International Journal of Osteopathic Medicine (2013) 16, 153e162

www.elsevier.com/ijos

RESEARCH REPORT

Which is the better method to improve perceived

hamstrings tightness e Exercises targeting neural
tissue mobility or exercises targeting hamstrings
muscle extensibility?
Bhavana Suhas Mhatre a,*, Yuvraj Lalit Singh b,
Janhavi Yogesh Tembhekar c, Amita Mehta d
a

P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre, Seth G.S. Medical College and KEM
Hospital, Parel, Mumbai 400012, Maharashtra, India
b
MGM School of Physiotherapy, Sector 30, Plot No. 46, Vashi, Navi Mumbai, Maharashtra, India
c
Kartavya Clinic, Nagpur, Maharashtra, India
d
PT School and Centre, Seth GSMC and KEMH, Parel, Mumbai 400012, Maharashtra, India
Received 8 June 2012; revised 9 January 2013; accepted 18 June 2013

KEYWORDS
Mulligans Bent Leg
Raising technique;
Neurodynamics;
Stretching;
Manual therapy;
Tissue mechanics

Recent studies suggest that subjects who perceive their hamstrings to be

tight are unlikely to have altered hamstring muscle extensibility or length. Altered
neural tissue mobility also referred to as altered neurodynamics could be a significant contributor to perceived hamstrings tightness. Conventionally, hamstrings
stretching exercises are employed to treat perceived hamstrings tightness. There
is a paucity of literature assessing the effectiveness of exercises targeting neural
tissue mobility or neurodynamics as opposed to conventional hamstrings stretching
exercises. With this aim, a prospective trial of 56 female physiotherapy students
with perceived hamstrings tightness was conducted. Study design used was two
group pre testepost test design with systematic random sampling. Subjects were
randomly divided into 2 groups; Group A received Mulligans Bent Leg Raise (BLR)
technique followed by Two Leg Rotation technique (TLRT) to improve neural tissue
mobility and Group B received passive hamstrings stretching to improve hamstrings
muscle extensibility. Outcome measures included knee flexion angle during Active
Knee Extension test and the Slump test. Intra group analysis showed statistically
significant improvement in knee flexion angle for both tests in both the groups.

Abstract

* Corresponding author.
E-mail addresses: suhasmhatre@yahoo.com (B.S. Mhatre), yuvraj555@hotmail.com, yuvrajls555@gmail.com (Y.L. Singh),
janhavi18@gmail.com (J.Y. Tembhekar), amitaam@gmail.com (A. Mehta).
1746-0689/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijosm.2013.06.002

154

B.S. Mhatre et al.

Inter group comparison showed that there was greater improvement in the group
receiving neural tissue mobility exercises with statistically significant improvement
in Slump test with cervical extension (mean difference was 7.214
, 95% confidence
interval 12.67 to 1.75). Thus it was concluded that exercises which target neural
tissue mobility are more effective than exercises targeting hamstrings muscle
extensibility in treating "perceived hamstrings tightness".
2013 Elsevier Ltd. All rights reserved.

Implications for clinical practice

 Inclusion of neurodynamics tests should be an important assessment procedure during clinical
examination of subjects with perceived hamstrings tightness so as to direct treatment interventions towards improving neural tissue mobility.
 Exercises targeting neural tissue mobility or neurodynamics are more effective than those targeting hamstrings muscle extensibility in improving immediate post intervention perceived
hamstrings tightness in subjects without back pain or pathology.
 Mulligans techniques of Bent Leg Raise (BLR) and Two Leg Rotation Technique (TLRT) can be used
to treat perceived hamstrings tightness in these subjects.

Introduction
Inability to extend the knee completely when the
hip is flexed accompanied by discomfort or pain
along the posterior thigh and/or knee is usually
attributed to hamstrings muscle tightness. Extensibility of this bi-articular muscle group is essential
for postures and activities of daily living. Assessment of extensibility and treatment of hamstrings
muscle tightness are considered injury preventive
and commonly incorporated by physical therapists
in their orthopaedic assessment and management.
Numerous tests such as Passive Knee Extension
(PKE), Popliteal Angle (PA), Straight Leg Raising
(SLR) and Active Knee Extension (AKE) have been
recommended to measure hamstrings muscle
extensibility.1 AKE is a reliable and recommended
test to measure hamstring muscle length.2 AKE
attempts to indicate hamstring muscle length by
measuring the angle of knee flexion during active
knee extension with the hip held at 90
of flexion.3
Normative data for AKE values is not available.
Based on studies by Kuilart and Youdas we can
consider subjects having knee flexion angle of
more than 20
on AKE test to have hamstrings
tightness or reduced hamstrings length.1,4 However, tests that are used to assess hamstrings
muscle length such as AKE, PKE and SLR combine
hip flexion and knee extension movements.
This stretches all tissues posterior to the axis of
rotation of these joints including both the hamstrings group and neural structures. Therefore,
these tests are unable to differentiate between

extensibility of hamstrings, neural tissues and

other soft tissues except when the ankle dorsiflexion as structural differentiation is added to
SLR.5 It is necessary to differentiate between
various anatomical structures because the treatment of altered neural tissue mobility is conceptually different from that of reduced hamstrings
extensibility.1
Hence, inclusion of neurodynamics tests should
also be a valuable assessment procedure during
clinical examination of subjects with perceived
hamstrings tightness. These tests assess the mechanical performance and sensitivity of the neural
structures and their related interfacing and
innervated tissues.5 Maitland, Shacklock, Butler
and Kuilart have proposed the use of the Slump
test in clinical examination for differentiation
between neural mechanosensitivity and hamstring
extensibility.1,5e7 Mechanosensitivity is the chief
mechanism by which the nervous system becomes
a source of pain with movements and postures. It is
thought to be a normal protective mechanism that
allows the nerves to respond to the mechanical
stresses imposed upon them during movement.5
The more mechanosensitive the nerve is the less
force is needed to elicit activity and the more
intense are the response. Neck flexion, knee
extension and dorsiflexion in Slump test elongates
the nerve bed from both the ends, increasing
tension in the connective tissue of the neural system leading to stimulation of C-type nerve fibers
present in the connective tissue of the peripheral
and central nervous system. This can be the source

Perceived hamstrings tightness

for discomfort and stretch pain experienced by the
subjects and the resistance felt by the therapist.
Frequently the resistance experienced is due to
muscle contraction and is considered as a response
to the mechanical stimulation of the related neural structure to protect the relevant neural structure.5,8,9 Neuropathodynamics is mechanical or
physiological dysfunction, that is intermittent,
dynamic and related to perturbations in movement
and sensitivity. It is postulated to be the cause of
pain without the presence of pathology or loss of
nerve conduction.5 Lew and Puentedura found
that 81 out of 100 asymptomatic subjects had a
positive Slump test, defined as having further
knee extension range of motion after cervical
extension.10
Conventionally, methods employed to treat
hamstring muscle tightness are passive stretching
exercises either performed by the therapist or by
subject. Kuilart et al. in their study concluded that
subjects who perceived they had tight hamstrings
were unlikely to have reduced hamstring length or
extensibility.1 It was postulated that neural
mechanosensitivity may play a significant role in
explaining perceived hamstring tightness. With
this view in mind, it can be hypothesized that exercises thought to target the neural mobility or the
neurodynamics system would be better methods of
treating perceived hamstrings tightness.
Various treatment strategies have been advocated to improve neurodynamics by targeting
different components of the neurodynamics system. Direct nerve mobilization (sliders, tensioners
and single joint nerve mobilization), addressing
the mechanical interface, postural correction and
ergonomic adaptations are ways of approaching
altered neurodynamics.8 Among exercises, which
target neural structures, Coppieters et al. and Ellis
et al. advocated the use of slider mobilization
exercises. In these exercises tension is increased
at one end and lessened at the opposite end of the
nerve, thus improving nerve excursion.8,11 Treatments of conditions that affect the nervous system
through the mechanical interface are directed at
optimizing the abnormal and undesirable forces
exerted on the nervous system by the interfacing
movement complex. These techniques are
believed to produce an opening action around a
nervous system and consist of movements of
joints, muscles and fascia.5 They ultimately affect
the mechanosensitivity of the neural structures.
There is however, lack of literature supporting
these claims. Resisted static contractions of hamstrings by pushing hip in to extension and knee in
to flexion against the therapists body has been
recommended as a means of treating both the

155
muscular and neural components for altered
mechanosensitivity of the sciatic nerve due to
hamstring strain.5
An exercise similar to this is the Bent Leg Raise
(BLR) advocated by Mulligan B for treating patients
with low back pain who have limited or painful
SLR.9,12 Mobilization of nervous tissue has been
postulated as one of the causes for improvements
seen post BLR by Hall T et al.9 The exercise of Two
Leg Rotation Technique (TLRT) advocated by Mulligan B for limited SLR is postulated to open the
lateral intervertebral foramen and move the neural structures.12 Both these techniques are easy to
apply, less time consuming and are thought to
affect all three components of neurodynamics
system. BLR is directed by the therapist and TLRT
performed by the patient. The presumed effects of
both these exercises are very much similar. TLRT
can be considered as an exercise to carry forward
the beneficial effects of BLR. Thus, these two were
chosen as part of exercise program aimed to
improve the neural tissue mobility. Evidence to
support the choice of BLR and TLRT is however
lacking. No researcher has yet combined these two
manual therapy techniques to target neural tissue
mobility. This study was then undertaken to evaluate the effects of an exercise program aimed to
improve neural tissue mobility/neurodynamics in
subjects who perceived their hamstrings to be
tight and then compare the same with the effects
of stretching exercises given to improve hamstring
muscle length.

Method
Ethical approval was obtained from the departmental ethics committee of PT School and Centre,
Seth GSMC and KEMH, Mumbai before the
commencement of the study. Fig. 1 is a flow diagram depicting the progress of participants
through the study process. 78 asymptomatic female students from Physiotherapy School and
Centre, Seth GSMC and KEMH, Mumbai aged 18e22
years, who reported that their hamstrings felt
tight volunteered for this study. Informed consent was obtained from all participants. Subjects
with pain or history of back or lower extremity
trauma, spinal pathology or lower limb pathology
were excluded from the study. Subjects were
included if they demonstrated a knee flexion angle
greater than 20
on examination using the AKE
test. Twenty two subjects with a knee flexion
angle less than or equal to 20
were excluded.
Fifty six subjects were included in the study
and were further assessed with the Slump test.

156

B.S. Mhatre et al.

Figure 1

Flow of subjects through the study process.

A universal double arm goniometer was used to

measure the knee flexion angle. The assessors
were blinded to group allocation. Two outcome
measures thus assessed were:
Outcome measure 1: Active knee extension test
(AKE): Subjects were positioned in supine without
a pillow underneath the head. The participants
left hip was flexed and stabilized to 90
by an assistant. They were then asked to slowly extend
their left knee until they felt the first stretch
sensation. They maintained this position till the
knee flexion angle was measured with the goniometer. This procedure was repeated three times
and mean of three readings was calculated.1
Outcome measure 2 (Slump test): The Slump test
was performed in a seated position using the
sequence described by Butler.7 Subjects were made
to sit erect at the edge of the plinth with their
hands crossed behind their back; therapist ensured
the sacrum was maintained in a vertical position.
They were asked to sag or slump and then flex their
neck by drawing chin to their chest. The therapist
then placed the subjects left foot in dorsiflexion
and asked them to extend their left knee. Knee
flexion angle was measured with a goniometer.
Subjects were then instructed to extend their neck
and try extending the knee further. Knee flexion
angle was again measured in this position.
Systematic random sampling was used to allocate the subjects to either Group A, or Group B.
Subjects numbered 1, 3, 5 and so on were allocated to Group A which received exercises to
improve neural tissue mobility and subjects
numbered 2, 4, 6 and so on were allocated to
Group B which received exercises to improve
hamstrings extensibility. Both the groups received

two sets of exercises-, one administered by the

therapist and the other exercise done independently by the subject. The interventional group
(Group A) performed two exercises to improve
neural tissue mobility which were
1) Mulligans Bent Leg Raise technique (BLR)9,12 e
The subject was asked to lie in the supine position on the plinth. The subjects flexed left
knee was placed on the therapists shoulder
and was asked to press the leg on to the therapists shoulder and then relax. At this point,
the therapist held the bent knee up as far as
possible in the direction of the left shoulder.
This position was sustained for 30 s, and then
the leg was lowered to the bed. This was
repeated three times with intermittent rest
period of 30 s (Fig. 2)
2) The two leg rotation technique was performed
by the patient (TLRT) was a modification of
bilateral leg rotation technique used by Mulligan
B.12 The subject in the supine position gripped
the side of the plinth with his hands and flexed
both the legs so that the feet were off the
plinth. With shoulders remaining on the plinth,
legs were slowly rotated to the right side, held
in this position for 30 s before returning to the
crook lying position and slowly straightened.
This procedure was repeated thrice with a
pause of 30 s between repetitions.
The control group (Group B) performed two
exercises to improve hamstring muscle length.
1) Passive hamstring stretch e With the subject in
the supine position, the therapist gripped the

Perceived hamstrings tightness

157

Figure 2

Mulligans Bent Leg Raise (BLR) technique.

left leg at the ankle while stabilizing the knee

to maintain full extension. The hip was flexed
to the point of mild tension in the hamstring
muscle. The leg was then placed on the therapists left shoulder and held for 30 s. The
opposite hip and knee were stabilized in
extension. The elevated leg was then returned
to the neutral position. The entire procedure
was then repeated a total of three times.13,14
(Fig. 3)
2) Passive hamstring self- stretch e With the
subject in the supine position, the left leg was
held in hip flexion and knee in extension to the
point of mild hamstring tension with the foot
against a wall. This position was maintained for
30 s and then lowered to neutral position. The
contra lateral leg was in anatomically neutral

Figure 3

position. The entire procedure was repeated a

total of three times.

Results
The data obtained was analyzed using SPSS 16.0.
Demographic data, mean knee flexion angle on
AKE, Slump test with cervical flexion and extension
are presented in Table 1. No significant difference
was noted between the groups with respect to age
(p 0.150), knee flexion angle on AKE (p 0.158)
and on Slump test with cervical flexion and
extension (p 0.213 and 0.503 respectively). The
average knee flexion angle on AKE test at baseline,
both groups taken together, in this study was
34.21
. Pre intervention e post intervention intra

Static stretching of hamstrings.

158
Table 1

B.S. Mhatre et al.

Descriptive statistics.
Group A

Age (in years)

AKE Pre (in degrees)
CxFlex Pre (in degrees)
CxExt Pre (in degrees)

22.32
31.78
35.54
24.54

Group B

(1.84)
(8.18)
(11.16)
(12.71)

21.46
34.64
39.46
26.69

p value

(2.50)
(6.65)
(12.12)
(12.26)

Standard error
difference

0.150
0.158
0.213
0.503

0.588
1.994
3.115
3.338

95% confidence interval

of the difference
Lower

Upper

2.035
1.141
2.316
4.442

0.321
6.856
10.173
8.942

Values expressed as Mean (SD).

Key e AKE Pre: Pre intervention knee flexion angle on Active Knee Extension test; CxFlex Pre: Pre intervention knee flexion angle
on Slump test with cervical flexion; CxExt Pre: Pre intervention knee flexion angle on Slump test with cervical extension.

group analysis for Groups A and B are presented in

Tables 2 and 3 respectively. Table 4 shows inter
group analysis.
Post intervention score on AKE showed that
mean knee flexion angle reduced significantly in
both groups. The AKE knee flexion angle reduced by
9.82 (6.59) degrees in Group A (p 0.00, 95%
confidence interval (CI) 7.26e12.37) and 10
(7.32) degrees in Group B (p 0.00 95%
CI 7.15e12.84). Between group comparison did
not show any statistically significant difference
(p 0.924, 95%CI 3.55e3.91). Post intervention
score on Slump test with cervical flexion showed
that mean knee flexion angle reduced significantly
in both groups. The knee flexion angle reduced by
16.42 (9.31) degrees in Group A (p 0.00, 95%
CI 12.81e20.04) and 12.14 (8.09) degrees in
Group B (p 0.00, 95% CI 9.00e15.28). The
reduction was more in Group A; however, the difference between the groups was not statistically
significant (p 0.072, 95% CI 8.96 to 0.391).
Post intervention score on Slump test with cervical
extension showed that mean knee flexion angle
reduced significantly in both groups. The knee
flexion angle reduced by 17.75 (11.78) degrees
in Group A (p 0.00, 95% CI 13.18e22.31) and
10.53 (8.31) degrees in Group B (p 0.00, 95%
CI 7.31e13.76). The difference between the

Table 2

groups was statistically significant (p 0.011, 95%

CI 12.67 to 1.75).

Discussion
The average knee flexion angle on AKE test at
baseline, both groups taken together, in this study
was 34.21
which was similar to the average knee
flexion angle on AKE test reported by Kuilart et al.
of 35.2
and also within the range of normative PKE
data reported by Youdas et al.1,4 85% of subjects
showed improvements in knee flexion range in
Slump test on cervical extension at the time of
initial assessment. This is similar to the study by
Kuilart et al. who reported that 83% of subjects
had either partial or complete relief of symptoms
after cervical extension on Slump test.1 This indicates that altered neural tissue mobility and
neural mechanosensitivity played a vital role in
explaining the feeling of perceived hamstrings
tightness.
However, the primary aim of the study was to
evaluate the effectiveness of the neural tissue
mobility exercises. The results of this study imply
that knee flexion angle in both the tests had a
significant reduction post exercises in both groups
with Group A showing more reduction as compared

Pre intervention e Post intervention analysis for Group A.

AKE (in degrees)

CxFlex (in degrees)
CxExt (in degrees)

Pre

Post

Mean change

p value

Standard
error of
mean

95% confidence interval

of difference
Lower

Upper

31.78 (8.18)
35.53 (11.16)
24.53 (12.71)

21.96 (8.20)
19.10 (8.61)
6.78 (7.95)

9.82 (6.59)
16.42 (9.31)
17.75 (11.78)

0.00
0.00
0.00

1.24
1.76
2.22

7.26
12.81
13.18

12.37
20.04
22.31

Values expressed as Mean (SD).

Key e AKE: Knee flexion angle on Active Knee Extension test; CxFlex : Knee flexion angle on Slump test with cervical flexion;
CxExt: Kknee flexion angle on Slump test with cervical extension.

Perceived hamstrings tightness

Table 3

159

Pre intervention -post intervention analysis for Group B.

Pre

AKE (in degrees)

CxFlex (in degrees)
CxExt (in degrees)

Post

36.64 (6.65)
39.46 (12.12)
26.78 (12.26)

Mean
change

24.64 (9.22)
27.32 (8.86)
16.25 (10.85)

10.00 (7.32)
12.14 (8.09)
10.53 (8.31)

p value

0.00
0.00
0.00

Standard
error of
mean

95% confidence interval

of difference
Lower

Upper

1.38
1.53
1.57

7.15
9.00
7.31

12.84
15.28
13.76

Values expressed as Mean (SD).

Key e AKE: Knee flexion angle on Active Knee Extension test; CxFlex : Knee flexion angle on Slump test with cervical flexion;
CxExt: Kknee flexion angle on Slump test with cervical extension.

to Group B. Mulligans BLR technique utilizes passive flexion at the hip which results in caudal
loading of the lumbosacral nerve roots and sciatic
nerve in the pelvis, followed by active hip extension. During hip extension, there is unloading of
these neural tissues, and they move in the cranial
direction.5,7 With hip flexion during BLR, there is
obligatory lumbar flexion. With lumbar flexion, the
lateral intervertebral foramina and central canal
open further facilitating caudal movement of the
neural structures.15e17 This movement of neural
structures could be effective in dispersing intraneural edema, thus restoring pressure gradients
and relieving hypoxia.18 Improved mechanics of
the neural structures would be one mechanism for
improvements noted post BLR. BLR also involves
isometric contraction of hip extensors followed by
stretch of the same muscles also referred to as
Post Isometric Relaxation. Post-isometric relaxation refers to the assumed effect of reduced tone
experienced by a muscle or a group of muscles
after brief periods following an isometric contraction.19e22 Improvements noted in Group A
could also be attributed to the effect of isometric
contraction on the connective tissues.16 Combination of contraction and stretches may be

Table 4

responsible for improving the viscoelasticity which

in turn improves tissue extensibility. Effectiveness
of Muscle Energy Technique (MET) to improve
hamstring extensibility has been documented by
Ballantyne et al.23 Group B received hamstrings
stretching exercises. Improvements seen in Group
B can be attributed in part to the effect of passive
hamstrings stretching. However, a number of trials
of hamstrings stretching in patients with spinal
cord injuries have found no significant effect.24e26
In contrast, a meta analysis of trials in the ablebodied population reported a beneficial effect
from relatively short stretch interventions (primarily between 30 s and 3 min a day).13 One
interpretation of these conflicting findings is that
the muscles of able-bodied individuals are more
responsive to stretch than those of their disabled
counterparts. However, a more likely interpretation is that reported beneficial effects of stretch in
able-bodied subjects are primarily due to changes
in subjects tolerance to an uncomfortable stretch
sensation.27 The concept of passive stretch
bringing about changes in subjects tolerance to
stretch rather than any change in actual extensibility of hamstrings was also advocated by Flopp
et al.28 The improvements seen in Group B thus

Inter group analysis.

Group A

Group B

p value

Mean
difference

Standard error
difference

95% confidence interval

of the difference
Lower

AKE Diff
(in degrees)
CxFlex Diff
(in degrees)
CxExt Diff
(in degrees)

Upper

9.82 (6.59)

10.00 (7.32)

0.924

0.179

1.86

3.55

3.91

16.43 (9.31)

12.14 (18.10)

0.072

4.286

2.33

8.96

0.39

17.75 (11.78)

10.54 (8.31)

0.011

7.214

2.72

12.67

1.75

Values expressed as Mean (SD).

Key e AKE Diff: Pre intervention-post intervention difference of knee flexion angle on Active Knee Extension test; CxFlex Dif: Pre
intervention-post intervention difference of knee flexion angle on Slump test with cervical flexion; CxExt Diff: Pre interventionpost intervention difference of knee flexion angle on Slump test with cervical extension.

160
may be attributed in part to change in stretch
tolerance of the individual to passive stretching. A
second mechanism could be an improvement in
neurodynamics due to a tensioner effect on the
neural structures.5 Passive stretching of hamstrings which is similar to SLR has been shown to
induce hamstrings and gluteal muscle activity.29
This protective contraction of hamstrings muscle
(innervated tissue as well as mechanical interface
for sciatic nerve) and gluteal muscles (mechanical
interface for sciatic nerve) could restrict the
excursion of the sciatic nerve. This may explain
the reason why tensioners are less effective than
sliders in improving neural mobility. This in turn
may explain why Group A which employed sliders
mobilization improved more than Group B which
employed tensioners mobilization for sciatic
nerve.
Both of the outcome measures used in the present study are actually psychophysical tests that
can incorporate significant psychosocial aspects.5
Thus, changes in pain responsiveness could also
in part explain the improvements noted in both
groups. The explanations for changes in pain
responsiveness have not been well understood.
Afferent input from muscles and joints during BLR,
TLRT or stretching may interfere with signals from
nociceptive fibers (stretch discomfort), subsequently inhibiting an individuals perception of
pain. This explanation is consistent with the gate
control theory of pain.30 Mulligans Mobilization
with Movement (MWM) is reported to cause pain
relief through neurophysiological effects like
sympathoexcitation, improvements in motor
function and non-opioid hypoalgesia in patients
with lateral epicondylalgia.31 Neuromodulation of
pain by the gate-control mechanism and activation
of descending pain-inhibitory systems, mediated
by areas such as the periaqueductal grey matter of
midbrain has been proposed as a possible mechanism for reduction of headaches by sustained
natural apophyseal glides (SNAGs) at C1 e C2
levels.31 Whether Mulligans BLR can have similar
neurophysiological effects needs to be further
evaluated Alternatively, changes in pain responsiveness may be psychologically mediated. It is
possible that participants anticipated the positive
effects of BLR and TLRT or stretching and therefore, their perception of pain during AKE and
Slump was dampened. According to the gate control theory, sensations of pain and discomfort are
affected by descending modulatory influences
from higher centers. Prior experiences of BLR and
TLRT (as all were Physiotherapy students), motivation (possibly from supervision), and elevated
mood and confidence from positive expectations

B.S. Mhatre et al.

of BLR and TLRT or stretching are all potential
psychological contributors explaining the participants altered perception of discomfort and willingness to tolerate greater stretch over time. The
notion that education enhances the patient understanding of pain and may reduce the sensitivity
of neurons and allow better movement should not
be missed.32 Education and expectation surely are
a part of modern neurodynamics. When a manual
technique is performed either by the therapist or
by the patient, a complex and intricate series of
conditioned responses occurs across the whole
psychophysical spectrum. Pain and fear, along with
muscle and autonomic changes, are just a few
kinds of responses.33 These effects on central
mechanism would contribute to the improvements
noted in both groups. Group A improved more
than Group B. The question of whether exercises
targeting neural tissue mobility are better at
improving pain responsiveness than exercises
targeting muscle extensibility needs further
inquiry.
Thus, exercises targeting neural tissue mobility/
neurodynamics were a better method to treat
perceived hamstrings tightness. Now, with an
understanding that subjects with perceived hamstrings tightness are more likely to be experiencing altered neurodynamics and respond better
to exercises targeting neural tissue mobility than
that targeting hamstring muscle extensibility,
there is a need to consider revising training and
therapy programs. We suggest that assessment of
neurodynamics with tests like the Slump and AKE
should be an essential part of preseason assessment in sports and in patients with low back pain.
Hamstrings stretches can give way to exercises
which improve the neural tissue mobility or neurodynamics in those with perceived tightness. It
would be worthwhile to discuss a recent point of
view proposed by Ledermann. According to him,
postural and structural asymmetries (like altered
neurodynamics) are unlikely to be the cause of
mechanical disorders.34 He challenges the practice
of manual and exercise therapy based on postural,
structural and biomechanical (PSB) model. Body
systems seem to have reserve capacity to allow for
asymmetry and imperfections to exist without
failure or symptoms. These asymmetries are unlikely to be changed by exercises, or manual
therapy in the long run un less the exercises are
rigorously followed. Would altered neurodynamics
be clinically relevant and would exercises targeting
neural tissue mobility rectify them in the long term
need to be studied further. In the present study,
there were 22 female subjects who perceived their
hamstrings to be tight, though were excluded as

Perceived hamstrings tightness

they had knee flexion angle lesser than 20
on AKE.
The reason for these exclusions could be the difference in the manner we perceive the sensation
of stretch. This perception would be influenced
psycho social factors, details of which are beyond
the scope of this article. The high number of exclusions also raises questions over the specificity of
the method used by us to measure hamstrings
muscle length. A significant limitation of this study
is that it did not examine the long term effects of
the either of the exercise methods which would be
required to determine if these approaches are
useful inclusions in training and therapy programs.
The subjects were all young healthy female physiotherapy students. This cohort of subjects did not
include professional sports persons or patients with
low back pain. Hence, the results of this study
need to be used with caution. Studies with sports
persons and patients with low back pain who
perceive their hamstrings to be tight need to be
performed to be more specific. Nevertheless, this
study still raises a question on the choice of exercises traditionally employed to treat perceived
hamstrings tightness.

Conclusion
Exercises targeting neural tissue mobility or neurodynamics are more effective than those targeting hamstrings muscle extensibility in improving
immediate post intervention perceived hamstrings tightness in subjects without back pain or
pathology. Further research is required to determine whether either approach produces long term
gains and if these gains are made in patients with
specific conditions such as low back pain or a
tendency to hamstring strains.

Author contribution statement

Contributions made by each author are as follows
1. Concept, idea and research design: Mhatre
Bhavana.
2. Acquisition of data: Mhatre Bhavana, Tembhekar Janhavi.
3. Analysis and interpretation of data: Mhatre
Bhavana, Singh Yuvraj.
4. Writing/review/editing of manuscript: Mhatre
Bhavana, Singh Yuvraj.
5. Final approval of manuscript: Mhatre Bhavana,
Singh Yuvraj.
6. Providing facilities and equipments: Mhatre
Bhavana, Mehta Amita.

161
7. Providing subjects: Mhatre Bhavana, Mehta
Amita.
8. Author who takes responsibility of integrity of
work as a whole: Mhatre Bhavana.

Acknowledgments
The authors express their gratitude for all subjects
for their voluntary participation. Also we wish to
acknowledge Ms. Swapnali Chavan who helped us
in data collection.

References
1. Kuilart KE, Woollam Barling E, Lucas N. The active knee
extension test and Slump test in subjects with perceived
hamstring tightness. Int J Osteopathic Med 2005;8:89e97.
2. Gajdosik R, Lusin G. Hamstring muscle tightness: reliability
of active knee extension test. J Orthopaedic Sports Phys
Ther 1983;63:1085e8.
3. Cameron DM, Bohannon RW. Relationship between active
knee extension and active straight leg raise test measurements. J Orthopaedic Sports Phys Ther 1993;17:257e60.
4. Youdas JW, Krause DA, Hollman JH, Harmsen WS,
Laskowski E. The influence of gender and age on hamstring
muscle length in healthy adults. J Orthopaedic Sports Phys
Ther 2005;35:246e52.
5. Shacklock M. Clinical neurodynamics. 1st ed. Edinburgh:
Elsevier; 2005.
6. Maitland G. The Slump test: examination and treatment.
Ausraliant J Physiother 1985;31:215e9.
7. Butler D. Mobilisation of the nervous system. 1st ed. Melbourne: Churchill Livingstone; 1991.
8. Coppieters MW, Alshami AM. Longitudinal excursion and
strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Orthopaedic Res 2007;
25:972e80.
9. Hall T, Hardt S, Schafer A, Wallin L. Mulligan bent leg raise
techniqueda preliminary randomized trial of immediate
effects after a single intervention. Man Ther 2006;11:
130e5.
10. Lew PC, Puentedura EJ. The straight-leg-raise test and
spinal posture: is the straight-leg-raise a tension test of a
hamstring length measure in normals?. In: Fourth biennial conference. Brisbane: Manipulative Therapists Association of Australia; 1985.
11. Ellis R, Hing W, McNair P. Comparison of longitudinal sciatic
nerve movement with different mobilization exercises: an
In Vivo study utilizing ultrasound imaging. J Orthopaedic
Sports Phys Ther 2012;42:667e75.
12. Mulligan B. Manual therapy NAGS, SNAGS, MWS etc..
6th ed. Orthopedic Physical Therapy Products; 2010.
13. Harvey L, Herbert R, Crosbie J. Does stretching induce
lasting increases in joint ROM? A systematic review. Physiother Res Int 2002;7:1e13.
14. Dadebo B, White J, George KP. A survey of flexibility
training protocols and hamstring strains in professional
football clubs in England. Br J Sports Med 2004;38:388e94.
15. Panjabi MM, Takata K, Goel VK. Kinematics of lumbar
intervertebral foramen. Spine 1983;8:348e57.
16. Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM,
Nowicki BH. Anatomic changes of the spinal canal and

162

17.
18.

19.
20.

21.

22.

23.

24.

25.

B.S. Mhatre et al.

intervertebral foramen associated with flexion-extension

movement. Spine 1996;21:2412e20.
Louis R. Vertebral radicular and vertebro medullary dynamics.
Anatomia Clinica 1981;3:1e11.
Cowell IM, Phillips DR. Effectiveness of manipulative physiotherapy for the treatment of neurogenic pain syndrome: a
single case studydexperimental design. Man Ther 2002;7:
31e8.
Chaitow L. Muscle Energy technique-advanced soft tissue
technique. 3rd ed. Churchill Livingstone; 2006.
Etnyre BR, Abraham LD. H reflex changes during static
stretching and two variations of proprioceptive neuromuscular facilitation techniques. Electroencephalography Clin
Neurophysiol 1986;63:174e9.
Carter A. Proprioceptive neuromuscular facilitation decreases
muscle activity during the stretch reflex in selected posterior
thigh muscles. J Sport Rehabil 2000;9:269e78.
Taylor DC, Brooks DE. Viscoelastic characteristics of muscle: passive stretching versus muscular contractions. Med
Sci Sports Exerc 1997;29:1619e24.
Ballantyne F, Fryer G. The effect of muscle energy technique
on hamstrings extensibility: the mechanism of altered flexibility. J Osteopathic Med 2003;6:59e63.
Harvey LA, Batty J, Crosbie J, Poulter S, Herbert RD. A
randomized trial assessing the effects of 4 weeks of daily
stretching on ankle mobility in patients with spinal cord
injuries. Arch Phys Med Rehabil 2000;81:1340e7.
Harvey LA, Byak AJ, Ostrovskaya M, Glinsky J, Katte L,
Herbert RD. Randomised trial of the effects of four weeks
of daily stretch on extensibility of hamstring muscles in

26.

27.
28.

29.

30.
31.

32.

33.
34.

people with spinal cord injuries. Aust J Physiother 2003;49:

176e81.
Lannin N, Horsley S, Herbert R, McCluskey A, Cusick A. Hand
splinting in the functional position after brain impairment:
a randomized controlled trial. Arch Phys Med Rehabil 2003;
84:297e302.
Magnusson M, Simonsen EB. A mechanism for altered flexibility in human skeletal muscle. J Physiol 1996;497:291e8.
Folpp H, Deall S, Harvey LA, Gwinn T. Can apparent increases in muscle extensibility with regular stretch be
explained by changes in tolerance to stretch? Aust J Physiother 2006;52:45e50.
Boyd B, Wanek L, Gray A, Topp K. Mechanosensitivity of the
lower extremity nervous system during straight-leg raise
neurodynamic testing in healthy individuals. J Orthopaedic
Sports Phys Ther 2009;39:780e90.
Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:171e9.
Vicenzino B, Paungamali A, Teys P. Mulligans mobilizationwith-movement, positional faults and pain relief: current
concepts from a critical review of literature. Man Ther
2007;12:98e108.
Moseley GL, Nicholas MK, Hodges PW. A randomized
controlled trial of intensive neurophysiology education in
chronic low back pain. Clin J Pain 2004;20:324e30.
Shacklock MO. The clinical application of central pain mechanisms in manual therapy. Aust J Physiother 1999;45:215e21.
Ledermann E. The fall of the posturalestructurale
biomechanical model in manual and physical therapies:
exemplified by lower back pain. CPDO Online J 2010:1e14.

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