Indian Journal of Physiotherapy and Occupational Therapy, October-December10.5958/0973-5674.2019.00132.1 2019, Vol. 13, No. 4 57 Effect of Passive Stretching v/s Myofascial Release in Improving Piriformis Flexibility in Females – A Comparative Study

Hiya A. Kukadia1, Ajay Malshikare2, Tushar J. Palekar3

1Graduate, 2Assistant Professor, 3Principal, Dr. D. Y. Patil College of Physiotherapy, Pune

Abstract Study Design: Comparative Study Design.

Background: Piriformis, a key internal rotator of the hip which develops muscular imbalance due to overuse and pressure. The eccentric contraction lead to loading of the piriformis muscle when the hip is excessively abducted and internally rotated causing over lengthening and compression on the muscle, which in turn causes several disabling conditions like low back pain, sciatica and much more.

Objective: Hence, the present study was conducted to see the prevalence of Piriformis tightness in young adult females, to compare the effects between two definitive forms of treatments which are passive stretching (STR) and myofascial release (MFR) on improving the flexibility of Piriformis muscles.

Procedure: In this study, 30 individuals were assessed for tightness and then recruited on the basis of inclusion and exclusion criteria. Individuals were sorted into two groups A and B. Pre and post assessment was taken by Range of Motion.

Result: Significant improvement in flexibility of Piriformis muscle was found post intervention compared to pre-intervention in both the groups (p<0.001). However greater improvement in flexibility was seen in group B (Myofascial Therapy) when compared to group A (passive stretching).

Conclusion: The effect of Myofascial release on piriformis flexibility is a more effective thanpassive stretching.

Keywords: Flexibility, Internal Rotator, Myofascial Release (MFR), Piriformis, Passive Stretching (STR), Range of Motion (ROM).

Introduction of the greater trochanter of the femur.1 It acts as external rotator of the hip below 60 degrees and internal rotator Piriformis muscle is flat muscle which lies below above 60 degrees, thus making it a key internal rotator and parallel to the posterior border of the gluteus of the hip joint.2 medius. The muscle originates of the from the pelvic surface of the middle three pieces of the sacrum, by three Piriformis muscle tightness is often confused with digitations and upper margins of the greater sciatic notch Piriformis Syndrome which is defined as neuritis of and insertion of the rounded tendon occurs at the apex sciatic never caused by an injured or irritated piriformis muscle3 whereas tightness is simply the shortening Corresponding Author of the length of the muscle due to sedentary lifestyle. Dr. Hiya Ami Kukadia There are various disabling conditions caused due to 201/A Raj Heights, opp Anand Nagar, M. G. Road, a simple tightness of Piriformis muscle like low back Kandivali (W), Mumbai-400067 pain, sciatic nerve pain through muscle hypertrophy or a Phone Number: (+91) 9890374796 nearby anomaly due to its anatomically closeness to the Email: [email protected], sciatic nerve, pain and allesthesia in hip, thigh, calf and [email protected] foot are symptoms that commonly occur in Piriformis 58 Indian Journal of Physiotherapy and Occupational Therapy, October-December 2019, Vol. 13, No. 4 syndrome.4 It also becomes hence making difficult to used to classify overweight, underweight and obesity in differentiate from other disease related to hip- spine adults. It is defined as a person’s weight in kilograms hence making it difficult to diagnose. divided by the square of his height in meters (kg/m2).7

Overuse and pressure on the muscle leads to Method muscular imbalance which in turn leads to chronic pain development in the lower back region. The piriformis Ethical clearance was obtained from the muscle consists of type 1 fibers which often tend to Institutional Ethical Committee. Individuals who develop shortness or tightness when is muscle is under came to the physiotherapy OPD and college were stress. The eccentric contraction during functional screened. Approximately 100 females were screened. activities can lead to loading of the piriformis muscle 30 individuals meeting the inclusion criteria and who when the hip is excessively abducted and internally were willing to participate in the study were included. rotated causing over lengthening and greater eccentric Individuals height and weight were recorded to find the load compression on the muscle.2 body composition. Then the individuals were sorted in the control group by chit method. There were two The conservative treatment for the tightness of the groups: muscle includes NSAIDs, muscle relaxants, hot/cold fermentation and to lengthen the muscle by stretching or 1. Group A receiving Passive stretching (STR) by releasing the fascia covering the muscle. 2. Group B receiving Myofascial release (MFR) Stretching has mainly two components by increasing Inclusion Criteria the resting length of the muscle and decreasing the 1. Females of age group 20-40 years. compression force on the sciatic nerve. Relaxation post stretching is explained as a reciprocal inhibition 2. Females with piriformis tightness mechanism of the automatic motor neurons which occur Exclusion Criteria in antagonist muscles. Passive stretching of Piriformis muscle is given by first flexing the hip at 90 degree then 1. Post-partum females adduction of the hip and lastly external rotation of the 2. Recent Hip Trauma or injury hip, this is known as the Adduction stretch. This stretch 3. Recent Abdominal Surgery will be sustained for 15-30 seconds and then relaxed. 5 Each stretch will be repeated 3 times per session, daily 4. Pregnant Females one session for 3 days. 5. Congenital anomalies The other treatment preferred is by myofascial The subjects were then assessed for the outcome release of the Piriformis muscle. Myofacial release is an measure using Hip ROM pre-intervention. After this example of manual therapy which has recently gained procedure, STR and MFR was administered to them for a lot of attention and popularity, also is widely used by a session post which individuals were assessed again for practitioners. The technique involves application of a low the said outcome. load- long duration stretch to the myofascial complex which intends to restore the optimal length, decrease Intervention Procedure pain and improve functional mobility of the muscle. Before starting with the intervention procedure Direct technique MFR is either given by knuckles or by were instructed not to undergo any other intervention for elbow or by other tools to slowly sink into the fascia piriformis tightness. and the pressure is applied is a few kilograms of force to contact the restricted fascia, apply tension or stretch the Testing For Tightness fascia.6 The release will be given for 3 minutes 3 times per session and for 3 session on alternative days. Subject position: Subject in high sitting, the leg being tested is supported by the therapist. Action: knee To avoid bias in the study the body composition or extension, hip adduction and internal rotation. the BMI of the participating females would be under normal to obesity class 1. Body mass index (BMI) is a simple index of weight-for-height that is commonly Indian Journal of Physiotherapy and Occupational Therapy, October-December 2019, Vol. 13, No. 4 59 Duration: Stretch was sustained for 30 seconds and repeated 3 times in a session.

Stretching technique:

Group B: Myofascial Release

Subject’s position: Prone

Therapist’s position: Standing beside the subject at the waistline, working on the contralateral side.

Technique: Piriformis muscle was located by an imaginary line drawn between the midpoint of the lateral aspect of the sacrum and the greater trochanter. A contact was established in the gluteal area about 3 cm from the sacrum. With an elbow, a gradual pressure Fig 1: Starting Position will be applied in an anterior direction. When the first layer of resistance was engaged, a constant pressure was maintained until that layer softened and the fibres of Piriformis were contacted (approximately 90 s). A line of tension was taken along the muscle, in the direction of the greater trochanter. Possibilities of muscle guarding were monitored and the depth of contact adjusted accordingly. The lower leg was lifted off the table to 90 of knee flexion while maintaining the pressure in the Piriformis. The leg was supported and guided into internal rotation with an active assistance from the client with direction. Duration: 3 minutes.

Result A total of 30 subjects were recruited for the study. In the study we considered hip as a single entity and all the subjects having piriformis tightness. They were Fig 2: End Position evaluated before and after the session. The demographic Test procedure characteristics of the participants were presented in Table 1. There is a positive significant difference in Treatment Protocol – 1 session with pre and post mean difference of all hip range of motions where assessment. individuals received MFR as intervention, the pre and post assessment of these ranges show an increase of Group A: Passive stretching – Adduction stretch range of motion more significantly in rotation ranges Subject’s position: supine (p<0.001) (Table 2). There is a positive difference in mean difference of all hip range of motions where Therapist position: on the side of the leg where the individuals received STR as intervention, the pre and stretch is to be given. post assessment of these ranges show an increase of range of motion more significantly only in rotation Technique: ranges (p<0.001) (Table 3). In the present study, the Step 1: flexion of hip at 90 degree intergroup analysis of mean STR and MFR values in the subjects which revealed significant improvement after Step 2: adduction of the hip the session and hence concluding that MFR was a better choice of treatment (p<0.001) (Table 4). Step 3: external rotation of the hip 60 Indian Journal of Physiotherapy and Occupational Therapy, October-December 2019, Vol. 13, No. 4 Table 1: Representing distribution of age group in a total of 30 samples.

Age (Years) No. of Subjects Percentage (%) 20-24 26 87 25-30 2 7 31-35 1 3 36-40 1 3

Table 2: Representing mean of Hip ranges in Group B

Mean (in degrees) No. of Group Internal External Abduction- p value subjects Flexion Extension Rotation Rotation adduction 1 (Pre) 15 96.53 24.13 19.8 19.07 29.13 0.001 2 (Post) 15 103 28.53 29.2 25.93 33.4

Table 3: Representing mean of hip ranges in Group A.

Mean (in degrees) No. of Group Internal External Abduction- p Value subjects Flexion Extension Rotation Rotation adduction 1 (Pre) 15 100.4 22.47 20.4 18.33 25.73 0.001 2 (Post) 15 102.7 24.93 23.87 22.93 28.67

Table 4: Representing mean difference of ranges (in degrees) of Group A and Group B

Group No. of Mean difference (in degrees) p value Subjects Flexion Extension Internal External Abduction- Rotation Rotation adduction MFR 15 6.467 4.400 4.267 9.400 6.867 0.001 STR 15 2.333 2.467 2.933 3.467 4.600

Discussion Before giving treatment to the individuals were asked if they had any sort of discomfort in their hip or if This study was conducted amongst female they had any sort of pain and if they had pain so was the individuals who presented with no apparent complain in pain radiating. Also, the individuals were palpated for their daily life. On asking and assessing these females presence of tenderness and if they had it were recorded. of age 18-40 it was found that 90% of the females had Later they were sorted into two groups by the chit tenderness on the origin of the muscle bulk and only on method. Myofascial release has widely practiced in used palpation was the pain made aware to them. According for treatment of more and more conditions nowadays. to Malika Mondal et al the prevalence of tightness in Going by definition it is basically the facilitation of piriformis muscle was found out to be 79.5% in the mechanical, neural and psycho-physiological adaptive sedentary individuals.2 potential as interfaced via musculo-facial system. The purpose for this study was to check the Myofascial release for piriformis muscle was given prevalence amongst female population and was to assess to the female individuals and significant increase in the effective method of treatment. The individuals were range of motion was noted. The treatment was given for a assessed using the sit and stretch test where she was session which lasted 3 minutes6 and significant decrease asked to sit of the plinth in high sitting the tested limb of pain was experienced by those individuals. Before was supported by the therapist and the knee was taken the session was given pre assessment of hip ranges passively into extension, hip into adduction and internal were taken and after the treatment post assessment was rotation. taken of the same. There was a significant increase in Indian Journal of Physiotherapy and Occupational Therapy, October-December 2019, Vol. 13, No. 4 61 all the ranges including flexion, extension, adduction, improvement lifestyle can be precisely more effective abduction, internal rotation and external rotation. To form of treatment. check for the authenticity of the treatment post one week one more assessment was taken post 1 week from Conclusion the session and there was increase in all hip range of The effect of Myofascial release on piriformis motion and decreases in tightness. The individuals even flexibility is a more effective than passive stretching. were relieved of any discomfort caused by the previous tightness. And also reported a difference in latent pain Conflict of Interest: Nil pre and post the course of treatment. Source of Funding: Self Similarly, the second group that is the STR (stretching group) of individuals received stretching for Ethical Clearance: Taken from the Institutional 30 seconds 3 times in a session. According to Brandy et Sub-Ethics Committee of Dr. D. Y. Patil College of al who reported that 30 seconds or 60 second stretching is Physiotherapy, Pune. more effective stretching than 15 second stretching8 and Ogura et al emphasized the importance of the duration of References stretching, reporting that 60 second stretching decreases 1. B.D Chaurasia. Human Anatomy Regional and muscle strength while 30 second stretching did not affect Applied, Dissection and Clinical Volume-2 9 muscle function. 2. Malika Mondal Et Al. Prevalence of Piriformis Tightness in Healthy Sedentary Individuals. July Hence the treatment time was decided as 30 2017, Vol 7; Issue 7:134-142 seconds of individual stretch, before the treatment was given all the hip range of motion were recorded prior 3. Quratulain Saeed, Arshad Malik, Samina Ghulam. and immediate post after the treatment ranges were Outcome of Specific Piriformis Stretching taken after the completion of the session of treatment. Technique in Females with Piriformis Syndrome. To assess the effect of treatment post assessment was October-December 2017; Vol 7; Issue 4: 55-57 taken after 1 week of the session. The individuals of this 4. Jun Chul Park, Jae Hun Shim, Sin Ho Hung. group didn’t have a significant difference in the pain The Effects of Three Types of Piriformis Muscle and their ranges had relapsed by a few degrees along Stretching on Muscle Thickness and the Medial with some of them even had tightness present. Precisely Rotation Angle of the Coxal Articulation. July 12th there was a decrease in flexion, extension abduction and 2017; Vol 29; Issue 10: 1811-1814 adduction as well. The internal rotation and external 5. Phil Page. Current Concepts in Muscle Stretching rotation didn’t have any decrease in the range. During for Exercise and Rehabilitation 2012 Feb: 7(1): the period of treatment, the individuals were advised 109-119 to continue with their daily activities and make no 6. M.S. Ajimsha, Binsu Daniel, S. Chithra. difference in their routine. This was done to prevent bias Effectiveness of Myofascial Release in in the study. Post completion of the study, statistical Management of Chronic Low Back Pain in Nursing analysis of the study was conducted by using paired Professionals. 5th May 2013, 18: 273-281. t-test, the individual effect of both the treatment proved to be significant in increasing all the ranges of the hip 7. Dipti Mohapatra, Tapaswini Mishra, Manasi statistically but clinically there was a better result in the Behera, Priyambada Panda. A Study of Relation MRF therapy group. The inter group study was analyzed between Body Mass Index and Dysmenorrhea and using unpaired t-test which revealed that the study is Its Impact on Daily Activities of Medical Students. strongly significant and both the treatment are equally Vol 9 Suppl 3 December 2016 Page: 297-299 effective in increasing the hip range of motion. But 8. Bandy WD, Irion JM, Briggler M.The Effect Of clinical perspective suggests that as myofascial release Static Stretch And Dynamic Range of Motion was more effective in improving the range by significant Training on the Flexibilty of Hamstring Muscle. J difference as well as was effective in decreasing the pain. ortho sports Phys, Ther, 1998, 27:295-300 The statistical result and the experimental result prove 9. Ogura Y Miyahara Y, Naito H, Duration of Static that myofascial release is a better choice of treatment Stretching Influences Muscle Force Production in and to avoid relapse of tightness, self-release techniques Hamstring Muscle. J Strength Cond Res, 2007, 21: along with a basic exercise regimen and difference in 788-792.