RANGE OF MOTION AND FLEXIBILITY - Human & Disease

RANGE OF MOTION AND FLEXIBILITY


RANGE OF MOTION AND FLEXIBILITY

What is the ROM? 
Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by the capsular and ligamentous structures surrounding that joint.

RANGE OF MOTION AND FLEXIBILITY What is the ROM ? Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by capsular and ligamentous structures surrounding that joint. What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors.
Flexibility










What is flexibility? and its components?

" Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When the injury occurs, there is almost always some associated loss of the ability to move normally due to pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors.

What are examples of flexibility?

 A decrease in ROM and/or in the flexibility of one joint can affect the entire kinetic chain. For example, a decreased ROM or flexibility in the shoulder can impact the function of the entire arm. In order to provide treatment for a loss of movement, the clinician must make the determination as to the specific cause i.e., loss of ROM or decreased flexibility. For example, is the specific cause due to joint effusion, adaptive shortening of connective tissue structures, changes in bony architecture, or alignment of the articular surfaces?

Importance of flexibility in movement

Normal flexibility and ROM are necessary for efficient movement. Joint movement may be viewed as the amount of joint ROM, the arthrokinematic glide that occurs at the joint surfaces, termed joint play, whereas flexibility is determined by the degree of extensibility of the periarticular and connective tissues that cross the joint. A number of anatomic factors can limit the ability of a joint to move through a full, unrestricted ROM. These include:

" muscles and their tendons

" connective tissue
 
" bone
 
" adipose tissue
 
" Skin
 
" neural tissue
 

When referring to ROM, three major movements are recognized ( Types of ROM ):

" Active range of motion (AROM). AROM, also called dynamic flexibility, refers to the degree to which a joint can be moved by a single muscle contraction, usually through the mid-range of movement. Active ROM does not maintain or increase strength, or develop skill or coordination except in the movement patterns used.

" Active assisted range of motion (AAROM). AAROM is an AROM where the effect of gravity has been removed. For example, performing shoulder abduction while lying supine.

" Passive range of motion (PROM). PROM refers to the degree to which a joint can be passively moved to the endpoint in the ROM. PROM is important for injury prevention. Passive ROM does not prevent muscle atrophy, increase strength or endurance, or assist circulation to the same extent that active, voluntary muscle contraction does. When referring to flexibility, two types are recognized, static and dynamic.

What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors.


CLINICAL PEARL

In the early stages of the rehabilitation process, ROM exercises are performed in the following sequence:

-PROM

-AAROM

-AROM

It is important to remember when making the transition from PROM to AAROM or AROM, that gravity has a significant impact, especially in individuals with weak musculature. These individuals may require assistance when the segment moves up against gravity, or moves downward, with gravity.

Types of flexibility in physical education:

1- Static flexibility. Static flexibility is defined as the range or motion available to a joint or series of joints. Increased static flexibility should not be confused with joint hypermobility, or laxity, which is a function of the joint capsule and ligaments. Decreased static flexibility indicates a loss of motion. The end-feel encountered may help the clinician differentiate the cause among adaptive shortening of the muscle (muscle stretch), a tight joint capsule (capsular), and an arthritic joint (hard). Static flexibility can be measured by a number of tests, such as the toe touch and the sit and reach, both of which have been found to be valid and reliable.

2- Dynamic flexibility. Dynamic flexibility refers to the ease of movement within the obtainable ROM. Dynamic flexibility is measured actively. The important measurement in dynamic flexibility is stiffness, a mechanical term defined as the resistance of a structure to deformation. An increase in ROM around a joint does not necessarily equate to a decrease in the passive stiffness of a muscle. However, strength training, immobilization, and aging have been shown to increase stiffness. The converse of stiffness is pliability. When a soft tissue demonstrates a decrease in pliability, it has usually undergone an adaptive shortening, or an increase in tone, termed hypertonus. There is growing research to suggest that the limiting factors to preventing increases in ROM are not only the connective tissues but are also the result of neurophysiological phenomena controlled by the higher centers of the central nervous system.

What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors. What are the examples of flexibility ? A decrease in ROM and/or in the flexibility of one joint can affect the entire kinetic chain. For example, a decreased ROM or flexibility in the shoulder can impact the function of the entire arm. In order to provide a treatment for a loss of movement, the clinician must make the determination as to the specific cause i.e., loss of ROM or decreased flexibility. For example, is the specific cause due to joint effusion, adaptive shortening of connective tissue structures, changes in bony architecture, or alignment of the articular surfaces? Importance of flexbility in movement Normal flexibility and ROM are necessary for efficient movement. Joint movement may be viewed as the amount of joint ROM, the arthrokinematic glide that occurs at the joint surfaces, termed joint play, whereas flexibility is determined by the degree of extensibility of the periarticular and connective tissues that cross the joint. A number of anatomic factors can limit the ability of a joint to move through a full, unrestricted ROM. These include: " muscles and their tendons " connective tissue " bone " adipose tissue " skin " neural tissue


A number of factors influence connective tissue deformation:

1- Sensory receptors

Two sensory receptors that monitor muscle activity, the muscle spindle and Golgi tendon organs (GTOs) play an important role when attempting to increase flexibility through stretching.

These two receptors can activate both spinal reflexes and long-loop pathways involving supraspinal centers. When a muscle is stretched, both the muscle spindles and the GTOs immediately begin sending a stream of sensory impulses to the spinal cord. Initially, impulses coming from the muscle spindles notify the CNS that the muscle is being stretched. Impulses return to the muscle from the spinal cord, causing the muscle to reflexively contract, thus resisting the stretch. The GTOs respond to the change in length and the increasing tension by firing off sensory impulses of their own to the spinal cord and, if the stretch of the muscle continues for an extended period of time (at least 6 seconds), impulses from the GTOs begin to override muscle spindle impulses and cause a reflex relaxation of the antagonist's muscle (autogenic inhibition).

CLINICAL PEARL
 
In any synergistic muscle group, a contraction of the agonist causes a reflex relaxation in the antagonist's muscle, allowing it to stretch and protect it from injury this phenomenon is referred to as reciprocal inhibition.

2- Tissue temperature

 At temperatures above 37 C :
the cross-links between collagen fibrils are broken more easily and more rapidly, with the most profound changes occurring between 40–45 C.

A number of key points must be remembered by the clinician in order to effectively manipulate temperature:

& The amount of force required to attain/maintain a desired deformation decreases as temperature increases.

& The time required to deform collagen to the point of failure is inversely related to temperature.

& The higher the temperature, the greater the load collagen is able to tolerate before failure.

&The higher the temperature, the greater the amount of deformation possible before failure.

Types of flexibility in physical education: 1- Static flexibility. Static flexibility is defined as the range or motion available to a joint or series of joints. Increased static flexibility should not be confused with joint hypermobility, or laxity, which is a function of the joint capsule and ligaments. Decreased static flexibility indicates a loss of motion. The end-feel encountered may help the clinician differentiate the cause among adaptive shortening of the muscle (muscle stretch), a tight joint capsule (capsular), and an arthritic joint (hard). Static flexibility can be measured by a number of tests, such as the toe touch and the sit and reach, both of which have been found to be valid and reliable. 2- Dynamic flexibility. Dynamic flexibility refers to the ease of movement within the obtainable ROM. Dynamic flexibility is measured actively. The important measurement in dynamic flexibility is stiffness, a mechanical term defined as the resistance of a structure to deformation. An increase in ROM around a joint does not necessarily equate to a decrease in the passive stiffness of a muscle. However, strength training, immobilization, and aging have been shown to increase stiffness. The converse of stiffness is pliability.


It is important to make a distinction between stretching and warm-up as the two are not synonymous but often confused by the layman. While stretching places neuro-musculotendinous units and their fascia under tension, a warm-up requires the performance of an activity that raises total body and muscle temperatures to prepare the body for exercise. Research has shown that warm-up prior to stretching results in significant changes in joint ROM.

Anecdotally, it would make sense not to perform stretching at the beginning of the warm-up routine because the tissue temperatures are too low for optimal muscle–tendon function, and are less compliant and less prepared for activity. Some advocate stretching after an exercise session, citing that the increased musculotendinous extensibility leads to the potential for improved joint flexibility. In one study, static stretching was done before, after, and both before and after each workout. All produced significant increases in ROM.

3- The amount of force used

 Viscoelastic changes are not permanent, whereas plasticity changes, which are more difficult to achieve, result in a residual or permanent change in length. The key factor for any change in connective tissue length is the deforming force, in particular, the magnitude and velocity applied. The application of low-load, long-duration forces is recommended. A muscle usually requires a greater stretching force initially, possibly to break up adhesions or cross-linkages, and to allow for viscoelastic and plastic changes to occur in the collagen and elastin fibers. Frequent stretching ensures that the lengthening is maintained before the muscle has the opportunity to recoil to its shortened state.

4- The direction of the stretch

 To stretch a muscle appropriately, the stretch must be applied parallel to the muscle fibers. The orientation of the fibers can be determined by palpation. Typically, in the extremities, the muscle fibers run parallel to the bone. 

A variety of stretching techniques can be used to increase the extensibility of soft tissues.

1- Static Stretching

Static stretching involves the application of a steady force for a sustained period. The stretch should be performed at the point just shy of the pain, although some discomfort may be necessary to achieve results. Small loads applied for long periods produce greater residual lengthening than heavy loads applied for short periods. Restoration of the normal length of the muscles. Weighted traction or pulley systems may be used for this type of stretching. It is important for the patient to realize that the initial session of stretching may increase symptoms. However, this increase in symptoms should be temporary, lasting for a couple of hours, at most.

Dynamic flexibility. Dynamic flexibility refers to the ease of movement within the obtainable ROM. Dynamic flexibility is measured actively. The important measurement in dynamic flexibility is stiffness, a mechanical term defined as the resistance of a structure to deformation. An increase in ROM around a joint does not necessarily equate to a decrease in the passive stiffness of a muscle. However, strength training, immobilization, and aging have been shown to increase stiffness. The converse of stiffness is pliability. When a soft tissue demonstrates a decrease in pliability, it has usually undergone an adaptive shortening, or an increase in tone, termed

2- Dynamic Stretching

 Dynamic stretching involves stretching by a muscular contraction to increase or decrease the joint angle where the muscle crosses, thereby elongating the musculotendinous unit as the end ROM is obtained Dynamic stretching is a specific warm-up using activity-specific movements to prepare the muscles by taking them through the movements used in a particular sport. Dynamic stretching does not incorporate end-range ballistic movements but rather the use of controlled movements through a normal ROM.

There is some debate as to whether the static or dynamic method is better to stretch a muscle. Static stretching is considered the gold standard in flexibility training. However, recent studies have found that static stretching is not an effective way to reduce injury rates, and may actually inhibit athletic performance. This is likely because the nature of static stretching is passive and does nothing to warm a muscle. More dynamic methods of stretching involve either a contraction of the antagonist muscle group thus allowing the agonist to elongate naturally in a relaxed state, or eccentrically training a muscle through its full ROM. The latter method would appear to address the problem that most injuries occur in the eccentric phase of activity. A study by Nelson that compared the immediate effect of static stretching, eccentric training, and no stretching/training on hamstring flexibility in high school and college athletes (75 subjects) found the flexibility gains in the eccentric training group to be significantly greater than the static stretch group.

3- Proprioceptive Neuromuscular Facilitation

 The proprioceptive neuromuscular facilitation (PNF) techniques of contract-relax (CR), an agonist contraction (AC), or a contract-relax-agonist contraction sequence (CRAC) can be used to actively stretch the soft tissues:

A- CR. CR stretching begins as does static stretching in that the clinician supports the patient and brings a limb to the end of ROM until a gentle stretching is felt. At that point, the clinician asks the patient to provide an isometric contraction of the muscle being stretched (the antagonist) for approximately 2 to 5 seconds after which the patient is asked to relax the muscle. The clinician moves the limb passively into the new range until a limitation is again felt and repeats the procedure two to four times.

B- AC. AC stretching uses the principle of reciprocal inhibition. The clinician moves the limb to the position of gentle stretch and asks the patient for a contraction of the muscle opposite the muscle being stretched (the antagonist). For example, when stretching the hamstring muscles, a simultaneous contraction of the quadriceps muscles can facilitate the stretch of the hamstrings. The contraction is held for 2 to 5 seconds and the technique is repeated 2 to 4 times.

C- CRAC. This technique combines CR and AC stretches.

The clinician takes the limb to the point of gentle stretch and performs a CR sequence (i.e., the resistance applied against the muscle being stretched). After contracting the muscle being stretched, the patient is asked to relax this muscle while contracting the opposing muscle group (antagonist), thus facilitating the stretch. For example, when stretching the hamstring muscles, the hamstrings are brought to a position stretch, the hamstrings are then contracted against resistance, and then relaxed, and then the quadriceps are contracted.

The majority of studies have shown the PNF techniques to be the most effective for increasing ROM through muscle lengthening when compared to the static or slow sustained, and the ballistic or bounce techniques, although one study found it to be not necessarily better.

The majority of studies have shown the PNF techniques to be the most effective for increasing ROM through muscle lengthening when compared to the static or slow sustained, and the ballistic or bounce techniques, although one study found it to be not necessarily better.


Other techniques that can assist in lengthening contractile tissue through relaxation include the following:

" The application of heat
 which increases the extensibility of the shortened tissues, and will allow the muscles to relax in length and more easily, reducing the discomfort of stretching. Heat without stretching has little or no effect on long-term improvement in muscle flexibility, whereas the combination of heat and stretching produces greater long-term gains in tissue length than stretching alone.

" Massage 
which increases local circulation to the muscle and reduces muscle spasm and stiffness.

" Biofeedback
which teaches the patient to reduce the amount of tension in a muscle. 

" Ballistic Stretching

This technique of stretching uses bouncing movements to stretch a particular muscle. The muscle is stretched by the momentum created from the bouncing movement of the body supplying the tensile force used for the stretch. The patient quickly relaxes the muscle when reaching the end of ROM. This is performed in a cyclical bouncing motion and repeated several times, thus engaging a neurological component called "active resistance" the contraction of muscles that resist elongation in the form of muscle reflex activity. In comparisons of the ballistic and static methods, two studies have found that both produce similar improvements in flexibility however, the ballistic method appears to cause more residual muscle soreness or muscle strain than those techniques that incorporate relaxation into the technique.

Further research is needed to determine the appropriate stretching frequency and duration for long-lasting changes in flexibility. Researchers have reported that techniques utilizing cyclic and sustained stretching for 15 minutes on five consecutive days increased hamstring muscle length and that a significant percentage of the increased length was retained one-week post-treatment. Other researchers have reported that after using four consecutive knee flexor static stretches of 30 seconds, the new knee ROM was maintained for 3 minutes but returned to prestretch levels after 6 minutes.

 A similar study using a sequence of five modified hold–relax stretches reported producing significantly increased hamstring flexibility that lasted 6 minutes after the stretching protocol ended. The specific duration, frequency, and number of stretching repetitions vary in the literature. Evidence to date has shown that stretches are generally held anywhere from 10 to 60 seconds, with the research recommending that stretches be held between 15 and 30 seconds. In contrast, little research has been conducted on the number of repetitions of a stretch in an exercise session, although it has been determined that 80% of the length changes occur in the first four stretches of 30 seconds each.

Current American College of Sports Medicine Guidelines recommend three to five repetitions for each stretching exercise.


RANGE OF MOTION AND FLEXIBILITY What is the ROM ? Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by capsular and ligamentous structures surrounding that joint. RANGE OF MOTION AND FLEXIBILITY What is the ROM ? Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by capsular and ligamentous structures surrounding that joint. What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors. Flexibility What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors. What are the examples of flexibility ? A decrease in ROM and/or in the flexibility of one joint can affect the entire kinetic chain. For example, a decreased ROM or flexibility in the shoulder can impact the function of the entire arm. In order to provide a treatment for a loss of movement, the clinician must make the determination as to the specific cause i.e., loss of ROM or decreased flexibility. For example, is the specific cause due to joint effusion, adaptive shortening of connective tissue structures, changes in bony architecture, or alignment of the articular surfaces? Importance of flexbility in movement Normal flexibility and ROM are necessary for efficient movement. Joint movement may be viewed as the amount of joint ROM, the arthrokinematic glide that occurs at the joint surfaces, termed joint play, whereas flexibility is determined by the degree of extensibility of the periarticular and connective tissues that cross the joint. A number


SELF-STRETCHING

Self-stretching techniques include any stretching exercise that is carried out independently by the patient after instruction and supervision.

CONTINUOUS PASSIVE MOTION

RANGE OF MOTION AND FLEXIBILITY What is the ROM ? Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by capsular and ligamentous structures surrounding that joint. RANGE OF MOTION AND FLEXIBILITY What is the ROM ? Range of motion (ROM) refers to the distance and direction a joint can move. Each specific joint has a normal ROM that is expressed in degrees. Within the field of physical therapy, goniometry is commonly used to measure the total amount of available motion at a specific joint. ROM of a joint may be limited by the shape of the articulating surfaces and by capsular and ligamentous structures surrounding that joint. What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors. Flexibility What is the flexibility ? and its components ? " Flexibility refers to the ability to move a joint or series of joints through a full, nonrestricted, injury, and pain-free ROM. Flexibility is dependent on a combination of joint ROM, muscle flexibility, and neuromuscular control. When injury occurs, there is almost always some associated loss of the ability to move normally due to the pain, swelling, muscle guarding, or spasm. The subsequent inactivity results in a shortening of connective tissue and muscle, loss of neuromuscular control, or a combination of these factors. What are the examples of flexibility ? A decrease in ROM and/or in the flexibility of one joint can affect the entire kinetic chain. For example, a decreased ROM or flexibility in the shoulder can impact the function of the entire arm. In order to provide a treatment for a loss of movement, the clinician must make the determination as to the specific cause i.e., loss of ROM or decreased flexibility. For example, is the specific cause due to joint effusion, adaptive shortening of connective tissue structures, changes in bony architecture, or alignment of the articular surfaces? Importance of flexbility in movement Normal flexibility and ROM are necessary for efficient movement. Joint movement may be viewed as the amount of joint ROM, the arthrokinematic glide that occurs at the joint surfaces, termed joint play, whereas flexibility is determined by the degree of extensibility of the periarticular and connective tissues that cross the joint. A number


CPM refers to passive motion performed by a mechanical device that moves the joint slowly and continuously through a controlled ROM.

 CPM machines have been designed for use on many body parts, including the hip, knee (most common), ankle, shoulder, elbow, wrist, and hand. The subject of CPM device use following surgery has been debated for years, with some surgeons advocating, and others opposing its use.

CLINICAL PEARL

CPM protocols vary significantly, ranging from 24 hours a day for as long as 1 month, to as little as 6 hours a day after surgery.


CPM refers to passive motion performed by a mechanical device that moves the joint slowly and continuously through a controlled ROM. CPM machines have been designed for use on many body parts, including the hip, knee (most common), ankle, shoulder, elbow, wrist, and hand. The subject of CPM device use following surgery has been debated for years, with some surgeons advocating, and others opposing its use. CLINICAL PEARL CPM protocols vary significantly, ranging from 24 hours a day for as long as 1 month, to as little as 6 hours a day after surgery.


The CPM machine is calibrated in degrees of motion and cycles per minute. The use of a CPM device has been promoted as a means to facilitate a more rapid recovery by improving ROM, decreasing the length of hospital stay, and lowering the amount of narcotic use. However, studies have shown that the effect of CPM devices on analgesia consumption, ROM, hospital stay, and complications has been variable:

" Data supports the use of CPM to decrease the rate of manipulation for poor ROM after total knee arthroplasty (TKA).

" The use of CPM has not been shown to result in more long-term increases in ROM than other methods of early movement and positioning.

CPM refers to passive motion performed by a mechanical device that moves the joint slowly and continuously through a controlled ROM. CPM machines have been designed for use on many body parts, including the hip, knee (most common), ankle, shoulder, elbow, wrist, and hand. The subject of CPM device use following surgery has been debated for years, with some surgeons advocating, and others opposing its use. CLINICAL PEARL CPM protocols vary significantly, ranging from 24 hours a day for as long as 1 month, to as little as 6 hours a day after surgery.


Static Stretching Guidelines

" Heat should be applied to increase intramuscular temperature prior to, and during, stretching This heat can be achieved either through low-intensity warm-up exercise or through the use of thermal modalities. The application of a cold pack following the stretch is used to take advantage of the thermal characteristics of connective tissue, by lowering its temperature and thereby theoretically prolonging the length changes the elasticity of a muscle diminishes with cooling.

Heat should be applied to increase intramuscular temperature prior to, and during, stretching This heat can be achieved with either through low-intensity warm-up exercise, or through the use of thermal modalities. The application of a cold pack following the stretch is used to take advantage of the thermal characteristics of connective tissue, by lowering its temperature and thereby theoretically prolonging the length changes the elasticity of a muscle diminishes with cooling.


" Effective stretching, in the early phase, should be performed every hour, but with each session lasting only a few minutes.

" With true muscle shortness, stronger resistance is used to activate the maximum number of motor units, followed by vigorous stretching of the muscle.

" Stretching should be performed at least three times a week using:
& Low force, avoiding pain

& Prolonged duration.
 
& Rapid cooling of the muscle while it is maintained in the stretched position Although it appears that the use of a CPM device does help regain knee flexion quicker post-TKA, it is not as effective in the enhancement of knee extension.

" Knee impairments or disability are not reduced with the use of a CPM at discharge from the hospital.

" Because of standardized inpatient hospital clinical pathways, the length of hospital stay is not decreased by the use of a CPM device but, depending on the hospital involved, the overall cost is not increased.

" Wound complications probably are not increased with the use of CPM, provided good technique is used in wound closure.
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