Volume : 3 | Issue : 9 | September 2014 • ISSN No 2277 - 8179

Research Paper

Immediate Effects of Single Session Post Isometric Physiotherapy

Relaxation Muscle Energy Technique Versus KEYWORDS : Osteoarthritis, Hamstring
Mulligan’s Bent Leg Raise Technique on Pain Flexibility, MET, BLR, AKE test
and Hamstring Flexibility in Knee Osteoarthritis
Participants: A Randomised Controlled Study

Department of Musculoskeletal Physiotherapy, C.U. Shah Physiotherapy College,

*P. Ratan Khuman Surendranagar, Gujarat. 363001. * Corresponding Author
Department of Neurological Physiotherapy, C.U. Shah Physiotherapy College,
Lourembam Surbala Surendranagar, Gujarat. 363001
Department of Musculoskeletal Physiotherapy, C.U. Shah Physiotherapy College,
Priyanka Patel Surendranagar, Gujarat. 363001.
Department of Musculoskeletal Physiotherapy, C.U. Shah Physiotherapy College,
Dhara Chavda Surendranagar, Gujarat. 363001.
ABSTRACT Osteoarthritis (OA) affects 33–46% of Indian adult with the consequence of pain, reduced function and restric-
tion in daily activities. In this study, single session of post isometric relaxation muscle energy technique (PIR-MET),
Mulligan’s bent leg raise technique (BLR) and MH alone were compared on pain and hamstring flexibility in knee OA. 90 participants were
selected and randomly allocated into three groups (PIR-MET+MH; BLR+MH and MH alone, n=30 in each group). Visual analog scale and
active knee extension test (AKE) were recorded at baseline and immediately after interventions. PRI-MET and BLR group were significantly
effective (p<0.05) in reducing pain and improving hamstring flexibility whereas the MH group did not (p>0.05). BLR group was more effec-
tive compare to PIR-MET and MH alone. In conclusion, a single session of PIR-MET and BLR technique were capable of reducing pain and
improving hamstring flexibility in knee OA.

INTRODUCTION: proving hamstring flexibility in knee OA are limited and yet

Osteoarthritis (OA) is one of the major public health problem to be documented. The effectiveness of PIR-MET 13,14 and BLR
which causes functional impairment that reduces quality of life technique 15,16 has been well documented in other conditions.
(QOL) worldwide as reported by World Health Organization.1 However, comparison between two methods have not yet been
According to 2012 data, the prevalence rate of OA in both rural documented in knee OA participants. So, effort of this study was
and urban India was ranging from 33% to 46 % of older adult to investigate and to compare the effectiveness of single session
population where female were more affected than men.2 The OA PIR-MET versus BLR technique along with MH and MH alone in
is a chronic joint degenerative disease which mainly affect the reducing pain and improving hamstring flexibility in knee OA
weight bearing joints specially the lower limb joints. participants. We hypothesized that the single session interven-
tion would be capable of reducing pain and improve hamstring
The pathophysiological changes in OA varies as the condition flexibility in knee OA participants.
progress affecting joint articular cartilage as well as soft tissue
around the joint.3,4 Apart from known articular source of pain in METHODOLOGY:
OA knee, tightness of hamstring muscle is one of the non-artic- In this single intervention assessor blinded randomized con-
ular source of pain. Tightness of hamstring muscles if not cor- trolled study, participants were recruited through advertisement
rected it is likely to develop flexion contracture of knee in later with pamphlet in a local newspaper. There were 162 respondents
stage of the disease.5 Previous studies reported that an increase to advertisement who were interested to participate in the study.
in hamstring muscle activation with knee OA was seen while Participants were screened with thorough physical examination
performing the activities of daily living. Normal knee joint load and 90 participants who fulfilled the selection criteria were re-
distribution may be altered due to over activation of hamstring cruited to volunteer in this study. Using a computer generated
muscle and contribution in disease progression in knee OA. Nor- randomization method 90 eligible participants were randomly
malizing altered hamstring muscle over activation would be as assigned into three groups (PIR-MET+MH: n=30; BLR+MH: n=30
important as strengthening the quadriceps muscle in preventing and MH: n=30). The included participants were of age above 40
the disease progression.6,7 years, both gender, radiographic evidence of grade I or II in Kell-
gren and Lawrence criteria for knee OA 17, bilateral (but tested
The Mulligan’s bent leg raise (BLR) technique is a method only severe side) or unilateral involvement, ambulate indepen-
of stretching which is painless in nature. It consist of gentle dently with or without assistive devices, ascend and descend at
stretching of hamstring muscles performed in a specific direc- least a flight of stairs and those who were willing to volunteer in
tion progressively towards hip flexion. It has been used as a this study. The participants were excluded if they had low back
method to achieve greater range of active knee extension (AKE) pain, sciatica, history of recent lower limb or spinal surgeries,
or straight leg raise (SLR) by increasing flexibility of hamstring pathologies or deformities related to spine, knee or hip joints,
muscles. This technique was designed to restore altered activa- any neurological disorders, other musculoskeletal problems as-
tion of hamstring muscles.8 On other hand, the muscle energy sociated with the knee joint. The study obtained prior approval
technique is a manual medicine soft tissue procedure that in- form the Institutional Ethical Committee. All participants pro-
corporate precisely directed and controlled, patient initiated- vided their demographic details (Table 1) after signing the in-
voluntary contraction of muscles (isometric or isotonic contrac- formed consent form before collecting baseline data.
tions) at varying levels of intensity against a distinctly executed
counterforce applied by therapist. MET are classified as active The baseline pre-intervention outcome measures consisted of
techniques in which the patient contributes corrective force de- pain assessment using visual analog scale (VAS) and knee joint
signed to improve musculoskeletal function and reduce pain.9,10 goniometry in active knee extension test (AKE) to assess the
flexibility of hamstring muscles. VAS is a self-completed uni-
There are variety of interventions on literature supporting pain dimensional single-item measure of pain intensity in the last 24
control in knee OA11,12 but interventions emphasizing on im- hours. The response options of the pain intensity were adhere to

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Research Paper Volume : 3 | Issue : 9 | September 2014 • ISSN No 2277 - 8179

score “0” represent “no pain” and the score “10” represent “worst
imaginable pain”. The higher the score of VAS indicates greater STATISTICAL ANALYSIS:
pain intensity and the lower the score indicates lesser pain in- All data were analysed with SPSS version 16 for windows. Mean
tensity.18 AKE test is an objective test for measuring tightness of and standard deviation were calculated using descriptive analy-
hamstring muscles with goniometer while active knee extension sis. The data normality test (always present) were verified by
and record knee flexion range of motion.19,20 AKE test has been Kolmogorov-Smirnov test. The inter group comparison of base-
showed excellent inter-rater and intra-rater reliability for assess- line and post intervention data were performed using one way
ing hamstring flexibility in healthy adults.20 ANOVA. The intra group comparison of VAS and ROM scores
were done using pair t-test to determine the differences due to
Prior to application of PIR-MET and BLR, participants were interventions. Post hoc Tukey test was performed further to de-
made to lie in prone position to receive moist heat to hamstring termine the post intervention inter group difference in VAS and
muscle for 20 minutes.21 Soon after the moist heat, the first ROM scores. For all analysis significance level was set at p=0.05
group received PIR-MET for hamstrings detailed by Leon Chai- (95%). Eta Squared and Cohen’s d were used to determine the
tow. 10 In a single session PIR-MET, the participants performed clinical meaningful changes due to PIR-MET, BLR and MH.
isometric contractions using 20% of their strength, 5 second
hold with 5 seconds rest time in between each contraction.10,13,14 RESULTS:
The second group received BLR technique detailed by Mulli- The demographic details at baseline were analysed and found
gan. During BLR technique participants performed isometric to be homogenous (age, height, weight, BMI, gender) with
contraction of hamstring muscle for progressively five greater p>0.05 (Table 1). Pre-intervention inter group comparison of
position of hip flexion, three pain-free repetitions with 5 sec- VAS and ROM score among the groups revealed no signifi-
ond hold.8,15 Both outcome measures were recorded by a single cant differences (p>0.05) in VAS (p=0.331) and ROM (p=0.998)
therapist who was blinded about group allocation. The outcome (Table 1). Intra group comparison using paired t-test shows
measures were recorded at baseline prior to and immediately af- significant difference (p<0.05) in VAS and ROM score of PIR-
ter asingle session interventions on the same day. MET and BLR groups (p=0.000) a (,) whereas the MH group
did not show significant differences in VAS (p=0.119) and ROM
Table 1: Demographic details with baseline and post inter- (p=0.090) (Table 2) (Figure 1, 2). Post-intervention inter group
vention scores comparison of VAS and ROM score among groups shows sig-
nificant difference (p<0.05) in VAS and ROM (p=0.000) (Table
PIR-MET+MH^ BLR+MH^ MH^ 1). Further, Post hoc analysis were used for multiple compari-
Variables P-value* son which shows greater significant improvement (p<0.05) in
(N=30) (N=30) (N=30)
BLR group with large effect size (d>0.8) compared to PIR-MET
and MH group in VAS and ROM scores. Comparison between
Demographic Detail PIR-MET and BLR groups shows no significant difference
(p>0.05) however, BLR groups shows greater improvements
Age (Year) 57.90±9.95 58.80±9.93 58.56±9.09 0.932 compared to the PIR-MET groups in VAS and ROM scores with
medium effect size (Table 3). Comparison of MH group with
Height PIR-MET and BLR group shows significant difference (p<0.05)
(centimetre) 162.58±9.33 162.72±9.08 163.37±7.33 0.932
in VAS and ROM (p=0.000) with large effect size (Table 3).

Weight Table 2: Intra group comparison

69.36±11.20
(kilogram) 69.86±11.34 75.03±10.01 0.088

Body mass Pre Post

26.50±4.46 26.61±4.31 28.23±3.48 0.193 PIR-MET
index Treatment^ Treatment^ P value Effect Size

Duration 5.80±4.29 5.76±4.18 5.40±4.17 0.920 VAS 6.40±0.93 4.50±1.22 1.75

(months)
0.000*
Male/ 19/11 18/12 20/10 ROM@ 54.96±6.26 45.33±6.87 1.46
Female
NA
Joint (P/ 6/21/3 6/21/3 8/18/4 BLR
TF/B)

Baseline Scores
VAS 6.76±1.04 4.13±0.97 2.61
0.000*
VAS 6.40±0.93 6.76±1.04 6.70±1.05 0.331
ROM@ 55.06±5.97 41.86±6.24 2.05
ROM@ 54.96±6.26 55.06±5.97 55.03±6.30 0.998
MH
Post Intervention Scores

VAS 6.70±1.05 6.40±1.24 0.119** 0.26

VAS 4.50±1.22 4.13±0.97 6.40±1.24
0.000**
ROM@ 45.33±6.87 41.86±6.24 54.63±5.88 ROM@ 55.03±6.30 54.63±5.88 0.090** 0.06

^ Mean & Standard deviation; P=Patellofemoral;

TF=Tibiofemoral; B=Both joint; N=number; One-Way ANOVA ^ Mean & Standard deviation; @Degree; Pair t-test (* significant
(* no significant difference = p>0.05);**Large effect size (Eta difference = p<0.05; ** no significant difference); Effect size
squared >0.138); @Degree (Cohen’s d) = Small – 0.2, Medium – 0.5, Large - >0.8

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Research Paper

Table 3: Multiple Comparison of PIR-MET, BLR and MH Groups

Outcome Group^ Group^ Effect Group^ Effect

Effect size*
Measure size** size**
PIR-MET BLR PIR-MET MH BLR MH

VAS 4.5±1.22 4.1±0.97 0.36 4.5±1.22 6.4±1.24 -1.57 4.1±0.97 6.4±1.24 -2.10

ROM@ 45.3±6.87 41.8±6.24 0.54 45.3±6.87 54.6±5.88 -1.47 41.8±6.24 54.6±5.88 -2.14

^ Mean & standard deviation; Post hoc (Tukey) test ( *no significant difference = p>0.05; ** significant difference = p<0.05); Effect size (Cohen’s d) = Small – 0.2,
Medium – 0.5, Large - >0.8; @Degree

to significant improvement in pain as well as hamstring flexibili-

ty compared to control intervention (MH alone). However, it was
found that BLR resulted in statistically significant and clinically
greater improvement compared to PIR-MET and control inter-
vention.

The study included a group of knee OA individuals average

aged 58.42±9.56 years, predominance of male 63.33% (PIR-MET
group-63.33%; BLR group-60%; MH group-66.66%) with height
of 162.89±8.53 cm, weight of 71.42±11.05 kg and BMI 27.11±4.14
kg/m2 represents the characteristic of individuals likely to be
affected with knee OA. It was also found that the tibiofemoral
joint was often affected (PIR-MET group – 63.33%; BLR group
– 70% and MH group – 60%) following with the patello-femoral
joint (PIR-MET group – 16.66%; BLR group – 20% and MH group
– 26.66%) and involvement of both the joint (PIR-MET group -
20%; BLR group – 10% and MH group – 13.33%) respectively.

VAS scores of PIR-MET and BLR group were positively change

from baseline scores to post intervention scores which was not
seen in MH group. PIR-MET group shows 1.9cm decrement in
pain intensity which was in accordance with previous study ob-
served after 6 weeks intervention.22 BLR group show 2.63cm de-
 Pre VAS  Post VAS creased in pain intensity whereas the MH group (control) shows
only 0.3cm which was not clinically significant importance. The
Figure 1: Comparison of VAS scores of PIR-MET; BLR tech- positive reduction in VAS scores of PIR-MET and BLR shows
nique & MH group that both the single interventions were capable of reducing pain
related to knee OA. But, it would require a complete treatment
approach to determine any beneficial effect of PIR-MET and BLR
technique that might contribute on pain.

The study observed significantly increased hamstring flexibil-

ity in AKE test following PIR-MET and BLR technique, but not
in the MH group. The PIR-MET groups shows 9.63 degree re-
duction in knee flexion ROM which was in accordance with an
earlier study which provided MET for 6 weeks.22 BLR technique
group demonstrated 13.2 degree reduction in knee flexion ROM
which had similar previous finding.16 Reduction in knee flexion
ROM in MH group was not clinically significant importance. A
few literature available on the single session of MET were also
found to have contradictory results to our findings. A previous
study on healthy asymptomatic participants with hamstring
tightness claimed that application of single session MET proce-
dure did not show biomechanical changes in hamstring muscle
apart from creating stretch tolerance.23 Another study on healthy
young women treated with 10 sessions MET show similar effect
with traditional stretching on restoring hamstring flexibility.24
This study did not observe any significant effect of moist heat
 Pre ROM  Post ROM alone on pain or hamstring flexibility but it may have compli-
Figure 2: Comparison of knee ROM scores of PIR-MET; BLR mentary positive effects of PIR-MET and BLR technique.21
technique & MH group
MET involving isometric contraction of muscles stimulate the
DISCUSSION: proprioceptors of muscle fibres which might produce pain relief
The study provided a controlled evaluation of a single session of via pain gate control theory. Immediately following an isomet-
PIR-MET and Mulligan’s BLR technique on its effects to pain and ric contraction, a muscle in hypertonic state could be lengthen
hamstring flexibility in knee OA participants. The finding shows passively to a new resting length.9,10 This theory might explain
that a single session PIR-MET intervention as well as BLR leads how there were changes in pain and hamstring flexibility after

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PIR-MET. Mulligan’s BLR technique involves hip flexion results CONCLUSION:

in caudal loading of lumbosacral nerve roots and sciatic nerve The results of this study show that a single session of Post Iso-
in the pelvis which has unloaded cranially during hip exten- metric Relaxation Muscle Energy Technique as well as Mulligan’s
sion.25,26 Flexion of hip joint during BLR lead to lumbar flexion Bent Leg Raise Technique along with moist heat are effective in
and further open the intervertebral foramina and the central reducing pain and improving hamstring flexibility in knee os-
canal which facilitates the neural structure to move caudally.27-29 teoarthritis participants. It was evident that the Mulligan’s Bent
Such neural structure movements could diffuse intraneural Leg Raise technique along with moist heat was the most effec-
oedema thereby restoring the pressure gradients and relieving tive compared to Post Isometric Relaxation Muscle Energy Tech-
neural hypoxia.30 This improvement in neural mechanics would nique with moist heat or moist heat alone in reducing pain and
be probably the mechanism of improvement in pain after BLR improving hamstring flexibility in knee osteoarthritis partici-
techniques.31 Decrease in knee flexion in AKE test may be due to pants.
temporary change in viscoelastic property 32 of hamstring mus-
cles as a result of PIR-MET or BLR technique. ACKNOWLEDGMENT:
The authors wish to thank all valuable volunteers of this study
As there are limited literature on similar interventional study for their cooperation. We are also extending our thanks to man-
design, we cannot comment on whether our findings are in ac- agement team of C.U. Shah Physiotherapy College for allowing
cordance to previous studies or not, but restricted on the imme- and encouraging us to conduct the research.
diate effectiveness of the interventions used in the study. One of
the major limitations of the study was that short term and long
term effectiveness of following changes on pain and hamstring
flexibility after the single interventions have not been investi-
gated. Before generalizing these results, further studies can be
conducted with long term follow-ups and multiple treatment
sessions. As these interventions could not stand alone interven-
tions in the management of knee OA, it can be combined with
other known effective interventions to investigate the additive
effects. The positive findings of this study may be useful for clini-
cians while planning short term goal in the management of knee
OA.

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