Interrater and Intrarater Reliability of the Active Knee Extension (AKE) Test among Healthy Adults

Comparing the immediate effects of different neural mobilization exercises on hamstring flexibility in recreational soccer players

Background

Hamstring strain injuries remain a challenge for both athletes and clinicians given the high incidence rate, slow healing, and persistent symptoms. Increased tension in the neural structures is a known causative factor for hamstring tightness for which neural mobilization has emerged as a significant adjunct to routine stretching techniques.

Objective

To compare the short-term effects of neural sliding and neural tensioning on hamstring length in male recreational soccer players with hamstring tightness.

Methods

Sixty-two participants between ages 18 and 30 years were randomly assigned to one of the two groups viz. neural sliding or neural tensioning. Participants in either group performed the given stretching protocol in three sets. The Active Knee Extension Test (AKET) and Sit and Reach Test (SRT) were recorded before intervention, immediately after intervention, and after 60 min. between- and within group-analysis was done using analysis of variance.

Results

Between-group analysis showed that neural tensioning was more effective than neural sliding in improving hamstring length on both measures, however this difference was negligible. Within-group analysis demonstrated that the mean post-test scores on the AKET test and SRT were significantly greater than the pre-test scores in both groups (p < 0 . 05 ). A reduction in the post-test scores was observed after 60 min, irrespective of the type of stretching (p < 0 . 05 ).

Conclusion

There was no difference in short-term effects of neural sliding or neural tensioning on hamstring flexibility in male recreational soccer players. Both groups showed improved flexibility immediately after the intervention with reduction in the effect after 60 min.

A New Measuring Approach in Assessing Hamstring Flexibility: Reliability, Validity, and Applicability of Isolated Hamstring Flexibility Test

OBJECTIVE

This study was planned to determine the reliability, validity, and applicability of the isolated hamstring flexibility test (IHFT).

DESIGN

A cohort study (diagnosis); level of evidence, 2.

SETTING

It was performed in the research and application laboratory.

PARTICIPANTS

Seventy-five individuals aged 18 to 25 years, selected through simple probability random sampling, with a normal Beighton Horan and Joint Mobility Index scores, and who volunteered to participate, were included for evaluation.

INTERVENTIONS

On then first and third days, participants underwent muscle strength, sit-and-reach test, active knee extension test, IHFT for validity and reliability. Stretching exercises were prescribed as a home program for 31 patients with limited knee extension, and measurements were repeated at the end of the eighth week.

MAIN OUTCOME MEASURES

Sit-and-reach test, active knee extension test, IHFT.

RESULTS

The test-retest reliability was high (intraclass correlation coefficient, 0.993). Our test demonstrated validity when compared in terms of flexibility gained. A significant difference was found between pre-post stretching exercise training in all 3 tests ( P < 0.05).

CONCLUSION

It was observed that the IHFT is reliable and applicable in determining hamstring flexibility. Given the absence of another test specifically measuring hamstring flexibility in isolation, its indirect validity was established through analysis with other tests using the gold standard for assessing gains in hamstring flexibility.

Shoulder MRI parameters in anticipating anterior shoulder dislocation: Are they a reliable and reproducible tool in clinical practice?

BACKGROUND

Anterior shoulder dislocation (ASD) is a frequently observed musculoskeletal injury that is often encountered in the context of sports activities or as a result of trauma. Several magnetic resonance imaging (MRI) parameters have been previously investigated for the purpose of characterizing the anatomical features, which could potentially be responsible for the episodes of instability. These measurements have the potential to identify patients who are susceptible to dislocation. Consequently, ensuring the reliability and consistency of these measurements is crucial in the diagnosis and the management of athletic or traumatic shoulder injuries.

METHODS

A group of four students, who had no previous experience in reading MRI series, were selected to perform radiographic measurements on specific parameters of MRI scans. These parameters were glenoid version, glenoid depth, glenoid width, humeral head diameter, humeral containing angle, and the ratio of humeral head diameter to glenoid diameter. The four participants conducted two distinct readings on a total of 28 sets of shoulder MRI scans. Simultaneously, the aforementioned measures were assessed by a consultant shoulder surgeon.

RESULTS

A total of 1512 measurements were categorized into nine sets: eight from students' measurements (two per student) and one from the consultant. Intra-rater reliability assessed by the intra-class correlation (ICC) test indicated excellent or good reliability for all parameters (p < 0.05), with glenoid depth showing the highest (0.925) and humeral-containing angles the lowest (0.675) ICC value. Inter-rater correlation, also evaluated using ICC, demonstrated strong correlation (p < 0.05), with glenoid diameter having the highest ICC score (0.935) and glenoid depth the lowest (0.849). Agreement analysis, expressed by Cohen's Kappa test, revealed substantial agreement (p < 0.05) for all parameters, with humeral head diameter having the highest agreement (0.90) and humeral-containing angle the lowest (0.73).

CONCLUSION

In this study, intra- and inter-rater MRI parameters are substantially concordant. Credibility comes from these reliability and agreement analyses' statistical significance. Glenoid diameter and depth are the most reliable intrarater and interrater, respectively. Best agreement was with the humeral-containing angle. These data demonstrate repeatability and clinical relevance.

LEVEL OF EVIDENCE

Level IV.

Recovery of spatio-temporal gait and functional parameters following unilateral eccentric exercise-induced muscle damage in the hamstrings

OBJECTIVES

This study aimed to analyze how spatiotemporal gait parameters, active knee extension range of motion, muscle activity, and self-perceived function change over a seven-day period in healthy individuals after exercise-induced muscle damage (EIMD) in the hamstrings.

DESIGN

Longitudinal cohort study.

METHODS

Twenty-four healthy males participated in four sessions before and after EIMD (pre-EIMD, 48 h, 96 h, and 168 h post-EIMD). A single-leg deadlift exercise was performed to provoke EIMD in the hamstrings of the dominant leg. Lower limb function perception, spatiotemporal gait parameters, active knee extension range of motion, and electromyographic (EMG) activity of the semitendinosus and biceps femoris muscles during gait and maximal isometric contraction were assessed bilaterally.

RESULTS

At 48 h, the EIMD-side showed reduced step length, active knee extension range of motion, maximal strength and EMG activity compared to baseline (P < 0.042), while increased relative EMG activity in the biceps femoris during gait (P = 0.001). At 96 h, step length and EMG activity on the EIMD-side reached similar values to those at baseline, whereas lower limb function perception and active knee extension range of motion returned to baseline state at 168 h post-EIMD. No changes over time were observed on the control-side.

CONCLUSIONS

Recovery from EIMD requires a multimodal assessment since the different parameters affected by EIMD recover at different paces. Active range of motion appears to be the last variable to fully recover. Self-perceived function should not be considered in isolation as it does not represent complete functional recovery.

Validity and reliability of a new hip flexor muscles flexibility assessment tool: The reactive hip flexor (RHF) test

BACKGROUND

The modified Thomas test is the most used and most reliable test to assess the hip flexors' flexibility. However it does not evaluate the interaction of both legs. The objective of this study is to propose a new assessment tool for hip flexor flexibility, the Reactive Hip Flexion (RHF) Test.

METHODS

An observational, intra-test, and test-retest study with repeated measures was carried out with the aim of assessing the validity and reliability of the RHF Test. The participants were males and females aged between 18 and 35 years old who had a training schedule of at least 2 days a week, without a musculoskeletal lower limb or lumbopelvic pathology. The reliability of the test was examined using the intraclass correlation coefficients (ICCs) by a two-way random model to establish inter-rater reliability and a two-way mixed model to assess intra-rater reliability. The precision was measured by the standard error of measurement (SEM). In addition, the minimum detectable change (MDC95%) was calculated.

RESULTS

Twenty-six participants (52 hips) (47% female) completed the study. No correlations were observed between anthropometric variables and RHF peak force or active knee extension (AKE) measurements. There was an excellent intra-rater and inter-rater ICC in the hip flexors' reactive peak force and the AKE measurements, with a low SEM.

CONCLUSIONS

This study demonstrated that the proposed RHF test technique is valid and reliable when used in healthy youth population.

The association of hamstring tightness with lumbar lordosis and trunk flexibility in healthy individuals: gender analysis

Objectives: The purpose of this study was to investigate if there is a relation between hamstring tightness and lumbar lordosis as well as trunk flexibility based on gender differences and to analyze the differences in hamstring tightness, lumber lordosis and trunk flexibility in healthy adults. Methods: One hundred young healthy adults were recruited and distributed into 2 equal groups according to gender: group A (female group) and group B (male group). Hamstring tightness (HT) was measured by Active Knee Extension (AKE) test and Straight Leg Raise (SLR) test, the angle of lumbar lordosis was measured with a flexible ruler from standing position and trunk flexion flexibility (TFF) was measured by Fingertip-to-Floor Test. Results: There was a significant correlation between TFF and both measures of HT (SLR, p = 0.001; AKE, p = 0.001) in females. While, there was a non-significant correlation in males (SLR, p = 0.900; AKE, p = 0.717). Moreover, there was a non-significant correlation between lumbar lordosis and HT measures in both groups as (p > 0.05). Furthermore, there were significant differences between males and females in hamstring flexibility, TFF and lumbar lordosis as (p < 0.05). Conclusion: Gender differences in the relationship between hamstring tightness and trunk flexion flexibility are significant. However, there was no significant difference between males and females in the relationship between hamstring tightness and lumbar lordosis.

Sensory, functional and electromyographic variables show different recovery patterns over a seven day period following exercise-induced pain in the hamstrings

BACKGROUND

Delayed-onset muscle soreness (DOMS) is common after unaccustomed exercises and can restrict performance if intense physical activities are performed while the muscle is still sore. This study aimed to evaluate the recovery process following exercise-induced DOMS over a seven-day period by evaluating sensory, functional, and electromyographic parameters.

METHODS

Twenty-four healthy males participated in four experimental sessions (Day-0, Day-2, Day-4, Day-7). Pain perception, pressure pain sensitivity, active range of motion, maximal isometric strength, and muscle activity of the hamstrings during the maximal isometric contraction were assessed bilaterally at each session. A single-leg deadlift eccentric exercise (5-sets of 20-reps) was performed at the end of Day-0 to induce DOMS in the dominant leg.

FINDINGS

At Day-2, the DOMS-side showed increased pain sensitivity and decreased active range of motion, strength and muscle activity compared to Day-0 (P < 0.015). Muscle activity on the DOMS-side reached similar values than at baseline on Day-4, whereas pain perception, pressure pain sensitivity, maximal isometric strength, and active range of motion had returned to the baseline state on Day-7. No changes over time were observed on the control-side, showing all variables an excellent reliability between values at Day-0 and Day-7 (Intraclass Correlation Coefficient > 0.90).

INTERPRETATION

Surface electromyographic values during a maximal isometric contraction recover faster than the other parameters. Given the heterogeneous path of altered variables towards DOMS recovery, trainers and clinicians should consider a multimodal assessment, including quantitative sensory and functional measures in addition to the subjective perception of recovery.

Comparison of utilizing modified hold-relax, muscle energy technique, and instrument-assisted soft tissue mobilization on hamstring muscle length in healthy athletes: Randomized controlled trial

INTRODUCTION

The hamstring muscle shortness is the primary risk factor for sports-related injuries. Numerous treatments are available for lengthening of hamstring muscle. The main purpose of this study was to compare the immediate effect of modified hold-relax, muscle energy technique (MET), and instrument assisted soft tissue mobilization-Graston techniques (IASTM-GT) on length of hamstring muscle in young healthy athletes.

METHODS

60 athletes comprising of 29 females and 31 males were recruited in the present study. Participants were allocated to 3 groups of IASTM-GT (N = 20, 13 male, 7 female), Modified Hold-relax (N = 20, 8 male, 12 female), and MET (N = 20, 7 male, 13 female). Active knee extension and passive straight leg raising (SLR), and toe touch test were performed before and immediately after the intervention by a blinded assessor. For the comparison of dependent variables across time, 3*2 repeated measure ANOVA was utilized.

RESULTS

Interaction of group by time was significant for passive SLR (P < 0.001). Interaction of group by time was not significant for active knee extension (P = 0.17). The results showed that dependent variables increased significantly in all groups. The effect size (Cohen's d) in the groups of IASTM-GT, modified Hold-relax, and MET was 1.7, 3.17, and 3.12, respectively.

CONCLUSION

Although the measures were improved in all groups, it seems that IASTM-GT can be used as a safe and efficient treatment, which can be a suitable candidate alongside modified hold-relax and MET for increasing the hamstrings muscle length in healthy athletes.

Effect of thoracic mobilization exercises on hamstring flexibility: a randomized controlled trial

Background and aim

The aim was to investigate the effect of thoracic mobilization exercises on hamstring flexibility.

Materials and methods

One hundred twenty individuals with hamstring tightness were included in the study. The participants were randomized into two groups: the experimental group (EG) (n = 60) or the control group (CG) (n = 60). The EG performed a home-based thoracic mobilization exercise program comprising 2 sets with 10 repetitions, once a day, 3 days a week, for 4 weeks. The CG performed active-assisted stretching of the hamstring comprising 3 sets with 10 repetitions for 15 seconds. The active knee extension (AKE) test was used to measure hamstring flexibility, and self-reported hamstring pain intensity was evaluated with a visual analog scale (VAS). All evaluations were conducted at the beginning and end of the intervention.

Results

Both groups showed significant improvement in AKE (p<0.05). Pain intensity during the stretching exercises was significantly decreased only in the EG. The improvements in AKE and VAS score were greater in the EG than in the CG (p < 0.05). Between-group effect sizes were large for AKE (d = 1.075) and VAS score (d = 1.077).

Conclusion

The current study showed that thoracic mobilization exercises may increase hamstring flexibility and reduce pain intensity during hamstring stretch exercises.

The Immediate Effect of Kinesio Tape on Hamstring Muscle Length and Strength in Female University Students: A Pre-post Experimental Study

Background

Kinesio tape has been proposed to improve the muscle extensibility. However, there are contradictory results in the literature.

Objective

To investigate the effect of Kinesio tape on hamstring muscle lengthening and on hamstring and quadriceps muscle strengthening in university students with hamstring muscle tightness.

Methods

In this pre-post experimental study, 96 female students with hamstring muscle tightness were recruited from Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, and randomly assigned to Kinesio tape, sham tape, or control groups (32 in each group). The inhibition technique was used for the Kinesio tape application, with the tape being applied from the muscle insertion to the origin. Measurements were taken before and 15 min after the intervention. Outcome measurements included active knee extension test to measure the hamstring muscle length, and isometric strength measurements of hamstring and quadriceps muscles using a handheld dynamometer.

Results

A significant increase in the immediate hamstring muscle length was found in both the Kinesio (P = 0.001) and sham (P = 0.004) tape groups, while no difference was noted in the control group (P = 0.066). The muscle lengthening was significantly greater in the Kinesio tape group than the sham tape (P = 0.001) and control (P = 0.001) groups. There was no difference in the pre- and post-measurements in the quadriceps and hamstring muscle strengths in all three groups.

Conclusions

These results demonstrate that applying Kinesio tape has an immediate effect on hamstring muscle extensibility, but has no effect on the quadriceps and hamstring muscle strengths.

ClinicalTrialsgov identifier NCT number

NCT03076840.

Comparison of dry needling and self-stretching in muscle extensibility, pain, stiffness, and physical function in hip osteoarthritis: A randomized controlled trial

BACKGROUND AND PURPOSE

Patients with hip osteoarthritis (OA) present myofascial trigger points in the hip muscles that may reduce muscle extensibility, provoke pain and stiffness, and decrease physical function. The purpose of the study was to compare the effects of dry needling (DN) intervention with a self-stretching protocol on muscle extensibility, pain, stiffness, and physical function in patients with hip OA.

MATERIALS AND METHODS

A single-blinded randomised controlled trial was designed. Thirty-eight participants with hip OA were randomly assigned to the DN group (n = 19) or the stretching group (n = 19). The DN group received three sessions of DN, and the stretching group followed a 3-week protocol. Hip muscle extensibility was the primary outcome and was measured using the Ely test, the modified Ober test, and the Active Knee Extension test. Pain, stiffness, and physical function were the secondary outcomes measured with the WOMAC questionnaire. The variables were assessed before and after treatment by blinded examiners.

RESULTS

DN was more effective than self-stretching for improving hip flexor and abductor muscles extensibility (p < 0.05). DN and self-stretching techniques improved hip extensor muscles extensibility, pain, stiffness, and physical function in patients with hip OA (<0.05). The DN group showed large effect sizes in all the variables (d > 0.8).

CONCLUSION

Three sessions of DN were more effective than three weeks of self-stretching to improve hip muscle extensibility in patients with hip OA. DN and self-stretching techniques decreased pain and stiffness and improved physical function in patients with hip OA.

The Immediate Effect of Adding Lumbar Mobilization to A Static Stretching Program on Hamstrings Range of Motion: An Exploratory Study

A contributing risk factor and a byproduct of a hamstrings strain is limited hamstrings range of motion (ROM). Some evidence supports static stretching (SS) and lumbar spinal mobilization therapy (LSMT) as an effective means for increasing hamstrings ROM. However, the efficacy of combining LSMT and SS for increasing hamstrings ROM is unknown. The objective of the study is to quantify the immediate effects of the combination of LSMT and SS compared to LSMT and SS on hamstrings ROM in a healthy population. Thirty participants were randomized by block allocation into one of three intervention groups: (1) LSMT (unilateral lumbar PA mobilization at L-4); (2) SS; or (3) combination of LSMT and SS. Hamstrings ROM was measured pre- and post-intervention by the active knee extension test (AKET). There was no group-by-time interaction effect (p = 0.871). Within group analysis revealed a significant statistical change and a large effect size: LSMT (p = .037, RCI = 3.36, d = 0.771); SS (p = 0.035, RCI = 2.94, d = 0.781); combination (p = .005, RCI = 4.21, d = 1.186. The findings suggest that the combination of LSMT and SS does not have a further effect on hamstrings ROM compared to the individual results of LSMT or SS.

Sex Differences in Pre-Season Anthropometric, Balance and Range-of-Motion Characteristics in Elite Youth Soccer Players

In soccer, injury epidemiology differs between males and females. It is clinically useful to know whether there are between-sex differences in selected characteristics relevant to primary injury risk and injury prevention practices. The purpose of this study was to explore between-sex differences in anthropometric, balance, and range-of-motion characteristics in Spanish elite male and female youth soccer players. This was a pre-season cross-sectional study. Sixty-nine males (age 16.8 ± 0.9 yr; height 175.9 ± 6.8 cm; mass 67.9 ± 6.3 kg) and thirty-seven females (age 17.2 ± 1.7 yr; height 164.0 ± 6.3 cm; mass 59.0 ± 5.8 kg) participated. Anthropometrics (standing/sitting height, bodymass, right/left leg length) and right/left anterior reach test (ART), hip internal/external active range of motion, active knee extension (AKE), and weightbearing lunge test (WBLT) were measured. Between-sex differences were assessed with Bonferroni-corrected Mann−Whitney U tests and Cliff’s delta (d). Between-sex significant differences (p < 0.003, d ≥ 0.50) were observed for anthropometric data and for hip internal rotation. No between-sex significant differences were observed for ART/AKE/WBLT measures. Between-sex significant differences with large effect sizes were identified for anthropometric data and right/left hip internal rotation. The present study adds new data to the literature for young Spanish male and female soccer players. The present findings will help inform clinical reasoning processes and future injury prevention research for elite male and female youth soccer players.

Acute effects of varying densities of foam roller on hamstring flexibility and eccentric strength

Background/Aims

Foam rolling is a popular form of self-administered soft tissue therapy, commonly used in sporting environments. There are several variations in foam roller types including differences in density. No studies have examined the effects of different density type rollers on performance. This study compares the effects of varying foam roller density on hamstring flexibility and eccentric hamstring strength in active men.

Methods

A total of 28 healthy male participants (height 176.7 ± 5.9 cm; body mass 75.8 ± 9.6 kg; age 21.6 ± 4.0 years) were randomly allocated to receive a low density, medium density or high density foam roller or allocated to a control group. Outcome measures included hamstring flexibility through active knee extension (°) and eccentric hamstring strength pre and immediately-post foam roller application.

Results

Significant foam roller x time interactions were found for hamstring flexibility (P<0.05). Significant increases in active knee extension were reported post-foam roller application for all foam roller densities (P<0.05). No significant changes in strength parameters (break angle, peak and average force and torque) were found (P>0.05). No significant interactions between strength parameters, limb, type of roller or time were found (P>0.05).

Conclusions

Foam roller use elicits immediate positive increases in hamstring flexibility through active knee extension assessment, with the lower density foam roller displaying the largest increases in hamstring flexibility. No change in strength parameters were noted with the increases in flexibility; however, this does not denote that injury risk is reduced because of this. Findings provide practitioners with insight to inform decision making for the use of different densities of foam roller in practical settings.

The roles of lower-limb joint proprioception in postural control during gait

The objective of the present study was to investigate the roles of lower-limb joint proprioception in postural control during gait. Seventy-two healthy adults including 36 younger and 36 older adults participated in two experimental sessions, i.e., lower-limb joint proprioception assessment session and gait assessment session. Lower-limb joint proprioception was assessed by joint position sense errors measured at the ankle, knee and hip of the dominant side. Postural control during gait was characterized by step length, step width and local dynamic stability. Results showed that hip proprioception contributed the most to postural control during gait among the lower-limb joint proprioception components, and that mechanisms for the hip proprioception effects were different between age groups. These findings highlighted the importance of incorporating hip proprioception enhancement exercises in postural control training programs, and the necessity of considering age-related differences in the effects of hip proprioception when designing these exercises.

The SWING test: A more reliable test than passive clinical tests for assessing sagittal plane hip mobility

BACKGROUND

Clinical assessment of sagittal plane hip mobility is usually performed using the Modified Thomas Test (for extension) and the Straight-Leg-Raise (for flexion) with a goniometer. These tests have limited reliability, however. An active swinging leg movement test (the SWING test), assessed using 3D motion analysis, could provide an alternative to these passive clinical tests.

RESEARCH QUESTION

Is the SWING test a more reliable alternative to evaluate hip mobility, in comparison to the clinical extension and flexion tests?

METHODS

Ten asymptomatic adult participants were evaluated by two investigators over three sessions. Participants performed 10 maximal hip extensions and flexions, with both legs straight and no trunk movement (the SWING test). Hip kinematics was assessed using a 3D motion analysis system. Maximal and minimal hip angles were calculated for each swing and represented maximal hip flexion (SWING flexion) and extension (SWING extension), respectively. The Modified Thomas Test and Straight-Leg-Raise were repeated 3 times for each leg. On the first day, both investigators performed all the tests (SWING + Modified Thomas Test + Straight-Leg-Raise). A week later, a single investigator repeated all the tests. Inter-rater, intra-rater, within-day and between-day reliability were evaluated using intra-class correlation.

RESULTS

Intra-class correlation coefficients for all the tests were superior to 0.8, except for the Modified Thomas Test's intra-rater, between-day (intra-class correlation 0.673) and the Straight-Leg-Raise's inter-rater, within-day (intra-class correlation 0.294). The SWING test always showed a higher intra-class correlation coefficient than the passive clinical tests. The only significant correlation found was for the Straight-Leg-Raise and SWING flexion (r = 0.48; P < 0.001).

SIGNIFICANCE

The SWING test seems to be an alternative to existing passive clinical tests, offering better reliability for assessing sagittal plane hip mobility.

Qualitative ultrasonography scale of the intensity of local twitch response during dry needling and its association with modified joint range of motion: a cross-sectional study

BACKGROUND

The relevance of local twitch response (LTR) during dry needling technique (DNT) is controversial, and it is questioned whether LTR is necessary for successful outcomes. Furthermore, because the LTR during the deep DNT may be evoked with different intensities, it is unknown whether the magnitude of LTR intensity is associated with optimal clinical results, especially concerning to the effects of joint maximal range of motion (ROM). This study aimed to (i) determine whether visual inspections can quantify the LTR intensity during the DNT through a qualitative ultrasonography scale of LTR intensity (US-LTR scale), and (ii) assess the differences of US-LTR scale associated with changes in the maximal joint ROM.

METHODS

Using a cross-sectional design, seven asymptomatic individuals were treated with DNT in the latent myofascial trigger point in both medial gastrocnemius muscles. During DNT, three consecutive LTRs were collected. The US-LTR scale was used to classify the LTRs into strong, medium, and weak intensities. The categories of US-LTR were differentiated by the velocity of LTRs using the optical flow algorithm. ROM changes in ankle dorsiflexion and knee extension were assessed before and immediately after DNT.

RESULTS

The US-LTR scale showed the third LTR was significantly smaller than the first one (p < 0.05). A significant difference in velocity was observed between US-LTR categories (p < 0.001). A significant difference in the ROM was observed between the strong and weak-medium intensity (p < 0.05).

CONCLUSIONS

The present findings suggest that the LTR intensity can be assessed using a qualitative US-LTR scale, and the effects of DNT on joint maximal ROM is maximized with higher LTR intensity. This study reports a novel qualitative method for LTR analysis with potential applications in research and clinical settings. However, further research is needed to achieve a broader application.

Effect of sciatic nerve mobilisation on muscle flexibility among diabetic and non-diabetic sedentary individuals: a comparative study

The purpose of the present study was to compare the effect of sciatic nerve mobilisation on muscle flexibility among diabetic and non-diabetic sedentary individuals. The study was a pre-post experimental-group design. A sample of 40 sedentary subjects was assigned into two groups; Group A (diabetics: 10 males and 10 females) and Group B (non-diabetics: 10 males and 10 females). Both groups were tested for hamstring and calf flexibility following which sciatic nerve mobilisation was given to the most affected lower limb in terms of reduced hamstring and calf flexibility. Hamstring flexibility was checked by active knee extension test and calf flexibility was checked with the distance-to-wall technique using a tape measure. It was a two-week program in which subjects were given sciatic nerve mobilisation using sliders technique after which flexibility was checked. Three sessions per week were given for two weeks and muscle flexibility of hamstring and calf was measured after the intervention. The present study findings reveal that sciatic nerve mobilisation by sliders technique when given to diabetic and non-diabetic groups of sedentary individuals for two weeks, enhance patient outcomes in both the groups in terms of increase in hamstring and calf flexibility, but results were more significant in non-diabetic individuals as compared to diabetic individuals. In conclusion, sciatic nerve mobilisation resulted in an increase of muscle flexibility of hamstring and calf muscles in both groups.

The effect of different neural mobilization exercises on hamstring flexibility and functional flexibility in wrestlers

This study aimed to compare the short-term effects of sciatic nerve neural sliding and neural stretching exercises on hamstring muscle length and functional flexibility in wrestlers. The study participants included 74 wrestlers. The athletes were randomly divided into two groups: neural sliding and neural stretching groups. The hamstring flexibility and the functional flexibility were assessed using the active knee extension limitation (AKEL) angle and the sit and reach (SR) test one day before and immediately after the neural mobilization exercises, respectively. A three-way repeated measures analysis of variance was conducted that examined the effect of mobilization type, time, and gender on interest in AKEL right leg, AKEL left leg, and SR test. There is not a significant difference between the effect of two different mobilizations on AKEL right and left leg, and SR test (P>0.05). It was determined there is statistically significant differences between premobilization and post-mobilization outcome measures for AKEL right leg (F=59.886, P=0.001), AKEL left leg (F=31.896, P=0.001), and SR test (F=22.630, P=0.001). There is not a statistically significant difference between males and females by these three measures neural sliding and neural stretching exercises to the sciatic nerve in wrestlers were effective in increasing hamstring flexibility and functional flexibility and not superior to each other.

THE RELIABILITY AND MINIMAL DETECTABLE CHANGE OF THE ELY AND ACTIVE KNEE EXTENSION TESTS

Background

Muscle length is a common component of the physical therapy examination, which may include the prone knee flexion (Ely) and active knee extension (AKE) tests. Clinicians using these tests should understand the clinimetric properties.

Purpose

To investigate the reliability and minimal detectable change (MDC₉₅) of the Ely and AKE tests.

Study Design

Reliability analysis.

Methods

Seventy-one asymptomatic adults (mean age 24.6 + /- 2.8 years) were recruited based on a convenience sample. Two examiners each performed the Ely and AKE test one time each in an intrasession design for the interrater reliability component, with one examiner repeating the tests one time 48 hours later to determine the intra-rater reliability. Results were recorded based on one trial per test and utilized a pelvic strap for the Ely test and an adjustable bolster for the AKE test. A separate researcher recorded measurements and results were blinded from the examiners.

Results

The Ely test had excellent intra-rater and inter-rater reliability with an intraclass correlation coefficient (ICC) (3,1) of 0.900 and ICC (2,1) of 0.914 respectively. The intra-rater and inter-rater reliability of the AKE test was good with ICC (3,1) of 0.882 and ICC (2,1) 0.886 respectively. The MDC₉₅ indicated that a change greater than or equal to 8° and 12° is required to exceed the threshold of error for the Ely and AKE test respectively.

Conclusion

The Ely and AKE tests have good to excellent inter-rater and intra-rater reliability for measuring rectus femoris and hamstring muscle length when stabilization of the pelvis and hip is accounted for. The MDC should be considered as a threshold for true change in the asymptomatic adult population.

Levels of Evidence

2b.

Dry Needling for Hamstring Flexibility: A Single-Blind Randomized Controlled Trial

CONTEXT

Hamstring muscle tightness is one of the most common problems in athletic and healthy people. Dry needling (DN) was found to be an effective approach for improving muscle flexibility, but there is no study to compare this approach with static stretching (SS) as a common technique for the increase of muscle length.

OBJECTIVE

To compare the immediate effects of DN and SS on hamstring flexibility in healthy subjects with hamstring tightness.

STUDY DESIGN

A single-blind randomized controlled trial.

SETTING

A musculoskeletal physiotherapy clinic at Tehran University of Medical Sciences.

SUBJECTS

Forty healthy subjects (female: 32, age range: 18-40 y) with hamstring tightness were randomly assigned into 2 groups of DN and SS.

INTERVENTION

The DN group received a single session of DN on 3 points of the hamstring muscles, each for 1 minute. The SS group received a single session of SS of the hamstrings, consisting of 3 sets of 30-second SS with a 10-second rest between sets in the active knee extension test (AKET) position.

MAIN OUTCOME MEASURES

The AKET, muscle compliance, passive peak torque, and stretch tolerance were measured at the baseline, immediately, and 15 minutes after the interventions.

RESULTS

Improvements in all outcomes was better for the DN group than for the SS group. DN increased muscle compliance significantly 15 minutes after the intervention, but it did not improve in the SS group.

CONCLUSION

DN is effective in improving hamstring flexibility compared with SS. One session of DN can be an effective treatment for hamstring tightness and increase hamstring flexibility. The improvements suggest that DN is a novel treatment for hamstring flexibility.

Effectiveness of hamstring stretching using a pressure biofeedback unit for 4 weeks: A randomized controlled trial

Background

Stretching and length test of hamstring muscles have been performed commonly to manage lower back pain (LBP) in sports rehabilitation. Previous literatures addressed that stretching techniques and length test of hamstring muscles should be performed with the pelvic maintained in an anterior tilt position. However, there is no study to determine the effectiveness of pressure biofeedback unit (PBU) to maintain in anterior pelvic tilting (APT) on length test and stretching of hamstring muscles.

Objective

To determine the effectiveness of hamstring muscles stretching using a PBU.

Methods

Forty participants with shortness of hamstrings randomized into two groups. Participants performed the active knee extension (AKE) stretching without (control group) or with PBU (intervention group) for four weeks. AKE tests without and with PBU were administered three times before and after hamstrings stretching by each group.

Results

The AKE test without PBU showed a significant main effect of time ( p < 0 . 01 ) but not of group ( p = 0 . 55 ) on the AKE angle. The AKE test with PBU showed a significant increase in the AKE angle in the post-intervention compared to the pre-intervention assessments in both groups ( p < 0 . 01 ). The difference of AKE angle between the pre- and post-intervention results was significantly greater in the intervention group than in the control group ( p < 0 . 01 ).

Conclusion

We recommend the use of a PBU to maintain the pelvic anterior tilting position when performing the AKE test or AKE stretching.

Immediate Effects of Dry Needling as a Novel Strategy for Hamstring Flexibility: A Single-Blinded Clinical Pilot Study

CONTEXT

There are numerous studies on the benefits of dry needling (DN) for pain relief. No studies exist examining the effects of DN on hamstring flexibility.

OBJECTIVE

To determine the immediate effects of DN on hamstring flexibility in healthy subjects with shortened hamstrings.

DESIGN

A single-blinded, pretest-posttest clinical pilot study.

SETTING

A university physiotherapy clinic.

SUBJECTS

A total of 15 healthy subjects (female = 11; age = 23.26 [4.3] y) with shortened hamstrings participated in this study.

INTERVENTION

Subjects received a single session of DN. Three locations on the hamstring muscle group were needled, each for 1 minute.

MAIN OUTCOME MEASURES

The active knee extension test, muscle compliance, passive peak torque, and stretch tolerance were measured at baseline, immediately, and 15 minutes after DN.

RESULTS

There were statistically significant improvements in all outcome measures immediately after DN and at the 15-minute follow-up. The effect sizes for all outcome measures were large (Cohen's d ≥ 0.8). No serious adverse events were observed with DN.

CONCLUSIONS

This is the first study that demonstrates the beneficial effects of DN on hamstring flexibility, muscle compliance, and stretch tolerance without added stretching. The beneficial effects of DN should encourage clinicians to use DN as a novel strategy for increasing muscle flexibility.

Pain-Free Versus Pain-Threshold Rehabilitation Following Acute Hamstring Strain Injury: A Randomized Controlled Trial

OBJECTIVE

The primary aim was to compare time from acute hamstring strain injury (HSI) to return-to-play (RTP) clearance following a standardized rehabilitation protocol performed within either pain-free or pain-threshold limits. Secondary aims were to compare isometric knee flexor strength, biceps femoris long head (BFLH) fascicle length, fear of movement, and reinjury occurrence at the 6-month follow-up between pain-free and pain-threshold groups.

DESIGN

Randomized controlled trial.

METHODS

Forty-three men with acute HSIs were randomly allocated to a pain-free (n = 22) or pain-threshold (n = 21) rehabilitation group. Days from HSI to RTP clearance, isometric knee flexor strength, BFLH fascicle length, fear of movement, and reinjury occurrence at the 6-month follow-up were reported.

RESULTS

Median time from HSI to RTP clearance was 15 days (95% confidence interval [CI]: 13, 17) in the pain-free group and 17 days (95% CI: 11, 24) in the pain-threshold group, which was not significantly different (P = .37). Isometric knee flexor strength recovery at 90° of hip and 90° of knee flexion was greater in the pain-threshold group at RTP clearance by 15% (95% CI: 1%, 28%) and by 15% (95% CI: 1%, 29%) at 2-month follow-up, respectively. Improvement in BFLH fascicle length from baseline was 0.91 cm (95% CI: 0.34, 1.48) greater at 2-month follow-up in the pain-threshold group. Two reinjuries occurred in both the pain-free and pain-threshold groups between RTP clearance and the 6-month follow-up.

CONCLUSION

Pain-threshold rehabilitation did not accelerate RTP clearance, but resulted in greater recovery of isometric knee flexor strength and better maintenance of BFLH fascicle length, compared to pain-free rehabilitation. J Orthop Sports Phys Ther 2020;50(2):91-103. Epub 28 Jun 2019. doi:10.2519/jospt.2020.8895.

Stretching and Progressive Resistance Exercise in Children With Cerebral Palsy: A Randomized Controlled Trial

PURPOSE

To evaluate the effect of stretching and progressive resistance exercise on range of motion and muscle strength in children with cerebral palsy.

METHODS

Thirty-seven children with spastic bilateral cerebral palsy and Gross Motor Function Classification System levels I to III were randomized to an intervention and a comparison group. The intervention included stretching of hamstrings and progressive resistance exercise, targeting the lower extremities for 16 weeks, followed by a 16-week maintenance program. Passive and active popliteal angle and muscle strength were evaluated at 0, 16, and 32 weeks.

RESULTS

After 16 weeks nonsignificant improvements were found in passive, active popliteal angle and quadriceps and hamstrings strength.

CONCLUSION

A 16-week stretching and progressive resistance exercise program followed by a 16-week maintenance program showed nonsignificant improvements in passive, active popliteal angle and muscle strength for the intervention group.

Pain-Free Versus Pain-Threshold Rehabilitation Following Acute Hamstring Strain Injury: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

BACKGROUND

Conventional guidelines recommend hamstring strain injury (HSI) rehabilitation should only be performed and progressed in complete absence of pain, despite lack of comparison to alternative approaches.

OBJECTIVES

The primary aim of this study was to compare the number of days from acute HSI to return to play (RTP) clearance following a standardised rehabilitation protocol performed within either pain-free or pain-threshold limits. The secondary aims were to compare isometric knee flexor strength, biceps femoris long head (BFlh) fascicle length, fear of movement and re-injury during a six-month follow-up between pain-free and pain-threshold groups.

METHODS

Forty-three men with acute HSIs were randomly allocated to either a pain-free (n=22) or pain-threshold (n=21) rehabilitation group. Days from HSI to RTP clearance, isometric knee flexor strength, BFlh fascicle length, fear of movement and re-injuries within six-month follow-up were reported.

RESULTS

The median time from HSI to RTP clearance was 15 days (95% CI = 13 to 17) in the pain-free group and 17 days (95% CI = 11 to 24) in the pain-threshold group, which was not significantly different (p = 0.37). Recovery of isometric knee flexor strength at 90/90 degrees of hip/knee flexion was greater in the pain-threshold group at RTP clearance by 15% (95% CI = 1 to 28) and by 15% (95% CI = 1 to 29) at two-month follow-up. BFlh fascicles were 0.91cm (95% CI = 0.34 to 1.48) longer at two-month follow-up in the pain-threshold group. Two re-injuries occurred in both the pain-free and pain-threshold group during six-month follow-up.

CONCLUSION

Pain-threshold rehabilitation did not accelerate RTP clearance but did result in greater recovery of isometric knee flexor strength and better maintenance of BFlh fascicle length improvements compared to pain-free rehabilitation. J Orthop Sports Phys Ther, Epub 28 Jun 2019. doi:10.2519/jospt.2019.8895.

A novel approach to improve hamstring flexibility: A single-blinded randomised clinical trial

Background

The hamstrings play a major role in body posture. Shortening or tightness of the hamstrings affects postural alignment and results in possible musculoskeletal pain.

Objectives

The aim of this study was to develop a novel approach to improve hamstring flexibility in young adults.

Method

A single-blinded randomised clinical trial included 60 participants aged 18-24 with shortened hamstrings recruited from the Hashemite University, Zarqa, Jordan. The range of motion of knee extension was measured with the hip at 90° flexion using a simple goniometer to detect the level of hamstring flexibility. Participants received either a passive hamstring stretch (PS), followed by two sets of 10 tibial nerve neurodynamic technique (ND), or PS followed by three sets of 10 repetitions of active knee extension-quadriceps activation (QA), or PS only.

Results

There was a significant improvement of hamstring flexibility in the QA group compared to the PS group (13.4 ± 12.1° vs. 6.2 ± 6.4°, p = 0.05). There was a significant improvement in hamstring flexibility post-intervention compared to pre-intervention in the PS group by 6.2 ± 6.4 (30.5 ± 10.8° vs. 36.6 ± 9.5°, p = 0.001), ND group by 9.3 ± 6.2 (26.7 ± 10.9° vs. 36.0 ± 9.5°, p = 0.001) and QA group by 13.4 ± 12.1 (20.3 ± 9.0° vs. 33.4 ± 8.9°, p = 0.001).

Conclusion

Quadriceps muscle activation following passive stretching of the hamstrings appears to be superior to the PS and ND techniques in improving hamstring muscle flexibility.

Clinical implications

Quadriceps activation following passive hamstring stretching can be used in physiotherapy settings to improve hamstring muscle flexibility.

Dry Needling Combined With Physical Therapy in Patients With Chronic Postsurgical Pain Following Total Knee Arthroplasty: A Case Series

Study Design Case series. Background This case series describes a combined program of dry needling and therapeutic exercise in a small group of patients with persistent pain following total knee arthroplasty (TKA). Case Description Fourteen patients who underwent TKA had persistent postsurgical pain and myofascial trigger points that were nonresponsive to treatment with conventional physical therapy and/or medication. The patients received a weekly dry needling treatment in combination with therapeutic exercises for 4 weeks. Pain perception was assessed preintervention and postintervention with a visual analog scale and function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index, 6-minute walk test, timed up-and-go test, 30-second chair-stand test, and knee joint range of motion. Outcomes After TKA, the patients had a mean ± SD symptom duration of 6.3 ± 3.1 months. Subsequent to dry needling, patients reported a significant mean ± SD decrease in pain intensity from 55.6 ± 6.6 to 19.3 ± 5.6 (P<.001) and improvements in Western Ontario and McMaster Universities Osteoarthritis Index scores from 10.1 ± 0.8 to 4.9 ± 1.0 for pain (P<.001), from 5.3 ± 0.4 to 2.4 ± 1.2 for stiffness (P<.001), and from 36.7 ± 2.0 to 20.1 ± 3.2 for function (P<.001). Knee flexion increased from a mean ± SD of 82.7° ± 5.2° to 93.3° ± 4.3° (P<.001), and joint extension improved from 15.8° ± 2.9° to 5.3° ± 2.4° (P<.05). The 6-minute walk test also showed improvement in postintervention values from a mean ± SD of 391.4 ± 23.7 to 424.7 ± 28.4 m (P<.05). Discussion After dry needling combined with therapeutic exercises, patients who had chronic pain following TKA showed clinically significant improvements in pain, range of motion, function, and myofascial trigger points. Future randomized clinical trials should further investigate the effectiveness of this protocol under similar conditions. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(3):209-216. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7089.

A comparison between active knee extension test and back-saver sit-and-reach test in assessing hamstring flexibility among healthy schoolchildren in India

Objective:

This study evaluated the correlation between the active knee extension test and the back-saver sit and reach test among healthy schoolchildren aged 9–13 years in India.

Method:

Five hundred and two healthy schoolchildren aged between 9–13 years were recruited from selected schools in India, and their hamstring flexibility for the right and the left leg was measured using the back-saver sit and reach test and the active knee extension test. The test protocol for the back-saver sit and reach test was taken from the FITNESSGRAM fitness test (while active knee extension test was performed according to the procedures taken from reliability studies). A Pearson's correlation coefficient was performed to identify the relationship between the two scores.

Results:

The mean (SD) of the test values were as follows: active knee extension test right leg: 29.09 (± 6.51); left leg: 29.07 (± 6.51). Back-saver sit and reach test right leg: 10.81 (± 1.79); left leg: 10.83 (± 1.70). The two showed a moderate correlation (right leg r=-.439 and left leg r=-.429, P≤.05). The active knee extension test was more sensitive to age increments, showing an overall decrease in the scores with advancing age.

Conclusion:

The active knee extension test and the back-saver sit and reach test are both tests that measure hamstring flexibility. The active knee extension test was found to be more sensitive to hamstring length changes, and should be used in the assessment of flexibility.

In vivo relationship between pelvis motion and deep fascia displacement of the medial gastrocnemius: anatomical and functional implications

Different authors have modelled myofascial tissue connectivity over a distance using cadaveric models, but in vivo models are scarce. The aim of this study was to evaluate the relationship between pelvic motion and deep fascia displacement in the medial gastrocnemius (MG). Deep fascia displacement of the MG was evaluated through automatic tracking with an ultrasound. Angular variation of the pelvis was determined by 2D kinematic analysis. The average maximum fascia displacement and pelvic motion were 1.501 ± 0.78 mm and 6.55 ± 2.47 °, respectively. The result of a simple linear regression between fascia displacement and pelvic motion for three task executions by 17 individuals was r = 0.791 (P < 0.001). Moreover, hamstring flexibility was related to a lower anterior tilt of the pelvis (r = 0.544, P < 0.024) and a lower deep fascia displacement of the MG (r = 0.449, P < 0.042). These results support the concept of myofascial tissue connectivity over a distance in an in vivo model, reinforce the functional concept of force transmission through synergistic muscle groups, and grant new perspectives for the role of fasciae in restricting movement in remote zones.