RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the Candidate & Address / S.SATHYANARAYANA,7/4, SUNDARA VINAYAGAR KOIL STREET, OLDWASHERMENPET,
CHENNAI-21, TAMILNADU.
2. / Name of the Institution / K.T.G. COLLEGE OF PHYSIOTHERPY
HEGGANAHALLI CROSS, SUNKADAKATTE
POST : VISWANEEDAM
BANGAORE 560 091.
3. / Course of Study & Subject / MASTERS IN PHYSIOTHERAPY
(Musculoskeletal Disorders and Sports Physiotherapy)
4. / Date of Admission to the Course / 29/05/2009
5. / Title of the Topic:
THE EFFECTS OF DURATION MAINTAINED HAMSTRING FLEXIBILITY AFTER A ONE TIME MODIFIED PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION STRETCHING IN NORMAL ADULTS.
6. / BRIEF RESUME OF INTENDED WORK:
6.1 Need of study:
Flexibility has been defined as the ability to move a joint or series of joints through a full, non restricted, pain free range of motion1. Flexibility is dependent on a combination of (1) joint ROM which may be limited by the shape of the articulating surface and by capsular and ligamentous structures surrounding the joint (2) muscle flexibility or the ability of the musculotendinous unit to lengthen2.
Importance of flexibility to the patient:
The restoration of or improvement in normal preinjury Range Of Motion is an important goal of any rehabilitation program most activities of daily living require relatively normal amount of flexibility. However some sport related activities, such as gymnastics, baller, diving or karate, require increase flexibility for superior performance3. A person who has a restricted Range Of Motion will probably realize a decreasing in performance capabilities lack of flexibility may also result in uncoordinated or awkward movement patterns4. Flexibility can be discussed in relation to movement involving only one joint such as the knees or movement involving a whole series of joints such as the spinal vertebral joint which must move all together to allow smooth bending or rotation of the trunk.
Stretching technique:
The maintenance of a full, non restricted Range Of Motion has long been recognized as an essential component of a rehabilitation program8. There are various stretching techniques which are available to improve the flexibility which are as follows – Ballistic stretching, static stretching & proprioceptive neuromuscular facilitation. The above mentioned stretching techniques have its own advantages and disadvantages based on effects, techniques which have been into many trails and studies.
Proprioceptive neuromuscular facilitation stretching technique:
Cornelius W. It is an approach to the therapeutic exercise based on the principles of functional human anatomy and neurophysiology16. It uses proprioceptive, cutaneous and auditory input to produce functional improvement in motor output and can be vital element in the rehabilitation process of many sports related injuries. These techniques have long been recommended for increase stretching flexibility and range of motion.
Holds relax technique:
It begins with an isometric contraction of the antagonist (muscle that will be stretched) with agonist resistant, followed by a concentric contraction of the agonist muscle combined with light pressure from the therapist to produce maximal stretch of the antagonist. This technique is appropriate when there is muscle tension on one side of a joint and may be used with either the agonist or antagonist.
The effect of proprioceptive neuromuscular facilitation stretching on Viscoelastic property is such that Creep is characterized by the lengthening of muscle tissue due to an applied fixed load. Stress relaxation is characterized by the decrease in force over time necessary to hold a tissue at a particular length. The musculotendinous unit deforms or lengthens as it is being stretched and goes through elastic and then plastic deformation before completely rupturing18. A single session of hold-relax stretching does not deform tissue enough to produce a permanent change (ie, a plastic deformation in the musculotendinous unit). Therefore the temporary improvement in hamstring flexibility may be attributed to changes in the elastic region caused by a single session of hold-relax stretching.
The Thixotropy property of tissue also under goes changes with proprioceptive neuromuscular facilitation. Thixotropy is the property to become more liquid after motion and return to a stiffer, gel like state at rest19. The Thixotropic property of muscle is thought to result from an increase in the number if stable bond between actin and myosin filaments when the muscle is at rest. Hence, the stiffness of muscle increases. A linear relationship exists between the time a muscle remains still and the stiffness of that muscle in response to a stretch and indeed, flexibility decreased in both groups as time passed20. However, but with activity the muscle becomes more fluid like because the stable bonds are broken or are prevented from forming. So based on Thixotropic properties, a temporary increase in flexibility to be maintained during periods of activity and to decrease during periods of inactivity.
The effect of proprioceptive neuromuscular facilitation technique in neural tissues is also responsible for increasing flexibility due to the inhibition of the homonymous muscle alpha motor neurons by the stimulation of the Golgi tendon organ27. This inhibitory effect is thought to diminish muscle activity and therefore, allow for relaxation so that the muscle can be stretched. This inhibitory effect has been suggested to increase muscle compliance, allowing for increased length during a stretch without stimulation of the stretch reflex. Increased sensitivity of primary and secondary musculotendinous afferent receptors, termed post contraction sensory discharge, after a muscular contraction has been demonstrated. This effect would potentially increase muscle spindle sensitivity to stretch. However, this increased sensitivity is disrupted when the muscle is stretched beyond the length of the traction.
Hypothesis:
Null Hypothesis:
There will be no significant differences in Hamstring flexibility between groups that trained with modified Proprioceptive Neuromuscular Facilitation Program.
Alternative Hypothesis:
There will be significant differences in Hamstring flexibility between groups that trained with modified Proprioceptive Neuromuscular Facilitation Program.
6.2 Review of Literature:
Herber TD (2007) The evidence derived from mainly laboratory based studies of stretching indicated that muscle stretching does not reduce delayed onset muscle sourness in young healthy adults23.
Bonnar BP & Deivert RG (2004) Concluded from the study that all 3 hold time conditions produced significant gains in range of motion compared to baseline measurements. The application of the finding suggest that clinicians could choose an of the hold-time and produce the same result to patient hip joint flexibility25.
Feland JB & Marin HN (2004) Have shown from the study results that CRPNF stretching using sub maximal contractions is just as beneficial at improving hamstring flexibility as maximal contractions and may reduce the risk of injury associated with PNF stretching24.
Bandy WD & Irion JM (1998) Compared static stretch and DROM, result from the study suggest that although both static stretch and DROM will increase hamstring flexibility a 30 second static stretch was more effective than the newer technique DROM for enhancing flexibility given the fact that a 30 second static stretch increase ROM more than 2 times that of DROM the use of DROM to increase flexibility of muscle must be questioned29.
Webright WG & Randolph BJ (1997) Studied that 6 weeks of nonballistic, repetive active knee extensions (30 repetitions twice daily) performed in a neural slump position improves hamstring flexibility in uninjured subjects, but is no different compared with static stretching (30 second, twice daily)29.
Comeron DM (1993) Showed that the significant correlation between the measurement obtained using their 2 tests suggests that both are providing an indication of the some basic phenomenon presumably hamstring musculotendinous length for this reason the AKE test may be useful alternative to the straight leg raise test for providing an indication of hamstring muscle length26.
Sullivan MK (1992) The result suggests that APT position was more important than stretching method for increasing hamstring muscle flexibility30.
DeVries HA (1986) Showed from study results that active self stretching and PNF-R stretches repetition for 30 seconds 3 days per week is not sufficient to significantly increasing hamstring length in this population11.
Wallin D & Ekblom B (1985) Compared and concluded that the ballistic stretching group improved muscle flexibility between the 30th and 60th day, as expected from the result of the initial 30 days with the three contract relax groups, when training with the contract relax method three times a week21.
Sady SP (1982) The findings indicate that PNF may be the preferred technique for improving flexibility, and that flexibility training results in an increasing consistency of flexibility scores22.
6.3 Objectives of the Study:
· The purpose of the present study is to measure the duration of maintained hamstring flexibility after a 1-time, modified hold-relax stretching protocol for normal adults.
7 / MATERIAL AND METHODS COLLECTION OF DATA:
7.1 Source of Data:
· KTG College of physiotherapy, Bangalore.
· KTG Chanre hospital, Bangalore.
7.2 Method of Collection of Data:
Research design:
· Experimental study.
Sample Size:
· 30 subjects with Hamstring muscle tightness
Material used:
· Goniometer
· Mat
· Polyvinylchloride pipe frame
· Stop watch
Evaluation tools:
· Active knee extension test (AKET).
· Physical activity readiness questionnaire (PARQ).
Inclusion criteria:
· Males.
· Age group 20-30 yrs.
· Healthy individuals (physical activity readiness questionnaire PARQ score 8 & above).
Exclusion criteria:
· Females.
· Medical problems like diabetes.
· Cardio vascular disorders.
· Sports person.
· Musculo skeletal disorder.
· Novice training or working out for more than 2 weeks.
· Subject undergoing any other training regime.
· Subjects under medication like NSAIDS.
· Subjects under nutrition supplementation programme.
Methodology:
7.3 Intervention to be carried on participants:
Procedure:
Consent:
· Prior to obtaining informed consent to participate in this study, potential participants will be asked to complete a pre-participation health screen (PARQ).
· Those who possessed any of the exclusion criteria for this study listed both above and in the health screen will be excluded from participation in this study.
· The subjects will be randomly assigned to the control group (Group A) & experimental group (Group B).
The Groups:
· Total number of subjects: 30 clients.
· Group A: Control group (CP) 15 subjects.
· Group B: One time modified PNF flexibility exercise 15 subjects.
Testing procedure:
Pre stretch Measurement:
· Subjects in both groups performed a total of 6 AKEs with a 60-second rest period between repetitions.
· The 5 AKEs served as warm-ups to decrease any effect that may occur with repeated measures performed from a cold start.
· The 6th AKE was recorded as the Prestrech measurement. When the subject could not extend his lower leg any farther without his thigh moving away from the cross-bar, he informed the investigator and held that position for approximately 2 to 3 seconds until a measurement was taken.
Post stretch Measurement:
· One AKE Measurement was taken at 0 minutes (immediately) and at 2, 4, 6, 16, and 32 minutes after the final stretch in the experimental group.
· The control group underwent the same post stretch measurement protocol immediately after 5 minutes of lying quietly on the table.
· Measurement of the angle of knee joint ROM was recorded.
Stretching protocol:
· The 15 subjects assigned to the stretching group received visual and verbal instruction in performing the modified hold-relax stretch. This modified hold-relax stretch will be performed with no hip rotation allowed by fixing thigh to Polyvinylchloride pipe frame28.
· Predetermined time intervals for stretching, contracting and relaxing will be used to standardize stretching methods for the stretching group. For each time the hamstring will be passively stretched until the subject first reported a mild stretch sensation and held that position for 7 second.
· Next, the subject maximally isometrically contracted the hamstring for 7 seconds by attempting to push his leg back toward the table against the resistance of investigator. After the contraction, the subject relaxed for 5 seconds.
· The investigator then passively stretched the muscle until a mild stretch sensation will be reported. The stretch will be held for another 7 seconds. The sequence will be repeated 5 times on each subject in the experimental group.
Outcome measure:
The outcome measure assessed in this study is:
· Duration maintained hamstring flexibility after a one timed modified proprioceptive neuromuscular facilitation stretching protocol measurement was taken at 0 minutes and at 2,4,6,16, and 32 minutes after final stretch.
Statistical Analysis:
· The statistical tool to be used for within the groups is Dependent T test and Between the groups is Independent T test.
7.4 Ethical Clearance:
· As the study includes human subjects ethical clearance is obtained from research and ethical committee of institution and institution.
8 / References:
1. Alter MJ. The science of stretching. Champaign. IL. Human kinetics 1988.
2. Zachewski J. Flexibility fir sports. In: sanders B, ed. sports physical therapy, Norwalk, CT, Appleton and Lange, 1990.
3. Surburg p. Flexibility training program design. In: Miller P, ed. Fitness programming and physical disability. Champaign, IL, Human Kinetics, 1995.
4. Condon SA, Hutton RS, Soleus muscle EMG activity and ankle Dorsiflexion range of motion from stretching procedures. Physical therapy. 1987, 67:24-30.
5. Chapman EA, deVries HA, Swezey R. Joint stiffness: effect of exercise on young and old men. J Gerontol. 1972, 27:218.
6. Basmajian J. Therapy exercise, 4th ed. Baltimore, Williams and Wilkins, 1984.
7. Entyre BR, antagonist muscle activity during stretching: a paradox reassessed. Med science sports. 1988, 20:285-289.
8. Corbin C, Noble L. Flexibility: A major component of physical fitness. In: cundiff DE, ed. Implementation of health fitness exercise programs. Reston, VA, American alliance for health, physical education, recreation and dance, 1985.
9. Bealieu Je, Arnheim DD, Prentice WE. Principles of athletic training. Madison, Brow and Benchmark, 1997.
10. Entyre BR, Lee EJ. Chronic and acute flexibility of men and women using three different stretching techniques. Res Q Exercise sport. 1988, 59:222-228.
11. De Vries HA. Physiology of exercise for physical education and athletics. Dubuque, IA, Brown, 1986.
12. Hubley CL, Kozey JW, Stanish WD. The effects of static stretching exercise and stationary cycling on range of motion and joint economy. J ortho Sports Physical Therapy. 1984, 6:104-105.
13. Herling j. It’s time to add strength training to our fitness programs. J physical education program. 1981, 79:17.
14. Wessel J, Wan A. Effect of stretching on intensity of delayed – onset muscle soreness, J sports Med. 1994. 2:83-8.
15. Zachewski J. Flexibility for sports. In: Sanders B, ed. Sports physical therapy, Norwalk, CT, Appleton and Lange, 1990.
16. Cornelius W, Jackson A. The effects of cryotherapy and PNF on hip extension flexibility. Athl train. 1984, 19:184.
17. Taylor DC, Dalton JD, Swaber AV. Viscoelastic properties of muscle-tendon units the biochemical effects of stretching. American journals sports medicine. 1990, 18:300-309.
18. Nikolaou PK, Maedonald BL. Biomechanical and histological evaluation of muscle after controlled strain injury. American sports medicine. 1987, 15:9-14.
19. Walsh EG. Postural Thixotropy: a significant factor in the stiffness of paralyzed limb, Paraplegia.1992, 30:113-115.
20. Lakie M, Robson LG. Thixotropic changes in human muscle stiffness and he effects of fatigue. Q J exp physical. 1988, 73:487-500.
21. Wallin D, Ekblom B. Improvement of muscle flexibility. A comparison between two techniques. Physical therapy.1985, 13(4): 263-8.
22. Sady SP, Wortman M. Flexibility training: Ballistic, static or proprioceptive neuromuscular facilitation? American sports medicine. 1982, 63(6):261-3.
23. Herbert RD, de Noronha M. Stretching to prevent or reduce muscle soreness after exercise. University of Sydney. 17: (4) CD004577, 2007.
24. Feland JB, Marin HN. Effect of sub maximal contraction intensity in contract relaxes proprioceptive neuromuscular facilitation stretching. Young university. 2004, 38(4):E18.
25. Bonnar BP. The relationship between isometric contraction duration during hold-relax stretching and improvement of hamstring flexibility. Department Athletic training service. 2004, 44(3):258-61.
26. Comeron DM. Relationship between active knee extension and active straight leg raise test measurements. Physical therapy department. 1993, 17(5):257-60.
27. Knott M, Voss DE. Proprioceptive neuromuscular facilitation: Patterns and techniques. 2nd ed. Philadelphia. PA: Harper and Row. 1968.
28. Scortt G. Differential responses to PNF stretch techniques. Sports medicine. 1990, 22:106-111.
29. Bandy WD, Webright. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscle. Physical therapy. 1998, Apr 27(4): 295-300.
30. Sullivan MK. Effect of pelvic position and stretching method on hamstring muscle flexibility. 1992, Dec: 24(12); 1383-9.
9 / Signature of the Candidate:
10 / Remarks of the Guide:
11 / Name and Designation of (in Block Letters)
11.1 Guide
11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of the Department
11.6 Signature
12 / 12.1 Remarks of the Principal
12.2 Signature
11