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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1 NAME OF CANDIDATE & SR.BEENA.EF ADDRESS C/o PROVINCIAL SUPERIOR MARIA PROVINCIAL HOUSE KOORKENCHERY, THRISSUR-7, KERALA 2 NAME OF THE INSTITUTION THE OXFORD COLLEGE OF PHYSIOTHERAPY J.P.NAGAR, 1ST PHASE, BANGALORE – 78 3 COURSE OF THE STUDY & MASTER OF PHYSIOTHERAPY SUBJECT (Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy) 2nd JUNE,2008 4 DATE OF ADMISSION 5 TITLE OF THE STUDY: “A STUDY TO ANALYSE THE EFECT OF GENDER, AGE, DOMINANT AND NONDOMINANT LIMB INDIVIDUALS. ON HAMSTRING MUSCLE LENGTH IN SEDENTARY 6 BRIEF RESUME OF THE INTENDED WORK 6.1. NEED FOR THE STUDY: A sedentary lifestyle is a major risk factor across a spectrum of preventable diseases that lower the quality of life. Sedentary lifestyle can lead to various problems like tightness of muscle, decreased muscle length, decreased joint range of motion and decreased flexibility hampering daily activities of an individual.1 It is becoming apparent that with sedentary nature of work for people in office jobs, desk top workers which is causing adaptive shortening that occur to a greater degree in hamstrings associated with low back pain.2 Since work environments have become increasingly automated and computerized, many workers may be living more sedentary life style and spending a greater proportion of their living sitting. Working individuals specially those in the office who sit for the prolonged period develop various problems caused due to hamstring tightness like anterior knee pain, low back ache, increased stress on posterior ligaments of spine and erector spine muscles which limits the motions of the pelvis.3,4 High incidence of decreased HML is a characterisitic of adolescent lumbar disc herniation 26. Studies have shown that hamstring muscle length is influenced by a number of factors. Factors affecting decreased flexibility are age, gender, BMI, occupation and physical inactivity. They have to be considered for any patient at the time of physical examination for tight hamstrings as these factors directly relate to flattening lumbar lordosis and pelvic tilt. 5 Many of the changes in our musculoskeletal system result more from disuse than from simple aging. As muscles age, they begin to shrink and lose mass. This is a natural process, but a sedentary lifestyle can accelerate it. Rehabilitation professionals routinely assess Hamstring muscle length (HML) in persons with injuries to the nervous or musculoskeletal system, such as hamstring muscle injury, spinal cord injury, low back pain or anterior knee pain.6 A reduction in muscle length has been proposed as a predisposing factor for developing hamstring muscle injury.7 The decreased length of the hamstring muscles often seen in patients with disorders has been suggested to result from muscle and connective tissue adaptive shortening.8 One of the roles of a physiotherapist is to address limitations in muscle length in order to minimize injury. Inspite of the fact that muscle length decreases with age, studies have shown that (James W Y, et al)9 there is no statistically significant age effect on HML. Also Studies by Walker JM, et al14 reported that there is no significant relationship that was attributable to gender and age. Even though many studies have been done on Hamstring tightness, differences in Hamstring muscle length between men and women; dominant and nondominant side have not been examined for a group of sedentary individuals over a wide range of ages. Hence, this study is intended to investigate the typical values of hamstring muscle length (HML) for men and women over a span of ‘60’ years. This information will be helpful for every physical therapist for examination as well as treatment and for future reference. 6.2 REVIEW OF LITERATURE GENDER, AGE James WY, et al (2005) 9 in his study on influence of gender and age on hamstring muscle length found that there is significant influence of gender on hamstring muscle length. But no loss of HML with advancing age. Bell RD, Hoshizaki TB (1981) 10 in his study on ‘Relationships of age and sex with range of motion of seventeen joint actions in human’s found that a general decline in flexibility as age increased with women having a greater range of motion than males throughout life. Carol SL, et al (1990)11 studied on Relationship of hamstring and hip flexor muscle length in age group 20-30 yrs, and found that age correlated positively with hamstring muscle length and negatively with hip flexor muscle length. Hamstring length increased in age where as hip flexor Length decreased with age. James B, et al (1989) 12 studied active and passive mobility of joints of lower limb in elderly men and women and found statistically significant differences in PSLR for the effects of gender and age. Roach KE, et al (1991) 13 have done a study on normal hip and knee active range of motion with relationship to age in 1982 subjects and found that normal values for all motions were lower in the oldest age group than in the youngest age group. Walker JM, et al (1984) 14 have studied active range of motion in the upper and lower extremities of normal subjects related to age, sex and physical activity in ’30’ men and ‘30’ women age groups of 60-69 and 75-84 years. They suggested there is no significant relationship. Kevin E.Y, et al (2003) 15 studied exercise, aging and muscle protein metabolism and reported that advancing age and physical frailty are associated with a reduction in the fasting rate of mixed and myosin heavy protein synthesis. This contributes to muscle protein wasting in advancing age. DOMINANT AND NON DOMINANT LIMB Marie Corkery et al( 2007)16 studied on normal values for lower extremities and stated that there is significant differences between right and left sides for hamstrings , rectus femoris and gastronemius muscles. Izge Gunal, et al (1996) 17 conducted study on normal range of motion of the joints of the upper extremity in male subjects with special reference to side and reported that range of motion on the right side were significantly smaller than those on the left. Wang SS, et al (1993) 18 studied lower extremity muscular flexibility in long distance runners and stated that males and tight hamstring muscles than females in both runners and non runners. Also the dominant leg hamstrings were tighter than in non-dominant leg hamstring in all subject HAND HELD UNIVERSAL GONIOMETER Lusin Gary, et al (1983) 19 conducted a study on reliability of goniometer measurement and reported that goniometry measurement is more reliable method for measuring the joint ROM in hamstring muscle tightness. Clapper Mary, Paul et al (1998) 20 as per the study to assess inter test reliability and goniometer reliability in physical medicine and rehabilitation and stated that a hand held universal goniometer with central 360oo scale in 50o increments with one side of the goniometer’s central scale covered with white adhesive paper helps to minimize tester bias during measurement. PKE Cameron DM, et al (1993)21 conducted a study on relationship between knee extension and straight leg raise measurements and reported that knee extension test may be a useful alternative to the straight leg raise test for providing an indication of Hamstring muscle length. Diana Hopper, et al (2005)22 studied the comparison between PSLR & PKE tools in measuring hamstring muscle length and found that PKE test is a reliable and effective indirect test for assessing HML. An advantage of the KE test is the minimal pelvic motion which occurs when compared to the SLR test. Intratesterreliability of PKE-0.89 Gajdosik RL, et al (1983)23 as per the study on reliability of knee extension in hamstring muscle tightness, concluded that KE test is more selective for measuring hamstring length than passive SLR, because KE test as a high test reliability, when body position is controlled the end point of motion is specifically defined and the measuring instrument is accurately placed. 6.3 OBJECTIVES OF THE STUDY: To examine the differences of Hamstring muscle Length (HML) between male and female as measured by passive knee extension (PKE) To examine the difference of HML between age groups as measured by PKE To examine the HML between dominant and non-dominant limb. 6.4 HYPOTHESIS: Null hypothesis: There is no difference in the factors of gender, age, dominant and non-dominant limb on Hamstring muscle length. Alternate hypothesis: There is difference in the factors of gender, age, dominant and nondominant limb on HML. 7 MATERIALS AND METHODS: 7.1. STUDY DESIGN AND SETTING: 7.1.1. STUDY DESIGN: Cross-sectional descriptive study. 7.1.2. SOURCE OF DATA: Final year students of Oxford college of physiotherapy Software companies in and around Bangalore Old age home – Little sisters of the poor 7.2. METHODOLOGY: 7.2.1. POPULATION: Male and female sedentary subjects of age 20-70 years. 7.2.2. SELECTION CRITERIA: INCLUSION CRITERIA Sedentary subjects Both sexes (male and female) Age between 20-70 years Subjects with full knee extension People willing to participate in the study Subjects who are able to understand properly. EXCLUSION CRITERIA Subjects with current low back pain History of hip, knee or low back surgery Hamstring strain or injury Neurologically impaired and non co-operative subjects Flexion deformity of knee Genu recurvatum. 7.2.3. SAMPLING SAMPLING METHOD: o Stratified sampling SAMPLE SIZE: o N=200 subjects o 100 male, 100 female. 7.2.4.PROCEDURE DEFINITION OF SEDENTARY LIFE: “A sedentary life is defined as being physically inactive at work and at home and failing to participate in exercise for at least ‘20’ continuous minutes at least three times a week”.24 Based on this definition as well as inclusion and exclusion criteria ‘200’ subjects will be selected by stratified sampling. After the explanation of procedure and instructions, the informed consent will be taken from the subjects. Subjects are stratified across 5’ age groups in ‘10’ year increments [20-29,3039,40-49,50-59,60-69 years]. Each group having ‘40’ subjects about equally divided between men and women. Indirect measurement of HML will be taken by PKE HML is measured by ‘PKE’ as described by Diana Hopper et al (2005)25 each subject is positioned in spine with the opposite leg is strapped to the Plinth. A cross bar so that 90o hip flexion is maintained throughout PKE measurement. This ensure that the distal anterior thigh maintains contact with the cross bar for all PKE measurements. The protractor is adjusted to read 90o when the knee is flexed to 90o. Subjects are positioned with their hands on the abdomen, cervical spine in neutral and eyes closed. Fulcrum is marked at the centre of the knee joint axis over the lateral joint line of the right leg. Two lines are drawn from this point, one joining this axis point to the centre of the greater trochanter of the femur, and a second joining the axis point to the apex of lateral malliolus. The stationary arm is placed along the lateral femur and the moving arm is aligned with the lateral fibula. Examiner extends the knee until the subject perceives the first onset of stretch in Hamstring. At this point the measurement of the goniometer is recorded. This procedure is then followed by three trails. The two most consistent of these measures are averaged and used for analysis. Both limbs are measured by this procedure. Duration of the study : Single time study No follow up b). Materials used: Hand held universal goniometer – 360o Examination table Cross bar Pillow Strap 7.3. OUTCOME MEASURES AND STATISTICAL ANALYSIS: 7.3.1. OUTCOME MEASURES: Passive knee extension (PKE) 7.3.2. STATISTICAL ANALYSIS: Student ‘t’ test (two tailed dependent) Anova Bonferroni post-hoc test 7.4 Does the study require any intervention to be conducted on patients or other humans or animals? No, this study doesn’t require any intervention. Has ethical consent for the study has been obtained from the institutions? Yes, it has been obtained from my institution. Ethical clearance form is attached as (Appendix - I) The informed consent will be obtained prior to the study from each subject (appendix - II) 8. REFERENCES: 1. J Collins, Effects of aging, 2004 Sep6-10 geneva, P:123-6. 2.Nelson BW, et al. the clinical effects of intensive exercise on chronic low back pain . J Musculoskeletal med. 1995;18: 971-81. 3.Magnusson SP et al. A randomized evaluation of cyclic and static stretching. Int J Sports med, 1998; 19(5): 310-316. 4.Halbersna JP et al .Sports stretching, effect on passive muscle stiffness of short hamstring, arch phy med rehab, 1996, 77(7), 688-692. 5Bob Anderson. flexibility, 2001june 12-14 paris p: 89-93 6.Maggee DJ. Orthopedic physical assessment, 4th ed, Philadelphia, PA: Saunders; 2002. 7.Hartig DE, Henderson JM .Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees. AMJ sports Med, 1999; 27: 173-176. 8.Gajdosik R. Effects of static stretching on the maximal length and resistance to passive to short hamstring muscles. JOSPT,1993; 14(6): 250255. 9.James WY et al. Influence of age, gender on hamstring muscle length in healthy individuals. JOSPT 2005; 35(4) :246-252. 10.Bell RD, Hoshizaki TB. Relationship of age and sex with range of motion of seventeenth joint actions in humans. Can I Appl sport sci, 1981; 6:202206. 11.Carol SL et al .Relationship of hamstring and hip flexor muscle length. Phy Ther 1990;70:611-618 12.James B, et al .Active and passive mobility of lower limb joints in elderly men and women. Am J PMR, 1989; 68: 162-167. 13.Roach KE, et al .Normal hip and knee active range of motion: the relationships to age. Physical therapy 1991; 71: 656-665. 14.Walker JM, et al .Active mobility of the extremities in older subjects, Phys Thera, 1984; 64: 919-923. 15.Kevin EY. Exercise, aging and muscle protein metabolism Jepi com health 2003;18:56-59 16.Marie Corkery etal.Establishing normal values for lower extremities. Phy Ther sport;2007 [8]:66-74 17.Izge Gunal et al. Normal range of motion of the joints of the upper extremity in male subjects, the journal of bone and joint surgery;1996; 78: 1401-1404. 18.Wang SS, et al .Lower extremity muscular flexibility in long distances runners, JOSPT 1993; 17: 102-107 19..Lusin Gary, et al .Hamstring muscle tightness Phy ther 1983; 63(7) :1085-1090. 20.Clapper Mary Paul, et al .Comparison of the reliability of the orthoranger and the standard goniometer for assessing active lower extremity ROM, phy ther 1998; 68(2) 214-218. 21.Camerson DM, et al .Relationship between knee extension and straight Leg raise,JOSPT 1993;17(5):257-260. 22. Diana Hopper et al .Evaluation of two massage techniques on HML in Female hockey players. Phys Ther Sport 2005;6 :137-145 23.Gajdosik.RL et al. Reliability of knee extension test in hamstring muscle Tightness . Phys Ther 1983;63(7):1085-1090 24.http://www.effects of aging .com/AAOS on line service fact sheet.html 25.Hopper.D, Conneely M, et al .Evaluation of the effect of two massage techniques on hamstring muscle length in female hockey players Physical therapy in sports, 2005(6) :137-139 26. Qingsan Z, etal.Adolescent lumbar disc herniation and hamstring tightness Tohku university school of medicine 2006 (31) :1810-1814 9 Signature of the Candidate 10 Remarks of the guide 11 Name and designation of the 11.1 Guide Mr.G.R.VIKRANTH.M.P.T ASST. Professor 11.2 Signature 11.3 Co-guide 11.4 Signature 11.5 Head of the Department MR.KG.KIRUBAKARAN.MPT PRINCIPAL 11.6 Signature 12. 12.1 Remarks of chairman and Principal 12.2 Signature MR.KG.KIRUBAKARAN APPENDIX-1 THE OXFORD COLLEGE OF PHYSIOTHERAPY J.P.NAGAR, 1 PHASE, BANGALORE – 560078. Review Board on Ethics for Research We hereby declare that the project titled, “A study to analyze the effect of gender, age, dominant and non-dominant limb on hamstring muscle length in sedentary individuals”. Carried out by SR.BEENA.EF of 1st Year M.P.T. has been brought forward for scrutiny to the board members. After analyzing the objectives, subjects involved and the methodology of the project, the following conclusions were drawn. The project does not cause any mental or physical harm to the subjects involved and there are no risks involved in the study. The performance of the study procedure will not cause any injury to the subjects. The board has evaluated and confirmed that the experimenter is trained and qualified in measuring outcome. The informed consent form ensures that the experimenter explains the procedure of the study to the subjects, their voluntary participation is confirmed and the identification of subjects is maintained confidential. More over the finding of the study will benefit similar subjects, the profession and the society. Hence the review board has no objections on the conduct of the study. Chairman of Department Review Board Project Guide Principal APPENDIX – 1I CONSENT FORM TITLE: “A STUDY TO ANALYZE THE EFFECT OF GENDER, AGE, DOMINANT AND NON-DOMINANT LIMB ON HAMSTRING MUSCLE LENGTH IN SEDENTARY INDIVIDUALS”. INVESTIGATOR: SR.BEENA.EF PURPOSE OF RESEARCH: I _______________________have been informed that this study is carried to know the effect of gender, age, dominant and non-dominant limb on hamstring muscle length. PROCEDURE: I have been explained that this study is conducted by using passive knee extension I am aware that I have to follow the researcher’s instruction as has been told to me. RISK AND COMFORT: I understand that there is no potential risk associated with this study and this study will not produce any harm to me by participating. I understand that there won’t be any discomfort throughout the study. I am aware that SR.BEENA.EF will help me for better understanding of the procedure. BENEFITS: I understand that this study helps to know the effect of gender, age, dominant and non-dominant limb on hamstring muscle length. ALTERNATIVES: I understand the procedure being studied is the standard way than compared to other studies which can be conducted by using other tools. CONFIDENTIALITY: All the data recorded will be kept in strictest confidence apart from the researcher no one will ever access to the data without your permission. If the data are used for publication in the medical literature or for the teaching purpose, no names will be used. PHOTOGRAPHY CONSENT: SR.BEENA.EF has explained to me that photographs are required in order to illustrate various aspects of the study for the thesis and other articles, and at presentations or conferences. These images may also be converted to electronic formats for use in multimedia presentations and documents accessible to others by computers for the purpose of sharing the results of the study and for promoting this research. By giving my consent I authorize SR.BEENA.EF to use any of the photographs taken of me in printed format, in slides for presentation, and in electronic format. REQUEST FOR MORE INFORMATION: I understand that I may ask any questions of the study at any time, SR.BEENA.EF is available to answer my questions, and copy of this consent form will be given to me to keep for my careful reading. REFUSAL OR WITHDRAWAL OF PARTICIPATION: I understand that my participation is voluntary and I may refuse to withdraw consent and discontinue participation at anytime. I also understand that she may not include my participation in the study at any time after he has explained the reason for doing so. INJURY STATEMENT: I understand that, in the unlikely event of the injury resulting directly/indirectly from my participation in this study, medical treatment will be available but no further compensation will be provided. I understand that my agreement to participation in this study and I am not waiver any of my legal right, I explained to _________________the purpose of the research, the procedure required and the possible risk and benefits to the best of my ability. Investigator: SR.BEENA.EF Investigator Signature Date: I confirm that SR.BEENA.EF has explained me the purpose of research study, the procedure and the possible risk and benefits that I may experience, I have read and I have understood this consent to participate as a subject in this research project. Candidate’s Signature Date: Witness Signature Date: APPENDIX – III PROFORMA Name : Group : Age : Serial No: Sex : Date of assessment: Address: INCLUSION CRITERIA Is the subject participating in exercise for at least ‘20’ continuous minutes at least three times? [Y/N] Is the group between 20-70 of both sex [Y/N] Is the subject with full knee extension [Y/N] Is the subject able to understand the procedure [Y/N] Is the subject willing to participate in the study? [Y/N] EXCLUSION CRITERIA Has a history of current low back pain [Y/N] Has a history of hip, knee or low back surgery [Y/N] Has hamstring strain or injury [Y/N] Has a history of neurological disease [Y/N] Has flexion deformity of knee Has hyper extension of knee [Y/N] [Y/N] HAMSTRING MUSCLE LENGTH PKE Gender / Age PKE DOMINANT LIMB Group (Y) MEN 20-29 30-39 40-49 50-59 60-69 WOMEN 20-29 30-39 40-49 50-59 60-69 Signature of the Subject: Signature of Witness: Signature of Investigator: Date: NON-DOMINANT LIMB