right elbow so look turn to the right
that uses developmental reflexes this is beyond what we're covering here but just
give you an example riding reflexes if you want to wake up
their elbow muscles they can straighten their elbow all the way have them stand
up plant their palms right on the kitchen table and do some little table
press ups or table push-ups as some of the writing reflexes helping them to
wait bear on that extremity so getting them out to the gym after that once they
woken up very very helpful so precautions don't overdo it don't let
them cheat use the wrong muscle be very precise about the direction you want
them to go and key if you're using that post isometric relaxation make sure that
they are relaxed before you start pulling on them because otherwise you
could tear the muscle so I'm going to show you just a couple techniques and
things and if you want to try some of these on yourself or someone if you have
someone there to practice with we're going to be focusing on the range of
motion or stretching say for the shoulder a person had been listening too
much or maybe they played too hard in their baseball game throwing and they
have rotator cuff irritation and they can't reach the romba forehead here I'm
showing them to increase shoulder flexion so make it easy set a goal
let's go I want to increase shoulder flexion I want your on to go all the way
up overhead okay well there's lots of motions to the shoulder but if we're
looking just primarily at the glenohumeral joint arm coming up
overhead of course the clavicle collarbone moves
the scapula move the shoulder blade moves there's a combination of motions I
would stabilize the scapula have them reach their arm overhead and if you're
thinking about well how do we use this post isometric relaxation you have to
think about okay what muscles are short and tight I can't reach sweet the arm
overhead the shoulder extensors with this miss
Doris I see pictured here at Terry's manger long head of the triceps
posterior deltoid those are the muscles they should feel the stretch
so you'll see several slides of these guidelines for range of motion state the
limitation shoulder can only flex 120 degrees when we say we still 180 what
are the short muscles we just name them what are you going to contract the shore
muscles okay we resist extend and pull your arm down toward your feet hold it
two three seconds lightly less than 20% of your effort relax and I'm going to
bring you more into a stretch I'm going to hold that stretch for 15 to 30
seconds how does that feel make sure they feel the stretch in the muscles
that you're aiming at because if you don't have in the right alignment
they're going to be feeling something else
some people will start arching their back because their last is really short
you remember connects to your back and just sort in the picture so I might say
okay I want you to keep your back flat on the table just asking them to bend
their hips and knees like flatten their back so that's an example three to five
reps how about abduction so in the picture
you see I'm abducting someone so you got stuck right there maybe move to 120
degrees and you can't go all the way up to 180 stabilizing the scapula by
holding my left hand on the top of his right shoulder blade here I'm just
bringing him up from his humerus so what are we stretching you can't
abduct can't bring your arm up sideways like a jumping that motion
what's short and tight pecs lacks long has a tricep Terri's major again some of
the same muscles shoulder adductors go through the same guidelines state
limitation what motion is limited how much what muscles are short and tight
what are you going to contract is short and tight ones lightly less than 20% of
effort relax and stretch them so it's going to get boring after a while
because you see the same thing happening over and over who hasn't done a straight
leg raise you want to lift that leg up what muscles are short and tight do you
think oh and hamstrings might be tight gas that might be tight let's try to
bring that leg up what are you going to stretch me flexors so these are your
hamstrings semi tendonosis time you're embar nosis biceps they come from the
ischial tuberosity down to the fibula and tibia and gastroc take a nice
bulging muscles in the back of your calf cashing from the posterior femoral
condyles all the way down below your ankle to the tip of your heel so you're
going to be stretching the whole back of the leg here knee flexors and hip
extensors if you're flexing the hip E&B stretching the hip extensors glute
Maximus and of course hamstrings go back to the guideline there straight leg
raise you want them say up to 80 to 90 degrees what's the limitation oh they
only get to 60 what's short and tight the hams the glutes the gastroc soleus
okay what muscle you going to contract those push your leg down to the floor
when I try to lift it up push it down give me less than 20% of your effort
okay relax oh stop arching your back stop lifting
your butt off the table oh your knee is starting to back there's things that you
need to do to correct them so that they get the good stretch I might even
dorsiflex their ankle pull your toes up toward your face so we stretch them
across there now take care with the straight leg raise sometimes know people
have disc problems spinal vertebral disc problems in the low back and they
shouldn't be getting numbness or pain you know other than a stretching
sensation down their legs so if that's an issue of course have them check to
the physician okay who's not tighten those hip flexors
right check out this that this girl happens to
be a fitness educator and body builder tight hip flexors so we're using a
sideline position now to keep her back from arching so
Baptist arches right up her pelvis just tips forward when I try to expand or
bring her right leg back so I have flexed her left hip and me as you see in
the picture to keep her back more flat otherwise she got back pain trying to
extend her leg there there's another position to get hip extension is called
the Thomas test see I have the hip and knee flexed on one side left side but
here I'm stretching the right side in this gentleman hanging the leg off the
table of course this assumes I have a very
sturdy table to work on so what are we stretching hip flexors iliacus muscle
from the internal iliac fossa psoas muscle comes off lumbar spine very
important it comes off the intervertebral discs as well no strong
contraction is allowed here if you put the psoas in a big stretch and you have
the contract too hard too fast you can actually tear someone's discs herniated
disk I had two patients previously who were suing their previous two different
physical therapists for doing that to them so very very cautious note we told
them less than 20% effort I tell them also when stretching their flexors
I want no back pain when I'm stretching the front of your hip I want you to feel
the front of the hip and thigh stretching I want no back pain
whatsoever and then some of the hip muscles come down the rectus Morris you
see coming down the leg here from the front of the hip bone ai is right down
into the patella doesn't show you the whole connection here but this rectus
coming across Sartorius a lot of hip flexors another position so I already
showed you three positions of stressing the hip flexors it would take of course
hours of a seminar to show you all the different positions it's just to give
you an example many ways to approach the problem here if I'm putting someone on
their belly prone if they had some back pain I might put some pillows underneath
them to keep their back from arching keep them more comfortable so just some
different options and again we're back to those guidelines space limitations
name the short muscles you guys got to know your muscles review I need to
review – even after teaching kinesiology in college for ten years I still review
could we forget and it makes you very precise it makes you quick
so you can come up with these remedies right away for people so a little nice
downtown of our Coast Guard we do some volunteer work with the Coast Guard
downtown Manhattan just thought you'd like to see a little shot of the city
remember – multiple joints can be involved so if you're doing some stretch
of the hamstrings trying to increase a straight leg raise trying to get his
legs straight up in front of them remember that gastrocnemius muscle
crosses the ankle joint so I'm going to add some dorsiflexion of the ankle at
the same time I don't squash his patella by pushing my hand against his kneecap
that's not good I see too many trainers doing that on people I'm holding my hand
above the patella above the kneecap so that I don't put too much compressive
force over it so just little things like that there's a little close-up of that
gastroc in red they're coming down from the knee to the ankle crossing two
joints review that anatomy it makes you sharp it makes it quick so same
guidelines this time for ankle dorsiflexion so same thing how about it
the wrist what about somebody with a golfer's elbow or if they have medial
epicondylitis too much typing too much gripping lifting you want to increase
wrist extension what are you going to stretch the wrist flexors risk flexors
are shown here in green in the action of flexing the wrist just some of the
flexor digitorum superficialis and profundus okay flex the clock by
radialis flexor carpi ulnaris guidelines range of motion they can
extend their wrist back to that 70 or 80 degrees you're looking for maybe they're
limited to 35 what muscles are short wrist flex those finger flexors what
again contract those band your wrist and fingers hold it one two three give me
less than 20% referent relax as you relax I'm going to start bending your
wrist back or to stretch those tendons stretch it 15 to 30 seconds see how they
do three or five reps same thing with the neck you can do some nice stretches
some cook someone could be sitting they could be laying down for this
but what's tight who's not tighten their upper traps right up in those upper
shoulder muscles so from the neck to the shoulder trapezius scapula elevator
tips the head to one side so here I'm planting down the acromion of the
scapula holding scapula and it's going to shrug up the scapula how do you do
contract the scapula shrug your shoulders up a little bit hold it to
three seconds relax and then pushing the acromion pushing the scapula down
lengthening the muscles on that side of the neck so very easy to do I've giving
you some of the pictures you have some of your stomach Lata mastoid here some
of the other muscles coming down splenius muscles some of your posterior
aspects of the scalenes so same guideline you can make a little chart
for this for any joint for that guidelines for range of motion okay so
you want them to be able to get climb and get going again get hiking get where
they want to go so you know muscle energy improves range of motion there's
plenty of literature out there I've definition tsa's at the end here to
look at if you're looking for more references feel free of course email me
or just google muscle energy or PMF under Google Scholar and you can see all
kinds of fabulous research it's very very well documented you see a nice
increase in flexibility when using these techniques remember being gentle is key
be specific identify what stiff what is it you want to do what's your goal
stretch gently into the new range and then teach the client how to do that on
their own using straps are using leaning against a wall leaning against the floor
whatever they can do remember if they're sore from the stretching might be sore
the next day they haven't stretched in a while
teach them how to use that ice pack ten or fifteen minutes on their to calm
things down or some people if they've had an injury might have some
anti-inflammatories prescribed by their physician you know whatever they need to
do massage is always great as well and you want to get them back to doing the
things they love right there I am kayaking out here on Long Island and
join me one day so a little case studies if you have some time identify on
someone what step what's tight try using some of this muscle energy technique PMF
technique actively have them contract those shorts just moss
as it relaxes you'll find you can move into a greater range of motion be sure
to follow the stretching with some activity that they would typically do if
they're a tennis player have them try some tennis swings afterwards they don't
have to be on the court but I'll have people bring something in at a lady I
was treating here who fell in broke her shoulder she happens to be an emergency
room practitioner and I said look your shoulders you know stiffness is finally
going down and what is it you'd like to do obviously have to move patients
emergency room she likes to bike ride she had trouble turning the handlebars
of the bike because the shoulder was stiff and unresponsive so what else do
you like to do I like to golf I want to go golfing bring your clump so
her last is that she brought her club and after doing the stretches in the
muscle energy she started showing me some of her swing I said I want you to
practice your swing but first you need to get those stretches and I showed her
how to do her own little contract relaxed muscle energy so come up with a
functional activity that can do especially something that they will
enjoy they're enjoying it they're going to go ahead and do it and include as a
home program they're giving you a few different references on some of these
very recent aspects of literature showing how well these muscle energy and
pmf techniques work there's also dr.

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Jay chou's book on
muscle energy is here for you I highly recommend to check it out so you have a
few different references there for you different literature is out so I wanted
to also think that pictures you saw of anatomy aboard with permission from
primal pictures a little reference for those folks and I'd like to give also a
special thanks to dr. verbum or and Susan Knight again especially for
helping with the technology aspect of getting this seminar out there to you
and I'd like to especially show my gratitude to all of you for taking the
time out of your busy schedule to come and enjoy this little chat on
flexibility and do feel free if you have further comments or questions to contact
me at edge aside Oh

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Anyone who loves or pursues or desires to obtain pain of itself, but because occasionally circumstances occur in which toil and pain can procure him some great pleasure. Which of us ever undertakes laborious physical exercise, except to obtain some advantage from it? But who has any right to find fault with a man who chooses to enjoy a pleasure?


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