OJHAS: 2010-3-13. Shankar G, Yogita. Effectiveness of passive stretching versus hold relax technique in flexibility of hamstring muscle.

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OJHAS Vol. 9, Issue 3: (Jul - Sep, 2010)


		Original Article

Effectiveness of passive stretching versus hold relax technique in flexibility of hamstring muscle


		Authors

Gauri Shankar,
Asst. Professor, Sumandeep Vidyapeeth, KJ Pandya College of Physiotherapy, Pipariya, Waghodia Road, Vadodara - 391760, Gujarat, India
Yogita,
Sumandeep Vidyapeeth, KJ Pandya College of Physiotherapy, Pipariya, Waghodia Road, Vadodara - 391760, Gujarat, India.


		Address For Correspondence

Gauri Shankar,
Asst. Professor, Sumandeep Vidyapeeth,
KJ Pandya College of Physiotherapy,
Pipariya, Waghodia Road,
Vadodara - 391760,
Gujarat, India
E-mail: gshankar2010@yahoo.com


		Citation

Shankar G, Yogita. Effectiveness of passive stretching versus hold relax technique in flexibility of hamstring muscle. Online J Health Allied Scs. 2010;9(3):13


		URL

http://www.ojhas.org/issue35/2010-3-13.htm


		Open Access Archives

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

This Article

Submitted: Jul 11, 2010; Accepted: Sep 9, 2010; Published: Oct 15, 2010

Abstract:

Aim: To compare the effectiveness of passive stretching and hold relax technique in the flexibility of hamstring muscle. Methods: A total of 80 normal healthy female subjects between age group 20-30 years referred to the department of physiotherapy, Sumandeep Vidyapeeth University, sampling method being convenient sampling. The subjects were randomly divided in two groups i.e. passive stretching group (n=40) and PNF group (n=40) and given passive stretching and proprioceptive neuromuscular facilitation technique respectively. Active knee extension range was measured before and after the intervention by goniometer. Results: t test showed a highly significant (p=0.000) increase in range of motion in PNF group. Conclusion: Proprioceptive neuromuscular facilitation technique is more effective in increasing hamstring flexibility than the passive stretching.
Key Words: Stretching; Flexibility; PNF; Hold-relax; Hamstring



		Introduction

Flexibility is a key component for prevention of injury and rehabilitation, stretching decreases injury, improves performance in sports for overall fitness.¹

Stretching is a therapeutic manoeuvre designed to increase mobility of soft tissue and subsequently improves range of motion by elongating structures that have adaptively shortened and have become hypomobile over time.²

Proprioceptive neuromuscular facilitation (PNF) is used as inhibition technique to assist with muscle elongation.³ Passive stretching and isometric contraction encourage flexibility or coordinate throughout limbs range of motion. Proprioceptive neuromuscular facilitation is used to supplement daily stretching and employed to quick gain in range of motion; decreases fatigue and prevent overuse injuries.⁴

A hold relax is a technique of facilitating normal muscle sensation and muscle awareness, used in treating hyper tonicity or motor dysfunction. It is often applied when there is muscle tightness in one side of joint and when immobility is the result of pain.⁵ It is a relaxation technique to obtain a lengthening reaction of muscle whose action is antagonist to movement limited in range, it means increasing range of movement in joints, it is effective, simple and pain free.³

Stretching recommendations are clouded by many misconceptions and conflicts, research reports despite being limited has been promoted for years as an integral part of fitness programme to decrease risk of injury, relieve pain associated with sports.⁶ The specificity of movement that person performs in regular physical activity and stretching method often define the development and improves body�s range of motion. Goal of all stretching programme is to provide joint mobility while maintaining joint stability.⁷

Muscle tightness is a limiting factor for optimal physical performance and an important intrinsic factor for sports injury.⁸

Hamstring is one of the commonest muscles often get tight as the biomechanics of hamstrings are complex because they pull over two joints - hip and knee so, their efficacy in producing force at knee is dictated by angle of hip joint. Greater hamstring force is produced with hip in flexion when hamstring are lengthened over joint, regardless of knee position.¹ Tight hamstrings can have profound effect on seated postural alignment. Posterior pelvic tilt is primary effect, with resultant kyphotic thoracic spine and stress on cervical spine either hyper extended or flexed. If hamstrings are unequally tight, the pelvis will rotate away from tighter hamstrings. For example; if right hamstrings is tighter, the pelvis will rotate towards left.⁹ Reduced hamstring muscles flexibility has been implicated in lumbar spine dysfunction, with number of studies showing positive correlation between decreased hamstrings flexibility and low back pain.¹⁰



		Methodology

A total of 80 asymptomatic subjects among students community of Sumandeep Vidyapeeth University, Baroda within 20-30 years of age group were included in this study who met the inclusion and exclusion criteria.

Inclusion criteria:

Age- 20 to 30 years
Sex � Females

Exclusion criteria:

Orthopedic problems
Neurological conditions
Psychological disorders

Instrumentation:

Double arm goniometer
Stop watch
Pen
Pencil and paper

Procedure: In this study, 80 subjects were included within age group 20-30 years who fulfilled inclusion criteria. Before starting intervention, active knee extension range in high sitting position with hip in 90 degree flexion measured through goniometer and again range was measured after completion of study in same way. Subjects were equally divided in two groups as follows.

Group 1: Passive Stretching Group which was given passive stretching

Procedure: Investigator kneel down on the mat and placed patient�s heel or distal tibia against own shoulder and placed both of hands along the anterior aspect of distant thigh to keep knee extended, opposite extremity is stabilized in extension by belt and held in place by therapist�s knee with in 0 degree extension, hip in neutral rotation and then investigator flexes the hip as far as possible.

Group 2: PNF Group which was given Hold Relax technique

Procedure: Subjects were randomly assigned and modified holds relax stretch performed with hip in neutral position. For each stretching, investigator gave passive stretching until the subject reports mild stretching sensation and hold that position for 7 seconds, next sub maximal isometric contraction of hamstring muscle for 7 seconds by asking to push her leg back towards table against resistance of investigator after contraction relaxation for 5 seconds, investigator then passively stretched the muscle until the mild stretch sensation was reported the stretch was hold for 7 seconds, this sequence was repeated 5 times on each subject.



		Results and Analysis

Figure 1: Shows Comparison of Range of Motion (ROM) between Passive Stretching & Hold Relax Group. (Note: BS = Before Stretching & AS = After Stretching)

This figure shows intragroup comparison between Group 1 (i.e. Passive Stretching) & Group 2 (i.e. Hold Relax) which clearly depicts that increase in Range of Motion (ROM) in Group 2.

In intergroup comparison there is increase in ROM (73.65⁰) after passive stretching in Group 1 and ROM increased after hold relax (79.32⁰) than before hold relax (73.05⁰) in Group 2.



		Discussion

The current study is a comparative study done with an attempt on increasing the hamstring length by using 2 different techniques, i.e. passive stretching and hold relax.

In this study, 80 normal female subjects have been taken and randomly divided into 2 groups. Active knee extension is measured using goniometer before any physical intervention and at the end of intervention it is measured again.

The study shows highly significant increase in ROM in both groups but this finding cannot be generalised or converted to clinically significant data since sample of male population in current study is not included, while comparing both groups, hold relax is found more effective than passive stretching (t-value -4.763).

Hold relax has been found to be more effective because the isometric muscle action completed immediately before the passive stretch which help to achieve autogenic inhibition - a reflex relaxation that occurs in muscle where the golgi tendon organ stimulated.

The present finding is in accordance with Scott Spernoga et al, who found that sequence of 5 modified hold relax stretching produced significant increase in hamstring flexibility.¹¹ On the basis of this study, modified hold relax protocol has been used and the present study shows that hold relax increases more range of motion¹¹, this is consistent with Sharman Malanie who found that proprioceptive neuromuscular facilitation produces superior ROM.¹²

Our current study is not in accordance with Worrell TW et al (1994), who found that 60 seconds stretching had no improvement in ROM as for ROM to be maintained, stretching must be continued¹³ and Sullivan MK et al., (1992) who concluded that there is no significant increase in hamstring flexibility with either of stretching technique.¹⁴

There is another study which shows there is no significant difference in ROM in standing and supine hamstring stretching as they are equally effective conducted by �Decoster LC (2004).¹⁵

Certain variables are uncontrolled in the study and their influence on the results is assumed to be null, the result affected by assumption which is different level of physical activity of subjects. The difference in the force applied for stretching to the subjects may be confounding factor in result obtained.



		Conclusions and Recommendations

It has been proved that study of effectiveness of hamstring lengthening there is highly significant increases in ROM with hold relax as compared to passive stretching, but further studies with different set of variables and situation are required to substantiate the current findings.

Further suggestions

The limitations of the current study were the sample size and female population. Though the result obtained was very highly significant to generalize the findings into a clinically useful data the study has to be replicated in a bigger sample size.

If the uncontrolled variables of the current study could be controlled, the sensitivity and specificity of the findings can be increased. Further studies should also aim at studying both the genders separately to obtain a more accurate and generalized results.



		References

Noble CCB. Flexibility � a major component of physical fitness. Journal of Physical Education 1980;51-57.
Kisner C, Colbey LA. Therapeutic Exercise Foundations And Techniques, Fourth Edition, FA Davis Company 2003. pp 173
Dena Gardiner M. Principles of Exercise Therapy, Fourth Edition, CBS Publication 2000.pp 89
Robert M. Facilitating Stretching. Third Edition 2007. Human Kinetics. 6:9
Mosby�s medical dictionary, Ellsevier, Eighth Edition
Schuback B, Hooper J. A Comparison of self stretching incorporating proprioceptive neuromuscular facilitation components and therapist applied proprioceptive neuromuscular facilitation technique on hamstring flexibility. Journal of Physiotherapy. 2004;90:51-57.
Karvitz L, Heyward VH. Flexibility Training. Journal of Fitness Training. 2000;7:18-20
Levangie PK, Norkin CC. Joint Structure and Function. Fourth Edition, FA Davis Company 2005. pp 376
Portoghese C. Rehabilitation Management. The interdisciplinary Journal of Rehabilitation. June 2005
James S, Joshua D. Lengthening the hamstrings muscles without stretching using �Awareness through movement� Journal of physical therapy 2006;86
Spernoga SG, Uhl TL. Duration maintained hamstrings flexibility after one time, modified hold relax stretching protocol. Journal of Athletic Training. 2001;6:44-48.
Malanie S. Proprioceptive neuromuscular facilitation stretching Mechanism and clinical implication. Journal of Sports Medicine 2006;36(11):929-939.
Worrell TW, Smith TL et al. Effect of hamstring stretching on hamstring muscle performance. Journal of Orthopaedic Sports 1994;20(3):154-159.
Sullivan MK, Dejullian JJ et al. Effect of pelvic position and stretching method on hamstring muscle flexibility. Journal of Medical Science, Sports exercise. 1992;24:1383-1389.
Decoster LC. Standing and Supine hamstring stretching are equally effective. Journal of Athletic training 2004;39(4);330-334.