RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
ANNEXURE- II
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.

NAME OF THE CANDIDATE PATEL SONIKABAHEN

SHANKARBHAI
AND ADDRESS
D/O SHANKARBHAI .D. PATEL
A-7, INDIA COLONY,
VIJALPOR
NAVSARI
GUJARAT-

2.

NAME OF THE INSTITUTION

3.

COURSE OF THE STUDY AND MASTER OF PHYSIOTHERAPY

SUBJECT
IN MUSCULOSKELETAL
DISORDERS AND SPORTS
PHYSIOTHERAPY

4.

DATE OF THE ADMISSION TO 29.6.2012

THE COURSE

5.

TITLE OF THE STUDY:

KRUPANIDHI
COLLEGE
OF
PHYSIOTHERAPY,
BANGALORE12/1,CHIKKA
BELLANDUR,CARMELARAM
POST,VARTHURHOBLI,
BANGALORE-560035

A STUDY TO FIND OUT EFFECTIVENESS OF FOUR TECHNIQUES: HOLD

RELAX, CONTRACT RELAX- ANTAGONIST CONTRACT, POSITIONAL
RELEASE THERAPY, AND SOFT TISSUE MOBILIZATION, IN ADULTS WITH
HAMSTRING TIGHTNESS.

6. BRIEF RESUME OF THE INTENDED WORK :

INTRODUCTION:
1

In human anatomy, the hamstring is any one of the three posterior thigh muscles
(semitendinosus, semimembranosus and biceps femoris) that make up the borders of the
space behind the knee, or their corresponding tendons.1
Muscle tightness is that tense feeling in specific muscles that can be very
uncomfortable. Everyone has experienced some muscle tightness or stiffness.
Psychological and physical stress can cause muscles to tense and spasm causing an achy
feeling.2
When a muscle has good flexibility the result is more effective and efficient
movement, because the flexible muscle allows the muscle tissue to accommodate imposed
stresses more easily-which can result in reduced risk of skeletal muscle strains during
exercises.(wallmann,2009:355; Bandy, Irion and Briggler, 1998:295; ).3
Tight hamstring muscles increase the patellofemoral compressive force because of
the increased passive resistance during the swing phase of ambulation and running.
Hamstring tightness has been reported to be the cause of posterior pelvic tilting, reduced
lumbar lordosis and exacerbation of existing pain in patients with low back pain. It has
been reported to play a role in different forms of lumbar inter-vertebral disc pathology.4
The main goal of a flexibility program should be to improve the range of motion of
a joint, by altering the extensibility limits of the specific muscles musculo-tendinous unit
and fascia to increase range of motion and efficiency of movement of the specific joint or
joints.3
Positional Release Therapy (PRT) also known by its parent term, strain
counterstrain, is a therapeutic technique that uses a position of comfort to resolve tissue or
somatic dysfunction, e.g., pain, tightness and spasm. Dr. Jones, D.O., an osteopathic
physician, first developed PRT in the 1950's, terming the technique at this time positional
release technique, later coining the technique strain counterstrain. Essentially, PRT is the
opposite of stretching.5
Soft tissue mobilization is a form of manual therapy somewhat similar to, but more
2

specific than, therapeutic massage and is often also referred to as a form of myofascial
release. All physical therapists are well educated concerning soft tissue mobilizations and
most have been trained in at least a few different forms of these type of techniques. Soft
tissue mobilization can either be performed manually (with the hands) or performed with
various types of instruments (instrument assisted soft tissue mobilization). Currently there
is little, if any, credible evidence that states that instrument assisted soft tissue
mobilization (IASTM) is more effective than manual soft tissue mobilization but
instrument assisted soft tissue mobilization is less physically demanding on the physical
therapist.6
Soft tissue mobilization techniques will seek to increase the mobility of tissues and
joint range of movement by removing physical restrictions to movement, that is, the
adhesions that can occur intramuscularly, between soft tissues or between soft tissue and
bone. However, as muscle length is also controlled by the neuromuscular system
hyperactivity in this system will also need to be addressed through appropriate techniques,
if musculoskeletal function is to be achieved.7
Proprioceptive Neuromuscular Facilitation (PNF) is a more advanced form of
flexibility training that involves both the stretching and contraction of the muscle group
being targeted. PNF stretching was originally developed as a form of rehabilitation. While
there are several variations of PNF stretching, they all have one thing in common; they
facilitate muscular inhibition. Various PNF stretching techniques based on Kabats
concept are: Hold Relax, Contract Relax, and Contract Relax Antagonist Contract
(CRAC) etc. The Hold Relax (HR) technique involves an isometric contraction of the
shortened muscle against maximum resistance followed by relaxation phase. The contract
relax (CR) PNF technique includes the concentric contraction of the shortened muscle
and then relaxation phase while in Contract Relax - Agonist Contract (CRAC) technique
isometric contraction of the shortened muscle followed by relaxation and later concentric
contraction of the opposing muscle or muscle group.8

6.1.NEED FOR STUDY:

The 'normal' range of hip flexion (measured when laying flat on your back and
3

raising the leg straight off the floor - knee straight) permitted by the hamstrings is in the
region of 80-90 degrees. Anything less than 80 degrees is considered 'tight.'9
The hamstring muscles are susceptible to tearing. If forced a muscle to go further
than it can normally go at speed it is likely to tear. Tight hamstrings can cause the hips and
pelvis to rotate back flattening the lower back and causing back problems. Tight
hamstrings can also be responsible for postural problems and other back problems such as
sacroiliac joint pain, as they will tend to pull the pelvis out of normal position.9
If muscles have tightened up then blood has been squeezed out of them therefore
the muscles are

working at less than 100 % of capacity and the performance will be

down as a result. Regular sports massage for hamstring muscles and hamstring stretching
to improve muscle condition will not only reduce the likelihood of injury but may also
improve sporting performance. 9

Soft tissue mobilization (either manual or instrument assisted) is an effective

technique to promote healing of certain type of musculoskeletal injuries when performed
by a skilled clinician but the technique is variable. Much like therapeutic massage, soft
tissue mobilization can improve blood flow, release histamine through stimulation of mast
cells, promote collagen synthesis, and increase the viscoelasticity of tissue.6
Soft tissue mobilization is an adaptable treatment tool which can be applicable for
use with numerous musculoskeletal pain and orthopedic conditions.6
PRT acts on the muscle spindle mechanism and its associated reflex
mechanism(which controls spasm) to promote a more normal firing of the spindle and a
more normal level of tension in the muscle , which results in a more normal relationship
within the various soft tissue surrounding the area.10

Numerous investigations establish PNF techniques as more efficacious than

traditional stretching exercises for range of motion or flexibility enhancement. 8

Children have greater flexibility in joints than adults, but as one ages the flexibility
4

scores decrease. This is due to physiological changes that cause decrease in overall
musculoskeletal flexibility.3

Loss of muscle function, increased intramuscular connective tissue, certain physical

and bio-chemical changes that occur in collagen all result in decreased range of motion, a
gradual decline in the efficiency of performance og activities of daily living and a
decrease in muscle extensibility.3

Considering the importance of hamstring flexibility in general and athletic

population, maintaining the flexibility of hamstring muscle is of utmost importance for
health care professionals and to achieve this goal one needs to know the most effective
and efficient technique to gain hamstring flexibility. 8

This study will compare the effectiveness of the PNF hold relax, contract relaxantagonist contract, positional release therapy, soft tissue mobilization techniques on the
tight hamstring muscle in order to find out most effective technique to improve flexibility
as well as the overall effectiveness of the four different techniques on flexibility in
general.

6.2.OBJECTIVES OF THE STUDY :

To find out effects of hold relax and contract relax-antagonist contract technique

on adults with hamstring tightness.

To find out the effects of positional release therapy on adults with hamstring

tightness.
To find out the effects of soft tissue mobilization on adults with hamstring

tightness.
To compare 4 techniques: hold relax, contract relax-antagonist contract, positional
release therapy, and soft tissue mobilization on adults with hamstring tightness.

HYPOTHESIS:
(A) Research hypothesis:
There is a significant difference in the effects of hold relax, contract relax
5

antagonist, Positional release therapy and soft tissue mobilization in adults with hamstring
tightness.

(B)Null hypothesis:
There is no significant difference in the effects of hold relax, contract relaxantagonist contract, Positional release therapy and soft tissue mobilization in adults with
hamstring tightness.

6.3.REVIEW OF LITERATURE:
1. Nagarwal A. K. et al:
A randomized pre-test post-test control group study showed that both hold relax and
contract relax antagonist contract are almost equal in their effectiveness for improving
hamstring flexibility.11

2. Scott G. Spernoga et al:

This article suggests that a sequence of 5 modified hold relax stretches produced
significantly increased hamstring flexibility. The hamstring flexibility was measured in
degree of active knee extension with hip flexed to 900.12

3. M.N Nachtwey, K. stricker july (2003):

27 healthy, male and female volunteers, 18-40 years of age were at random assigned to a
direct and an indirect hold relax group. Both the techniques were repeated five times a
day. Result showed that both hold relax technique direct as well as indirect can be
effectively practiced to induce muscle relaxation of the hamstrings and increase hip joint
of motion.13

4. Bonnar b. P. et al:
The purpose of this study was to determine the isometric contraction hold time that best
produces gains in hip range of motion after 3-sec hold relax, 6 sec hold relax, and 10 sec
hold relax PNF stretch. 60 active individuals were randomly assigned to a 3 hold relax, 6
hold relax, or 10 hold relax PNF stretch. All the subjects were passively taken to the end
range of motion 3 times and a goniometric measurement was taken. All 3 hold time
conditions produced significant gains in range of motion.14
6

5. PHILLIP A. GRIBBLE et al:

This study was determined that both static and hold-relax techniques significantly
improved hamstring flexibility. Participants of both techniques reached a plateau in
flexibility improvement between Weeks 4 and 5. Thus, static and hold-relax stretching are
equally effective in improving hamstring ROM.15

6. Ryan, Edwin E et al:

He reported that contract relax-antagonist contract form of PNF stretching is effective to
improve medial and lateral stability with or without warm-up. Contract relax-antagonist
contract PNF of hamstring, plantar flexors, and hip flexors was performed during warmup and stretching only.16

7. Gideon Praveen Kumar (2011):

A randomized intervention trial study including thirty-six male subjects (18-30 age) who
exhibited bilateral hamstring muscle tightness. Each subject, one leg was given hold
relax; whereas the other side cyclic loading was given. After 3 week of treatment period
the results showed that both hold relax and cyclic loading hamstring stretch have equal
effect in improving flexibility.17

8. Mohd. Waseem, et al :
Using a Pre-test and Post-test design with random assignment, 20 healthy male subjects
with hamstring tightness were randomly allocated to two study groups. Outcome was
measured in terms of active knee extension test (AKE).the results

showed

that

Positional release therapy improves the active knee extension that is hamstring
flexibility.18

9.A.kumaresan et al:
Experimental study design was used for this study. This study showed that positional
release therapy can be used as an adjunct with other conventional treatment methods for
the relief of the pain and trapezitis.19
7

10.Diana Hopper et al:

This study was done using randomized, controlled single blind design study. Subjects
were divided into control group, classic soft tissue mobilization, and dynamic soft tissue
mobilization. This study showed that dynamic soft tissue mobilization is more effective
than classic soft tissue mobilization in improving hamstring flexibility.20

11. MacDonald, Graham et al:

The study was done to show the effect of self- myofascial release (SMR) via foam roller
application on knee extensor force and activation and knee joint range of motion. The
results proved that self myofascial release with foam rolling is effective to improve
muscular function and knee joint range of motion.21

12. Cameron Dm, Bohannon Rw (1993):

This study showed that, there was a significant relationship between active knee
extension test (AKET) and active straight leg raise (ASLR). The AKET test is useful
alternative to the straight leg raise test for providing an indication of hamstring muscle
length.22

13. Teddy W. Worrell, et al:

Three testers performed repeated AKET measurements on 22 subjects. Intraclass
correlation coefficients (ICC) were used to calculate intratester and intertester reliability
The AKET may provide a more accurate method for determining hamstring flexibility and
quantifying changes that occur as a result of injury and stretching procedures.23

7.MATERIALS AND METHODOLOGY:

7.1.SOURCE OF DATA:
8

(A)POPULATION:
Both males and females who satisfy the criteria from the population of the study.

(B)SAMPLE SIZE:
120 subjects with age of 21-31 years and to be divided into four groups with 30
subjects each.

7.2. METHOD OF COLLECTION OF DATA:

7.2.1(A) SAMPLING TECHNIQUE:
Random sampling method

(B) MEASURMENT TOOLS:

Active knee extension test.
Straight leg raise.
Chair sit and reach test.
7.2.2. STUDY DESIGN:
Comparative study with pre-test and post-test design.

7.3. SELECTION CRITERIA:

1.INCLUSION CRITERIA:

Both males and females.

Age 21-31 years.

9

Subjects diagnosed with hamstring tightness.

Subject with positive active knee extension test.

2. EXCLUSION CRITERIA:

Individual with back pain.

Individual with soft tissue injury.

Individual with fracture in knee joint.

Systemic illness.

7.4.DURATION:
12 weeks

7.5.MATERIALS REQUIRED :

Chair.
Couch.
Universal Goniometer.

7.6. PROCEDURE:

Subjects will be screened on the basis of the selection criteria and the informed
consent will be obtained from them.

Participants will be explained about the whole procedure and if neede task will be
demonstrated.

Active knee extension test(AKET):

Subjects were assessed for hamstring tightness using the AKET. The

subject was in supine position with hips in 90 degree flexed and knee flexed. A PVC
cross bar was used to maintain the proper position of hip and thigh. The testing was done
on the right lower extremity and subsequently the left lower extremity and the pelvis were
10

strapped down the table to stable the pelvis and control any accessory movements.
Landmarks used to measure hip and knee range of motion were greater trochanter, lateral
condyle of femur and the lateral malleolus which were marked by a skin permanent
marker. The fulcrum of the goniometer was centered over the lateral condyle of the femur
with the proximal arm secured along the femur using greater trochanter as a reference.
The distal arm was aligned with the lower leg using the lateral malleolus as a reference.
The hip and knee of the extremity being tested was placed into 90 degree flexion with the
anterior aspect thigh in contact with the horizontal bar of the PVC frame at all times to
maintain hip in 90 degrees of flexion. The subject was then asked to extend the right
lower extremity as far as possible until a mild stretch sensation was felt. A full circle
goniometry was then used to measure the angle of knee flexion. Three repetitions were
performed and an average of the three was taken as the final reading for knee flexion
range of motion (hamstring tightness). You can consider your hamstrings tight if the angle
between your leg and the vertical is greater than 20 degrees.

GROUP A:
HOLD RELAX:
After pre-treatment ROM measurement, subjects received PNF- Hold Relax
stretching. The subjects were in supine position with their left lower extremity strapped
down the table. Pre-determined time intervals for stretching, contracting and relaxing
were used to standardize the method utilizing a stop watch. For each stretch, the
investigator stretched the hamstring muscle by passively flexing the hip with knee fully
extended, allowing no hip rotation. The lower leg was rested on the investigators right
shoulder. The hamstring muscle was stretched until the subject first reported a mild stretch
sensation; this position was held for 7 sec. Next, the subject then isometrically contracted
the hamstring muscle for 3 sec by attempting to push his leg down towards the table
against the resistance of the investigator. Following this, the subject was asked to relax for
5 sec. The investigator then passively stretched the muscle until a mild stretch sensation is
reported. This stretch was held for 7sec. This sequence was repeated 5 times with each
sequence separated from each by a 20 second interval. This was followed by post
treatment measurement of ROM at the end of first, second and third week. The treatment
was given 3 times per week for period of 3 weeks.

11

GROUP B:
CONTRACT RELAX -ANTAGONIST CONTRACT:
After pre-treatment ROM measurement, subjects received PNF-Contract RelaxAntagonist Contract (CRAC) stretching. The procedure followed was similar to the PNFHR procedure except that instead of the post relaxation passive stretch the subjects were
asked to concentrically contract the opposing muscle (quadriceps muscle), by attempting
to further raise the leg, for 7 sec. This sequence was repeated 5 times with each sequence
separated from each by a 20 second interval. This was followed by post treatment
measurement of ROM at the end of first, second and third week. The treatment was given
3 times per week for period of 3 weeks.

GROUP C:
POSITIONAL RELEASE THERAPY:
After pre-treatment another group was given position release therapy. Position the
patient comfortably most often lying down. Palpate the affected area and areas that may
be associated due to referred pain. Palpate the selected tender point (tp)-instruct the
patient to relax the area. Passively move the pain stops and patient only feels pressure.
Release the pressure-but maintain light contact over the tender point to monitor response.
Maintain the position for 90 seconds hold longer if patient is feeling therapeutic pulse,
tissue tension changes or movement. Encourage the patient to relax-slowly return to
neutral position.

GROUP D:
SOFT TISSUE MOBILIZATION:
Subjects were positioned lying Prone with the hip and knee in a neutral relaxed
position. Each subject received a massage, based on traditional Swedish massage
techniques, on the hamstring muscle Group. The specific techniques included effleurage,
kneading, Picking up, and shaking.22 the total massage consisted of five Strokes of each
of these techniques and was completed in 5 min.

12

7.7. Does the study require any investigation to be conducted on patients or other
humans or animals?
Yes, the study will be conducted on humans i.e on adult subjects and informed
consent will be taken prior to the study.

7.8. Has the ethical consent for the study has been obtained from the institution is
case?
Yes, it has been obtained from the institution.

8.REFERENCES:
1. Http://en.wikipedia.org/wiki/Hamstring.
2. Http://www.chirocommunity.com/muscletightness.htm.
3. Wallmann, 2009:355; Bandy, Irion and Briggler, 1998:295; magnusson 1998:66.
Stretching techniques on hamstring flexibility on female adolescent.
4. Marras WS. Flexibility and velocity of the normal and impaired lumbar spine.
Archives of Physical Medicine and Rehabilitation 1986; 67: 1865-1869.
5. Http://prt-i.com/.
6. Http://physicaltherapycolumbus.com/columbus-physical-therapy-services/soft
tissue mobilization.
7. Http://www.premierglobal.co.uk/courses/massage/52448.
8. Etnyre BR, Abraham LD. Gains in range of ankle dorsiflexion using three popular
13

stretching techniques. American journal of physical medicine 1986, 65: 189.

9. Http://www.sportsinjuryclinic.net/sport-injuries/thigh-pain/tight-hamstringmuscles.
10. Http://goeata.org/protected/EATACD12/downloads/PDF/presentation-Pierce.pdf(
11. Nagarwal A.K.1, Zutshi K +, 2, Ram C. S. 3, Zafar R. 3 ,1 Jamia Hamdard, New
Delhi. Improvement of Hamstring Flexibility: A Comparison between Two PNF
Stretching Techniques International Journal of Sports Science and Engineering
Vol. 04 (2010) No. 01, pp. 025-033
12. Scott G. Spernoga,* Timothy L. Uhl,

Brent L. Arnold, and Bruce M.

Gansneder
Duration of Maintained Hamstring Flexibility After a One-Time, Modified HoldRelax Stretching Protocol. Journal athletic Training. 2001 Jan-Mar; 36(1): 4448.
PMCID: PMC155401.
13. M.N Nachtwey, K. Stricker July 2003 Effects of the PNF-hold-relax-technique,
direct and indirect, on hamstring muscle flexibility.
14. Bonnar BP, Deivert RG, Gould TE. The relationship between isometric
contraction durations during hold-relax stretching and improvement of hamstring
flexibility. Journal of Sports Medicine and Physical Fitness. 2004 Sep; 44(3):25861.
15. Phillip A. Gribble, Kevin M. Guskiewicz, William E. Prentice, Edgar W. Shields.
Effects of Static and Hold-Relax Stretching on Hamstring Range of Motion Using
the flexibility LE1000 Journal Sport Rehabilitation, Volume 8, Issue 3, August.
16. Ryan, Edwin E1; Rossi, Mark D1; Lopez, Richard. The Effects of the ContractRelax-Antagonist-Contract Form of Proprioceptive Neuromuscular Facilitation
Stretching on Postural Stability Journal of Strength & Conditioning Research: July
2010 - Volume 24 - Issue 7 - pp 1888-1894.
17. Gideon Praveen Kumar, PhD Comparison of cyclic loading and hold relax
technique in increasing resting length of hamstring muscles Hong Kong
Physiotherapy Journal Volume 29, Issue 1, June 2011, Pages 3133.
18. Mohd. Waseem, Shibili Nuhmani, Abu Shaphe. The impact of muscle energy and
positional release therapy techniques on hamstring muscle flexibility: a pilot study.
Journal of Physical Education and Sports Management 04/2012; 3(1).
19. A.kumaresan1 G.Deepthi1 Vaiyapuri Anandh 2 S.Prathap3 1. A.kumaresan,
Effectiveness of Positional Release Therapy in Treatment of Trapezitis. Page 71
14

international journal of pharmaceutical science and health care issue 2, volume 1

February, 2012 issn: 2249-5738.
20. Diana Hopper, S Deacon, S Das, A Jain, D Riddell, T Hall, K Briffa. Dynamic soft
tissue mobilization increases hamstring flexibility in healthy male subjects. British
journal of sports of medicine. 2005; 39:594-598.
21. Macdonald, Graham; Penney, Michael; Mullaley, Michelle; Cuconato, Amanda;
Drake, Corey; Behm, David G.; Button, Duane C. An Acute Bout of Self
Myofascial Release Increases Range of Motion without a Subsequent Decrease in
Muscle Activation or Force. Journal of Strength & Conditioning Research: POST
ACCEPTANCE, 10 May 2012doi: 10.1519/JSC.0b013e31825c2bc1.
22. Cameron DM, Bohannon RW. Relationship between active knee extension and
active straight leg raise test measurements. Journal of Orthopaedic Sports Physical
Therapy. 1993 May; 17(5):257-60.
23. Teddy W. Worrell, Michael K. Sullivan, Joseph J. Dejulia Reliability of an ActiveKnee-Extension Test for Determining Hamstring Muscle Flexibility. Journal of
9

sports
and rehabilitation, Volume 1, Issue 3, August.181-187.
SIGNATURE
OF CANDITATE
(SONIKABAHEN
SHANKARBHAI
PATEL)

10

REMARKS OF GUIDE

11.1

11.2

NAME AND DESIGNATION MR. SUBRAMANIAN

OF GUIDE
ASST. PROFESSOR
MPT (MUSCULOSKELETAL DISORDERS
AND SPORTS PHYSIOTHERAPY)
SIGNATURE
SD/-

11.3

CO-GUIDE (IF ANY)

11.4

SIGNATURE

11.5

HEAD OF THE DEPARTMENT

MR.MASIH MUHAMMAD KHAN

MPT (MUSCULOSKELETALDISORDERS
AND SPORTSPHYSIOTHERAPY)

11.6

SIGNATURE

SD/-

PRESENTED TO THE RESEARCH

COMMITTEE AND APPROVED

12.
1

REMARKS OF THE CHAIRMAN AND PRINCIPAL

APPROVED AND FORWARDED

12.
1

SIGNATURE

15
SD/-