Rajiv Gandhi University of Health Sciences s106

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA ANNEXURE- II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE Mr.Ujjal Neog AND ADDRESS NAKATANI KALU GOAN,P.O- BHARALUA TINI ALI,GAURISAGAR,DISTRICT- SIVASAGAR,ASSAM PIN-785664

2. NAME OF THE INSTITUTION KRUPANIDHI COLLEGE OF PHYSIOTHERAPY CHIKKA BELLANDUR,CARMELARAM POST,VARTHUR HOBLI,BANGLORE

3. COURSE OF THE STUDY AND MASTER OF PHYSIOTHERAPY (MPT) SUBJECT MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY.

4. DATE OF THE ADMISSION 27/07/2012 TO THE COURSE

5. TITLE OF THE STUDY “ A Comparative Study To Analyze The Effect Of Muscle Energy Technique(MET-post isometric) VS Active Release Technique(ART) To Improve Hamstring Flexibility In Asymptomatic Sedentary Lifestyle Individual”.

6. BRIEF RESUME OF THE INTENDED WORK : 6.1. NEED OF THE STUDY :

A sedentary lifestyle is defined as being physically inactive at work and at home and failing to participate in exercise at least for 20 continuous minutes, 3 times a week.

Sedentary life style lead to various problems like tightness of muscles, decrease muscles length, decrease joint ROM and thereby decrease muscle flexibility hampering the daily activity of living1.

Many changes of our musculoskeletal system results more from disused then from simple ageing. As muscle age, they begin to shrink and loose mass. This is the natural phenomenon, but a sedentary lifestyle can accelerate it. Joint becomes more restricted and flexibility decreases because of changes in tendon and ligaments1.

Today machines have obviously made life easier, but also have created serious problems instead of walking-we drive; rather than climbing stair- We use elevators.

But in our earlier day we were more active, but now we spend much of our leisure time sitting without daily physical exertion, where in our body muscles become weak and tight and loose. We tend to lose touch with our physical nature2.

Those Muscle which are response to stress by shortening(postural muscles ) comprises the following : gastronomies ,soleus, hamstring, short adductor of thigh, tensor fascialata, quadrates lumborum, erector spine muscle, lattismus dorsi, upper trapezius, scalene, sternomastoid, levator scapulae, pectoralis major and flexor of arm3.

Hamstring muscle is one of the common muscle group associated with low back ache, located at the back of the thigh, associated with the movement at both hip and knee joints.

The Shortening of hamstring occurs in those who spend a lot of time in sitting, and if they are constantly held in position that tends to shorten them they become adjusted to that position. If these people stand with hip and knee fully extended this will cause both direct pain in the immediate area and referred pain in the low back4.

Many people suffer with tight hamstrings and most of the time it will not cause a problem but can be more prone to tear and also limit the activity. Tight hamstring can also be responsible for postural problems and other back problems as they will tend to pull the pelvis out of the normal position, and in long run can possibly influence the sacroiliac and lumbar spine dysfunction5,6,7,8.

When individual with tight hamstring lean over to make the bed, low back compensates for the lack of flexion capability at hip often resulting in injury, because adequate hip flexion capability is believed to lessen the likelihood of development of low back pain9.

An individual with tight hamstring will have a limit stride length. This translates to taking more steps over a given distance than an individual with more flexibility. More steps means more work and more impact, greatly increasing to potential for fatigue10.

Techniques previously investigated to improve hamstring flexibility include static stretching, exercises, heat, massage and proprioceptive neuromuscular facilitation (PNF). Each of this intervention has demonstrated clinical and experimental success, with most comparative analyses indicating that MET is superior in its ability to increase flexibility11, 12, 13.

Muscle energy technique(MET) is a manual technique devopled 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 contracted muscle,strengthening muscles,increasing joint range of motion.14

Active release technique (ART) is a manual therapy for treating a soft tissue problem in muscles, joints and connective tissue. Therapists use palpation to locate area of tension or adhesion in a specific tissue. Then the tissue is taken from a shortened position to a lengthened position while using manipulation.15

Tissue that are perceived as abnormal are then treated with stretching and sliding movement at specified tension that are included to increase the movement of tissue by removing or breaking up adhesion16.Both MET and ART increase the flexibility of hamstring, so this study intended to compare and find which of these techniques is effective in increasing the hamstring flexibility.

6.2. REVIEW OF LITERATURE : HAMSTRING FLEXIBILITY:

1. Matte (1995)17 in his study on “active isolated stretching” says that, the implementation of flexibility enhancement program provides the following long-term benefits. The complete range of motion of the joint tends to be increased and maintained. Additionally, there has to be a decrease in muscle soreness and resulting increase in functional activity from the employment of a flexibility enhancement program

2. .Magnussan SP (1998)18 on a team At Denmark test centre, sports medicine research has reviewed the literature on “passive properties of human skeletal muscle during stretch maneuvers” and found that with repeated stretches; muscle stiffness declined, but retarded to baseline values with one hour, while long term stretching (>3 weeks) increased joint ROM as result of change in stretch tolerance rather than in passive properties.

3. Scott G et al ( 2001)12 in a study on 30 male subjects with limited hamstrings flexibility in right lower extremity where randomly assigned to a control group or an experimental group to assess the duration of maintained hamstrings flexibility after a one time modified hold relax stretching protocol. All the subjects performed six warm up active knee extension, with last repetition serving as the pre stretch measurement. The experimental group receive 5 modified hold relax stretch whereas the control group rested quietly supine on an table for 5 min. Post test measurement where reconducted for both group at 0,2,4,6,8,16 and 32 minute. Our findings suggest that a sequence of 5 modified (hold-relax) stretch produced significantly increased hamstrings flexibility that lasted 6 min after stretching protocol. MUSCLE ENERGY TECNIQUE

4 .Ballantyne et al in (2003)8; A significant increase in range of motion was observed at the knee (p< 0.019) following a single application of MET to the experimental group. 5.Madeleine Smith , B.clin SC.et al(2005)11; did a study on comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group states that, it is appeared to b sustained improvement by one week following the initial treatment.

6.Lewit(1991)14in a study treated 351 patients with painful muscle group by MET(post isometric relaxation) in 244 patients, Analgesia was immediately achieved in 223 and in 21 there was no effect.

7 . Smith et al (2008)15 also reported significant increases in hamstring length using two groups of varying length contraction using Muscle Energy Technique (MET). Increases in hamstring flexibility were evident immediately post-test, with improvements can only account for changes in flexibility of the hamstring muscles and did not evaluate movement control characteristics or injury statistics. Therefore, increases in flexibility cannot be correlated with changes in stability, efficiency or strength.

8.Edward(1993)2 MET has advantage of allowing the patient to control the movement, when it is given for increasing flexibility of muscles, so if too much pain is reproduced by this technique, the patient can terminate the procedure.

ACTIVE RELEASE TECHNIQUE

9.James W George et al (2006)14 Study on the effect of ART on the hamstring flexibility, 20 asymptomatic young men with no prior injury to the hamstring sit and reach test score of all the participants increase after treatment.

10. George JW, Tunstall AC, Tepe RE, Skaggs CD(2006) 22, conducted a study on the effects of active release technique(ART)on hamstring flexibility on twenty male subjects and concluded that a single ART treatment increased hamstring flexibility in a group of healthy, active male participants. 11.Schiottz-Christensen et al. (1999) performed a pilot study with 28 patients with upper extremity overuse syndromes. The patient were treated with ART twice a week for four weeks ,with those patients still complaining of pain being provided with another four weeks of treatment and concluded that 71% of the subjects reported that they felt better after having been treated with active release technique(ART)25.

12. Robb A, Pajaczkowski J.c.(2011) carried a study on the immediate effect on pain thresholds using active release technique on adductor strains and concluded that the application of active release technique( ART) to treat groin strains is of benefit in increasing pain thresholds amongst ice-hockey players26.

RELIABILITY AND VALIDITY

13.Richard Gajdosik et al (1983)15 did a study on “hamstring muscle tightness: Reliability of an active knee extension test” and concluded that high reliability resulted from strict body stabilization methods, a well-defined end point of motion, and accurate instrument placement. If conducted properly, the test should provide therapists with an objective and reliable tool for measuring hamstring muscle tightness.

14. Richard Gajdosik et al (1983)15 goniometry measurement is more reliable method for measuring the range of motion of the hamstring flexibility.

15.C.M. Norris el at (2005)16 did a study on “Inter-tester reliability of a self-monitored “Active knee extension test” and found that the AKE test when used in conjunction with goniometry, accurate surface marking, and manual monitoring of the test leg is a reliable measure of hamstring muscle length. 6.3. OBJECTIVES OF THE STUDY:

1. To find out the efficacy of active release technique to improve the hamstring flexibility in sedentary individuals.

2. To find out the efficacy of MET to improve the hamstring flexibility in sedentary individuals.

3. To Compare the efficacy of active release technique Vs MET technique to improve the hamstring flexibility in sedentary individuals. 6.4. HYPOTHESES :

a). Research hypothesis :

There is a significant difference between muscle energy technique Vs active release technique in improving the hamstring flexibility in sedentary individuals.

b). Null hypothesis :

There is a no significant difference between muscle energy technique Vs active release technique in improving the hamstring flexibility in sedentary individuals. MATERIALS AND METHODS :

7.1. STUDY DESIGN AND SETTINGs:

7.1.1. STUDY DESIGN :

 A Comparative Experimental Study

7.1.2. SOURCE OF DATA:

 Krupanidhi College Of Physiotherapy And Recoup Hospital

7.2. METHODOLOGY :

7.2.1. POPULATION :

 40 Sedentary Male population between age group of 20 – 45 year. 7.2.2. SELECTION CRITERIA:

1.INCLUSION CRITERIA

 Age between 20 – 45 years  Sedentary Males  Subjects not involved in any flexibility program  Subjects lacking at least 20 degree of knee extension in AKE test  Subjects willing to participate

2. EXCLUSION CRITERIA

 Subjects with low back ache  Hamstrings injury and strains  Knee deformities and injuries  Athletes  Any previous surgery around the knee and hip

7.2.3. SAMPLING METHOD AND SAMPLE SIZE

a) Sampling method: simple random sampling

b) Sample size : 40 subjects 7.2.4. PROCEDURE

The subjects will be included based on selection criteria, after which an informed consent will be obtained from them. Pre treatment assessment of the hamstring muscle length will be taken by using AKE test (Popliteal angle measurement) and the same will be repeated at the last day treatment session for post treatment scores.

30 subjects will be randomly assigned to two groups through lottery method, Group-A and Group-B.

Group A: Subjects will be given Muscle energy technique

Group B: Subjects will be given Active release Technique.

Active Knee Extension Test procedure

Pre and Post follow up measurement data on popliteal angle will be collected from both the groups.

Subjects will be assessed for hamstring tightness using the active knee extension test (popliteal angle). The subject will be in supine position with the hip flexed 90 degrees and knee flexed. A cross bar will be used to maintain the proper position of hip and thigh. The testing will be done on the right lower extremity and subsequently on the left lower extremity and the pelvis will be strapped down to the table for stabilization. Marking will be done in the greater trochanter, lateral condoyle of the femur and the lateral malleollus of ankle for measuring hip and knee range of motion. The Fulcrum of the goniometer will be centered over the lateral condyle of the femur using greater trochanter as a reference. The distal arm will be aligned with the lower leg using the lateral malleolus. The subject will be then asked to extend the right lower extremity as far as possible until a mild stretch felt.

A full circle goniometer will be used to measure the angle of knee flexion. Three repetition will be performed and an average of the three will be taken as final reading of popliteal angle15.

Group A: Muscle energy technique(post isometric)

Subjects lay supine with their thigh fixed at 90° flexion, and the hamstring muscle stretched to the onset of discomfort by passive knee extension moderate isometric contraction (about 25% of maximum effort(10)of the hamstring muscle was then elicited for a period of five seconds. After a period of three seconds of relaxation, the technique will be repeated three times (for a total of four contractions). For a duration of 2 week.

Group B: Active release technique.

It is done with combine effort of both subjects along with therapist. Before the technique started subject was lying on supine position and performs 10 repetition of active knee extension test as warm up and procedure will be explained to the subject before the short of treatment started. For active release technique subject positioned in supine

With hip and knee flexed so that the hamstring muscle become in shorten position and the First therapist palpated over the origins, insertions and muscle bellies of hamstring muscles to find the texture and tissue tension then a mild pressure will be given toward the origin of the hamstrings and advised the subject to actively extend the leg, this gives the stretch sensation to the subject. 5 stretches will be given each treatment session for 2 weeks.14.

MATERIALS REQUIRED  Goniometer

 Cross bar

 Examination table.

 Skin marker

OUTCOME MEASURES

Active Knee Extension Test.

7.3. STATISTICAL ANALYSIS

 Dependent ‘T’ test for within groups.

 Independent ‘T’ test for between groups.

7.4 a) Does the study require any investigation to be done on patients or other humans or animals? Yes, the study will be conducted on humans, i.e on adult subjects under the department of

physiotherapy and informed consent will be taken prior to the study.

b) Has the ethical consent for the study been obtained from the institution is case?

Yes, ethical clearance has been obtained from the institution.

REFERENCES .

1) Chaitow L. An Introduction To Muscle Energy Technique 2001 2nd edition, Harcourt Publisher London. 2) Robert V. Hockey Physical Fitness-The Pathway Of Healthful Living 8th edition Chapter- 6

3) Best TM Garrett WE. Physician And Sport Medicine 1996;24(8).

4) Burkett LN: Causative Factor Of Hamstring Strain, med science sport execrise1970(1):39- 42

5) Ballantyne, Fiona and Fryer, Gary and McLaughlin, Patrick ; The Effect of Muscle Energy Technique on Hamstring Extensibility: The Mechanism of Altered Flexibility, Journal of Osteopathic Medicine.,2003 6 (2). pp.59 to 63.

6) Madeleine Smith, B.Clin. SC, Gary Fuyer et al; A study on comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group.

7) Susan hall, Basic of biomechanics Page 136-137

8) Harris ML , Flexibility, Physical therapy, 1996

9) James W George DC, Andrew C.Tunstall DC et al. The effects of Active Release Technique on the hamstring flexibility: A pilot study, journal of manipulative and physio logical therapeutics(2006);29:1-14.

10) Gajdosik Richard, Lusin G. Hamstring muscle tightness. Reliability of an active-knee- extension test. Phys Ther. 1983 Jul;63(7):1085-90.

11) Norris CM, Mathews M. Applied Clinical Physiology. Inter-Tester reliability of a self- monitored active knee extension test. Journal of Bodywork and Movement Therapies 2005; 9: 256-259.

12) Mattes AC.1995” URL: http://www.active isolated stretching.com” sorasoto F1.

13) Magnusson SP. Passive properties of human skeletal muscle during stretch maneuvers. Scand J Med Sci Sports. 1998 Apr; 8(2):65-77.

14) Chaitow L, MET Variations: Possible Neurological Mechanisms;

http://www.leonchaitow.com/PDFs/METpaper.pdf; accessed November 10, 2011

15) Ekstrand, J. G., Frequency of Muscle Tightness and Injury in soccer players. The American Journal of sports medicine, 1983, vol(4),pp124-128.

16) Mason DL, Dickens V, Vail A. Rehabilitation for hamstring injuries. Cochrane Database Syst Rev 2007; :CD004575.\

17) Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: A systematic review of the literature. Sports Health: A Multidisciplinary Approach 2009; 1:154 18) AGRE, J. Hamstring injuries: Proposed aetiological factors, prevention,and treatment.J Sports Med. 1983 vol (4) 2:21–33.,.

19) WORRELL, T.W., AND D.H. PERRIN. Hamstring muscle injury: The influence of strength, flexibility,warmup, and fatigue. J. Orthop. Sports Phys. Ther. 1992 Vol 16(1):12–18.

Sd/- 9 Signature of the candidate

10 Remarks of the guide MASIH MUHAMMAD KHAN PRINCIPAL Name And Designation Of KRUPANIDHI COLLEGE OF 11 The Guide PHYSIOTHERAPY

11.1 Guide

11.2 Signature Sd/-

MASIH MUHAMMAD KHAN PRINCIPAL 11.3 Head of the KRUPANIDHI COLLEGE OF Department PHYSIOTHERAPY

11.4 Signature Sd/-

12.1 Remarks of Chairman Approved and forwarded 12 and Principal

12.2 Signature Sd/-