Research Article - Clinical Practice (2022) Volume 19, Issue 4


Corresponding Author:
Sufian Ahmed
Shalamar Institute of Health Sciences,Lahor


Background Muscular flexibility is vital for typical human working. Tightness in the hamstring muscles can lead to various injuries and postural disturbance. The prevalence of hamstring muscle tightness is very high in females reflecting many factors related to office workload, domestic workload, and biological differences. This study aims to compare the immediate effects of Hold-Relax (HR) stretching and Muscle Energy Technique (MET) in improving flexibility of hamstrings in healthy young adult females and to compare which technique is better for immediate relaxation and increasing flexibility of tight hamstrings. Objectives To determine the effectiveness of hold-relax stretching and muscle energy technique for improving hamstring flexibility. Material and Methods This study recruited 26 subjects by using a purposive sampling technique. Participants were randomly divided into two equal groups. Age of group A (22.46 ± 0.88) year and group B (22.00 ± 0.91) year. Subjects in group A were given Hold Relax Stretching (HRS) and Group B underwent the Muscle Energy Technique (MET). Both groups received only one session of stretching. In hold-relax stretching group the muscle was stretched passively by researcher and held this position is held for 7 to 10 seconds. The subject then performed isometric contractions for 3 seconds, following a relaxation period of 10 seconds, then passive stretch was applied until a mild stretch sensation was reported. This stretch was held for 7seconds with three repetitions. The muscle energy technique group performed isometric contractions for 7 to 10 seconds with a relaxation period of 10 seconds with 3 repetitions. Pre and post-test reading was taken using a goniometer in the active knee extension test and straight leg raise for both groups before and after the stretch and was noted in the range of motion table. Comparison of all variables was calculated through SPSS. Results Pretreatment straight leg raise was 49.92 ± 6.61 it increased to 68.15 ± 7.79 after hold-relax stretching and Pretreatment straight leg raise was 55.00 ± 3.89 it increases to 79.92 ± 9.56 after muscle energy technique. Active knee extension (AKE) was 130.46 ± 6.49 after HRS it increases to 140.77 ± 6.73. and Active Knee Extension (AKE) was 131.92 ± 8.68 after MET it increases to 151.77 ± 11.7. However, within the group comparison did not show a significant difference in AKE and SLR in the MET group. The difference was statistically significant (p-value <0.001). Conclusion Within the group, the muscle energy technique showed more improvement and comparing the two groups, both techniques are effective in improving the hamstring muscle flexibility.


Trigger point, Physiotherapy treatments, theragun, massage ball use,percussive therapy.


“A Trigger Point (TrPs) is a hyperirritable point in taunt band of the skeletal muscle. On palpation patient presents referred pain and jump sign”. TrPs are tender to touch and can refer pain to the distant part of the body. Patients may have regional and continuous pain, resulting in a reduced Range of Motion (ROM). Trigger points are present in the specific syndrome known as myofascial pain syndrome which presents approximately 16-18 trigger points all over the body. There are two types of trigger points Active TrPs and Latent TrPs [1-3].

Trigger point releasing tools have been found to increase Range of Motion (ROM) and reduce the risk of injury. The soft tissue component of connective tissue is called Fascia. It is known that fascia surrounds each muscle and organ in the body. Techniques to release trigger points in muscles are a form of myofascial release. Tools are typically used for trigger point release foam rollers, massage balls, vibrating rollers, and percussion therapy [4-6].

The effectiveness of Theragun on improving muscle flexibility. The reason behind this is the Theragun activates the Golgi tendon organ and results in a relaxation reaction from the higher center, which reduces the tension in the respected muscle, improves blood circulation and nutrition to the tissue, increases the removal of toxic material from tissue that leads to decrease tightness and improve muscle flexibility. Theragun has proved the fascia releasing a tool in past research, they hypothesize that Theragun has reduced muscle fatigue and increased the range of motion of the muscle. Theragun has the potential for early muscle recovery. Theragun is effective in the treatment of deep tissue, with benefits including pain reduction, increased blood flow, improved scar tissue, decreased lactate, reduced muscle spasms, increased lymphatic flow, inhibition of the Golgi reflex, increased range of motion, and better recovery based on the principles of fascial connective tissue treatment. The patient can use Theragun by himself but it is an electric device so it can’t be handed over to the patient to use it by himself. Most people like to buy a massage gun that can provide relief. The patient can’t use it at home by himself because it is difficult to handle. Theragun can cause muscle soreness because it increases the local temperature due to repeated movements. The mild inflammation and pain complained by a patient after overuse of Theragun [7-10].

As a myofascial trigger point, pressure release needs the application of pressure to the deep muscle layer to reduce muscle tension. From a physics point of view, a hard massage ball would be advantageous for providing pressure to the deep muscles, as the force induced would be more concentrated on the target tissue rather than being dispersed, as occurs with the use of a soft massage tool [11].

On the other hand, the firm pressure of a hard massage ball may cause muscle twitch. The effectiveness of the technique of myofascial selfmassage using tennis balls in fitness. The massage ball is the tool to release the trigger point in the muscle. The massage ball is easy to use for pain relief therapy and trigger point therapy. A hard massage ball causes increased ischemic compression and pain relief. Massage balls don’t always give relief to pain. Patients report soreness and an increase in pain after using massage balls [12-15].

a supported hand and pain pressure threshold was measured by pressing the algometer on the trigger point till they feel pain and said to stop. Readings were recorded in pounds Lbs. Then massage to group A was provided with theragun on hand with the intensity at Level 1, and group B with a hard massage ball on hand with the maximal intensity that can cause aggravation of pain in the trigger point. Pain intensity in group B was measured by the Visual Analog Scale (VAS) to control the ischemic compression. In group, A Theragun was applied by the researcher while in group B participants rolled a massage ball under his/her hand by aggravating pain up to 7 VAS. The intervention was provided with a hard massage ball and theragun for 1 minute with an interval of 30 seconds so that two readings were taken (for pre and post-value) in pounds, with the interval of 30 secs and no follow-up. Post-reading was taken in the same manner as in pre-readings. Readings were documented in the table. The whole procedure took only five minutes. The difference between pain pressure threshold PPT before and after intervention determined the effectiveness of tools.


A total of 32 participants (13 males and 19 females) were recruited for this study from age 22 to 25 shown in the table. Demographic variables with Mean ± SD of continuous variable i.e. Age (23.06 ± 1.014), BMI (21.766 ± 1.525), and frequency of discrete variable, Gender (male 13, female19).

In between groups comparison, the results show that there is no significant difference between Theragun and massage ball treatment results with p >0.05.

■Independent samples test

During the pretest mean pressure-bearing capacity of the male was 30.23 ± 3.219lbs and the female was 29.47 ± 2.065lbs. The difference was not statistically significant (p-value 0.423). Independent sample t-test shows that the t-value for the pretest is 0.063 and in the post-test, it is 0.232 which is >0.05 so statistically, the null hypothesis is approved that there is no difference between the two treatment methods.

■Correlations between two groups

Paired sample t-test shows post-test results of theragun and massages ball 33.13 ± 2.24 and 34.38 ± 3.423 with the Standard error of .562 and .856 respectively TABLES 1- 6.

TABLE 1. Demographic variables

  No. of subjects
Gender Group A Group B  2
Male 7 6
Female 9 10

TABLE 2. Demographic variables



Sig. (2-tailed)
Pretest 30.23 ± 3.219 29.47 ± 2.065 0.063
Post Test 33.08 ± 2.783 34.21 ± 2.992 0.232

TABLE 3. Gender Distribution

Gender Frequency Percent
Male 13 40.6
Female 19 59.4
Total 32 100

Among the subjects, 13(40.6 %) were male and 19 (59.4 %) were female.

TABLE 4: Between group comparison

             Male Female p-value
Pretest 30.23±3.219 29.47±2.065 0.423
Post Test 33.08±2.783 34.21±2.992 0.288

TABLE 5: Independent Samples Test

Demographic variables  Mean ± SD
Age 23.06 ± 1.014
BMI 21.766 ± 1.525

TABLE 6: Correlations between two groups

Treatment methods Pretest  Posttest
Theragun Treatment 28.94 ± 1.389 33.13 ± 2.247
Massage ball treatment 30.63 ± 3.202 34.38 ± 3.423

The current study compared the effects of theragun and massage balls in treating the trigger point of the adductor pollicis muscle.

Mechanical impact devices are an emerging type of myofascial release intervention used by sports medicine professionals. Despite their popularity, there are few published peer-reviewed studies on these devices, creating a gap between evidence and clinical practice. Lack of recommendations or evidence-based reviews to guide clinical practice. These devices are used by practicing healthcare professionals. The goals of previous studies were to examine the efficacy of theragun in plantar fasciitis, taut bands of the trapezius, hamstring shortening, back pain, and calf tightness. In this study, statistical analysis shows that there is no difference in these treatment methods, theragun and massage ball has been widely used for the treatment of muscle tightness in past research and clinical practices separately. In this study, we compared the effects of both treatments, and the results of theragun treatment were 28.94 ± 1.389 pretests and 33.13 ± 2.247 post-test with standard error of 0.3 and 0.5 while in the massage ball treatment pretest 30.63 ± 3.202 and 34.38 ± 3.423 are posttests. With standard error mean 0.800 and 0.856. To update our knowledge it is the first study that measures the PPT of latent trigger points and treatment of trigger points among medical students [16-17].


We concluded that in medical students of the 4th and final year between the ages of 22 to 25 years with normal BMI, a latent trigger point of adductor pollicis muscle was present. In the quasi-experiment, time was constant for both groups. Both groups were receiving treatment and pretest-posttest PPT readings were taken with an algometer. There was no difference in the treatment of theragun and massage. Both were equally effective for patients.

The massage ball was much easier for patients to use while theragun was used by the researcher.


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