"End range is where the magic happens"
What a great line that McKenzie clinicians love to use. Fortunately, any and all clinicians can utilize it! We should all be consistently using end range to reintegrate new sensory (proprioceptive,etc) information as to facilitate proper movement and control. Here are just a couple applications to reintegrate at the 'magical end range':
Co-contractions Rhythmic Stabs at End Range;
Progress unloaded to loaded (supine, quad, kneeling, stand)
Progress unloaded to loaded (supine, quad, kneeling, stand)
It so crucial to facilitate the newly gained range of motion immediately after any reset technique. Reintegration of this new range dramatically improves retention on their new mobility and movement quality. For the above exercise the patient is taken to the newly gained end range and re-educated by way of manual stabilization. A light pressure is applied in two directions perpendicular to each other, working around the chosen joint (down&left, left&up, up&right, and so on). The more distal the joint you perform the stabs at, the higher moment arm you created and thus more challenging it will be to the patient. This is much more challenging and functional than random, single perturbations put on the arm (alternating isometrics per PNF) as the patient must rely on sustained synergistic, similar to real movement thereby making it much more functional. Perform about 5-10x for 10”holds.
Assistive to End Range with Sustained Isometric Contraction at End Range (use for UT, HS, etc) followed by Progressive Resistance Concentric Contraction
Eccentric motions are how are muscles control motion and work a majority of the time. Yes, your bicep is curling the weight but the triceps are eccentrically controlling the motion and doing just as much work in regards to the smoothness and coordination of that movement. Further, working in the opposing direction will likely be non-painful especially if we can keep it active-assistive (we help them move). For the example above, we add some assist (AAROM) to the motion to a lengthened position (thus were working on the L UT) while the patient provides mild resistance when the barrier is reached. Then, slowly progressive resistance is maintained throughout the concentric (shortening) period; usually start with assistive and work up to active, light resistance, and moderate resistance. This technique can lead to normal excitability of the motor neurons and increase the timing and sequencing pattern . Again, we build up the resistance and motion to get to the pt’s end range. Often patients have a difficult time with loaded active motion but working them in the opposite direction (stretch) seems to work very well in slowly loading the tissue back up. This is only effective after a reset. Then the body and brain is ready to find a new physiological end range.
These are just two simple examples of manual techniques to work at end range but all exercises and correctives should get to the pt’s (pain free) end range.
