RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the Candidate
and Address /
YOGESH JAGANNATH CHAUDHARI.
SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, PANDESHWARA,
MANGALORE-575001
2 /

Name of the Institute

/ SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE.
3 /

Course of Study and

Subject / Master of Physiotherapy (MPT)
2 years Degree Course.
“Musculoskeletal Disorders & Sports”.
4 /

Date of Admission

To Course / 10/06/2009.
5 /

Title of the Topic

/ “A Study to Find outthe Effects of Mulligan's Bent Leg Raise Technique and Muscle Energy Techniques in Improving the Hamstring Flexibility Among Healthy Young Adults.”
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Brief resume of the intended work:
6.1 Need for the study:
Muscle flexibility is defined as “The ability of amuscle to lengthen allowing one joint (or more than one joint in series) to move through range of motion” and loss of muscle flexibility “as decrease in the ability of the muscle to deform”. Resulting in decreased range of motion about a joint.1
Hamstring muscle group comprises of biceps femoris, semitendinosus and semimembrenosus muscles.2 Hamstring strains are common athletic injury with a tendency to recur. 3,4 Lack of flexibility has been suggested as a predisposing factor to hamstring strains.5,6 Clinicians have generally considered flexibility training to be an integral component in the prevention and rehabilitation of injuries, as well as a method of improving one’s performance in daily activities and sports.7,8
A prospective study of 146 soccer players demonstrated that 21% of players developed hamstring injuries and that these players had significantly reduced hamstrings flexibility prior to sustaining the injury compared with non injured players.9
Anatomical causes of reduced muscle extensibility have been categorised as ‘muscle shortness’ and ‘muscle stiffness’.10A short muscle is a musculotendinous unit that has a reduced capacity to be lengthened due to a reduction in the number of sarcomeres in series,11,12or a reduction in the length or elasticity of the connective tissues (such as occurring with scar tissue formation following injury).10.
Physiological cause of reduced muscle extensibility relate to the contractility of the muscle cells. Activity in alpha motor neurons that results in muscle contraction can increase the force necessary to elongate the homologous muscle, and this muscle will have increased stiffness, and decreased flexibility.13For example, the spasticity of muscles in those with upper motor neuron lesions leads to increased muscle contractility and, therefore, increased stiffness.13However, physiologically reduced muscle extensibility can also occur in the absence of electromyographic activity, and the mechanisms for this are not well understood.14
Passive stretching of various muscle groups, particularly the hamstrings, has been reported to improve the length and extensibility of muscles in both short and long-term periods after stretching.15,16
Additionally, it has been reported that post-isometric stretching techniques, such as Muscle energy techniques (MET) and Proprioceptive Neuromuscular Facilitatory techniques, produce greater changes in range of motion and muscular extensibility than static or ballistic stretching, both immediately following treatment17,18 and in long term.19,20
Muscle Energy Technique (MET) is a form of manual therapy in which patients muscles are actively used on request, from a precisely controlled position in specific direction and against a counter force.21 MET is claimed to be useful for lengthening a shortened muscle, improving range of motion at a joint.22
The basic mechanism or physiology behind the MET in post-isometric relaxation refers to the subsequent reduction in tone of the agonist muscle after isometric contraction. A strong muscle contraction against equal counterforce triggers the Golgi Tendon Organ (GTO). The afferent nerve impulse from the GTO enters the dorsal root of spinal cord and synapse with an inhibitory motor neuron. This stops the efferent motor impulse and reduces the muscle tone, which in turn result in relaxation or lengthening of agonist.21
It is claimed to be effective for a variety of purposes including lengthening a shortened muscles, as a lymphatic or venous pump to aid the drainage of fluid or blood and increasing the range of motion.23,24
The Mulligan’s Bent Leg raise (BLR) technique has been described as a means of improving range of Straight Leg Raise (SLR) in subjects with LBP and/or referred thigh pain.25The SLR test has biomechanical effects on pelvis movement, on lumbo-sacral neural structures and hamstring muscles.26
There is a scarcity of the studies documenting the efficacy of Mulligan’s Bent Leg Raise techniques on hamstrings flexibility in subjects among healthy subjects. So The efficacy of BLR can be explored by comparing it with muscle energy technique on hamstring muscle group flexibility among healthy young adults.
Hence this study is intended to compare the effects of Muscle Energy Technique and Mulligans Bent Leg Raise technique in improving flexibility of hamstring muscle group among healthy young adults.
6.2 Review of Literature:
1.Mohd. Wassim M et al.(2009) had done a study to investigate the effectiveness of Muscle Energy technique (MET) on hamstring flexibility in normal Indian collegiate males and concludedthat there was a significant improvement in the hamstring flexibility.(range of motion) in collegiate males.27
2.AzadehShadmehr et al.(2009) had done a study to findthe effectiveness of static stretch and muscle energy technique on the flexibility of hamstring muscles and concludedthat static stretch or MET had similar effect on restoring flexibility to hamstrings.28
3.Medeleine Smith et al. (2008) done a study comparing two muscle energy techniques for increasing the flexibility of hamstring muscle group and concluded that altering the duration of the passive stretch component does not have a significant impact on the efficacy of MET for short-term increase in muscle extensibility.29
4. Peter Wrightet al.(2008) conducted a study to establish any significant change in hip internal rotation range of movement following application of either Post-isometric relaxation or Reciprocal inhibitionmuscle energy technique and concluded that there was a significant increase in internal rotation range of motion of hip clinically and statistically in bothtechniques,but there was nosignificant difference among the technique.30
5.Toby Hall et al. (2005) done a randomized control trail to find out the immediate effects after single intervention of Mulligan’s Bent Leg Raise Technique and concluded that single intervention of Mulligan’s BLR technique, resulted in improvement in range of the SLR 24 hr later but not immediately after the intervention.25
6.Kate Elisa Kuilart et al. (2005) conducted a study on the active knee extension test and slump test in subjects with perceived hamstring tightness and concluded that there was a routine use of the slump test in the assessment of patients with perceived hamstring tightness in order to aid differentiation between muscular and neural structure.31
7.C.M. Norris et al. (2005) had done a study to find out the inter-tester reliability of self-monitored active knee extension test and concluded that the active knee extension test when used in conjunction with goniometry is a accurate and a reliable measure of hamstring muscle length.32
8. Ballantyne F et al.(2003) done a study to investigate the effectiveness of muscle energy technique in increasing passive knee extension and to explore the mechanism behind any observed change. They concludedthat muscle energy technique produced an immediate increase in passive knee extension, this observed change in range of motion is possibly due to an increased tolerance tostretch as there was no evidence of visco-elastic change.23
9. Ching Shan Anita Ng et al.(2003)has done a study to compare the immediate and lasting effects between passive stretch and muscle energy technique(MET) on hamstring extensibility which was measured using AKE and concludedthatMET appeared to be more effective than passive stretching for increasing hamstring extensibility immediately post-treatment and still at 0ne hour later.33
10.Glen M. Depino et al. (2000) had done a study to determine the duration of hamstring flexibility gains, as measured by an active knee-extension test, after cessation of an acute static stretching protocol. and concluded that four consecutive thirty second static stretches enhances hamstring flexibility as determined by increased knee-extension range of motion.34
6.3 Objective of the study
  1. To compare the effects of Mulligan’s BLR Technique and
Muscle Energy Technique on hamstring flexibility among young healthy adults.
6.4 Hypothesis:
Experimental hypothesis:
There will be significant difference between Muscle Energy Technique (MET) and Bent Leg Raise Technique(BLR) in improving hamstring flexibility.
Null hypothesis:
There will be no significant difference between MET and BLR in improving hamstring flexibility.
Material and Methods:
7.1 Source of data:
The subjects will be taken from the general population of Mangalore.
Sampling: CONVENIENT SAMPLING.
Sample size: 60
Subjectswill be allocated into three following groups.
Group 1 = Muscle Energy Technique.
Group 2 = Mulligans Bend Leg Raise Technique.
Group 3 = Control group.
7.2 Method of collection of data:
Participants who has hamstring flexibility less than 75 degrees in Active Knee Extension test will be included in this study. A written consent (approved by the institution) will be obtained stating voluntary acceptance by the subject in this study. Subjects will be clearly explained about the study. Basic demographic details will collected from the subjects containing Name, Age, Sex, limb length measurement, muscle Girth and level of physical activity and history of any lower limb surgeries undergone, history of any lower limb injuries to fulfill the inclusion criteria.
Measurement procedure :
  1. Researcher 1 – will be blinded to group allocations and will take the outcome measurement prior to and after the treatment.
  2. Researcher 2 – will perform the procedure (either MET or BLR).
After the group allocation, participants will be given their respective treatments for 2 weeks (3 sessions per week). Pre and post measurement will be taken during each treatment sessions.
Outcome measurement (AKE) procedure:
The participants will be requested to lie supine and experimental hip is flexed to 90º and strapped to stabilizing bar. The thigh of the opposite leg is firmly secured with a strap to minimize the rotation of pelvis. The participants are asked to extend the knee as much as possible and the measurement is taken by a universal goniometer.29
Intervention protocol :
Group1: Muscle Energy Technique29
The subject is made to lie on the couch in supine lying. The hip is passively flexed and the leg is extended until tension is sensed by the researcher and the subject reports a moderate stretching sensation.
The participant is asked to provide a moderate knee flexion isometric contraction against the researchers shoulder for 7-10 sec, and this is followed by 2-3 sec relaxation and immediately after that the leg is passively stretched to the palpated barrier or tolerance to stretch and held for 30 seconds. The leg is then lowered to the table for a short resting period of 10 sec. This procedure is repeated for two more times.
Group 2: Bent Leg Raise Technique25
The subject is positioned in supine lying on a couch. The hip and knee passively flexed to 90º, the subject is asked to provide a knee flexion isometric contraction for 5 sec against the researcher shoulder`s immediately after that, hip flexion rang is increased. As the hip flexion in gradually increased abduction component is added in between if the patients feels any discomfort or pain. The above procedure is performed in 5 progressively greater position of hip flexion. [Until as if the knee is touching the chest]. This procedure is repeated two more times.
Materials to be used:
  1. Couch
  2. Straps
  3. Stabilizing bars
  4. Wall clock
Inclusion Criteria:
Healthy young adults (male) between age of 20-30yrs.
Subjects Active knee extension ROM< 75 ̊.
Exclusion Criteria:
Low back pain, sciatica.
Subjects underwent any lower limb and spine surgeries.
Pathologies and Deformities related to knee and hip joint.
Any neurological disorders.
Statistical analysis:
Study design: Experimental study design.
TEST: Paired “t”-test with Repeated Measures.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
YES
Muscle energy technique and mulligan’s bent leg raise technique will be given to increase the hamstring muscle flexibility in health young adults.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Ethical clearance has been taken from the institute ethical clearance committee.
List of references.
  1. Garrett WE, Calif, JC, Bassett FH: Histochemical correlates of hamstring injuries. Am J Sports Med 12:98-103, 1984.
  2. Zachezewski JE. Improving flexibility. In scully RM, Barnes MR, cds. Physical therapy. Philidelphia, Pa: JB, Lippinocott Go:1989-69.
  3. Agre JC. Hamstring injuries: proposed aetiological factors,prevention, and treatment. Sport med.1985;2:21–33.
  1. Worrell TW, Perrin DH. Hamstring muscle injury: the influence ofstrength, flexibility, warm-up, and fatigue.J Orthop SportsbPhysTher.1992;16:12–18.
  2. Jonhagen S, Nemeth G, Eriksson E. Hamstring injuries in sprinters: the role of concentric and eccentric hamstring muscle strength and flexibility. Am J Sports Med. 1994;22:262-266.
  3. Worrell TW, Perrin DH, Gansneder BM, Gieck JH. Comparison of isokinetic strength and flexibility measures between hamstring injured and noninjured athletes. J Orthop Sports Phys Ther. 1991;13:118 –125.
  4. Coole WG, Gieck JH. An analysis of hamstring strains and their rehabilitation. J Orthop Sports Phys Ther. 1987;9:7– 85.
  5. Sady SP, Wortman M, BlankeD.Flexibility training: ballistic, static or proprioceptive neuromuscular facilitation. Arch Phys Med Rehabil. 1982;63:261–263.
  6. Witvrouw E, Danneels L, Asselman P, D’Have T, CambierD.Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. A prospective study. Am J Sports Med 2003;31:41–6.
  7. Sahrmann SA. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby; 2002.
  8. Tabary JC, Tardieu C, Tardieu G, Tabary C. Experimental rapid sarcomere loss with concomitant hypo extensibility. Muscle Nerve. 1981; 4:198–203.
  9. Tabary JC, Tabary C, Tardieu C, Tardieu G, GoldspinkG. Physiological and structural changes in the cat’s soleus muscle due to immobilization at different lengths by plaster casts.Physio.1972;224:231–44.
  10. Mense S, Simons DG. Muscle pain: understanding its nature,diagnosis, and treatment. Philadelphia: Lippincott Williams &Wilkins; 2001.
  11. McHugh MP, Kremenic IJ, Fox MB, Gleim GW. The role of mechanical and neural restraints to joint range of motion during passive stretch. Med Sci Sports Exerc1998;30:928–32.
  12. William D Bandy; Jean M Irion; Michelle BrigglerThe effectof time and frequency of static stretching on flexibility ofthe hamstring. Physical Therapy; Oct 1997; 77, 1090-1096.
  13. Feland, J.B., Myrer, J.W., Schulthies, S.S., et al., 2001. The effect of duration of stretching of the hamstring muscle group for increasing range of motion in people aged 65 years or older. Physical Therapy 81, 1100–1117.
  14. Cornelius, W.L., Ebrahim, K., Watson, J., et al., 1992. The effects of cold application and modified PNF stretching techniques on hip joint flexibility in college males. Research Quarterly in Exercise and Sports 63 (3), 311–314.
  15. Moore, M., Hutton, R., 1980. Electromyographic investigation of muscle stretching techniques. Medicine and Science in Sport and Exercise 12 (5), 322–329.
  16. Handel, M., Horstmann, D., Dickhuth, H., et al.,1997. Effects of contract-relax stretching training on muscle performance in athletes. European Journal of Applied Physiology and Occupational Physiology 76 (5), 400–4089.
  17. Magnusson, S.P., Simonsen, E.B., Aagaard, P., Sorensen, H.Kajer, M., 1996b. A mechanism for altered flexibility in human skeletal muscle. Journal of Physiology 487, 291–298.
  18. Leon Chaitow,et al. ‘Muscle Energy Techniques’ Churchill Livingstone.New York 1996.
  19. Greenman, P.E., 2003. Principles of Manual Medicine, third- ed Lippincott Williams and Wilkins, Baltimore.
  20. Ballantyne F, Fryer G, McLaughlin P. The effect of muscle energy technique on hamstring extensibility: the mechanism of altered flexibility. Journal of Osteopathic Medicine. 2003;6(2):59-63.
  21. Freyer G. et al. Muscle energy concepts: a need for change. J. osteopathic medicine. 2000: 3: 54-59.
  22. Toby Hall_, Sonja Hardt, et al., Mulligan bent leg raise technique—a preliminary randomized trial of immediate effects after a single intervention. Manual Therapy 11 (2006) 130–135.
  23. Burns SH, Mierau DR. Chiropractic management of low back pain. In: Singer KP, editor. Clinical anatomy and management of low back pain. Oxford: Butterworth-Heinemann; 1997. p. 344–57.
  24. Mohd. Waseem ,ShibiliNuhmani and C. S. Ram Efficacy of Muscle Energy Technique on hamstring muscles flexibility in normal Indian collegiate males Calicut Medical Journal 2009; (7).e4.
  25. AzadehShadmehr, Mohmmad Reza Hadian et al, Hamstring flexibility in young women following passive stretch and muscle energy technique Journal of Back and Musculoskeletal Rehabilitation Volume 22, Number 3 143-148.2009.
  26. Madeleine Smith, B.Clin.Sc.,et al. A comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group Journal of Bodywork and Movement Therapies (2008) 12, 312–317.
  27. Peter WrightandIan Drysdale.A comparison of post-isometric relaxation (PIR) and reciprocal inhibition (RI)muscle energy techniquesapplied to piriformis.British College of Osteopathic Medicine, Lief House, 120-122 Finchley Road, London NW3 5HR, UK 5 November 2008.
  28. Kate ElissaKuilart, Melanie Woollam, The active knee extension test and Slump test in subjects with perceived hamstring tightness. International Journal of Osteopathic Medicine 8 (2005) 89-97.
  29. C.M. Norrisa,_, M. Matthews et al. Inter-tester reliability of a self-monitored active knee extension test Journal of Bodywork and Movement Therapies (2005) 9, 256–259.
  30. Ching Shan Anita Ng et al. A comparison of the immediate and lasting effects between passive stretch and muscle energy technique(MET) on hamstring extensibility. Victoria university Melbourne, Australia 2003.
  31. GlenM. DePino, MEd, ATC; William G et al.Duration of Maintained Hamstring Flexibility After Cessation of an Acute StaticStretching Protocol Journal of Athletic Training Journal of Athletic Training 2000;35(1):56–59.

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Signature of the Candidate
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Remarks of the Guide
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Name & Designation of:

11.1 Guide
11.2 Signature / DR.RAMAPRABHU.K.R
Assistant Professor in Physiotherapy.
11.3 Co-Guide (If Any)
11.4 Signature / DR.KARTHIKEYAN G.
Associate Professor in Physiotherapy.
11.5 Head of the
Department

11.6 Signature

/
DR. T.JOSELEY SUNDERRAJ PANDIAN
Associate Professor in Physiotherapy and P.G Coordinator.
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12.1 Remarks of Chairman and Principal
12.2 Signature /
DR.RAMPRASAD M.
Associated professor in Physiotherapy and Principal

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