Comparison of Treatment Outcome of Proprioceptive Neuromuscular Facilitation (hold-Relax) Technique and Muscle Energy Techniques on Hamstring Tightness in Asymptomatic Males

Corresponding Author:

Samiya Noreen
Senior Lecturer Elite college of management science, Pakistan
E-mail: samiyanoreen09@gmail.com

Received: 22 December, 2021, Manuscript No. M-50461 Editor assigned: 24 December, 2021, PreQC No. P-50461 Reviewed: 05 January, 2022, 2022, QC No. Q-50461 Revised: 07 January, 2022, Manuscript No. R-50461 Published: 14 January, 2022, DOI. 10.37532/fmcp.2022.19(1).1819-1832

Abstract

Objective: The purpose of this study was to see the comparison of the effectiveness of PNF (hold-relax) stretching and Muscle energy technique on hamstring tightness in asymptomatic males.

Methodology: This randomized clinical trial was conducted at the OPD physiotherapy department, PSRD Lahore. In this study 60 males were randomly selected in three groups GROUP A males were treated with PNF hold relax stretching. GROUP B males were treated with METS (post isometric relaxation) GROUP C males were treated with METS (autogenic inhibition)

Performa was filled and informed consent was taken from each male. Questioner used for data collection was AKET, SLR, Sit and Reach test were also used for assessment of hamstring tightness.

GROUP A: PNF (hold relax) stretching 30 sec 3 times=1 session 4 sessions in two weeks.

GROUP B: METS (post isometric relaxation) 10 sec 3 times=1 session 4 sessions in 2 weeks.

GROUP C: METS (autogenic inhibition) 10 sec 3 times=1 session 4 sessions in 2 weeks.

Results: Males in group A showed marked improvement as compared to group B and C. P value (0.000) less than 0.05 is considered significant. The mean age of Males for Group A and B was 26+1.2 and 26+0.9 respectively and for group C Mean value was 27+1.16.

Conclusion: It is concluded from the study that PNF hold relaxed stretching of hamstrings in males with hamstring tightness is a significant treatment outcome on AKET more than METS. However, on SLR and SART, all three techniques have an equal effect. When groups B and C were analyzed it was seen that Group B and C showed significant results on AKET, SLR test, sit and reach test and have effect in improving the outcome but the two groups have an insignificant difference between each other so they both have an equal effect, both are equally effective.

Keywords

PNF (Proprioceptive Neuromuscular Facilitation), METs (Muscle Energy Techniques), Muscle Tightness

Introduction

A decrease in muscular flexibility reduces not only the functional level of an individual but also harms the musculoskeletal system due to overuse [1]. The capability of an individual to move efficiently depends on his flexibility. It is a fundamental element that allows the tissue to adapt easily to stress. Muscle tightness is caused by a decrease in the ability of a muscle to deform which results in decreased range of motion at the acting joints [2]. Hamstrings are a group of muscles that tend to get shortened. These are the three muscles that cover the posterior aspect of the thigh, consisting of the biceps femoris, semitendinosus, and semimembranosus [2]. Tightness of this muscle group results in the prevalence of low back pain [3]. Hamstrings are two joint-acting muscles and are most frequently damaged in the body [4]. The hamstring belongs to the muscles of the posterior compartment of the thigh. Among semimembranosus, semitendinosus, and biceps femoris, the short head of the biceps does not cross the knee joint. Mobility is associated with the integrity of the joint as well as flexibility or ward extensibility. This is essential for painfree and smooth unrestricted movements of the body to perform daily activities of life [5]. Hypomotility is Reduced mobility and limited motion are terms used to describe hypomobility. There is a wide range of pathological processes which limit movement and impair mobility. Hypo mobility due to adaptive shortening of soft tissues is a result of different disorders or malfunctioning [6]. Dynamic flexibility is also called active mobility or active range of motion of a joint. An extent to which muscle contracts actively to move a segment of the body in an available range of motion. It depends on the extent of joint mobility and tissue resistance faced during movement [6]. Passive mobility or passive range of motion. An extent to which a segment of the body is passively moved in an available range. It is dependent on the flexibility of surrounding muscles and connective tissues of a joint [6]. Dynamic stretching, an external force is applied to move the body segment beyond the point of resistance and within the available room. The site of stabilization, the direction of speed, duration, and intensity of stretch is controlled by the therapist. It can also be achieved passively by the patient with assistance or independently [6]. Static stretching, a widely used method to increase the length of muscle by autogenic inhibition which excites the Golgi tendon organ. In this procedure, the resistance to musculotendinous stretching not only involves the viscoelastic properties of connective tissues and muscles but also involves neurological reflex [1]. Muscle energy technique is a manual technique developed by osteopaths that are used by many Professionals. It is effective because of many reasons because it helps in lengthening a Shortened muscle, strengthening a muscle, as a lymphatic or pump to assist the drainage of fluid and blood, and helping in increasing the range of motion of a limiting joint [7].

Objective

■ Primary objective

The Aims and objective of the study are to find out the more effective treatment technique for hamstring tightness.

■ Secondary objective

To find out the effect of hamstring stretching on the improvement of chronic back pain.

To increase the hip range of motion of flexion.

To increase the knee extension range of motion.

Hypothesis

■ Null hypothesis

There is no difference between proprioceptive neuromuscular facilitation stretching and muscle energy technique (autogenic inhibition) in the improvement of hamstring tightness.

■ Alternative Hypothesis

Muscle energy technique (autogenic inhibition) is more effective. The proprioceptive neuromuscular facilitation(hold-relax) in increasing the hamstring muscle. Tightness is more effective. Muscle energy technique (reciprocal Inhibition) is more effective. All three interventions have the same effect on improving hamstrings extensibility.

Material and methods

It is a Quasi Randomized Clinical Trial (Q-RCT). The study is to be done at the OPD Department of PSRD (Pakistan Society of Rehabilitation and Disability) Study was completed within 6-8 months.

Nonprobability purposive sampling technique is to be used. Group allocation was goldfish randomization.

Group A patient was treated with proprioceptive neuromuscular facilitation (hold-relax).

Group B patient was treated with muscle energy technique (post isometric relaxation).

Group C patient was treated with muscle energy technique (autogenic inhibition).

■ Sample size calculation

A prior analysis for repeated measure ANOVA within and between interactions was run using:

F=0.25

Alpha=0.05

Beta=0.95

Was run to calculate sample size which gave us a sample size of 54 considering the margin of dropout a sample size of 60 clients will be taken by dividing 20 participants in each group.

Software is G POWER 3.0.10

■ Data analysis

Data entry and analysis are to be done by using SPSS 16. Quantitative variables are to be presented by using mean SD. Qualitative variables are to be presented by using frequency tables and appropriate graphs where applicable. ANOVA is to be applied to see the difference in the treatment outcome on SLR, sit and reach test, Active knee extension test.

■ Inclusion criteria

Age 20-30 years.

Females

90-90 test<50

SLR<70

■ Exclusion criteria

Neurological problem with lumber region.

Patient with back and spine fractures.

Patient with any structural deformity of the spine.

Patients with Mental disabilities

Patient with an active complaint of low back pain and lower extremity.

Females.

Methods

A total of 60 asymptomatic male subjects of PSRD College of Rehabilitation Sciences with hamstring muscle tightness were included in the study. The criteria for inclusion were healthy males between the ages of 20 and 30 years with hamstring muscle tightness of 20 degrees (inability to achieve greater than 160º of knee extension with hip at 90º of flexion is considered hamstring tightness). Subjects were excluded if they had a neurological problem in the lumbar region, any Deformity of the knee, hip, and back, history of participation in a stretching or yoga program in the last six months, history of trauma at the hip, knee, or back, or any injury to the hamstring and other muscles in the lower limb. The study received ethical clearance, and informed consent was received before the intervention from each subject. The subjects were screened according to the inclusion criteria. They were randomly allocated through the goldfish method of randomization into three groups. Measurements of the dependent variable were obtained by another therapist who was blinded to group assignment. Informed consent will be taken from every male telling about the safety of the study and their right to withdraw from the study at any time. Demographic details (name, age, sex) will be noted along with medical history.

Group A receives moist superficial heat and the PNF (Hold-Relax) technique of stretching.

Group B receives moist superficial heat and METS (reciprocal inhibition technique).

Group C receives moist superficial heat METS (autogenic inhibition technique).

For PNF Hold-Relax Technique each subject in Group A was comfortably positioned in a supine lying position on a plinth with the hip fixed at 90 degrees of flexion, and a therapist then stretched the hamstrings passively until the subject felt and reported a mild stretch sensation; that position was held for 30 seconds. The subjects were asked to perform maximal isometric contractions of the hamstrings for 7 seconds by attempting to push their leg back toward the table against the resistance of the therapist. After the contraction, the subjects were instructed to relax for 5 seconds. This sequence was repeated three times for each session equal to one set on the alternate days.

Group-B males were treated with METS (reciprocal inhibition technique) 10 seconds thrice equal to one set and three sets on alternate days in a week were given.

Group-C males were treated with METS (autogenic inhibition) 10 seconds hold thrice equal to one set and three sets on alternate days in a week were given.

■ Assessment criteria

Data was collected by the assessor by using a pre-designed Performa. Improvement regarding the outcomes of the treatment was measured by using SLR, Sit and Reach test, and Active Knee Extension Test.

Results

■ Mean values of age and BMI(TABLE 1 and TABLE 2)

TABLE 1. Mean values of age and BMI

TABLE 2. Within subjects effects SLR.

■ SLR within subject’s effects (TABLES 3-12)

TABLE 3. Tests of Within-Subjects Effects (Straight Leg Raise).

TABLE 4. Estimated marginal means (Straight Leg Raise).

TABLE 5. Within subjects effects SART.

TABLE 6. Multivariate Tests.

TABLE 7. Sitandreach test.

TABLE 8. Test of within subjects effects for SART.

TABLE 9. Estimated marginal means.

TABLE 10. Within subjects factors AKET.

TABLE 11. One way ANOVA Straight Leg Raise Test.

TABLE 12. Difference of straight leg raise test remained insignificant between treatment groups and within groups with value of 0.206.

The table shows that difference of the straight leg raise test remained insignificant between treatment groups and within groups with a value of 0.206.

There was a statistically insignificant difference between groups for change in straight leg raising as determined by one-way ANOVA (F(2,57)=1.623, p=0.206). A Tukey post hoc test revealed that improvement in SLR was significantly after treatment as compared to pretreatment stages but there was no statistically significant difference between the groups (p=0.206) (TABLES 13-18).

TABLE 13. Post Hoc tests (Multiple Comparisons).

TABLE 14. Homogeneous Subsets.

TABLE 15: One way sit and reach test.

TABLE 16: One way sits and reach test between treatment groups and within groups.

TABLE 17: Post Hoc Tests (sit and reach test).

TABLE 18: Homogeneous Subsets (sit and reach test).

The table shows that difference of the active knee extension test remained significant between treatment groups and within groups with a value of 0.04 (TABLES 19-22).

TABLE 19. One-way active knee extension test.

TABLE 20. Difference of active knee extension test remained significant between treatment groups and within groups with value of 0.04.

TABLE 21. Post Hoc Tests (aket44).

TABLE 22. Homogeneous Subsets (aket44).

Observations

■ Within groups

A repeated-measures ANOVA with a Greenhouse-Geisser correction determined that mean SLR differed statistically significantly for group A and C while insignificantly for group B, at the end of the treatment (F(2.034, 38.653)=54.05, p<0.05) for group A, (F(3.115, 59.182)=11.739, p>0.05) for group B, and (F(2.707, 51.433)=8.076, p<0.05.

A repeated-measures ANOVA with a Greenhouse-Geisser correction determined that mean sit and reach test differed statistically significantly for all C groups, at the end of the treatment (F(2.531, 48.084)=6.508, p<0.05) for group A, (F(3.316, 63.010)=15.696, p>0.05) for group B, and (F(2.898, 55.068)=13.834, p<0.05.

A repeated-measures ANOVA with a Greenhouse-Geisser correction determined that mean AKET differed statistically significantly for group A and C while insignificantly for group B, at the end of the treatment (F(2.98, 56.620)=27.581, p<0.05) for group A, (F(3.068, 58.287)=21.282, p>0.05) for group B, and (F(2.412,45.833) =51.255, p<0.05.

■ Between Groups

There was a statistically insignificant difference between groups for change in straight leg raising as determined by one-way ANOVA (F(2,57)=1.623, p=0.206). A Tukey post hoc test revealed that improvement in SLR was statistically significant after treatment as compared to pretreatment stages but there was no statistically significant difference between the groups (p=0.206).

There was a statistically insignificant difference between groups for change in sit and reach rest as determined by one-way ANOVA (F(2,57)=0.550, p=0.580). A Tukey post hoc test revealed that improvement in sit and reach test was statistically significant after treatment as compared to pretreatment stages but there was no statistically significant difference between the groups (p=0.580)

There was a statistically significant difference between groups for change in active knee extension as determined by one-way ANOVA (F(2,57)=6.066, p=0.004). A Tukey post hoc test revealed that improvement in active knee extension was statistically significant after treatment for group A as compared to group C (p=0.003). there was no significant difference between group A and group B (p=0.068) and group B and group C (p=0.489)

Discussion

The purpose of this study was to see the effects of PNF hold relax hamstring stretch and METS so that flexibility of hamstrings can be improved.

In this study 60 males were taken, the subjects were allocated to three groups, Group A who received PNF hold relax stretching, Group B who received METS post isometric relaxation, and Group C who receive METS autogenic inhibition. Three scales were used to test the significance of the results. These include the Active knee extension test, Straight leg Raise, Sit and Reach test. Observations were taken before and after the treatment sessions. Based on results, it was shown that Group A had more pronounced effects of treatment as compared to Group B and Group C [8-16].

GROUP A, B, and C showed the significance of results with the calculated value of 0. In the activation knee extension test. The value for straight leg raise was 0.000. For Sit and Reach test, the values were the ere same for Group A and B that is 0.000, and for group C value 0.001 was else significant. These results showed that there is a significant difference between the three treatment groups [17-21].

Group B and C showed insignificant results with the calculated value of 0.206 for SLR and 0.580 for SART but Group A showed with the calculated value of 0.03 for AKET a significant value. This result showed that there is a significant difference between Group A From Group B and C which shows that Group A is a more effective treatment Group.

A blinded randomized design of the study was conducted to see the effect of static stretching of muscles surrounding the knee on knee joint position sense. Joint position sense in 45 degrees of knee flexion was improved to a great extent [13].

A randomized control trial on 48 subjects was conducted to find the effects of two different stretching techniques on ROM, balance, and muscle activation. Both the techniques showed a significant increase in knee extension angle.

Some studies also showed that there is no effect of stretching on the tightness and flexibility of the muscles. An RCT was conducted to see the effects of stretch on the extensibility of muscles and tolerance of stretch with patients of chronic MSK pain. It was concluded that stretch did not improve the extensibility of muscles but it increased tolerance to stretch of muscles [11].

Stretching is associated with a composite and multifactorial relation with a hamstring strain. It can be more beneficial if the technique used and the time duration for holding stretches are adequate. The repetitions are not as much important as time duration [22].

A study of static stretching and proprioceptive neuromuscular facilitation stretch on hamstrings length after a single session was conducted. This study showed that there was a significant increase in knee extension after applying static stretch and proprioceptive neuromuscular technique in a single session. A marked difference in ROM was observed in the control group and the other group [23].

Many studies showed that there is an equal effect of static stretching and hold relax on the hamstring. Similarly, PNF stretching has also an effect on hamstrings. All three techniques have the same effect but out of all PNF stretching hold relax has a more pronounced effect [3].

So it was concluded that stretching techniques have significant effects on muscle flexibility and range of motion. Different techniques are used to achieve the effects of improved extensibility of hamstrings. Static stretching in the form of PNF hold relax was more significant as compared to other stretching techniques like self-stretching, ballistic stretching, etc.

Conclusion

It is concluded from the study that PNF hold relax technique on hamstrings in males with hamstring tightness is a significant treatment outcome on AKET. Males with hamstring tightness, when treated by PNF hold relax showed a significant result treatment outcome when analyzed on AKET, SLR, SIT AND REACH TEST. GROUP B and C showed a significant difference between pre and posttreatment session but there are insignificant results between the two Groups as value are (p>0.05) that is 0.206 on SLR and 0.580 on SART respectively.

Recommendations and limitations

The limitations of this study were that it was conducted in a single Department. It was not funded. The time duration was very limited to complete it. The sample size was low as it had to be completed in a short period. Loss to follow up was present which was less than 10% who had little effect on result findings.

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