Immediate effects of lumbar fascia stretching on hamstring flexibility: A randomized clinical trial

Abstract

BACKGROUND:

The hamstring muscles have a great tendency to decrease their extensibility, a phenomenon that presents a distinct clinical entity called short hamstring syndrome (SHS), in addition to problems with adjacent structures.

OBJECTIVE:

The objective of this study was to evaluate the immediate effect of lumbar fascia stretching on the flexibility of the hamstring musculature.

METHODS:

A randomized controlled trial was carried out. Forty-one women between 18 and 39 years old were divided into two groups: the experimental group received a technique of fascial stretching in the lumbar area while the control group participated in a magnetotherapy machine that was turned off. Hamstring flexibility in both lower limbs was measured by the straight leg raising test (SLR) and the passive knee extension test (PKE).

RESULTS:

The results showed statistically significant improvements ( $p<$ 0.05) in the SLR and the PKE for both groups. There was a large effect size (Cohen’s d) for both tests. There was a statistically significant correlation between the International Physical Activity Questionnaire (IPAQ) and the SLR.

CONCLUSION:

The inclusion of lumbar fascia stretching might be an effective part of a treatment protocol to increase the flexibility of the hamstring muscle observing an immediate result in healthy participants.

Keywords

Back muscles fascia hamstring muscles range of motion

1. Introduction

Short hamstring syndrome (SHS) is a pathology that presents a distinct clinical entity of unknown etiology, characterized by a decrease in the extensibility of the hamstring musculature, which can influence the dynamics of the spine as well as the movement of the pelvis [1, 2, 3, 4, 5]. The flexibility of hamstring muscles will vary depending on age and gender: there is a greater length of this musculature in the females compared with the male population and a decrease in older people [6]. Proper muscle function is essential to maintaining an independent lifestyle [7]. A reduction in the flexibility of the hamstring muscles is the main predisposing factor for suffering an injury to said musculature. In addition, it has also been related to the appearance of knee pain, lower back and pelvic pain, as well as a reduction in range of motion. In this way, adequate flexibility of the hamstring muscles is part of the rehabilitation and training programs for professional and amateur athletes [8]. Moreover, variations according to the geographic area due to cultural and racial factors have been described [9]. Furthermore, the presence of this syndrome seems to be more common in children older than 10 years

Indeed, the incidence of chronic low back pain increases by 15% in that population with SHS [10]. Thus, the decrease in the flexibility of the posterior thigh muscles is related to the presence of low back pain. This pathology has a prevalence of 84% in society, and it ranks among the top 10 causes of sick leave; thus, it generates significant costs around the world [11]. Moreover, this pathology is associated with an alteration in the movement of the pelvis and consequently, a change in the function of hamstring muscles [12].

Treatment protocols have been developed to increase the extensibility of the hamstring muscles and in the prevention and correction of SIC [13]. All these treatment techniques include different types of stretching, where we can include positional stretching [14], dynamic stretching [14], static stretching [14], ballistic stretching [13, 15, 16], as well as inhibition of the suboccipital musculature [17], neurodynamic techniques for the sciatic nerve [18], plantar fascia approach [19] and myofascial treatment [20, 21, 22].

Recent studies have shown the importance of fascial tissue in the transmission of forces during movement [23, 24]. The Osteopathic Terminology Dictionary [25] defines fascial relaxation techniques as ‘a manual technique that involves constant feedback to the osteopathic professional, who is the one who passively moves a portion of the patient’s body in response to the sensation of movement’. The person’s forces are located using the sensations of ease and wider regions are joined. Although it has not been possible to demonstrate the relaxation capacity of the fascia, it is believed that stimulation of the existing mechanoreceptors in this tissue is the most probable trigger with regard to the production of fascial release [26].

The hamstring musculature is part of the superficial posterior chain, which is in charge of maintaining standing, favoring dorsal extension and reducing anterior flexion of the body [27]. This muscular chain extends from the cranial to caudal direction, from the superciliary arch of the frontal bone to the plantar aspect of the distal phalanges of the toes, including both the thoracolumbar fascia and the hamstring musculature [27].

The hamstring muscle is one of the main muscles responsible for controlling the movement of the hip and lower back [28, 29], and is also responsible for ensuring good alignment of the pelvis and spine [30]. The shortening of said muscles is also related, at the lumbar level, to the appearance of Scheuermann’s disease, spondylosis, spondylolisthesis and protrusion of the intervertebral disc [30, 31]. In this way, an increase in tension in the hamstring muscles will generate hyperkyphosis in the lower back by reducing anterior pelvic rotation and lumbar lordosis and generating a posterior pelvic tilt [32, 33].

This study aimed to help improve treatment for the problem mentioned before, which can be included within a therapeutic framework to combat SHS [3, 4, 5]. In recent years, several studies have been carried out with different techniques for stretching hamstring muscles [13, 15, 16], as well as the treatment of other structures belonging to the posterior superficial chain [17, 19]. With regard to the latter intervention, myofascial stretching techniques have been shown to be effective both in the short and medium-term [21, 22]. Different techniques for stretching the hamstring muscles have been performed with the aim of increasing the flexibility of the lower back in general [34, 35, 36]. For this reason, the objective of this study was to evaluate the immediate impact of lumbar fascia treatment on the flexibility of hamstring muscles.

Figure 1.

Flowchart of the study process.

2. Material and methods

2.1 Design and participants

A randomized clinical trial was carried out, designed according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [37]. Each group of participants was randomly allocated to the experimental or control group through a closed envelope system (the assessor did not know to which group each individual belonged).

The study participants were included in either the control or experimental group. Inclusion criteria were 1) females, 2) age between 18 and 39 years old, 3) willing to participate in the study, 4) not participating in specific flexibility training at the same time 5) not participating in sports activities as professionals and 6) Asymptomatic individuals (people without pain or any type of discomfort in the entire posterior kinetic chain). A priori sample size calculation indicated that 40 patients per group were required to detect a significant difference in the flexibility variation tests between the control group and the intervention group (effect size d $=$ 0.32; alpha $=$ 0.05, beta $=$ 0.08) using the G-Power Software [22]. A total of 41 participants were included. The recruitment of all study participants was carried out in a Physiotherapy and Osteopathy Clinic during the months of March and April 2019. The exclusion criteria were as follows: any alteration that prevents normal communication between the participant and the therapist when conducting the study; having suffered any type of hamstring injury; present acute or chronic low back pain at the time of the performance; and neurological and/or musculoskeletal pathology (Fig. 1).

2.2 Procedure

The study was performed throughout April 2019, with measurements for study participants collected in that month. Before the start of all the procedures that were carried out with the patients included in the study, each subject was informed about the techniques to be used and had to sign an informed consent. In such a way that during this process, the subject was excluded from the study by refusing to participate in it. Neither the assessor nor the therapist were blinded to the study.

After their authorization to participate in this study, anthropometric data were collected from the participants, as well as some questions about aspects related to their daily life: age, occupation, weight, height, and the number of times performing a sport (and type of sport) per week. Subsequently, and before carrying out the pretreatment assessment maneuvers, the participants completed the International Physical Activity Questionnaire (IPAQ).

All variables were measured at baseline and the end of the program by the same assessor. Participants allocated to the control group were evaluated using the same variables and were given the option to participate in the program once the study was completed.

For the experimental group, one session of the ‘Hands Crossed’ technique, described by Andrzej Pilat in his book Myofascial Therapies: Myofascial Induction [38], was performed. To carry out this technique the participants were placed lying prone, with a wedge under their feet for greater comfort. The position of the therapist was just to one side. In the initial stage of the technique, the hands must be together and well attached to the participant’s skin in the lumbar zone, exerting three-dimensional pressure. Always using a constant force, the therapist’s hands will be separated little by little as tension barriers are overcome in the patient, with a minimum time of one and a half to three minutes. After finishing the technique, leave your hands on the patient’s body for a few seconds and then gently remove them. of the patient, at the level of the lower back and with both hands on the patient [38].

Meanwhile, in the control group the participant was placed in the same magnetotherapy equipment (Medicarin, Spain), but turned off so that said group would not receive any type of treatment. All participants received the intervention by the same therapist. All the procedures that were carried out, both in the experimental group and in the control group, were carried out in the same place and with the same environmental conditions.

Once the intervention was carried out, the measurement tests were evaluated immediately without having spent more than 30 seconds. First was evaluated the SLR test and then the PKE test. Both measurement tests were performed successively, only recording the results obtained in the first measurement test between both tests (approximately 15 seconds).

Likewise, all the therapeutic acts framed within this study followed the standards of the Guide to Good Clinical Practice (PCB) carried out by the International Conference on Harmonisation of Technical Requirements for Pharmaceuticals for Human Use [39].

2.3 Ethical considerations

The Ethics Committee of the Universidad Católica San Antonio de Murcia approved the research proposal for this study (registration no. CE031906). According to Law 41/2002 from 14 November (current Spanish law), which regulates the autonomy, rights and obligations of participants with regard to information and clinical records – and also regulates the right to receive information and to informed consent – only participants that agreed to participate in the study after obtaining informed consent were included. The study was registered on ClinicalTrials.gov under identifier NCT04345055.

2.4 Outcome measures

Two angular tests were used to measure the extensibility of the hamstring muscles: the straight leg raising test (SLR) and the passive knee extension test (PKE).

To perform the SLR, the participant is placed in a supine position with the knees extended and the hips in a neutral position. Meanwhile, the therapist uses her or his internal hand to hold the leg in a neutral position with total knee extension and hip flexion according to tolerance. The therapist uses her or his internal hand to place the goniometer over the greater trochanter of the femur. Stretching will stop when the participant shows discomfort from the stretch or attempts to compensate for the movement by pelvic retroversion or knee flexion [40] (Fig. 2). This test presents an intraobserver reliability of 0.89 and interobserver reliability of 0.97 [41, 42], as well as a sensitivity of 0.91 and a specificity of 0.26 [43].

Figure 2.

Execution of the SLR test.

For execution of the PKE, the participant is placed in the supine position with the lower limb to be measured in hip and knee flexion. The therapist stabilizes the hip in 120 ${}^{\circ}$ flexion and in a neutral position with respect to rotation, abduction and adduction. With the inner hand, the knee is extended until it presents an unpleasant sensation when stretched. With the external hand, the goniometer is placed at the articular interface of the knee [44] (Fig. 3). The PKE has an intraobserver reliability of 0.98 and an interobserver reliability of 0.96 [45].

Figure 3.

Execution of the PKE test.

Both the SLR test and the PKE were performed successively for 3 times, without any rest between repetitions, and the results obtained were recorded after performing the 3 repetitions. The results with a better score were selected for data analysis. As appears in the bibliography [40, 44], both tests were carried out maintained constant visual contact with the participant, stopping the stretching when the latter shows a situation of discomfort due to the stretching or if he tried to compensate for the movement.

Before carrying out the intervention, the participant had to complete the International Physical Activity Questionnaire (IPAQ). The questionnaire was explained to all participants and any doubts they had about any question in the questionnaire were answered. They were allowed to ask the evaluator if they had any questions when answering. This original version of the questionnaire presents a Kappa coefficient interrater reliability of 0.6. It is an instrument designed to measure the level of physical activity in an adult population, with an age range between 15–69 years and is widely used [46, 47]. It allows the measurement of the amount of physical activity carried out by each participant, and it serves as a reference when making recommendations about physical activity [46, 47].

2.5 Statistics

To carry out this study, a statistical analysis was performed in order to respond to the objectives set, using SPSS version 24.0. The mean (M) and standard deviation (SD) of the quantitative variables collected prior to the study were determined to generate a description of the sample. Subsequently, two box plots were also generated: one for the pretreatment values of the SLR test and another for the same values of the PKE test. The Shapiro-Wilk tests was used to assess the homogeneity of the sample. The Wilcoxon T test was employed for the analysis of the measurement variables (SLR and PKE). The statistical values of interest were the intragroup differences between the experimental and control groups, as well as the intergroup differences for the pretreatment and posttreatment measures. Likewise, Cohen’s d was calculated to analyse the effect size. Finally, Spearman’s correlation coefficient was used to determine the correlation between the evaluated variables (IPAQ, SLR pretreatment values and PKE pretreatment values). A $p$ value $<$ 0.05 was considered significant. The statistical analysis was carried out with the SPSS 24.0. The data analysis was performed twice to ensure that the analysis was performed correctly, and in addition to this it was checked by all the authors of the article.

3. Results

The mean age in the experimental group was 25.81 $\pm$ 5.86 years, while in the control group it was 28.15 $\pm$ 6.58 years. There were no differences between the groups with regard to weight, height and body mass index (BMI). Regarding the pretreatment measures under analysis: the experimental group presented 74.84 $\pm$ 9.84 in the SLR and 18.31 $\pm$ 7.61 in the PKE while the control group presented 79.66 $\pm$ 11.70 and 18.18 $\pm$ 5.80, respectively (Table 1). All participants finished the study without loss.

Table 1
Characteristics of the participants

	Experimental group mean (SD)		Control group mean (SD)
Age	25.81	(5.86)	28.15	(6.58)
Weight (Kg)	61.13	(9.74)	62.05	(7.72)
Height (m)	1.65	(0.05)	1.65	(0.05)
BMI (Kg/m ${}^{2}$ )	22.38	(3.77)	22.48	(2.03)
PRE-SLR ( ${}^{\circ}$ )	74.84	(9.84)	79.66	(11.70)
PRE-PKE ( ${}^{\circ}$ )	18.31	(7.61)	18.18	(5.80)
Total_Met_IPAQ	7628	(3112.36)	8123	(3254.28)

BMI: body mass index; PRE-SLR: pretreatment measures in the Straight Leg Raising Test; PRE-PKE: pretreatment measures in the Passive Popliteal Angle Test; Met: metabolic equivalent of task.

A box plot was generated to determine homogeneity in the distribution of pretreatment values for both the SLR and PKE. These graphics revealed great variability because the ‘whiskers’ of both figures appear quite far from the median. In Fig. 4, the image on the left shows the descriptive data of the participants in the SLR test, while the image on the right is of the descriptive data of the participants in the PKE test. In both images, the axis y represents the absolute values in degrees that can be obtained in both tests, while the degree x lacks a representative value but only to visually determine the magnitude of participants who are in each interval of results. On the other hand, there were extreme values in the SLR that exceeded the ‘whiskers’ in said diagram.

Table 2

Intergroup and intragroup changes in outcome scores from baseline to post

Measure	Time	Experimental group mean $\pm$ SD	Control group mean $\pm$ SD	Intergroup differences mean differences ( $p$ )		Intragroup differences mean differences ( $p$ )
				Baseline	Post	Experimental group	Control group
SLR
	Baseline	74.84 (9.84)	79.66 (11.70)	4.81 (0.45)	7.46 (0.78)	17.92 ( $<$ 0.01)	5.64 (0.01)
	Post	92.76 (8.22)	85.30 (7.91)
PKE
	Baseline	18.31 (7.61)	18.18 (5.80)	2.12 (0.26)	4.48 (0.68)	7.03 ( $<$ 0.01)	2.03 (0.01)
	Post	11.28 (5.61)	16.15 (5.59)

SLR: Straight Leg Raising Test; PKE: Passive Knee Extension Test; SD: standard deviation; Baseline: pre-treatment assessment; Post: post-treatment assessment; $p$ : $p$ -value of signification.

Figure 4.

Box diagram of the descriptive data of the participants in the SLR and PKE tests.

Two measurement tests were used in this study: SLR and PKE. Regarding the SLR, there was an improvement of 17.92 in the experimental group between the pretreatment and posttreatment measure, while in the control group it was 5.64. Regarding the PKE, there was an improvement of 7.03 in the experimental group, while in the control group it was 2.03. Both tests showed significant intragroup differences for the experimental and control groups. However, there was no significant intergroup difference for either test after the intervention (Table 2).

Table 3

Correlation (Spearman r) between the physical activity and flexibility tests

	SLR	PKE
IPAQ	0.33 (0.03)	$-$ 0.18 (0.25)
SLR		$-$ 0.57 ( $<$ 0.01)

IPAQ: global physical activity questionnaire; SLR: Straight Leg Raising Test; PKE: Passive Knee Extension Test.

The analysis of the effect size (using Cohen’s d) between the post-intervention means showed a high effect size ( $>$ 0.8) in both groups (d $=$ 0.92 in SLR; d $=-$ 0.86 in PKE). With regard to the intragroup comparison, the intervention group obtained an effect size of d $=$ 1.97 in the SLR and d $=$ 0.01 in the PKE.

Finally, the correlation between the evaluated variables was analysed with the Spearman’s correlation coefficient to determine whether there was a correlation between the measures and the level of physical activity measured using the IPAQ. There was a statistically significant correlation between the IPAQ and the pretreatment measure in the SLR. The correlation between the IPAQ and the PKE was not significant (Table 3).

4. Discussion

The main objective of this study was to evaluate the immediate impact of treatment of the lumbar fascia on the flexibility of the hamstring muscles. For this, two groups were established, a control group and an experimental group. In response to the established main objective, in the results obtained in the present study there was statistical significance in both groups when making the intragroup comparison in the PKE and SLR tests, however, no intergroup differences were found. Other researchers have performed similar studies in which osteopathic techniques have been applied in asymptomatic participants [42, 45]. Taylor et al. [48] applied an isometric contract-relax technique in the cervical area in asymptomatic participants; there was no significant difference in the flexibility of the hamstring muscles between the treatment and control groups. The present study revealed similar results, although the intervention technique was different and targeted a more proximal area relative to the hamstring muscles. Nevertheless, the current study and Taylor et al. [48] used the PKE test and presented a similar Cohen’s d (d $=$ 0.14).

The immediate effects of the neurodynamic sciatic nerve sliding technique have also been evaluated in asymptomatic participants, in order to evaluate its effectiveness in the flexibility of the hamstrings. The results of these studies are in line with those shown in the present study. Park et al. [42] applied the neurodynamic sciatic nerve sliding osteopathic technique five times; there was a significant difference with an immediate increase in hamstring flexibility with a test similar to SLR with a Cohen’s d of 2.21. These results are similar to the present study, where there were significant intragroup differences with a similar effect size (d $=$ 1.97). However, Park et al. [42] did not include a control group in order to perform intergroup comparisons. On the other hand, neurodynamic sciatic nerve sliding has also been compared with another osteopathic technique (Mulligan technique [45]). In that study, there was a significant improvement in the flexibility of the hamstrings – similar to that found in the present study – when evaluating it with the SLR test (d $=$ 0.96), without any differences between the two applied osteopathic techniques.

Notably, other studies that have evaluated various osteopathic techniques on the immediate effect on hamstring flexibility have not employed a control group, which has been included in the present study. Despite the effectiveness of the evaluated technique on hamstring flexibility, there were no statistically significant differences compared to the control group (which received no treatment).

Other similar investigations in the treatment of other remote structures belonging to the superficial posterior chain have shown results equivalent to those obtained in our study [19, 22, 48, 49, 50], showing an immediate improvement in the flexibility of the hamstring muscles. The evidence shows that the improvement obtained through the fascial treatment of remote structures is due to the transmission of forces through the intramuscular and intermuscular connective tissue, through the superficial posterior chain [51, 52, 53, 54].

Although there was no statistically significant difference, the current data confirmed that the osteopathic ‘Hands Crossed’ technique does produce a clinical improvement in terms of hamstring flexibility in asymptomatic people. Thus, this absolute improvement would mean a 23.94% increase in the SLR test (7.08% in the control group) and a 62.32% increase in the PKE tests (12.56% in the control group). These values confirm this clinical change assuming a difference greater than 10% according to the criteria of Ayala et al. [2] (i.e. these changes would not be attributed to measurement error). In addition this improvement is greater than 6.4%, which would be, according to Brandy et al. [55], a real change in the flexibility of hamstring muscles. Furthermore, as can be seen in the previous results, the clinical change is much higher in the intervention compared to the control group.

The present study also evaluated the correlation between the physical activity performed and the flexibility of the hamstring muscles, with significant correlations with the SLR test. These results should be evaluated with caution because there was no relationship for the PKE test despite the fact that both tests evaluate hamstring flexibility. Physical activity has been shown to be effective in increasing hamstring flexibility [56, 57], whereas in the present study, the correlations only appear with one of the tests.

The present study is the first study in which an osteopathic technique (‘Hands Crossed’) has been evaluated and compared with a control group (no intervention). Furthermore, the flexibility of the hamstrings was evaluated with two different tests with good reliability in order to obtain an assessment of the effectiveness of this technique. Despite this design, there were a number of weaknesses. First, it was not possible to blind the participants to the treatment they received. Second, it was not possible to followup with participants to determine whether the control group performed any type of stretching, physical activity or other activity that positively influenced hamstring flexibility. In this study have not been used an imaging method to assess hamstring flexibility that allow us a more reliable data about this variable and have not been used a gold standard method to measure physical activity as accelerometers. Finally, the results obtained in the present study are those established immediately, without being able to verify if the instantaneous improvements achieved would be maintained in the medium or long term, as well as not being able to know the effect of this technique in the population with SHS having included a healthy population.

5. Conclusion

The present study demonstrated that, in healthy people, the application of a session of the ‘Hands Crossed’ technique provided immediate clinical effectiveness in hamstring flexibility compared with the control group. These data provide information for the inclusion of this technique in treatments focussed on increasing hamstring flexibility in patients with hamstring problems. Nevertheless, there were no statistically significant differences in the experimental compared with the control group, so it is recommended to investigate different protocols for applying this technique. In addition, it should be applied in a larger sample size in order to increase the statistical power.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.

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Immediate effects of lumbar fascia stretching on hamstring flexibility: A randomized clinical trial

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2.1 Design and participants

2.2 Procedure

2.3 Ethical considerations

2.4 Outcome measures

3. Results

Table 1 Characteristics of the participants

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

Funding

References

Table 1
Characteristics of the participants