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Hamstring (HS) muscles are susceptible to decreased extensibility. MET has been shown to improve HS extensibility in healthy, Asymptomatic Adults with HS tightness.
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Effectiveness of Muscle Energy Technique on Hamstring Extensibility in Healthy, Asymptomatic Adults With Hamstring Tightness_Pang
Hamstring (HS) muscles are susceptible to decreased extensibility. MET has been shown to improve HS extensibility in healthy, Asymptomatic Adults with HS tightness.
Hamstring (HS) muscles are susceptible to decreased extensibility. MET has been shown to improve HS extensibility in healthy, Asymptomatic Adults with HS tightness.
Extensibility in Healthy, Asymptomatic Adults with Hamstring Tightness: An Evidence-Based Review Judy Pang, MS, DPT(c) UCSF/SFSU Graduate Program in Physical Therapy Clinical Problem
Muscle extensibility is an essential element of normal biomechanical functioning (Wassem et al., 2010)
The hamstring (HS) muscles are susceptible to decreased extensibility
Significance of Problem
Do you have tight HS?
Have you treated someone with tight HS? http://www.cartoonstock.com/directory/h/hamstrings_gifts.asp Significance of Problem Difficult to determine prevalence of HS tightness
Decreased HS extensibility is often associated with: Hip and knee movement dysfunctions Patellofemoral pain/patella tendinopathy HS strains Lumbosacral postural changes/ low back pain Bakhtiary et al., 2011, Wassem et al., 2010, Ayala, 2011, and Shadmehr et al., 2009
Relevance to PT Benefits of flexibility (Wassem et al., 2010) Improved ROM, function, coordination and movement Reduced injury risk and improved athletic performance
PTs utilize a variety of interventions to treat HS tightness (Bakhtiary et al., 2011) Static and ballistic stretching Proprioceptive neuromuscular facilitation (PNF) Eccentric training (ECC) Muscle energy technique (MET)
Purpose Primary Examine current literature regarding the effectiveness of MET on improving HS extensibility in healthy, asymptomatic individuals with HS tightness
Secondary Compare the effectiveness of MET to no treatment or an alternative treatment for improving HS extensibility in healthy, asymptomatic individuals with HS tightness Definition: Hamstring shortness Hamstring shortness Lacking >15-30 of knee extension in popliteal angle test
Active Knee Extension: ICC=0.99 (Gajdosik and Lusin, 1983)
Passive Knee Extension: ICC=0.93 (Gnat et al., 2010) Wassem et al., 2010, Shadmehr et al., 2009, Smith and Fryer, 2008 & Ballantyne et al., 2003, http://nexusphysicaltherapy.com/a_hamstring.html
Definition: Muscle Energy Technique A manual technique that involves A muscle, or group of muscles
Voluntarily contracted isometrically Sub-maximal: 75% maximum voluntary isometric contraction (MVIC)
Specific direction
Defined length of time Mitchell & Mitchell, 1995
Application of MET Stretch the muscle to a palpated barrier Produce sub-MVIC Muscle relaxes; clinician maintains stretch Clinician takes up the slack following relaxation Muscle lengthened to new barrier Repeat process
Smith and Fryer, 2008 Theory Explanation Supported? Neurological Reflex muscle relaxation Biomechanical Viscoelastic changes Sensory Tolerance to stretch Theoretical Construct
The exact mechanism is still unclear
Magnusson et al., 1996, Ballantyne et al., 2003, Weppler et al., 2010, Folpp et al., 2006, Chaitow L, 2009 No No Yes PNS: Gate Control Theory of Pain CNS: Activates Brain Pain Centers Circulating Biomarkers Theoretical Construct: Sensory Theory Decrease Pain Muscle Energy Technique Increase Tolerance to Stretch Increase HS Extensibility Chaitow Leon, 2009 Gap in Literature
Limited research supporting and validating the use of MET No systematic review or meta- analysis
Small sample sizes
High variability in MET application parameters
Attempt to collect and pool existing data http://www.experienceproject.com/stories/Took-The-Do-You-Have-Gaps-In-Your-Knowledge-Quiz/1434705 Research Questions Population Intervention Comparison Outcome Healthy, asymptomatic persons with short HS Muscle Energy Technique -No treatment
-Alternative technique -PKE
-AKE Foreground Primary
In healthy, asymptomatic persons with short HS, how effective is MET at improving HS extensibility? Secondary
How does MET compare to no treatment or other treatments at improving HS extensibility in healthy, asymptomatic persons with short HS? Null Alternative Application of MET on the HS muscle will not improve HS extensibility in healthy, asymptomatic persons with short HS Application of MET on the HS muscle will improve HS extensibility in healthy, asymptomatic persons with short HS
MET is not as effective compared to no treatment or an alternative technique at improving HS extensibility MET will be more effective than no treatment or an alternative technique at improving HS extensibility
S e c o n d a r y
P r i m a r y
Hypotheses Expected Findings At least 10 articles matching criteria
Reject both null hypotheses
Expect MET to be effective at improving HS extensibility
MET is more effective compared to no treatment and alternative treatments
Search Methods Data bases Searched:
Recursive search Keywords: Muscle energy technique MET Post-isometric relaxation Active muscular relaxation technique Hamstring Tightness Flexibility Shortness Extensibility Length
Last search date: 5.02.12 Search Methods Inclusion criteria MET to the HS muscles Outcome measure: PKE and/or AKE No restrictions on age or gender Persons with short HS
Exclusion criteria PNF Non-English language articles Hamstring injuries or lower extremity injuries Neurological impairments
Articles identified through database and recursive search: (n=33) Number of duplicates removed: (n=5) Articles screened: (n=28) Articles excluded due to irrelevance or to not meeting following inclusion criteria: (n=24) -Patient population -Knee extension not an outcome measure -MET not performed -If study directly used PNF instead of MET
Articles selected for inclusion in evidence based review: (n=4) Search Results *A secondary reviewer confirmed that the four studies met the inclusion and exclusion criteria and were appropriate for this review. All studies were RCTs, level 1b Study Characteristics Abbreviations: PA:popliteal angle, N=number of participants, y.o.:years old, PKE: passive knee extension, AKE: active knee extension
Author HS Criteria (PA)
N Age (y.o)
Female
Male
Outcome Time of Measurement (days) Ballantyne A et al., 2003
Not stated
40 18-45 Ave 23.4
22
18
PKE
1 Shadmehr A et al., 2008
30
30
20-25
30
0
PKE
28 Smith M and Fryer G, 2009
15
40 Ave 22.1
17
33
AKE
1 Waseem M et al., 2010
20
40
18-25
0
40
AKE
5
Author MET Intervention Comparison Results
MVIC (%) Contraction Time (sec) Relaxation Time (sec) Ballantyne A et al, 2003 75 5 3 Control MET Shadmehr A et al., 2008 50 10 10 Static, passive stretch
Both Smith M and Fryer G, 2009 40 2-3 10 Chaitows MET Both Smith M and Fryer G, 2009 40 30 10 Greenmans MET Both Waseem M et al., 2010 75 5 3 Eccentric Training with theraBand
MET 40- 75% 2-30 sec 3-10 sec Abbreviations: MVIC: maximum voluntary isometric contraction, MET: muscle energy technique Study Characteristics Statistical Analysis
Extracted means and standard deviations for knee extension ROM Single group effect size Two- group effect size
Each study weighted by inverse variance prior to pooling data
Calculate Q statistic to determine homogeneity: random vs. fixed model
Grand effect sizes and 95% CI were calculated
Forest Plot
Grand effect sizes converted to clinical units
-1 0 1 2 3 4 5 6 7 Shadmehr et al. Smith & Fryer: Chaitow Smith & Fryer: Greenman Waseem et al. Ballantyne et al. Grand Effect Size Effect Size (d) Results: Single Group Effect Sizes Significant Q: Random effects model Small <0.3 Moderate 0.3-0.8 Large >0.8
-1 -0.5 0 0.5 1 1.5 2 Waseem et al. Ballantyne et al. Shadmehr et al. Grand Effect Size Effect Size (d) Small <0.3 Moderate 0.3-0.8 Large >0.8
Jewell 2008
0.56 (0.18, 0.95) STATISTICALLY SIGNIFICANT! Discussion Null Alternative Application of MET on the HS muscle will not improve HS extensibility in healthy, asymptomatic persons with short HS Application of MET on the HS muscle will improve HS extensibility in healthy, asymptomatic persons with short HS
MET is not as effective compared to no treatment or an alternative technique at improving HS extensibility MET will be more effective than no treatment or an alternative technique at improving HS extensibility
S e c o n d a r y
P r i m a r y
Discussion: Why is MET effective? PNS: Gate Theory CNS: Activates Brain Pain Centers Circulating Biomarkers Decrease Pain Muscle Energy Technique Increase Tolerance to Stretch Increase HS Extensibility Response Bias Chaitow Leon, 2009 Discussion: Effect of Dosing 100 110 120 130 140 150 160 170 180 Shadmehr et al. Smith & Fryer: Chaitow Smith & Fryer: Greenman Waseem et al. Ballantyne et al. Study K n e e
E x t e n s i o n
( d e g r e e s ) Pre-MET Post-MET -1 0 1 2 3 4 5 6 7 Shadmehr et al. Smith & Fryer: Chaitow Smith & Fryer: Greenman Waseem et al. Ballantyne et al. Grand Effect Size Time of measurement (days) 28 1 1 5 1 5X Discussion: Harm and Cost Harm & Risk No studies indicated any harm or adverse effect May potentially strain/tear HS or cause neural symptoms
Cost Not addressed in literature No materials needed Time efficient Direct PT care Cost of PT education and possibly continuing education
Clinical Units Conversion
Commonly assume 5 measurement error and a 10 Minimally Clinically Important Difference (Weijer et al., 2003)
ES (95% CI) Clinical Units Significant? Single Group 1.56 (0.58, 2.54) Two-Group 0.56 (0.18, 0.95) Abbreviations: ES: effect size, CI: confidence interval No
No
2.2 -9.7 1.4 -7.1 Clinical Implication
Statistically significant but not clinically significant Dependent on type of population Longer treatment duration
MET should be trialed Statistically significant Trends toward 10 MCID Low cost Money Time Low risk of harm
Heterogeneity in qualitative aspects of study designs Lack of standardization for MET parameters Subjective MVIC No studies had muscle-tendon stiffness data Real versus apparent muscle extensibility
Directions for Further Research Larger sample size
Standardize MET protocol
More representative population Age History of HS injury Abnormal fibrous tissue & cross-linkages
Longer term of treatment
Muscle-tendon stiffness data
http://scholasticadministrator.typepad.com/.a/6a00e54f8c25c9883401676355388a970b-popup Conclusions MET is a statistically significant intervention at improving HS extensibility
MET is more effective than no treatment or alternative treatments
Not clinically significant
Further research needed to provide standardization and clear guidance for the use of MET in patients with HS injuries
-1 0 1 2 3 Single Group Grand Effect Size Two-Group Grand Effect Size 0.56 (0.18, 0.95) 1.56 (0.58, 2.54) Effect Size (d) Acknowledgements Betty J. Smoot, PT, DPTSc Erica A. Pitsch, PT, MPT, DPT Diane Allen, PT, PhD Kristine Amii, MS, DPT(c) Aaron Chung, MS, DPT (c) UCSF/SFSU MS-DPT class of 2012 References Ayala F, Baranda PS, Croix MDS, Santonja F. Absolute reliability of five clinical tests for assessing hamstring flexibility in professional futsal players. J Sci Med Sport. 2012;15(2):142-147. Smith M, Fryer G. A comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group. J of Bodywork and Movement Therapies. 2008;12(4):312-7. Wassem M, Nuhmani S, Ram CS, et al. A comparative study of the impact of muscle energy technique and eccentric training on popliteal angle: hamstring flexibility in Indian collegiate males. Serbian J of Sport Sci. 2010;4(1):41-46. Bandy WD, Irion JM, Brigger 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(4):295-300. Sheard PW, Smith PM, Paine TJ. Athlete compliance to therapist requested contraction intensity during proprioceptive neuromuscular facilitation. Manual Therapy. 2009; 14:539-543 References Bakhtiary AH, Fatemi E, Khalili MA, et al. Localised application of vibration improves passive knee extension in women with apparent reduced hamstring extensibility: a randomised trial. J of Phys Ther. 2011;57(3):165-71. Shadmehr A, Hadian MR, Naiemi SS, et al. Hamstring flexibility in young women following passive stretch and muscle energy technique. J of Back and Musculoskeletal Rehab. 2009;22(3):143-8. Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67-81. Marshall PWM, Cashman A, Cheema BS. A randomized controlled trial for the effect of passive stretching on measures of hamstring extensibility, passive stiffness, strength, and stretch tolerance. J Sci Med in Sport. 2011;14(6): 535- 540. Petersen J, Hlmich. Evidence based prevention of hamstring injuries in sport. Br J Sports Med. 2005;39:319-323. Gnat R, Kuszewski M, Koczar R, Dziewonska A. Reliability of passive knee flexion and extension tests in healthy subjects. J Manipulative Physiol Ther. 2010;33(9): 659-665.
References Law RYW, Harvey LA, Nicholas MK, et al. Stretch exercises increase tolerance to stretch in patients with chronic musculoskeletal pain: a randomized controlled trial. Phys Ther. 2009;89:1016-1026. Ballantyne F, Fryer G, McLaughlin P. The effect of muscle energy technique on hamstring extensibility: the mechanism of altered flexibility. J of Osteo Med. 2003;6(2):59-63. Chaitow L, MET Variations: Possible Neurological Mechanisms; http://www.leonchaitow.com/PDFs/METpaper.pdf; accessed November 10, 2011. Grubb ER, Hagedorn EM, Inoue N, Leake MJ, Lounsberry NL, Love SD, Matus JP, Morris LM, Stafford KM, Staton GS, Waters CM http://www.mc.uky.edu/athletic_training/docs/ModalityProject_MuscleEnerg y_Spring2010.pdf Magnusson SP, Simonsen EB, Dyhre-Poulsen P, McHugh MP, Kjaer M. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Arch Phys Med Rehabil.1996;77:373-368. Fryer G. Muscle energy concepts - a need for change. J of Osteo Med. 2000;3(2):54-59. Gaidosik R, Lusin G. Hamstring muscle tightness. Reliability of an active- knee-extension test. Phys Ther. 1983;63(7):1085-90.
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