Comprehensive Guide to Mobility, Stretching and Contractures Management

Functional Mobility and Range

The ability of body segments or structures to move in a way that permits range of motion (ROM) for functional activities is a common definition of mobility (also known as functional ROM). It is also known as functional mobility, which is the capacity of an individual to start, regulate, or maintain active motions of the body to carry out motor tasks. In terms of functional range of motion, mobility is linked to both soft tissue flexibility and joint integrity. In this case, an individual's ability to carry out their functional tasks and activities is dependent on the flexibility of the soft tissues surrounding or crossing joints. Importantly, full or "normal" ROM is not always what is meant by the range of motion required to carry out functional tasks.

Hypomobility: Causes and Implications

A necessary degree of muscle function, including strength, endurance, and neuromuscular control, is also necessary to maintain adequate soft tissue mobility and joint range of motion. Sufficient muscle function not only permits functional mobility but also regulates applied physical stresses and may guard against musculoskeletal injuries. restricted extensibility in soft tissues or adaptive shortening are common causes of hypomobility, or restricted functional motion. Hypomobility may result from a number of reasons, such as:

1. Prolonged immobility of a body segment;
2. Sedentary lifestyle;
3. Postural malalignment with changes in muscle length; and
4. Reduced muscle performance, or weakness, linked to problems of the musculoskeletal or neuromuscular system.
5. Tissue damage that causes pain and inflammation. 
6. Birth defects or acquired malformations. A component that reduces soft tissue extensibility, which restricts movement, can also cause a reduction in muscle function. Hypomobility may be a factor in a person's participation and activity constraints.

Stretching Therapies: Enhancing Mobility and Function

When limited mobility negatively impacts function or raises the risk of injury, stretching therapies constitute a crucial part of a personalized rehabilitation program. Stretching exercises are also seen to be a crucial component of conditioning regimens for sports and fitness that are intended to enhance wellbeing and lower the chance of injury or reinjury. Any treatment technique intended to improve soft tissue extensibility and improve range of motion (ROM) by lengthening (or stretching) components that have hypomobility shortened due to adaptive processes is referred to as stretching. A therapist cannot identify which structures are limiting motion or whether, when, and what kinds of stretching techniques are necessary until they have conducted a thorough examination, evaluation, and diagnosis of their patient's issues. Manual stretching and joint mobilization/manipulation which need direct, "hands on" involvement by a practitioner might be the most appropriate approaches early in the rehabilitation process. Eventually, a more appropriate intervention would be patient-performed self-stretching exercises carried out on their own following thorough teaching and close monitoring.

Mechanical Stretching and Effective Self-Stretching Methods

The use of a mechanical stretching device makes sense in certain circumstances, especially after manual therapies have failed. Any increases in range of motion (ROM) should be utilized on a regular basis for strengthening and functional exercises, regardless of the kind of stretching that is employed as an intervention. The goal of the stretching therapies covered in this chapter is to increase the contractile and noncontractile parts of muscle-tendon units and periarticular structures' extensibility. Throughout the chapter, the effectiveness of these approaches is examined. There are discussed and illustrated self-stretching exercises for every part of the body in addition to the stretching methods for the extremities.

Adaptability

The capacity to rotate a single joint or a group of joints freely and painlessly over an unconstrained range of motion (ROM 100) is known as flexibility. Flexibility is determined by the interaction of muscle length, joint integrity, and periarticular soft tissue extensibility. When the muscle tendon units that cross a joint have sufficient extensibility to flex and yield to a stretch force, flexibility is at its highest. Joint ROM and flexibility are further influenced by the periarticular connective tissues' ability to deform and the arthrokinematics of the moving joint, which refers to the ability of the joint surfaces to roll and slide.

Dynamic and Passive Flexibility

Dynamic flexibility

The degree to which an active muscle contraction can rotate a joint over its available range of motion is known as the active mobility, or active ROM. The degree and quality of tissue extensibility, as well as a muscle's capacity to contract over range of motion, determine dynamic flexibility.

Passive flexibility

This kind of adaptability is also known as the degree to which a joint may be passively rotated over its accessible range of motion, also known as AM or passive mobility or passive ROM, is dependent on the extensibility of the soft tissues that cross and surround a joint. While necessary, passive flexibility does not guarantee dynamic flexibility.

Insufficient mobility

Reduced movement or limited range of motion at one or more joints is referred to as hypomobility. Hypomobility is linked to numerous disease processes, and a variety of variables may be involved in motion limitation.

Breakage

From minor tightness to irreparable contractures, restricted motion might occur. The adaptive shortening of the muscle-tendon unit and other soft tissues that span or surround a joint is known as contracture, and it causes restricted range of motion and strong resistance to both passive and active stretching. The functioning capacities of individuals with contractures might be severely compromised by their limits.  It is unclear to what extent the restriction must lose mobility due to decreased soft tissue extensibility in order to be classified as a contracture. While the word "shortness" refers to a partial loss of mobility, the most common definition of contracture is a virtually total lack of motion. In clinical and fitness contexts, the term "tightness" is frequently used to characterize restricted motion resulting from adaptive shortening of soft tissue, specifically modest muscular shortening. Adaptive shortening of the contractile and noncontractile components of muscle is often referred to as "muscle rightness."

Contractures Categorized by Location

The side of the joint with the tight tissue is known as a contracture. if the side of flexion is where the tension is. It is referred to as a flexion contracture along the flexion/extension joint axis. An elbow flexion contracture is the medical term for a patient who lacks full elbow extension due to shortened elbow flexors. Hip adduction contracture is the term used to describe a patient who has tight hip adductors and is unable to fully abduct the leg.

Contrasting Contracture with Contraction

It is not appropriate to use the terms contracture and contraction interchangeably. Contracture refers to the process of active tension building in a muscle during shortening or lengthening.

Different Contracture Types

One method to further define contractures is to characterize them as pathological alterations in the many myogene soft tissue types that are involved.

Contraction of Myostatic Muscles

A myostatic (myogenic) contracture lacks distinct muscle pathology even though the musculotendinous unit has adapted to shorten and there is a notable decrease of range of motion. From a morphological point of view, each sarcomere length remains same even though there can be a decrease in the total number of sarcomere units in series. Stretching exercises can help alleviate myostatic contractures in a reasonable amount of time.

Contracture Pseudomyostatically

Hypertonicity, or spasticity or rigidity, linked to a central nervous system lesion, such as a cerebrovascular accident, spinal cord damage, or traumatic brain injury, can also cause impaired movement and limited range of motion. A pseudomyostatic contracture may also result from discomfort, guarding, or spasms in the muscles. Both conditions result in increased resistance to passive stretch because the implicated muscles seem to be in a continual state of contraction. Thus, apparent contracture or pseudomyostatic contracture are phrases employed. Complete passive extension of the ostensibly shortened muscle is therefore achievable if neuromuscular blocking techniques are used to temporarily lessen muscle tension.

Periarticular and Arthrogenetic Contracture

An intra-articular disease gives rise to an arthrogenic contracture. Adhesions, synovial proliferation, joint effusion, abnormalities in articular cartilage, or the production of osteophytes are a few examples of these alterations. Normal arthrokinematics motion is restricted by periarticular contractures, which occur when connective tissues that cross or attach to a joint or the joint capsule become immobile.

Irreversible Contracture and Fibrotic Contracture

Muscle and periarticular structures may attach to one another due to fibrous alterations in their connective tissue, which can lead to the formation of a fibrotic contracture. It is frequently challenging to restore ideal tissue length, even though it is conceivable to stretch a fibrotic contracture and finally increase range of motion."

Irreversible Soft Tissue Contractures

When a significant number of relatively non extensible fibrotic adhesions, scar tissue, or heterotopic bone replace malformed muscle and organized connective tissue, there may be a permanent loss of soft tissue extensibility that cannot be restored without surgery. These alterations may happen following extended periods of immobility in which the tissues are compressed, or they may result from tissue damage and the ensuing inflammatory reaction. It gets harder to regain ideal mobility and the likelihood that the contracture may become irreversible the longer a fibrotic contracture has existed or the more extensive the tissue replacement. By using stretching techniques on certain muscles and joints and allowing mobility limits to develop in other muscles or joints, a patient's total function may be enhanced through a process known as "selective stretching." It is crucial for the therapist to balance mobility and stability for optimal functional performance, taking into account the patient's functional needs while choosing which muscles to stretch and which to allow to become somewhat shortened. Patients who have lifelong paralysis usually make the decision to let certain muscle-tendon units and joints experience constraints.

Functional Adaptations in Spinal Cord Injury

For instance: For a patient with a spinal cord injury to be independent when sitting, trunk stability is required. The patient lacks active control of the back extensors when they have thoracic and cervical injuries. A patient can lean into the slightly shortened structures and have some degree of trunk stability for prolonged sitting if the hamstrings are regularly stretched to maintain or improve their extensibility and modest hypomobility is allowed to develop in the low back extensors. The patient must nevertheless, however, be able to move freely enough to dress and transfer themselves. Reduced function may result from excessive low back motion restriction. A patient with spinal cord injury who does not have innervation to the intrinsic finger muscles can regain the capacity to grasp utilizing a tenodesis action by allowing alight hypomobility to develop in the long flexors of the fingers while keeping the wrist extensors mobile.

Overstretching and Excessive Movement

Hypermobility (excessive mobility) is the result of overstretching, which is defined as stretching considerably beyond the typical length of muscle and range of motion of a joint and the surrounding soft tissues. Some healthy persons with normal strength and stability who play sports requiring a lot of flexibility may need to overstretch in order to crest selective hypermobility. If the dynamic muscle control of the joint and/or the static supporting structures are insufficient to keep the joint in a stable, functional posture during activities, hypermobility may result in harmful joint instability. Joint instability can lead to pain and increase the risk of musculoskeletal injuries.