RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE
Annexure II
Proforma For Registration Of Subject For Dissertation

1.

Name of the
candidate and
Address (In Block
letters)

DURRIYA KAGALWALA
701/B SARKAR RESIDENCY, DRMASCARHENHAS
ROAD, MAZGOAN, MUMBAI: 400010

2.

Name of institution:

CITY COLLEGE OF PHYSIOTHERAPY,

MANGALORE

3.

Course of study and

Subject:

MASTER OF PHYSIOTHERAPY (MPT) 2 YEARS

DEGREE COURSE
MUSCULO-SKELETAL DISORDERS AND SPORTS
PHYSIOTHERAPY

4.

Date of Admission to
course:

28th JUNE, 2013

Title of the topic:

A COMPARATIVE STUDY TO IMPROVE

FLEXIBILITY OF HAMSTRING MUSCLE AND
RANGE OF MOTION WITH THE HELP OF FOAM
ROLLER AND MUSCLE ENERGY TECHNIQUE IN
ADULT INDIVIDUALS.

5.

6.

Brief resume of the intended work:

6.1) Introduction and need of the study
Hamstring injuries particularly strain of a muscle is commonly seen in individuals
and professional sporting population particularly involving jumping and sprinting
activities. Most epidemiological studies have proved its high prevalence rate in
football players.1 Also a major problem with hamstring strain is the high incidence
of its reinjury. This high occurrence of injury is prevalent due to lack of flexibility
of muscle and muscular imbalances.2 Flexibility and stretching exercises during
warm up have led to decrease in stiffness of muscle which lessens the load across
muscle tendon unit and thus prevent injury.3

Flexibility is defined as the ability to move a single joint or series of joints

smoothly and easily through an unrestricted pain free ROM. Stretching helps to
improve the flexibility of muscle which is defined as any therapeutic maneuver
designed to increase the extensibility of soft tissues, thereby improving flexibility
by elongating structures that have adaptively shortened and become hypo mobile
over time.
Stretching helps to increase functional range of motion, reduction in the incidence
and severity of injury, delay in the onset of muscular fatigue, prevention and
alleviation of muscle soreness after exercise, improvement in posture and muscle
and symmetry.
Various techniques have been recognized to improve flexibility of a muscle like
manual or mechanical stretching exercise, self stretching, neuromuscular
facilitation and inhibition techniques, muscle energy techniques, soft tissue
mobilization and manipulation etc.4
The foam roller is a dense foam cylinder that a person rolls their bodyweight over
to increase ROM for a specific body region, as a type of selfmyofasial release. It is
hypothesized that during the rolling, direct and sweeping pressure is exerted on the
soft tissue causing the fascia to stretch and increase ROM. 5 Friction is also created
during the rolling movement and this friction causes the fascia to increase in
temperature and possibly change to a more fluid like state.6 This change in state
allows for the breaking apart of fibrous adhesions between the different layers of
the fascia and restores the soft tissue extensibility.7It is also said that higher the
pressure and longer the duration of application of foam roller greater the effects in
extensibility and ROM are observed8
Muscle energy technique (MET) is a manual technique developed by osteopaths
that is now used in many different manual therapy professions. It is claimed to be
effective for a variety of purposes, including lengthening a shortened or
contractured muscle, strengthening muscles, as a lymphatic or venous pump to aid
the drainage of fluid or blood, and increasing the range of motion (ROM) of a
restricted joint.9This procedure employ voluntary muscle contraction by the patient
in a precisely controlled direction and intensity against a counterforce applied by
the practitioner.10
Need of the study
Hamstring muscle injuries are one of the most common musculo-tendinous injuries in
the lower extremity. They occur primarily during high speed or high intensity exercises
and have a high rate of recurrence. Also lack of hamstring flexibility has been the single most
important characteristics of hamstring injuries. 10Also considering the number of
people who participate in fitness and athletic activities there needs to be a better
understanding of what needs to be done before activity to improve performance and
assure injury prevention. 11 With the help of studies it is known that stretching
exercises performed before and after exercises have definitely reduced the risk of

injury and also leads to delayed onset of muscle sorenes.12 Hence this study will be
conducted to stretch out the tight hamstring muscle with use of foam roller and
muscle energy technique so as to minimize the risk of injury and muscle soreness.
Recent studies performed have shown the use of foam rollers in improving
hamstring flexibility and range of motion when used for a short duration. 6 Lack of
research is present in order to demonstrate the beneficial effects of foam rollers for
a longer duration of time in order to achieve long term effects of flexibility and
range of motion of hamstring muscle. Hence this study shall be concentrated for a
longer duration of time to achieve long term effects of flexibility of hamstring
muscle and range of motion.
With the help of research and development foam rollers have gained popularity
among athletes as it is a self use tool as compared to muscle energy technique
performed with the assistance of therapist. But lack of research is present on the
comparative effects of the efficacy of foam roller and muscle energy technique to
improve flexibility. Hence in this study I would like to compare the use of foam
roller and muscle energy technique proving to be more beneficial to improve
flexibility of hamstring muscle.
Research question
Will there be any improvement in hamstring flexibility in individuals who are
treated with foam roller exercises and muscle energy technique?
Hypothesis
Alternate Hypothesis There will be statistically significant improvement in
hamstring flexibility in individuals who are treated with foam roller exercises and
muscle energy technique.
Null hypothesis- There is no statistically significant improvement in hamstring
flexibility in individuals who are treated with foam roller exercises and muscle
energy technique.
6.2) REVIEW OF LITERATURE
1. Sullivan KM et al., (2013) Evaluated the use of foam roller to examine the
acute effects on lower extremity range of motion and subsequent muscle length
performance of foam roller on hamstring at a constant pressure and a constant
rate and concluded that the use of the foam roller had no significant effect on
muscle strength, and can provide statistically significant increases in ROM,
particularly when used for a longer duration.6
2. MacDonald G et al., (2013) The study was aimed to determine the effect of

self-myofascial release via foam roller application on knee extensor force and
activation and knee joint ROM and concluded that an acute bout of selfmyofascial release of the quadriceps was an effective treatment to acutely
enhance knee joint ROM without a concomitant deficit in muscle performance.5
3.

Mohd. Waseem et al., (2009) studied the Efficacy of Muscle Energy

Technique on hamstring muscles flexibility in normal Indian collegiate males
and concluded that MET is significantly improving the hamstring flexibility or
range of motion in collegiate males.9

4.

Ballantyne et al., (2003) studied the effect of muscle energy technique on

hamstring extensibility and the mechanism of altered flexibility and concluded
that muscle energy technique significantly improved extensibility of hamstring
muscle.10

5. Anthony D Amico et al., (2013) studied the acute effects of self myofascial
releasing rollers for hamstring muscle on muscle strength, power, and flexibility
compared to static stretching and control and she concluded self myofascial
release increases ROM as much as static stretching and increases isometric
jumping ability compared to static stretching.11
6. Orth Jessica et al., (2011) states that the use of foam rollers helps to ease pain
and tight muscles as the adhesions formed in the muscle lead to pain and loss of
mobility of muscle can be broken down with the help of foam roller and hence
flexibility of a muscle can be improved.7
7. Curran PF et al., (2008) The study was aimed to determine whether the
pressure and contact area on the lateral thigh differ between a Multilevel rigid
roller (MRR) and a Bio-Foam roller (BFR) for participants performing self
myofascial release and concluded that the significantly higher pressure and
isolated contact area with the MRR suggest a potential benefit in SMR.8
8. Mac Donald et al., (2013) studied the use of foam roller as a recovery tool
following an intense bout of exercise and concluded that foam roller was
beneficial in attenuating muscle soreness while improving vertical height jump,
muscle activation, passive and dynamic range of motion.12
9.

Carrey Rossi et al., (2009) has studied about the use of foam rollers to improve
flexibility, range of motion and overall fitness and concluded that foam roller
acts as a self myofascial release helping to improve flexibility and mobility.13

10.

Catherine Fiscella et al., (2004) has published the use of foam rollers in
rehabilitation as a multipurpose tool to improve flexibility, core strengthening,
balance training, propioception and increase body awareness and states that in
flexibility training foam rollers relieve tightness or restriction in the fibrous
bands of connective tissue or fascia that encase muscle throughout the body.14

11.

Michelle Hamilton et al., (2010) mentions the use of foam roller prior to
warm up of physical activity breaks down adhesions of muscles, improves
blood circulation, releases muscle tightness and improves range of motion.15

12.

Emad T et al., (2013) studied the Efficacy of Muscle Energy Technique versus
Static Stretching Technique in Increasing Hamstring Flexibility Post Burn
Contracture and concluded that MET is more effective than static stretching
alone to improve a hamstring muscle flexibility post burn contracture.16
Ahmad Faheem et al., (2010) performed A Comparative Study Of The Impact
Of Muscle Energy Technique And Eccentric Training On Popliteal Angle:
Hamstring Flexibility In Indian Collegiate Males and concluded that more
significant hamstring flexibility was attained with muscle energy technique as
compared to eccentric training.17
Nagarwal AK et al., (2010) studied Improvement of Hamstring Flexibility
with A Comparison between Two PNF Stretching Techniques (hold relax and
contract relax technique) and concluded that both are equally effective in
improving hamstring flexibility.18
Davis DS et al., (2008) studied the concurrent of four clinical test to measure
the flexibility of hamstring muscle and concluded that the knee extension angle
test should be used as the gold standard measure for hamstring muscle length.19
Fredriksen H et al., (1997) studied passive knee-extension test to measure
hamstring tightness and concluded that the passive knee extension test is a
simple and reliable method, and the associated pelvic motion is minimal.20
Gajdosik R et al., (1983) studied reliability of active knee extension test to
measure hamstring tightness and concluded that the test should provide
therapists with an objective and reliable tool for measuring hamstring muscle
tightness.21
Mier et al., (2011) studied the accuracy and feasibility of video analysis for
assessing hamstring flexibility and validity of the sit-and-reach test and
concluded that SLR and sit and reach tests are very reliable methods for
assessing flexibility, and the SR validity for hamstring flexibility was found to
be moderate in women and low in men.22

13.

14.

15.

16.

17.

18.

6.3) OBJECTIVES OF THE STUDY

1. To study the efficacy of foam roller exercises in improving hamstring
flexibility.
2. To study the efficacy of muscle energy technique in improving hamstring
flexibility.
3. To compare the efficacy of foam roller and muscle energy technique in
improving hamstring flexibility.
MATERIAL AND METHODS

7.1. STUDY DESIGN

The study is a comparative group design with a pre and post test to be performed.
7.2. SOURCE OF DATA
Individuals with complains of lack of flexibility of hamstring muscle and range of
motion referred to Physiotherapy department of City College of Physiotherapy
Mangalore.
7.2(I) Definition of study subjects
Individuals with complains of lack of flexibility aged between 20 50 years.
7.2 (II) Inclusion and Exclusion criteria
INCLUSION CRITERIA

Individuals with complains of lack of flexibility in hamstring muscles

Age group of 20 -50 years.
Male and female patients.
Patients who were willing for the study

EXCLUSION CRITERIA

Patients with vascular problems like deep vein thrombosis, varicose veins
etc.
Patients with back pain
Patients with spine surgery
Patients with neurological impairments.
Cognitive and mental impairments
Patients who are orthopedic handicap such as limb deformities, muscular
paralysis and weakness.
Patients with recent surgeries of hip, knee and ankle
Non co-operative patients.

7.2 (III) STUDY SAMPLING DESIGN, METHOD AND SIZE:

SAMPLE DESIGN
Comparative design
METHOD OF COLLECTION OF DATA
Individuals fulfilling the inclusive and exclusive criteria would only be recruited.

SAMPLE SIZE
The sample consists of 60 participants with stag satisfying the inclusion and
exclusion criteria and referred to the physiotherapy department.
7.2(IV) Follow Up
Pre test evaluation was done on the first day prior to treatment and post treatment
evaluation was done after exercises after 4 weeks.
7.2(V) Parameters and statistical tests used.
Paired and unpaired t test will be used.
7.2 (VI) Duration of study
The study will be conducted over duration of 12 months.
7.2 (VII) Methodology
Normal individuals fulfilling the inclusion and exclusion criteria will be selected
for the study and the patients will be explained about the nature of treatment and
will be asked to fulfill the consent form.
The individuals selected will be evaluated prior and post the intervention with sit
and reach test, passive knee extension test and active knee extension test. These
tests will be performed to determine the flexibility of hamstring muscle and range
of motion prior to the test and its improvement post the test. Each individual will
perform a set of exercises (forward bend, L-stretch exercise) post the intervention.
The outcome measures that will be used prior and post the intervention of foam
roller exercises or muscle energy technique are:
1. Sit and reach test.
2. Passive knee extension angle test.
3. Active knee extension angle test.
The frequency of the treatment for every individual participating in the study will
be thrice a week for a duration of 4 weeks, a total of 12 sessions will be given.
60 individuals participating in the study will be divided randomly into 2 Groups
i.e. A and B consisting of 30 individuals each.
Group A: Foam roller exercises for hamstring will be given.
Group B: Muscle energy technique for hamstring muscle will be given.

For Group A
Foam roller exercises will be given for hamstring muscle.
These outcome measures sit and reach test, passive knee extension angle test and
active knee extension angle test will be used to determine the flexibility of
hamstring muscle and range of motion of an individual prior to foam roller
intervention.
The individual will sit on the floor placing a 6 inch foam roller underneath their
hamstrings perpendicular to the body, closer to the back of the knee. The leg of the
test leg should be extended and the foot should be dorsiflexed to 90 degrees
pointing straight upwards. The non-test leg should be bent where the foot is flat on
the floor. The subject should place their hands beside their hips behind the roller
and they should push up elevating their body from the floor slightly shifting to the
side of the test leg and putting entire body weight on the roller. The subject should
roll along the roller so that he or she moves on top of the roller, from knee
(hamstring insertion) to buttock (hamstring origin), and then the motion is reversed
from buttock to knee.
15 back and forth motions should be made which should take roughly 60 seconds.
A break of 30 seconds will be given and the similar procedure will be carried out 2
more times. Hence 3 sets of foam roller will be given. Progression of exercises will
be carried out at regular intervals with increased number repetition of movement
followed by increased number of sets in individuals showing improvement of
flexibility.
These outcome measures sit and reach test, passive knee extension angle test and
active knee extension angle test will be used to determine the improvement of
flexibility of hamstring muscle and range of motion of an individual post foam
roller intervention.
Group B
Muscle energy technique will be given for hamstring muscle.
These outcome measures sit and reach test, passive knee extension angle test and
active knee extension angle test will be used to determine the flexibility of
hamstring muscle and range of motion of an individual prior to muscle energy
technique intervention.
In supine lying with the hip flexed to 90 degree the knee of the subject will be
extended to the point where patient experiences discomfort and at this point the
subject is asked to perform a moderate isometric contraction (approx 75%of
maximal) for a duration of 5 seconds and then asked to relax for a duration of 3
seconds after which the knee is further extended to a point where the patient

experiences discomfort.
This should be performed 5 times in one set. A rest period of 30 seconds should be
given. 3 sets of muscle energy technique will be carried out. Progression of
exercises will be carried out at regular intervals with increased number of repetition
of movement followed by increased number of sets in individuals showing
improvement of flexibility.
These outcome measures sit and reach test, passive knee extension angle test and
active knee extension angle test will be used to determine the improvement in
flexibility of hamstring muscle and range of motion of an individual post muscle
energy technique intervention.
7.3 Does the study require any investigation to be conducted on patients or
other human or Animal? If so, please describe briefly.
Yes
The study requires non invasive investigations and interventions to be
conducted on individuals. They include physical examination inspection,
palpation and ROM etc. Treatment intervention includes foam roller exercise
and muscle energy technique.
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes
Ethical clearance has been obtained from the ethical committee of our
institution to carry out the investigations and interventions on individuals
necessary for the study.
List Of References:
1. J Petersen, P Holmich. Evidence based prevention of Hamstring injuries in
sports. Br J Sports Med. 2005; 39: 319-323.
2. Mathew Prior, Michelle Guerin, B and Karen Grimmer. An Evidence-Based
Approach to Hamstring Strain InjurySports Health. 2009; 1(2): 154164.
3. Alison Tooley. The role of exercise in prevention of hamstring injury. Sports
EX Medicine. 2009; (39): 12.

4. Carolyn Kisner, Lynn Alen Colby. Therapeutic exercises: foundations and

techniques; Stretching for impaired mobility; (6); 65-94.
5. MacDonald GZ, Penney MD, Mullaley ME, Cuconato AL, Drake CD, Behm
DG, Button DC. An acute bout of self-myofascial release increases range of
motion without a subsequent decrease in muscle activation or force. J Strength

Cond Res. 2013; (3): 812-21.

6. Sullivan KM, Silvey DB, Button DC, Behm DG. Roller-massager application to
the hamstrings increases sit-and-reach range of motion within five to ten
seconds without performance impairments. Int J Sports Phys Ther. 2013; (3):
228-36.
7. Orth, Jessica. Ease your pain and tight muscles using a foam roller. Special
Walfare: The Professional Bulletin of the John F. Kenned. 2011; 24(4): 38-40.
8. Curran PF, Fiore RD, Crisco JJ. A comparison of the pressure exerted on soft
tissue by 2 myofascial rollers. J Sport Rehabil. 2008; (4): 432-42.
9. Mohd. Waseem, Shibili Nuhmaniand C. S. Ram. Efficacy of Muscle Energy
Technique on hamstring muscles flexibility in normal Indian collegiate males.
Calicut Medical Journal 2009; 7(4): 43-48.

10. Ballantyne F, Fryer G, McLaughlin P. The effect of muscle energy technique on

Hamstring extensibility: the mechanism of altered flexibility. Journal of
Osteopathic Medicine. 2003; 6(2): 59-63.

11. Nagarwal A.K., Zutshi K Ram C. S, Zafar R. Improvement of Hamstring

Flexibility: A Comparison between Two PNF Stretching Techniques
International Journal of Sports Science and Engineering. 2010; (04): 25-033.

12. Anthony DAmico and Christopher Morin Effects of Myofascial Release on

Human Performance: A Review of the Literature. Myofascial release and
human performance. 2013; 1-45.

13. Carey Rossi. On a R 11: with a foam roller you can improve your flexibility,
range of motion and overall fitness. Muscle and Fitness /Hers. 2009; 70-73.

14. MacDonald, Graham Z.; Button, Duane C.; Drinkwater, Eric J.; Behm, David
G. Foam Rolling as a Recovery Tool Following an Intense Bout of Physical
Activity. Medicine and science in Sports and Exercise; 2013; 19-25.

15. Catherine Fiscella. Using foam rollers in fitness setting. Idea Fitness Journal.
2004;1(2): 58-62.

16. Michelle Hamilton A tool that boosts flexibility and recovery. Runner's World,
2010; 42-47.

17. Emad T. Ahmed, Safa S. Abdelkarim Muscle Energy Technique versus Static
Stretching Technique in Increasing Hamstring Flexibility Post Burn Contracture
Int J Health Rehabil Sci. 2013; 2(1): 22-27.

18. Ahmad Faheem Ahmad shahmim Anali Agarwal. A Comparative Study of the
Impact of Muscle Energy Technique and Eccentric Training on Popliteal Angle:
Hamstring Flexibility in Indian Collegiate Males. Serbian Journal of sports
sciences. 2010; (1); 327-333
19. Fredriksen H, Dagfinrud H, Jacobsen V, Maehlum S. Passive knee extension
test to measure hamstring muscle tightness. Passive knee extension test to
measure hamstring muscle tightness. Scand J Med Sci Sports.1997; 7(5): 27982.
20. Gajdosik R, Lusin G. Hamstring muscle tightness. Reliability of an active-kneeextension test. Phys Ther. 1983; 63(7):1085-90.
21. Miler CM Accuracy and feasibility of video analysis for assessing hamstring
flexibility and validity of the sit-and-reach test. Res Q Exerc Sport. 2011; 82(4):
617-23.
22. Davis DS, Quinn RO, Whiteman CT, Williams JD, Young CR. Concurrent
validity of four clinical tests used to measure hamstring flexibility. J Strength
Cond Res. 2008; (2): 583-8.

SIGNATURE OF THE CANDIDATE

1
0

REMARKS OF GUIDE

Appropriate and feasible study

recommended

NAME AND DESIGNATION (in

Mrs. P KALAVATHI
11 Block Letters)
ASSOCIATE PROFESSOR
11.1 GUIDE
11.2 SIGNATURE

1
2

11.3 CO GUIDE (If any)

------------------

11.4 SIGNATURE

-------------------

11.5 HEAD OF THE DEPARTMENT

NA

11.6 SIGNATURE

-------------------

12.1 REMARKS OF THE

TOPIC IS APPROPRIATE AND HAS

CLINICAL APPLICATIONS.
RECOMMENDED.

CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE