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Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. Name of the Candidate SHAH ANISH SUNILBHAI and Address SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MANGALORE SHREE DEVI COLLEGE OF 2. Name of the Institution PHYSIOTHERAPY, BALLALBAGH, MANGALORE, 5750003 MASTER OF PHYSIOTHERAPY(MPT) 3. Course of study and 2 YEARS DEGREE COURSE. subject (MUSCULOSKELETAL DISORDER AND SPORTS PHYSIOTHERAPY) 4. Date of Admission to 20th MAY 2008 Course 5. Title of the Topic “A COMPARATIVE STUDY BETWEEN THE EFFECTIVENESS OF ‘STATIC STRETCHING (ACTIVE)’ AND ‘AWARENESS THROUGH MOVEMENT’ TECHNIQUE IN IMPROVING THE FLEXIBILITY OF HAMSTRING MUSCLES IN ASYMPTOMATIC INDIVIDUALS.” 1 6. Brief resume of the intended work : 6.1 Need for the study The hamstring group of muscles is situated on the back of the thigh and consist of three muscles namely the semitendinosus, the semimembranosus, and the long head of biceps femoris. These muscles act as flexors of the knee and extensors of the hip and are twojoint muscles. The hamstring muscles are important contributors to the control of human movement and are used in a wide variety of activities from running and jumping to forward bending during sitting or standing and a range of postural controls. The term Tightness, a very non-specific term, describes a mild restriction of motion.1 Flexibility means “ability of a muscle to lengthen, and allowing one joint (or more than one joint in a series) to move through a Range Of Motion (ROM)”, and loss of muscle flexibility as “a decrease in the ability of the muscle to deform”, resulting in a decreased ROM about a joint.2 Tightness in the hamstring muscles may be due to insufficient strength (forcegenerating capacity) impairment or imbalance, or dyssynergic contraction that can place excessive strain on the hamstring muscles.3 Sitting for long periods, may also result in tightness of hamstring muscles for, whilst the muscles are lengthened over the posterior hip in sitting, they are shortened where they cross the posterior knee. Restricted flexibility can be related to a number of variables, including joint capsule or other soft tissue restrictions. Lack of hamstring flexibility is the most common cause for muscle strains in atheletes.4 Reduced hamstring flexibility has been implicated in lumbar spine dysfunction a strong positive correlation exists between decreased hamstring flexibility and low back pain. Good muscle 2 flexibility allows the tissue to accommodate the stress imposed, thereby increasing the efficiency and effectiveness of movement which in turn helps in preventing or minimizing the injuries. A variety of methods like static stretch,5 Propioceptive Neuro-muscular Facilitation,6 dynamic range of motion,7 active motion in the neural slump position,8 ‘Awareness through movement’ technique (ATM),9 etc. have been used to increase the hamstring muscle flexibility. Static stretching has been universally accepted as a safer form of stretching. In this method, the soft tissues are lengthened just past the point of tissue resistance and then held in the lengthened position for an extended period of time with a sustained stretch force. “Awareness Through Movement” (ATM) technique is a process of verbally guiding a person through an activity during which movements are done slowly and continuously, within a comfortable range of movement, noticing when effort in other areas of the body interfered with these specific movement intentions and trying to reduce those efforts and breathe easily through the entire process. Several studies have been done on Static stretching and “Awareness Through Movement (ATM)” technique for improving flexibility of hamstring muscles. So the purpose of the study is to compare the effectiveness of Static stretching and “Awareness Through Movement (ATM)” technique on increasing the hamstring flexibility in asymptomatic individuals as measured by knee extension range of motion with Universal Goniometer. 3 Research Question Whether there is a significant difference after administration of Static stretching(active) and “Awareness Through Movement” (ATM) technique on flexibility of hamstring muscles. Null hypothesis There will be no difference in flexibility of hamstring muscles after administration of Static stretch(active) and “Awareness Through Movement” (ATM) technique. Alternate hypothesis There will be a significant difference in flexibility of hamstring muscles after administration of Static stretch(active) and “Awareness Through Movement”(ATM) technique. 6.2 Review of literature The results of one of the literature revealed that stretching exercises can benefit athletes and social exercisers in numerous ways, including improving flexibility, reducing the incidence of injury and enhancing the athletic performance.10 Stretching regimen significantly increased flexibility and decreased the incidence of lower extremity injuries in a group of military basic trainees as compared with a control group.11 Further the result of one of the study shows that using a slow, static stretch of the hamstrings muscles for 15 seconds and holding the stretch for 15 seconds caused increase in the Range Of Motion(ROM) of the hamstring muscles, as measured by straight leg raising.12 A study was done on the effect of 4 time and frequency of Static stretching on the flexibility of hamstring muscles states that 30 seconds duration of stretch is an effective amount of time to sustain a hamstring muscle stretch in order to increase the range of motion.13 One of the study comparing the effectiveness of static, ballistic, and PNF stretch states that static stretch has the least associated injury and is the safest and most frequently used method of stretching.14 A comparative study of static, dynamic, and PNF stretching techniques on the flexibility of hamstring muscles indicated that all the three methods produced significant improvements in hamstrings flexibility.15 A study shows that “Awareness Through Movement”(ATM) technique improves balance and coordination in people with multiple sclerosis.16 Further the result of one of the study revealed that ATM technique improves balance and mobility in people with chronic cardiovascular accident.17 Researchers in Australia found no effect of ATM technique on hamstring muscle flexibility.12,13 Also, one of the study stated that ATM technique can be used to lengthen the hamstring muscles.9 The findings of one of the study indicated that the ATM intervention was not effective in increasing hamstring length when compared with relaxation procedures or no treatment.18 The ‘Active Knee Extension Test’(AKET) is an objective and reliable tool for measuring the hamstring muscle tightness.19 5 6.3 Objectives of the study 1) To know the effectiveness of Static stretching(active), in improving hamstring muscle flexibility. 2) To know the effectiveness of “Awareness Through Movement”(ATM) technique in improving hamstring muscle flexibility. 3) To compare the effectiveness amongst the two groups of people which were given the above mentioned therapies. 6 MAT 7. Materials and methods : 7.1 Source of data 1) Shree Devi Education Trust Colleges. 7.2 Method of collection of data 60 volunteers with asymptomatic hamstring muscle tightness between age group between 18-30 years will be randomly assigned into two groups. Group A : Consists of 30 individuals to whom Static stretch(active) of the hamstring muscles will be given for 5 days a week for 3 weeks. Group B : Consists of 30 individuals to whom “Awareness through Movement(ATM)” technique will be given to the hamstring muscles for 5 days a week for 3 weeks. Inclusion Criteria: 1) Age group of individual should be 18-30 years. 2) Both sexes are included in the study. 3) Asymptomatic individuals with hamstring muscle tightness. 4) The subjects must not have an active knee extension angle greater than 150 degrees(full extension=180 degrees) as measured by Active Knee Extension Test. Exclusion criteria: 1) Subjects having a history of orthopedic problems, surgery, or injury to the back, pelvis or lower extremities, or history of hamstring injury. 2) Subjects having neurologic dysfunction. (eg. multiple sclerosis, cerebral palsy, or peripheral neuropathy) 7 3) Subjects having an active knee extension angle greater than 150 degrees(full extension=180 degrees) as measured by Active Knee Extension Test. Study Design: Comparative cohort study. Sampling: Block random sampling. Statistical Test: 1) Paired t-test 2) Unpaired t test. 3) One way ANOVA test. 4) Post hoc test. Outcome Measure: 1) Active knee extension range of motion (AROM) with hips flexed at 90 degrees as measured with a Universal Goniometer-360 degrees. METHODOLOGY: The techniques used will be explained to the subjects and all the subjects will have to sign an institution approved informed consent prior to participation in the study. The subjects will be screened and assessed on the day one. The above mentioned outcome measure will be evaluated and reported before giving treatment. The subjects of Group A will be administered Static stretching(active) for a period of 3 weeks. The subjects of Group B will administered “Awareness Through Movement(ATM)” technique for a period of 3 weeks. 8 Static stretching(active) for subjects belonging to group A: The subject faces the table with their hips square, maintained erect torso, with their arms on their hips, looks straight ahead, and flex forward at the waist until a hamstring stretch is perceived. The stretching regimen will be performed 3 times, for 30 seconds each, with a rest period for 15 seconds. “ Awareness Through Movement” technique for persons belonging to Group B: The movement segment will began with the subjects in the long sitting position. The subjects will have to perform the extension of the knee, internal rotation of the hip, and anterior tilt of the pelvis; all at the same time and vice versa, an organization of movements designed to lengthen the hamstring muscles from both ends. These movements will be done slowly and continuously, with the subjects resting when tired, and not to push into the end-range of knee extension. The session lasts for 30 minutes where the ratio of movement to rest will be 2:1. TOOLS: Universal Goniometer (360 degrees). 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. Subjects receive Static stretching and ATM technique. 7.4 Has ethical clearance been obtained from your institution in case of 7.3? Yes. 9 8. List of References: 1) Carolyn Kisner and Lynn Allen Colby. Therapeutic Exercise: Foundations and Techniques, Stretching (pg. no. 171-215), Fourth Edition, Jaypee Publishers, New Delhi, 2002. 2) Zachezewski JE. Improving flexibility, In: Scully RM, Barnes MR, eds. Phys Ther. Philadelphia, Pa: JB Lippincott Co; 1989; 698-699 3) Agre JC. Hamstring injuries: proposed etiological factors, prevention, and treatment. Sports Med. 1985; 2: 21-33. 4) Kujala UM, Orava S, Jarvinen M: Hamstring injuries: Current trends in treatment and prevention. Sports Med. 1997; 23: 397-404. 5) Bandy WD, Irion JM. The effect of time on static stretch on the flexibility of the hamstring muscle. Phys Ther. 1994; 74: 845-850. 6) Sullivan MK, Dejulia JJ, Worrel TW. Effect of pelvic position and stretching method on hamstring muscle flexibility. Med Sci Sports Exer. 1992; 24: 1383-1389. 7) Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther. 1998; 27:295-300. 8) Webright W, Randolph B, Perrin D. Comparison of non-ballistic active knee extension in neural slump position and static stretch techniques on hamstring flexibility. J Orthop Phys Ther. 1997; 26: 7-12. 10 9) James Stephens, Joshua Davidson, Joseph De Rosa et al. Lengthening the hamstring muscles without tretching using “Awareness Through Movement”. Phys Ther, 2006; vol 86. 10) Smith CA. The warm-up procedure, to stretch or not to stretch: a brief review. J Orthop Sports Phys Ther. 1994; 19: 12-17. 11) Hartig, DE, Henderson JM. Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees. Am J Sports Med. 1999; 27: 173-176. 12) Gajdosik RL. Effects of static stretching on the maximal length and resistance to passive stretch of short hamstring muscles. J Orthop Phys Ther. 1991; 14: 250-255. 13) Bandy WD. and Irion JM: The effect of time and frequency of static stretch on flexibility of the hamstring muscles . Phys Ther. 1997; 77: 1090-1096. 14) Smith L.L., Brunetz M.H, Chenair T.C. et al, The effects of static and ballistic stretching on delayed onset muscle soreness. Research Quarterly, 1993; 64(1): 103107. 15) Lucas KE, Nuzik S, Personius W et al. Low load prolonged stretch vs high load brief stretch in treating knee contractures. Phys Ther. 1984; 64: 330. 16) Stephens J, DuShuttle D, Hatcher C, et al. use of Awareness Through Movement improves balance and balance confidence n people with multiple sclerosis: a randomized controlled study. Neurology Report. 2001; 25: 39-49. 11 17) Baton G. Deutsch JE. Effects of Feldenkrais Awareness Through Movement On balance in adults with chronic neurological deficits following stroke: a preliminary study. Complementary Health Practice Review. 2005: 10: 203-210. 18) Michelle James, Gregory Kolt, Janet McConville et al. The effect of a Feldenkrais program and relaxation procedures on hamstring length. Austr Phys. 1998:vol 44: no 1. 19) Gajdosik , Ri Lusin, G. Hamstring muscle tightness: reliability of an active kneeextension test. Phys Ther. 1983; 63: 1085-1090. 12 9. Signature of the Candidate 10. Remark of the Guide 11. Name and Designation of Prof. S. PADMAKUMAR (In Block Letters) PRINCIPAL, 11.1 Guide SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MANGALORE-03. 11.2 Signature 11.3 Co-guide 11.4 Signature 11.5 Head of Department Prof. S. PADMAKUMAR 11.6 Signature PRINCIPAL, SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MANGALORE-03. 12. 12.1 Remark of the Chairman And Principal 12.2 Signature 13 14 15