Post Isometric Relaxation - Essay Example

An Investigation to Determine Whether Post-Isometric Relaxation Combined with Prior Application of Massage is more Effective in Promoting Increased Hamstring Flexibility than Post Isometric Relaxation Alone Introduction One of the most important aspects of chiropractics and osteopathy is concerned with enabling patients to maintain and restore maximum movement and functional ability throughout the lifespan (Vickers and Zollman, 1999). This is particularly important in circumstances where the process of ageing or that of injury or disease threatens movement and function. It is true that a great majority of people experience difficulties with movement. In this relation, therapeutic muscle stretching has had known positive roles in inducing muscle flexibility (Ghaffarinejad et al., 2007). In this context, a distinction must be made between muscle relaxation techniques and muscle stretching techniques. These techniques are usually applied on the muscles that are hypertonic, and before application of these techniques as modes of manual therapy, it is important to demonstrate muscle tightness. In the muscles, there are stretch receptors called Golgi tendon organs, located in the tendons of the agonist muscles (Schwellnus, 2009). These receptors limit overstretching of the muscle bundles through their reactions to inhibit muscle contractions beyond a certain limit. It is known physiologically that these organs react through inhibition of efferent motor neurons impulse transmission, preventing further contraction of the muscles. This leads to reduction of the muscle tone, which results in agonist relaxation and lengthening. It is important to note that the Golgi tendon organs react to both passive and active movements. This leads to an important therapeutic physical principle of passive mobilisation of a joint, since these Golgi tendon organs respond to both active and passive movements. Therefore, judicious application of passive mobilisation along with direct massage may have a good effect on relaxing muscles (MacKay-Lyons, 2002). Literature Review There is a considerable interest in the efficacy of such therapies, and research has continuously added volumes of evidence in this area. Therefore, a critical review of literature would be prudent to find out the gaps in research, so a discernible research design can be crafted in order to find out whether post-isometric relaxation alone or combined with massage may be more effective in treating hamstring tightness in order to result in better flexibility in this group of muscles (Prior et al., 2009). As has been elucidated earlier, muscle hypertonicity may be viewed as a physiologic condition leading to increased sensitivity of the stretch reflex, hyperactivity, and muscle shortening. Clinically, although there is no evidence of fascial hypertrophy and shortening, it can be determined during the muscle length assessment, where the muscles feel resilient with a restricted, end-range feel leading to a resistance to stretch with minimal involvement of the fascia (Clark et al., 2000). When there is involvement of the fascia, the muscle may appear less resilient and hence tight due to shortening of the fascia. Due to this noncontractile component of the muscle dysfunction, restoration of the function would need stretching of the muscle along with its fascia (Koulouris and Connell, 2005). Further to this research has shown that stretching may impair balance, reaction, and movement times (Winters et al., 2004). Muscle energy technique is in frequent use that aims normalise skeletal muscles and somatic tissue dysfunctions. Application of this technique needs appropriate training. A basic approach is postisometric relaxation which can be easily integrated into the massage therapy, and this can be effectively applied for enhancing relaxation of muscles (Roberts, 1997). The term muscle energy technique covers a number of procedures, of which postisometric relaxation is most frequently used, and it can be accomplished through incorporation of a massage therapy. The muscle energy technique has been demonstrated to reduce muscle tension (Smith and Fryer, 2008). This technique is designed to stretch the shortened muscle.bundles. Postisometric relaxation involving muscle energy technique uses active muscle contraction at varying intensities from precisely controlled positions in a specific direction against a counteracting force. This means, the client must actively participate in this process by muscular contraction and inspiration and expiration during manual treatment techniques. As has been highlighted, the prime importance is on soft tissues and muscles which are responsible for abnormal joint pains and movement limitations (Goodridge, 1981). Literature has indicated many benefits of postisometric relaxation, which are stretching of tight muscles and fascia, reduction of muscle tonus, improvement of local circulation, strengthening of weak musculature, and mobilisation of joint restrictions. Essentially, this method uses muscle contraction initiated by the patient followed by relaxation and stretch of an agonist or antagonist muscle. This makes it a mobilisation technique using muscular facilitation and inhibition (Wilson et al., 2003). Muscle energy has been considered to be extremely valuable for corrections of positional faults or joint hypomobility. The reason is that this technique combines methods to increase extensibility of periarticular tissues with methods to restore a length-tension relationship to the muscles controlling the movements of the joint. Therefore, there is an element of periarticular soft tissue mobilisation inherent in this. Physiologically, this takes advantage of the principles of the segmental facilitation (Mason, 2009). When the gamma motoneuron discharge to the muscle spindle is excessive, less external stretch is required to fire the primary annulospiral endings which reflexly fire the extrafusal muscle fibers via the alpha motor neuron. This involves exaggerated spindle responses provoked by motions that may tend to lengthen the facilitated muscle leading to creation of a restrictive fault. In that context, this bears resemblance to functional technique in that it aims to restore the normal neurophysiology of the segment (Mitchell, 1995). While talking about hamstring flexibility, although there is a paucity of studies and objective data in this area, the findings from a study by Burns and Wells (2006) may be reviewed which may throw some light in this proposed study. Muscle energy technique in that sense is considered to be an established manipulative intervention used for treatment of somatic dysfunctions in joints, despite absence of objective data that point to its efficacy. Extrapolating the findings to the hamstrings, somatic dysfunction in the hip region often results in sensitivity changes, such as, tenderness, hypertonicty of the muscles, asymmetry, and restricted range of motion of the affected areas. Sensitivity change is subjective and can be recorded from the reports of the patients (Burns and Wells, 2006). Examination by palpation will detect tissue tension and asymmetry. Mechanical measurements may aid this. Gross hip range of motion can be a parameter to objectively assess the hamstrings following intervention, since hypertonicity of the hamstrings may cause diminished range of motion. Along with that, regional range of motion barriers may also be overcome using muscle energy techniques. Muscle energy techniques have been shown to improve gross range of motion in other areas of the body (Ehrenfeuchter, 2000). It has been postulated that hypertonic restrictor muscles may limit segmental motions. Shorten and hypertonic hamstrings may cause reduced range of motion (Luckenbill-Edds and Bechill, 1995). Therefore effective lengthening of these larger muscle groups may help to restore gross physiologic range of motion, since it has also been postulated that distortion of articular relationships and motion loss result from reflex hypertonicity of the musculature crossing the dysfunctional joint. The relevance of therapeutic massage comes in when it has been found that increased muscle tone may tend to compress the joint surfaces resulting in hydraulic locking of the articulation (Bush and Vorro, 2008). It seems plausible due to the fact that restoration of motion to the articulation can result in a reseating of the distorted joint relationships with reflex relaxation of the previous hypertonic musculature. Tissue massage in Osteopathy and physiotherapy language consists of repeated stroking maneuvers which may both be diagnostic and therapeutic in nature (McCombs, 2006). The massage strokes are applied to specific areas of the body leading to beneficial reflex effects in the tissues of those zones. It has been proposed that massage produces local mechanical effects on the underlying connective tissues and cells resulting in reflex mechanisms that reduce sympathetic activity to produce vasodilatation (Vaughn and Nitsch, 2008). Objectives Based on this literature review, it is clear that postisometric relaxation can help hamstring tightness leading to easing of the movement of the hip joint. The question remains whether massage has any positive effect if it is applied over the hamstrings if it is applied before the postisometric relaxation. Although theoretically, it could have positive effect, there is no study available which can demonstrate the comparative effects of massage followed by postisometric relaxation on the hamstrings as compared to postisometric relaxation alone. With this, this proposed study aims to examine the effects of these two modalities of therapy on hamstring tightness. Aims To propose an investigation to determine whether postisometric relaxation combined with prior application of massage is more effective at promoting increased hamstring flexibility than post isometric relaxation alone. Literature Search To build a scientific basis of evidence, a comprehensive literature search was undertaken and then evaluated critically. For the purpose of the review of literature, to support the rationale, need, and continuation of the project, this author conducted a literature search across databases (Evans, 2002). Those accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, and CINAHL and Cochrane databases were searched to identify relevant literature on osteopathy and physiotherapy to reduce hypertonicity of hamstring muscles. HighWire Press was also searched. These sites were accessed through online registration in the respective websites. The search for relevant literature began with identification of the key words (Evans, 2003). These words were coined from the rationale and the focus question of this particular research. Then through application of Boolean logic, some combinations of key words were decided to be searched. The initial search was conducted on the abstracts of the prospective articles, and if an article could be narrowed down with presence of the combination key word terminology, a detailed search was undertaken on that article (Finfgeld, 2003). The articles that appeared in the reference of these articles were also located and searched to see whether they match the inclusion criteria mentioned above. The key words in the search included "hamstring hypertonicity", "hamstring tightness", "physiotherapy", "postisometric relaxation", "muscle energy technique", "massage", "hamstring massage", "controlled trial", and "randomised controlled trial." Only 6 articles were located and none of them were on hamstring muscle energy technique, and none compared the effects of massage followed by postisometric relaxation. However, these provided a guideline as to this proposed investigation may be designed. Methodology Subjects will be recruited from the first year medical students as the control group and the experimental group will be recruited from patients attending physiotherapy outpatients with hip movement restrictions. For each group, it was decided that X participants will be recruited. Informed consent will be requested from each of the participants following ethical approval of the study design. Inclusion and exclusion criteria will be used to exclude participants who have disorders involving bony hip joint, acute undiagnosed pain, or hypermobility. For the control group, the first year medical students will be selected since this may reduce the possibility of previous subject exposure to muscle energy techniques (Boyajian-O'Neill et al., 2008). It will also be important to ensure that all subjects recruited were unfamiliar with the technique. The experimental subjects will be randomly assigned the either study groups by asking them to draw a slip of paper with group assignment printed on it. It could be expected that this would prevent group assignment based on bias or preference. The subjects including those in control group will be blinded to the treatment type and the measurements obtained. The physiotherapist will be blinded to the measurements in each subject. All muscle energy techniques and massage treatments will be performed in the biomechanics laboratory (Burns and Wells, 2006). In the treatment group B, only postisometric relaxation will be applied, and in the treatment group C, initial massage followed by postisometric relaxation will be applied. The control group A will receive no treatment. The treatments will be applied to the hamstrings of the affected thigh according to the basic procedures in each plane of motion, flexion extension, abduction and adduction, and rotation (Buchmann et al., 2005). The hip joint will be brought to the barrier of motion in each of these planes. The instructor would provide isometric resistance for 3 to 5 seconds or massage followed by isometric resistance for 3 to 5 seconds as the case may be, following which the subjects will be asked to relax their muscles completely and a new barrier of motion will be engaged by the instructor. Three repetitions will be performed (Ingber, 1989). Measurements Active range of motion of each of the subjects of the hip pretreatment and posttreatment following 1 to 2 minutes after intervention will be recorded. A goniometer will be used for this purpose. These measurements will be recorded for all three groups in all three plains of motion. In many cases it may be expected that improvement will occur over time. Therefore, repeated measures need to be taken every day for each of the patients over a period of 3 weeks. The mean of set of data for all ranges of motion will be calculated for each individual, and the difference will be available from the baseline data. This will generate a frequency distribution of full range of motions in degrees in each of the three planes before and after intervention protocols. For comparisons between study groups, the magnitude of difference in range of motion between pretreatment and posttreatment will be tested with an analysis of variance statistical design. This data will then be examined for potential differences within subjects for each plane and intervention using a paired t test, which would determine whether paired sets differ significantly from each other under the assumptions that the paired differences are independent and distributed normally or identically (Cassidy et al., 1992). Results If the analysis reveals significant differences between the groups, it would indicate the validity of the hypothesis that massage followed by postisometric relaxation can be a better alternative in hamstring tightness management in comparison to postisometric relaxation alone. Relevance to Physiotherapy and Conclusion This study will not address the cause of potential restrictions or somatic dysfunctions in the hamstring apparatus, and therefore, the mechanism of improvement of range of motions may not be delineated. All study subjects were having some subacute hip range of motion problems. The measurements will be done by a goniometer, which may further limit the results of this study, where actually a 3-D motion analysis could be the best way to measure the improvement in the range of motion. If the hypothesis of this study is proved, it can lead to a customised way of using massage and muscle energy technique for the hip region with hamstring postisometric relaxation and massage. The area under treatment should govern the amount of force and counterforce applied by the physiotherapist. For the hip and the hamstrings, pounds of treatment force may be required. Further study is necessary to address the issues related to the efficacy and refinement of the muscle energy technique in the process of opitimising triplanar motion in the hip. References Boyajian-O'Neill, LA., McClain, RL., Coleman, MK., and Thomas, PP., (2008). Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. J Am Osteopath Assoc; 108: 657 - 664. Buchmann, J., Wende, K., Kundt, G., and Haessler, F., (2005). Manual treatment effects to the upper cervical apophysial joints before, during, and after endotracheal anesthesia: a placebo-controlled comparison. Am J Phys Med Rehabil; 84(4): 251-7. 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Passive Versus Active Stretching of Hip Flexor Muscles in Subjects With Limited Hip Extension: A Randomized Clinical Trial. Physical Therapy; 84: 800 - 807. Read More