Research Article - Clinical Practice (2022) Volume 19, Issue 1

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)

Descriptive Statistics
Treatment group of patient N Minimum Maximum Mean Std. Deviation
Group 1 age of participant 20 23 28 25.5 1.67
height of participant 20 53 65 61.447 2.9283
weight of participant 20 30 70 49.51 10.989
straight leg raising pre-value 20 65 90 74.65 6.513
BMI 20 11.95 33.08 20.4779 5.09808
sit and reach test  Pre-treatment 20 7.62 30.8 19.1978 7.50212
aketpre1 20 113.64 130 123.058 5.69371
Valid N (listwise) 20
Group 2 age of participant 20 24 28 25.9 1.41
height of participant 20 53 67 61.005 3.5174
weight of participant 20 40 83 57.86 14.125
straight leg raising pre-value 20 59 90 77.9 8.053
BMI 20 14.62 42.95 24.1877 6.20355
sit and reach test  Pre-treatment 20 6.35 23.47 15.6315 4.17474
aketpre1 20 117 133.45 125.442 5.50883
Valid N (listwise) 20
Group 3 age of participant 20 25 30 27.8 1.704
height of participant 20 57 65 61.769 2.17
weight of participant 20 43 70 55.56 7.673
straight leg raising pre-value 20 73 97 82.77 7.619
BMI 20 18.35 29.28 22.5874 3.00405
sit and reach test  Pre-treatment 20 6.54 27.94 16.9144 5.21447
aketpre1 20 118.3 136.01 128.186 5.37373
Valid N (listwise) 20

TABLE 1. Mean values of age and BMI

Descriptive Statistics
Treatment group of patient Mean Std. Deviation N
Group 1 straight leg raising pre value 74.65 6.513 20
straight leg raising first session value 73.39 4.466 20
straight leg raising second session value 78.92 4.463 20
straight leg raising third session value 83.32 3.616 20
straight leg raising fouth session value 89.36 2.42 20
Group 2 straight leg raising pre value 77.9 8.053 20
straight leg raising first session value 81.36 9.926 20
straight leg raising second session value 87.21 8.538 20
straight leg raising third session value 88.9 8.746 20
straight leg raising fouth session value 89.9 9.474 20
Group 3 straight leg raising pre value 82.77 7.619 20
straight leg raising first session value 88.42 9.793 20
straight leg raising second session value 91.2 12.906 20
straight leg raising third session value 94.35 9.692 20
straight leg raising fouth session value 93.51 9.615 20

TABLE 2. Within subjects effects SLR.

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

Straight Leg Raise
Treatment group of patient Source Type III Sum of Squares df Mean Square F Sig.
Group 1 factor1 Sphericity Assumed 3440.682 4 860.171 54.05 0
Greenhouse-Geisser 3440.682 2.034 1691.269 54.05 0
Huynh-Feldt 3440.682 2.28 1508.838 54.05 0
Lower-bound 3440.682 1 3440.682 54.05 0
Error (factor1) Sphericity Assumed 1209.498 76 15.914
Greenhouse-Geisser 1209.498 38.653 31.291
Huynh-Feldt 1209.498 43.327 27.916
Lower-bound 1209.498 19 63.658
Group 2 factor1 Sphericity Assumed 2154.607 4 538.652 11.739 0
Greenhouse-Geisser 2154.607 3.115 691.72 11.739 0
Huynh-Feldt 2154.607 3.796 567.627 11.739 0
Lower-bound 2154.607 1 2154.607 11.739 0.003
Error (factor1) Sphericity Assumed 3487.433 76 45.887
Greenhouse-Geisser 3487.433 59.182 58.927
Huynh-Feldt 3487.433 72.12 48.356
Lower-bound 3487.433 19 183.549
Group 3 factor1 Sphericity Assumed 1750.52 4 437.63 8.076 0
Greenhouse-Geisser 1750.52 2.707 646.669 8.076 0
Huynh-Feldt 1750.52 3.2 547.017 8.076 0
Lower-bound 1750.52 1 1750.52 8.076 0.01
Error (factor1) Sphericity Assumed 4118.201 76 54.187
Greenhouse-Geisser 4118.201 51.433 80.07
Huynh-Feldt 4118.201 60.802 67.731
Lower-bound 4118.201 19 216.747

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

Straight Leg Raise
Treatment group of patient factor1 Mean Std. Error 95% Confidence Interval
Lower Bound Upper Bound
Group 1 1 74.654 1.456 71.606 77.702
2 73.394 0.999 71.304 75.485
3 78.919 0.998 76.83 81.008
4 83.316 0.809 81.623 85.008
5 89.364 0.541 88.231 90.496
Group 2 1 77.902 1.801 74.133 81.671
2 81.358 2.22 76.712 86.004
3 87.212 1.909 83.216 91.208
4 88.901 1.956 84.808 92.995
5 89.898 2.118 85.464 94.332
Group 3 1 82.765 1.704 79.2 86.331
2 88.419 2.19 83.835 93.002
3 91.203 2.886 85.162 97.243
4 94.351 2.167 89.815 98.887
5 93.509 2.15 89.009 98.009

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

Descriptive Statistics
Treatment group of patient Mean Std. Deviation N
Group 1 sit and reach test  Pre treatment 19.1978 7.50212 20
sit and reach test after 1st session 17.7236 7.71662 20
sit and reach test after 2nd session 16.9312 8.08717 20
sit and reach test after 3rd session 19.8133 7.19791 20
sit and reach test after 4th session 24.6253 5.90005 20
Group 2 sit and reach test  Pre treatment 15.6315 4.17474 20
sit and reach test after 1st session 17.5396 5.35018 20
sit and reach test after 2nd session 21.2855 5.87083 20
sit and reach test after 3rd session 21.2877 4.67437 20
sit and reach test after 4th session 23.8136 5.75489 20
Group 3 sit and reach test  Pre treatment 16.9144 5.21447 20
sit and reach test after 1st session 18.474 3.39046 20
sit and reach test after 2nd session 20.9177 4.37805 20
sit and reach test after 3rd session 21.9964 3.68976 20
sit and reach test after 4th session 22.9301 3.24912 20

TABLE 5. Within subjects effects SART.

Multivariate Testsa
Treatment group of patient Effect Value F Hypothesis df Error df Sig.
Group 1 factor1 Pillai's Trace 0.904 37.771b 4 16 0
Wilks' Lambda 0.096 37.771b 4 16 0
Hotelling's Trace 9.443 37.771b 4 16 0
Roy's Largest Root 9.443 37.771b 4 16 0
Group 2 factor1 Pillai's Trace 0.82 18.177b 4 16 0
Wilks' Lambda 0.18 18.177b 4 16 0
Hotelling's Trace 4.544 18.177b 4 16 0
Roy's Largest Root 4.544 18.177b 4 16 0
Group 3 factor1 Pillai's Trace 0.821 18.350b 4 16 0
Wilks' Lambda 0.179 18.350b 4 16 0
Hotelling's Trace 4.588 18.350b 4 16 0
Roy's Largest Root 4.588 18.350b 4 16 0
a. Design: Intercept,  Within Subjects Design: factor1, b. Exact statistic

TABLE 6. Multivariate Tests.

Treatment group of patient Within Subjects Effect Mauchly's W Approx. Chi-Square df Sig. Epsilonb
Greenhouse-Geisser Huynh-Feldt Lower-bound
Group 1 factor1 0.098 40.458 9 0 0.633 0.738 0.25
Group 2 factor1 0.641 7.746 9 0.562 0.829 1 0.25
Group 3 factor1 0.501 12.04 9 0.213 0.725 0.869 0.25

TABLE 7. Sitandreach test.

Treatment group of patient Source Type III Sum of Squares df Mean Square F Sig.
Group 1 factor1 Sphericity Assumed 721.75 4 180.437 6.508 0
Greenhouse-Geisser 721.75 2.531 285.193 6.508 0.002
Huynh-Feldt 721.75 2.952 244.508 6.508 0.001
Lower-bound 721.75 1 721.75 6.508 0.02
Error (factor1) Sphericity Assumed 2107.285 76 27.727
Greenhouse-Geisser 2107.285 48.084 43.825
Huynh-Feldt 2107.285 56.085 37.573
Lower-bound 2107.285 19 110.91
Group 2 factor1 Sphericity Assumed 859.061 4 214.765 15.696 0
Greenhouse-Geisser 859.061 3.316 259.042 15.696 0
Huynh-Feldt 859.061 4 214.765 15.696 0
Lower-bound 859.061 1 859.061 15.696 0.001
Error (factor1) Sphericity Assumed 1039.864 76 13.682
Greenhouse-Geisser 1039.864 63.01 16.503
Huynh-Feldt 1039.864 76 13.682
Lower-bound 1039.864 19 54.73
Group 3 factor1 Sphericity Assumed 499.171 4 124.793 13.834 0
Greenhouse-Geisser 499.171 2.898 172.228 13.834 0
Huynh-Feldt 499.171 3.476 143.613 13.834 0
Lower-bound 499.171 1 499.171 13.834 0.001
Error (factor1) Sphericity Assumed 685.57 76 9.021
Greenhouse-Geisser 685.57 55.068 12.45
Huynh-Feldt 685.57 66.04 10.381
Lower-bound 685.57 19 36.083

TABLE 8. Test of within subjects effects for SART.

Treatment group of patient factor1 Mean Std. Error 95% Confidence Interval
Lower Bound Upper Bound
Group 1 1 19.198 1.678 15.687 22.709
2 17.724 1.725 14.112 21.335
3 16.931 1.808 13.146 20.716
4 19.813 1.61 16.445 23.182
5 24.625 1.319 21.864 27.387
Group 2 1 15.631 0.934 13.678 17.585
2 17.54 1.196 15.036 20.044
3 21.286 1.313 18.538 24.033
4 21.288 1.045 19.1 23.475
5 23.814 1.287 21.12 26.507
Group 3 1 16.914 1.166 14.474 19.355
2 18.474 0.758 16.887 20.061
3 20.918 0.979 18.869 22.967
4 21.996 0.825 20.27 23.723
5 22.93 0.727 21.409 24.451

TABLE 9. Estimated marginal means.

Descriptive Statistics
Treatment group of patient Mean Std. Deviation N
Group 1 aketpre1 123.058 5.69371 20
aket11 127.191 3.9301 20
aket22 129.354 3.53312 20
aket33 131.546 5.18087 20
aket44 133.418 4.80021 20
Group 2 aketpre1 125.4415 5.50883 20
aket11 128.502 4.90962 20
aket22 132.3475 5.26297 20
aket33 134.299 6.3135 20
aket44 136.598 4.69836 20
Group 3 aketpre1 128.186 5.37373 20
aket11 130.7225 3.39649 20
aket22 134.881 3.07457 20
aket33 136.061 3.00132 20
aket44 138.204 3.68322 20

TABLE 10. Within subjects factors AKET.

N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Minimum Maximum
Lower Bound Upper Bound
Group 1 20 89.36 2.42 0.541 88.23 90.5 84 95
Group 2 20 89.9 9.474 2.118 85.46 94.33 63 105
Group 3 20 93.51 9.615 2.15 89.01 98.01 77 108
Total 60 90.92 8 1.033 88.86 92.99 63 108

TABLE 11. One way ANOVA Straight Leg Raise Test.

ANOVA
Straight leg raising fouth session value 
Sum of Squares df Mean Square F Sig.
Between Groups 203.423 2 101.711 1.623 0.206
Within Groups 3572.881 57 62.682
Total 3776.304 59

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).

Multiple Comparisons
Dependent Variable: Straight leg raising fourth session value 
Tukey HSD 
(I) Treatment group of patient (J) Treatment group of patient Mean Difference (I-J) Std. Error Sig. 95% Confidence Interval
Lower Bound Upper Bound
Group 1 Group 2 -0.534 2.504 0.975 -6.56 5.49
Group 3 -4.146 2.504 0.231 -10.17 1.88
Group 2 Group 1 0.534 2.504 0.975 -5.49 6.56
Group 3 -3.611 2.504 0.326 -9.64 2.41
Group 3 Group 1 4.146 2.504 0.231 -1.88 10.17
Group 2 3.611 2.504 0.326 -2.41 9.64

TABLE 13. Post Hoc tests (Multiple Comparisons).

straight leg raising fouth session value
Tukey HSDa
Treatment group of patient N Subset for alpha=0.05
1
Group 1 20 89.36
Group 2 20 89.9
Group 3 20 93.51
Sig. 0.231
Means for groups in homogeneous subsets are displayed. a. Uses Harmonic Mean Sample Size=20.000

TABLE 14. Homogeneous Subsets.

Descriptives
Sit and reach test after 4th session 
N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Minimum Maximum
Lower Bound Upper Bound
Group 1 20 24.6253 5.90005 1.31929 21.864 27.3866 14.22 34.29
Group 2 20 23.8136 5.75489 1.28683 21.1202 26.507 11.43 38.05
Group 3 20 22.9301 3.24912 0.72653 21.4094 24.4507 17.33 30.48
Total 60 23.7897 5.07568 0.65527 22.4785 25.1009 11.43 38.05

TABLE 15: One way sit and reach test.

ANOVA
sit and reach test after 4th session 
Sum of Squares df Mean Square F Sig.
Between Groups 28.755 2 14.378 0.55 0.58
Within Groups 1491.237 57 26.162
Total 1519.992 59

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

Multiple Comparisons
Dependent Variable: sit and reach test after 4th session 
Tukey HSD 
(I) Treatment group of patient (J) Treatment group of patient Mean Difference (I-J) Std. Error Sig. 95% Confidence Interval
Lower Bound Upper Bound
Group 1 Group 2 0.81169 1.61747 0.871 -3.0806 4.704
Group 3 1.69523 1.61747 0.55 -2.1971 5.5875
Group 2 Group 1 -0.81169 1.61747 0.871 -4.704 3.0806
Group 3 0.88354 1.61747 0.849 -3.0088 4.7758
Group 3 Group 1 -1.69523 1.61747 0.55 -5.5875 2.1971
Group 2 -0.88354 1.61747 0.849 -4.7758 3.0088

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

sit and reach test after 4th session
Tukey HSDa
Treatment group of patient N Subset for alpha=0.05
1
Group 3 20 22.9301
Group 2 20 23.8136
Group 1 20 24.6253
Sig. 0.55
Means for groups in homogeneous subsets are displayed. a. Uses Harmonic Mean Sample Size=20.000.

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).

Descriptives
N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Minimum Maximum
Lower Bound Upper Bound
Group 1 20 133.418 4.80021 1.07336 131.1714 135.6646 121.76 141.7
Group 2 20 136.598 4.69836 1.05059 134.3991 138.7969 128.46 145
Group 3 20 138.204 3.68322 0.82359 136.4802 139.9278 133 144.01
Total 60 136.0733 4.7875 0.61806 134.8366 137.3101 121.76 145

TABLE 19. One-way active knee extension test.

ANOVA
aket44 Sum of Squares Df Mean Square F Sig.
Between Groups 237.316 2 118.658 6.066 0.004
Within Groups 1114.972 57 19.561
Total 1352.288 59

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

Multiple Comparisons
Dependent Variable: aket44 
Tukey HSD 
(I) Treatment group of patient (J) Treatment group of patient Mean Difference (I-J) Std. Error Sig. 95% Confidence Interval
Lower Bound Upper Bound
Group 1 Group 2 -3.18 1.3986 0.068 -6.5456 0.1856
Group 3 -4.78600* 1.3986 0.003 -8.1516 -1.4204
Group 2 Group 1 3.18 1.3986 0.068 -0.1856 6.5456
Group 3 -1.606 1.3986 0.489 -4.9716 1.7596
Group 3 Group 1 4.78600* 1.3986 0.003 1.4204 8.1516
Group 2 1.606 1.3986 0.489 -1.7596 4.9716
*: The mean difference is significant at the 0.05 level.

TABLE 21. Post Hoc Tests (aket44).

aket44
Tukey HSDa
Treatment group of patient N Subset for alpha=0.05
1 2
Group 1 20 133.418
Group 2 20 136.598 136.598
Group 3 20 138.204
Sig. 0.068 0.489
Means for groups in homogeneous subsets are displayed. a. Uses Harmonic Mean Sample Size = 20.000.

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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