EFFECT OF ECCENTRIC TRAINING USING THERA-BAND,
MUSCLE ENERGY TECHNIQUE AND STATIC STRETCHING IN HAMSTRING MUSCLE FLEXIBILITY
OF PATIENTS WITH MECHANICAL LOW BACK PAIN
Submitted by
Dr.M.Aejaz M Siddiqui
Parul institute of physiotherapy
Year of Enrolment 2019-20
Registration no
190720301005
Research guide
Dr.Amalkumar Bhattacharya
MBBS, M.D (MEDICINE)
Faculty of Medicine
PARUL UNIVERSITY, LIMDA, WAGHODIA
VADODARA-391760, GUJARAT-INDIA
Signature of the PHD Scholar Research Guide
Forwarded by,
Head of Department (H.O.D)
Dean (D.S & R)
TABLE OF CONTENTS
1.
Introduction
2.
Review of
literature
3.
Scope and
statement of the problem
4.
Objectives of
the studies
5. Hypothesis
6. Methodology tools and technique
Inclusion
and exclusion criteria
Sample
Design
Instrumentation
Procedure
7. Schedule of the
proposed research work/Protocol
8. REFERENCES/Bibliography
APPENDICES
Appendix: A Consent Form
Appendix:
B Data collection form
INTRODUCTION
Stretching is used as part of physical fitness and rehabilitation
programme because it is thought to positively influence performance and injury
prevention. Numerous studies1,3,5 have been conducted to investigate
the effectiveness of stretching. Shortness and contracture of hamstring muscle
may cause limitation in range of motion(ROM), that restrict the normal range of
muscle. This potentially harmful condition may be managed with a stretching
programme, which may be positively influence an individual’s functional
capacity of daily living and decrease of injuries. Knee extension range of
motion from tight hamstring muscle have been linked to injuries such as
hamstring tendonitis and hamstring strains. These patient often receive
specific hamstring-stretching exercises as part of an overall rehabilitation
programme. Several studies have reported an immediate increase in knee
extension ROM following the application of hamstring stretching exercises.2,4,5
Flexibility has been defined as the ability of a muscle to lengthen and
allow one joint(or more than one joint in a series.) to move through a range of
motion2. Increased flexibility is one of the basic concerns addressed in the day to day practice of
physical therapy. It is a goal for any patient recovery from a period of
immobilization or injury involving the connective tissue. Optimal flexibility
is also desirable for participants in most athletic activity and normal day to
day function. A shortened muscle may create imbalance at joints and faulty
postural alignment that may lead to injury and joint dysfunction.
Extensibility is defined as the ability to
stretch a muscle tendon unit to its
fullest length1. Muscle contracture result in decreased
extensibility joint motion. physical therapist have used many different method
to maintain and increased joint motion and prevent deformity and dysfunction resulting
from the muscle contracture .Research with clinical trials has long advocated
the use of thermotherapy to increase flexibility in conjunction with a
stretching program design to lengthen tissue. Lengthening the musculotendinous
unit and supporting connective tissue increase the range of motion(ROM) through
which a joint can move as well a the muscle ability to respond to stress placed
upon it .
Two
terms critical to the physical properties of hamstring muscle require
definition. Elasticity is defined as the tendency of a tissue to return to its
resting length after passive stretch, somewhat like a rubber band. Plasticity
is defined as the tendency of a tissue to assume a new and greater length after
passive stretch, somewhat like stretching of chewing gum. Plasticity is the
critical property that enables a tissue to lengthen permanently.
Increased hamstring stiffness could
be a possible contributing factor to low back injuries. Clinical observations
have suggested that hamstring tightness influences lumbar pelvic rhythm.
Movement restrictions or postural asymmetry likely lead to compensatory
movement patterns of the lumbar spine, and subsequently to increased stress on
the spinal soft tissues and an increased risk of low back pain (LBP).
REVIEW
OF LITERATURE
Three types of stretching have been traditionally defined in
literature in an effort to increased flexibility: balastic stretching,
proprioceptive neuromuscular facilitation and static stretching. Ballastic
stretching is a technique involving a rhythmic bouncing position to lengthen
the muscle. Proprioceptive neuromuscular facilitation involves the use of brief
isometric contractions of the muscle to be stretched before statically
stretching the muscle. Static stretching, considered the “gold standard“ for measuring
flexibility, is elongating the muscle to tolerance and sustaining the position
for length of time.2,15
Through
static stretching stimulation of golgi tendon organs located in the myotendious
junction is achieved resulting decreased muscle tone, additionally a slowly
applied stretch helps reduce muscle tone by reducing the degree of myotatic
reflex contraction, both neurophysiologic responses participate in the
effectiveness of the technique to elongate the muscle through both elastic and plastic deformation
of its non contractile component.
David et al8 state that a
combination of static stretch and short wave diathermy treatment increased the
extensibility of hamstring muscle more than static stretch treatment.
Knight et al4 evaluated
the effect of superficial heat, deep heat and active exercises warm up prior to
stretching compared with stretching alone on the extensibility of calf muscle, They concluded that use of
ultra sound for 7 minute prior to stretching might be the most effective for increases ankle
dorsiflexion.
The
literature reflects some interesting differences of opinion commonly held
beliefs regarding flexibility training and consideration of static stretching
as the gold standard. Some author have questioned the importance of using
static stretching to help reduce injuries and improve performance.
Murphy
made a compelling argument against the use of static stretching. Although
static stretching is often used as part of pre-activity preparation, Murphy
argued that the nature of static stretching is passive and does nothing to
warm muscle. Murphy suggested a better
opinion for maintaining or increasing flexibility of a muscle is through active
contraction using dynamic range of motion, there by adding fourth type of
stretching.
Dynamic
range of motion is technique that allows the muscle to elongate naturally and
in it relaxed state. This elongation is achieved by having the subjects
concentrically contract the antagonist muscle to move the joint through the
full available range in a slow controlled manner to stretch agonist muscle
group. Murphy theorized that range of motion is performed, metabolic processes
increase, These increase cause an increase in temperature that lead to allow
for smoother contraction. This wormed muscle is more pliable and more
accommodating to the forces placed on muscle, leading to increase flexibility
gains.
Although
Murphy arguments were interesting, Bandy et al found that, when comparing
dynamic range of motion with static stretching, the flexibility gains achieved
with static stretching programme were
greater than those achieved in a dynamic range of motion. Therefore gold
standard for increasing flexibility is still considered static stretching.
Previous
author1 suggested that most of injuries occurs in the eccentric
phase of activity. Although early groups have examined dynamic range of
motion, none have investigated the use of an eccentric agonist contraction to
improve flexibility, eccentric training a muscle through a full range of motion
theoretically could reduce injury rates and improve the performance of subject
and flexibility.
Russel
et al2 proved that in males ages 15-17 years old, hip flexion range
of motion gains with eccentrically training were equal to those made by static
stretching of hamstring muscle.
Muscle energy technique (MET) is a
manual technique developed by osteopaths that is now used in many different
manual therapy professions. It is claimed to be effective for a variety of
purposes, including lengthening a shortened or contractured muscle, strengthening
muscles, as a lymphatic or venous pump to aid the drainage of fluid or blood,
and increasing the range of motion (ROM) of a restricted joint.1
While muscle energy techniques are widely used by osteopaths and other manual
therapists, there is limited research supporting and validating its use, as
well as limited evidence to substantiate the theories used to explain the
effects of MET. Several researchers have examined the effect of contract-relax
techniques (similar to MET) on hamstring flexibility, and found that these
techniques produced increased muscle flexibility.10,11
Felipe Jose Jandre Reis et al,
evaluated Influence of Hamstring Tightness in Pelvic, Lumbar and Trunk Range of
Motion in Low Back Pain, and they found that : Participants with LBP showed
restriction in the pelvis and TF(trunk flexion) range of motion, but had higher
a mplitudes in the lumbar spine during forward bending.
Ju-hyun lee and
collegues check the effect of
hamstring stretching and nerve mobilization for patients with radicular lower
back pain and they found that Hamstring stretching and nerve mobilization can
be usefully applied for the therapy of patients with radicular lower back pain.18
Sousan Nikzad and collegues check the Relationship
Between Hamstring Flexibility and Extensor Muscle Activity During a Trunk
Flexion Task, and found that hamstring flexibility plays an important role in
the patterns of trunk and lower limb muscle activity onset, offset, and
recruitment.19
Yasuaki Mizoguchi and colleagues examine Physical
function characteristics in Japanese high school volleyball players with low
back pain and suggested that hamstring flexibility must be checked and improve
for these groups of athlete to increase their lumbar flexibility.2
Many researchers
have investigated various methods and techniques to determine the most effective
way to increase joint ROM and muscle extensibility. Despite the numerous studies
conducted, controversy still remains within clinical practice and the literature
regarding the best methods and techniques for stretching.
Also we can find that will increase in
hamstring flexibility will reflect the mechanical low back pain.
SCOPE AND STATEMENT OF THE PROBLEM
·
A shortened muscle may create imbalance at joints and faulty
postural alignment that may lead to injury and joint dysfunction, therefore
stretching is important to prevent such injuries.
·
MET (5sec) when compared to long duration static stretching takes
less time and therefore can be incorporated quick stretching of muscle.
·
MET (5sec) is a simple technique than apparatus equipped long
duration stretching technique.
· In
static stretching chance of injury is also high. Thus a new term dynamic
stretch comes, but again injury occurs in eccentric phase of activity.
· Eccentric
stretching comes into play. Because theoretically and practically could reduce
the rate of injury and improve performance.
·
Many stretching techniques are
employed by athletes and patients in clinical and sporting settings, to
increase flexibility.
STATEMENT
OF PROBLEM
Whether any of these two intervention eccentric training with
thera-band, and Muscle Energy Technique(MET) will be more effective than the
static stretching in improving hamstring muscle flexibility in patient with
mechanical low back pain?
Whether changes in hamstring flexibility
will effect mechanical low back pain?
OBJECTIVE
OF THE STUDY
The purpose of study is to determine the effect of eccentric
training, MET and static stretching on hamstring flexibility in increasing knee
extension ROM in patients with mechanical low back pain.
Also improvement in mechanical low back
pain after that.
Hypothesis
Experimental hypothesis:
Eccentric training with thera band or MET improves hamstring muscle flexibility more than static
stretching.
Null hypothesis:
There is no difference between the effect of eccentric training, MET and static stretching to improve
flexibility of hamstring muscle.
Operational
definitions:
Static stretching: it is defined as elongating the muscle to
tolerance and sustaining the position for a length of time.3
Eccentric training: Is defined as, to lengthen the muscle by
eccentric agonist contraction to improve flexibility.2
Flexibility: It is has been defined as the ability of muscle to
lengthen and allow one joint (or more than one joint in a series) to move
through a range of motion.2
Tight hamstring: It will be determine by the 90-90 test.
Muscle energy technique (MET): It
is a manual medicine procedure that has been described as a gentle form of
manipulative therapy effective for treating movement restriction of both the
spine and extremities.
METHODOLOGY
TOOLS AND TECHNIQUES
Samples: a total sample of 90 subjects having mechanical low back
pain with hamstring tightness with age group of 20-60 years.
Source of subjects: All the subjects will be recruited from
physiotherapy Clinics and health Centres.
Inclusion
criteria:
· Age
group 20-30 years.
· Subjects
with tight hamstring muscle.
(Inability to achieve 20 degree of active knee extension.)90-90
test.
· Patients
with mechanical back pain.
Exclusion
criteria:
·
Hyper mobility of knee joint.
·
Subjects under medication(muscle relaxants, corticosteroid).
·
Skin disease like skin ulcers and warts.
·
Open wounds and ulcers.
·
Neurological problems
·
Circulatory problems like arterial and venous disease.
·
Metal implants in the legs
Method of
selection and assigning:
Method will be the random sampling. On the basis of inclusion and
exclusion criteria all the subject will be informed the purpose of the study,
and an informed consent will be taken from them prior to participation. The subjects will be then randomly assigned
to Group-A, Group-B & Group-C. Each group consist of 30 subjects.
Design of the study:
It will be a comparative study. The study has pre-test, post-test
experimental design. Measurement was taken prior to and at the end of 3rd,
6th and 8th week post treatment session. It will be a
double blinded study, the subjects being unaware of the groups they belong to.
Variables:
Dependant
variables:
·
Active knee extension range of motion by 90-90 test
·
Hamstring flexibility.
·
Intensity of pain
Independent
variables
- Static
stretching.
- Eccentric
training.
- MET
Equipment/Instrumentation/Tools:
- A black
coloured thera band will be used.
- A standard
transparent full circle goniometer will be used, the transparency of the
goniometer is helpful in noting the marks (lines and dotes) drawn over the
skin.
- A standard
stop watch will be used to note duration of static stretching.
Procedure/Technique:
The informed
consent will be obtained from all the subjects, after the study procedure
explained. Subjects will be randomly assigning in to Group-A, Group-B and
Group-C
Group –A: eccentric training with thera band.
The eccentric group (n =30) will
perform range-of-motion eccentric training for the hamstring muscles. The
subject lay supine with the left leg fully extended. A 3-ft (0.91-m) piece of
black theraband will be wrapped around the heel and the subject held the ends
of the theraband in each hand. The subject will be instructed to keep the right
knee locked in full extension and the hip in neutral internal and external
rotation throughout the entire activity. The subject will then instruct to
bring the right hip into full hip flexion by pulling on the theraband attached
to the foot with both arms, making sure the knee remained locked in full
extension at all times. Full hip flexion defined as the position of hip flexion
at which a gentle stretch was felt by the subject. As the subject pulls the hip
into full flexion with the arms, he will instruct to simultaneously resist the
hip flexion by eccentrically contracting the hamstring muscles during the
entire range of hip flexion. The subject will instruct to provide sufficient
resistance with the arms to overcome the eccentric activity of the hamstring
muscles, so that the entire range of hip flexion took approximately 5 seconds
to complete.
Once
achieved, this flexed hip position held for 5 seconds, and then the extremity
is gently lowered to the ground (hip extension) by the subject’s arms. This
procedure will be repeated 6 times, with no rest between repetitions, thereby
providing
a total of 30
seconds of stretching at the end range2.
Group—B: static stretching technique.
The static
group (n =30) will statically stretch for 30 seconds 3 days per week for 6
weeks using methods described by Bandy et al3 and Russel et al
2 Subjects will perform the hamstring stretch by standing erect with the
left foot planted on the floor and the toes pointing forward. The heel of the
foot to be stretched placed on a plinth/chair with the toes directed toward the
ceiling. The subject then flexed forward at the hip, maintaining the spine in a
neutral position while reaching the arms forward. The knee remained fully
extended. The subject continued to flex at the hip until a gentle stretch was
felt in the posterior thigh. Once this position was achieved, the subject
maintained this position for 30 seconds.
Group—C: MET
This group will
receive MET, here PIR technique of MET will be used, which will be repeated 4
times (5 second contraction, 3second relaxation) in each session for a period
of 3 days a week for 6 weeks.
Apart from this
patient will also receive conventional treatment for the low back pain in the
form hot pack and isometric abdominal and pelvic bridging exercises for the
given period of time.
Methods of measurement
Terminal
extension is determined as the point at which the researcher felt a firm
resistance to the movement. Once terminal extension reached, the researcher
holding the goniometer ensure proper alignment and the blinded goniometer is
revealed to the assisting examiner for the measurement to be read and recorded.
Zero degrees of knee extension was considered full hamstring muscle
flexibility. No warm-up was allowed before data collection.
Protocol/Schedule:
Assessment: pre-test measurement of hamstring flexibility will be
performed with 90-90 test. Subjects, who will be found suitable for the study,
will be requested to sign consent forms. A detailed subjective examination will
be done.
We include subjects with mechanical low back pain having hamstring
tightness. And we will also take oswestry disability scale and NPRS to evaluate
the pain and disability in such patients.
Subject allotted in different groups will be given treatment for
the 3 days a week for 6 weeks. Measurement will be taken prior and after the
end of 3rd and 6th week. Last measurement is taken after
the 2 week of rest period.2
Total duration of the study will be for 6 weeks and there will be
rest period of 2 weeks after the last treatment session to check for the
effectiveness of each intervention. So total protocol for the study will be of 8
weeks.
Total duration for the study will be of 1 year.
DATA COLLECTION
All the required data will be
collected by me. Consent form will be given to the subjects in vernacular
language also.
DATA ANALYSIS
Data will be collected from control
and experimental group; will be analysed with suitable statistical test
probably one way ANOVA test will be used for post-test analysis.
REFERENCES/BIBILOGRAPHY:
1.
Kenneth C. Wessling, Dawn A Devane: Effect of static stretching vs.
SS and US combined on hamstring muscle extensibility in healthy woman. Physical
therapy, May 1987;67(5);674-69.
2.
Russel T. Nelson; William D. Bandyt: Eccentric training and static
stretching improves hamstring flexibility of high school males. Journal of
athletic training,2004 :39(3):254-258
3.
Bandy WD, Irion JM, Brigller M,: The effect of static and dynamic
range of motion training on the flexibility of hamstring muscle. -JOSPT
1998:27(4)295-300.
4.
Clauda A Knight, Carrie R Rutledge Susan J Hall. Effect of
superficial heat, deep heat and active exercises warm up on the extensibility
of hamstring. Physical Therapy 2001;81;(6)1206-1214.
5.
James W. Youndas, David A. Krause. The effect of static stretching
of the hamstring muscle-tendon unit on active knee extension range of motion,
JOSPT july 2003,33(7).
6.
Rather Aijaz Y, puja Chaudhary,
Nishat Quddus, Ultra sound and prolonged long duration stretching
increase hamstring muscle extensibility more than identical stretching alone.
indian Journal of O.T &P.T.
vol.1,no.3(2007-2009).
7.
Ian W. muir et al, Effect of hamstring stretching exercises on the
resistive torque during passive knee extension in healthy subjects.
8.
David O.Draper et al, shortwave diathermy and prolonged stretching
increase hamstring flexibility more than prolonged stretching alone .JOSPT
vol.34, no.1, jan2004.
9.
Cynthia C.norkin, Measurement of joint motion, a guide of
goniometry.
10. Kris Jensen, Richard P Di Fabilo, Evaluation
of eccentric exercises in treatment of patellar tendonitis. physical therapy
vol.69, no.3, march1989
11. Ballentyne
F, Fryer G, Mc Laughlin et al. The effect of muscle energy technique on
hamstring extensibility : The mechanism of altered flexibility.Journal of osteopathic medicine.
2003;6(2):59-63.
12. Magnusson
SP, Simonsen EB, Aagaard P, Dyhre-Poulsen P, McHugh M, Djaer M. Mechanical and
Physiological Responses to Stretching With and Without Pre-isometricContraction
in Human Skeletal Muscle. Archives of Physical Medicine and Rehabilitation.
1996; April 77: 373-8
13. Dong Ho
Kwak, PT1, 2), Young Uk Ryu, PT, PhD2)*
Applying
proprioceptive neuromuscular facilitation
stretching: optimal contraction intensity to attain the maximum increase in
range of motion in young males
(J. Phys. Ther.
Sci.,27: 2129–2132, 2015)
14. Landon
Lempke, Rebecca Wilkinson, Caitlin Murray, and Justin Stanek The Effectiveness
of PNF Versus Static Stretching on Increasing Hip-Flexion Range
Of motion.
(Journal of Sport Rehabilitation, 2018, 27, 289-294).
15. Phil
Page, PT, PhD, ATC, CSCS, FACSM
Clinical
commentary.current concepts in muscle stretching for exercise and
rehabilitation
The
International Journal of Sports Physical Therapy | Volume 7, Number 1 |
February 2012 | Page 109.
16. Hashim Ahmed, MPT), Amir Iqbal, MPT),
Shahnawaz Anwer, MPT, ),Ahmad Alghadir, MS, PhD, PT) Effect of modified
hold-relax stretching and static stretching on hamstring muscle flexibility. J.
Phys. Ther. Sci. 27: 535–538, 2015.
17. Buasell
RB, Li YF. Power Analysis for Experimental Research: A Practical Guide For
The Biological, Medical and Social Sciences. Cambridge, UK: Cambridge
University; 2002.
18. Felipe Jose Jandre
Reis, Adriana Ribeiro Maced et al,Influence of
Hamstring Tightness in Pelvic, Lumbar and Trunk Range of Motion in Low Back
Pain and Asymptomatic Volunteers during Forward Bending. Asian spine general,
2015,9:4
19. Abdul
sattar et al, Effect of Strethching programme of hamstring muscles on low back
pain among surgeons. Vol 2,
issue 4, 2019.
20. Ju-hyun Lee, PT, MS1),
Tae-ho Kim, PT, PhD1)*The treatment effect of hamstring stretching and nerve
mobilization for patients with radicular lower back pain. J. Phys. Ther. Sci.
29: 1578–1582, 2017
21. Erica N. Johnson, DPT,
James S. Thomas, PhD, PT. Effect of Hamstring Flexibility on Hip and Lumbar
Spine Joint Excursions During Forward-Reaching Tasks in Participants With and
Without Low Back Pain. Arch Phys Med Rehabil Vol 91, July 2010.
22.
Sousan Nikzad,
MSc, Soraya Pirouzi, Shohreh Taghizadeh, PhD, and Ladan Hemmati, PhD.
Relationship Between Hamstring Flexibility and Extensor Muscle Activity During
a Trunk Flexion Task. Journal of Chiropractic Medicine. March 2020.
23.
Takaaki Nishimura, RPT, MS1, 2), Ryo Miyachi, RPT,
PhD3) Relationship between low back pain and lumbar and hip joint movement in
desk workers. J. Phys. Ther. Sci. 32: 680–685, 2020
24.
Yasuaki
Mizoguchi, MSa , Kiyokazu Akasaka, PhDb,c,∗ , Takahiro Otsudo, PhDb,c , Toby Hall, PhDd,e Physical function
characteristics in Japanese high school volleyball players with low back pain A
case-controlled study. Mizoguchi et al. Medicine (2020) 99:46.
APPENDIX: A
CONCENT FORM
Title- Effect of eccentric training using thera-band, MET and static
stretching in improving hamstring muscle flexibility of patient with mechanical
low back pain
You are invited to participate in the study which is being
done as part of fulfilment of PHD programme .
Introduction – This research is being undertaken to find the
effect of eccentric training using thera-band, MET and static stretching in improving hamstring muscle flexibility
About the Procedure- Subjects fitting the inclusion criteria
would undergo an evaluation procedure and treatment.
Benefits of participation—the study benefits you
in a way that it will increase your awareness regarding exercise and use of
flexibility of muscle.
Risk of participation- there is no any as such risk regarding
intervention.
Right to withdrawal— you have the right to withdraw from the
research at any point of time as desirabable
Confidentiality
All the information about you would be kept confidential and
limited to me and research guide
Dr. Amalkumar sir and will not be shared any person who is
not a part of this study. We also request you to use the data, and photograph
for presentation and publication purpose.
Declaration
I, ----------------------- voluntarily agree to participate
in this study. I have been informed to my satisfaction level about the
procedure, risk, and benefits of the study. I reserve my right to withdraw at
any point of time and I understand participation is voluntarily and refused to
participate will have no penalty or loss of benefits to whichever I am
entitled. I understood that no compensation is being offered or is available or
my participation and I have contact address of Mr. siddiqui M. Aejaz, if I require any
further clarification.
_____________
Signature
Contact
address
Mr.
siddiqui m. aejaz
Email:
aijaz00786@yahoo.com
Cell:
9173006095
APPENDIX: B
DATA COLLECTION FORM
Name: Date:
Age: Sex:
Address:
Contact no:
Occupation:
Symptom:
Test performa:
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Day 1
Pre-Test
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1st week
Post-Test
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2nd week
Post-Test
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3rd week
Post-Test
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4th week
Post-Test
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5th week
Post-Test
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6th week
Post-Test
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After 2 week follow up
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90-90 test
NPRS
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Group-B
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Group-C
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