“COMPARATIVE STUDY BETWEEN THE EFFECTIVENESS OF

BOWEN TECHNIQUE AND DYNAMIC SOFT TISSUE

MOBILIZATION IN INCREASING HAMSTRING FLEXIBILITY” by

SAROJ KUMAR YADAV Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

In partial fulfillment

of the requirements for the degree of

MASTER OF PHYSIOTHERAPY [M.P.T.]

in

MUSCULOSKELETAL DISORDERS AND SPORTS

PHYSIOTHERAPY Under the guidance of

Prof. U.T.IFTHIKAR ALI

PROFESSOR

Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY

MANGALORE

2013

DEDICATED

TO

MY

BELOVED

FAMILY

AND

LATE JUGATI DEVI

YADAV

&

FRIEND

LATE AMIT SHRESTHA

LIST OF ABBREVIATIONS USED

ACL- Anterior Cruciate Ligament.

AKE- Active Knee Extension.

AKET- Active Knee Extension Test.

ANOVA- One-way analysis of variance.

AROM-Active range of motion.

BT-Bowen Technique.

CSA - current sample of athletes.

DOMS- Delayed Onset Muscle Soreness.

DSTM- Dynamic Soft Tissue Mobilization.

EMG- Electro Myography.

FSPS- Forward swing phase stretch.

HML- Hamstring Muscle Length.

HSR- Hamstring strain rates.

ICC- Intraclass correlation coefficient.

MET- Muscle Energy Technique.

MRI- Magnetic resonance Imaging.

PA- Popliteal angle.

PG- Parallelogram goniometer.

PKE- Passive Knee Extension.

PROM- Passive Range of Motion.

PSLR- Passive straight leg raise.

PST-Purposive Sampling Technique.

ROM- Range of Motion.

SEM- Standard error of measurements.

SHT- Stretching holding time.

SPS- Stance phase stretch.

STE- Stretching technique.

STM- Soft Tissue Mobilization.

TOST- Taking of the shoe test.

UG- Universal goniometer.

ABSTRACT

BACKGROUND AND OBJECTIVES:

The hamstring muscles are commonly linked with movement dysfunction at the lumbar

spine, pelvis and lower limbs, and have been coupled with low back pain and gait

abnormality. Hamstring strains are regularly cited as a sport-related injury, with high risk

of recurrence and lengthy recovery times.

Hamstring muscle injuries are one of the most common musculotendinous injuries in the

lower extremity. They occur primarily during high speed or high intensity exercises and

have a high rate of recurrence. Lack of hamstring flexibility was the single most important

characteristics of hamstring injuries in athletes.

Bowen Technique and Dynamic Soft Tissue Mobilization both helps in improving

hamstring flexibility. So the main objective of this study is to compare the effectiveness of

Bowen Technique and Dynamic Soft Tissue Mobilization in improving hamstring

flexibility. This will help us to find out the most effective treatment to improve hamstring

flexibility in individuals with hamstring tightness.

METHODOLOGY:

60 subjects aged 18-30 years from Dr. M. V. Shetty College of physiotherapy, Mangalore

were recruited for this study after obtaining informed consent. The subjects were divided

into two groups of 30 each. Pre-test and Post-test measurements were taken by Active

Knee Extension Test. Group A received Bowen Technique and Group B received Dynamic

Soft Tissue Mobilization.

RESULTS:

Average change in Dynamic soft tissue mobilization group after treatment was

7.133+1.383 with a change of 24.71% and in that of Bowen technique group, average

change was 11.233+3.148 with a change of 37.91%.Test shows that there is high

significant difference between groups with respect to treatment effect as p=0.000<0.01 so

Bowen technique is significantly better compared to Dynamic soft tissue mobilization.

INTERPRETATION & CONCLUSION:

In this study the two groups showed significant increase in hamstring flexibility after

receiving the techniques. However, Bowen Technique is comparatively more effective than

Dynamic Soft Tissue Mobilization in improving flexibility of hamstring muscle.

KEYWORDS:

Flexibility; Hamstring tightness; Bowen Technique; Dynamic Soft Tissue Mobilization;

Active Knee Extension Test.

TABLE OF CONTENTS

SL.NO CHAPTER PAGE NO

1. INTRODUCTION 1-16

2. AIMS AND OBJECTIVES 17

3. REVIEW OF LITERATURE 18-43

4. METHODOLOGY 44-54

5. RESULTS 55-65

6. DISCUSSION 66-71

7. CONCLUSION 72-73

8. SUMMARY 74-75

9. BIBLIOGRAPHY 76-85

10. ANNEXURES 86-92

LIST OF TABLES

SERIAL

NO

TABLES PAGE NO

5.1 DEMOGRAPHIC REPRESENTATION OF DATA 55

5.2 AGE WISE DISTRIBUTION OF SUBJECTS 57

5.3 COMPARISON OF PRE MEASUREMENTS BETWEEN

GROUPS

59

5.4 T0 FIND EFFECTIVENESS WITHIN THE GROUPS 60

5.5 COMPARISON OF EFFECT BETWEEN THE GROUPS

62

5.6 TO FIND EFFECT OF AGE ON THE ON THE

TREATMENT EFFECT

64

5.7 T0 FIND AN EFFECT OF GENDER ON THE TREATMENT

65

LIST OF FIGURES

SERIAL

NO

FIGURES PAGE

NO

1.1 HAMSTRING MUSCLE 1

4.1 HAMSTRING TIGHTNESS 49

4.2 INSTRUMENTATION 50

4.3 ACTIVE KNEE EXTENSION TEST 51

4.4 DYNAMIC SOFT TISSUE MOBILIZATION 52

4.5 BOWEN TECHNIQUE 53

4.6 BOWEN TECHNIQUE 54

LIST OF GRAPHS

SERIAL

NO

GRAPHS PAGE

NO

5.1 DEMOGRAPHIC REPRESENTATION OF DATA 56

5.2 AGE WISE DISTRIBUTION OF SUBJECTS 58

5.3 T0 FIND EFFECTIVENESS WITHIN THE GROUP 61

5.4 COMPARISON OF EFFECT BETWEEN THE GROUPS 63

INTRODUCTION

INTRODUCTION The word ham originally referred to the fat and muscle behind the knee. String refers to

tendons, and thus, the hamstrings are the string-like tendons felt on either side of the back

of the knee. The hamstrings are a two-joint muscle bulk comprises biceps femoris longus

and brevis, forming the lateral mass of hamstrings, and the semimembranosus and

semitendinosus, making up the medial mass.

All except the short head of biceps femoris cross both the hip and knee joints. As a group,

the hamstrings flex the leg at the knee joint and extend the thigh at the hip joint. They are

also rotators at both joints.1

HANSTRING MUSCLE

FIGURE1.1

BIOMECHANICS OF HAMSTRING MUSCLE:-

The role of the hamstring muscles as knee flexors is incontrovertible. However, it is

important to recognize that because these muscles attach on both the medial and lateral

aspects of the knee joint, pure knee flexion requires activity of both the medial and lateral

muscle mass. Contraction of only the medial hamstrings produces knee flexion with medial

rotation of the knee: contraction of only the lateral muscle mass produces knee flexion with

lateral rotation of the knee joint.

In addition to flexing and rotating the knee, the hamstrings reportedly contribute to the

stability of the knee. The hamstrings provide active resistance to anterior glide of the tibia

on the femur. Thus they are described as important adjuncts to the anterior cruciate

ligament and perhaps a critical substitute in the ACL- deficient knee. There is considerable

evidence from cadaver studies indicating that the hamstring muscles decrease the strain on

the ACL. There also is evidence that individual with ACL insufficiencies increase the

activity of their hamstring muscles in some activities such as hill climbing.

The hamstrings muscle also play an essential role in extension of the hip. EMG data

reveals that the hamstring muscles are active in hip extension even when the knee is flexed.

EMG evidence also suggests that the hamstring muscles can contribute to adduction of the

hip. The biceps femoris longus demonstrates activity during lateral rotation of the hip.2

With isometric contraction, the integrated EMGs of the semitendinosus and

semimembranosus muscles at a knee flexion angle of 60° were significantly lower than

that at 90°. During maximum isokinetic contraction, the integrated EMGs of the

semitendinosus, semimembranosus and short head of the biceps femoris muscles increased

significantly as the knee angle increased from 0 to 105° of knee flexion. On the other hand,

the integrated EMG of the long head of the biceps femoris muscle at a knee angle of 60°

was significantly greater than that at 90° knee flexion with isometric testing. During

maximum isokinetic contraction, the integrated EMG was the greatest at a knee angle

between 15 and 30°, and then significantly decreased as the knee angle increased from 30

to 120°. These results demonstrate that the EMG activity of hamstring muscles during

maximum isometric and isokinetic knee flexion varies with change in muscle length or

joint angle, and that the activity of the long head of the biceps femoris muscle differs

considerably from the other three heads of hamstrings.3The absolute hamstring muscle

lengths differed between genders they were not different when standardized as a

percentage of the femur length.4

The hamstrings are active during normal locomotion. The most prominent period of

activity is at the transition between the swing and stance periods of the gait cycle. The role

of this activity is to slow the extension of the knee in late swing and to help extend the hip

in the stance phase.2

PATHOMECHANICS OF HAMSTRING MUSCLE:-

EFFECT OF WEAKNESS:-

Weakness in knee flexion in the erect posture produces little disability. However, weakness

of the hamstrings may produce more functional impairment at the hips, where the

hamstring muscles provide a substantial part of extension strength. The superimposed

weight that creates a flexion moment at the knee during a squat produces a flexion moment

at the hip. That flexion moment is resisted by a muscular extension moment generated at

least in part by the hamstring muscles. Consequently, weakness of the hamstrings may

result in significant difficulty in bending and lifting.2

EFFECT OF TIGHTNESS:-

Hamstring tightness is a common condition found in both symptomatic and asymptomatic

subjects. Tightness of the hamstrings results in limitations in knee extension ROM when

the hip is flexed. Large amount of hamstring tightness can produce knee flexion

contractures, an inability to reach full knee extension. A tight hamstring causes increased

patellofemoral compressive force, which may eventually lead to patellofemoral syndrome.

Poor hamstrings flexibility has been associated with low back pain in cross-sectional

studies in both adolescents and adults.2

Hamstring tightness is the inability to stretch the muscle through full range of amplitude.

Muscle is a prime mover and stabilizer of body that contains muscle spindle, as its

functional unit and golgi tendon organs plays important role in determining the length and

function of muscular components. Tightness of this muscle can play a role in sport related

injuries, lumbar spine disorder and general low back pain.5

HAMSTRING INJURY:

Hamstring injury is defined by the anatomical site within the muscle that is affected, and

injury must be present in one or more of the component muscles. The hamstring muscles

are commonly linked with movement dysfunction at the lumbar spine, pelvis and lower

limbs, and have been coupled with low back pain and gait abnormality.6,7,8Hamstring

strains are regularly cited as a sport-related injury,9,10 with high risk of recurrence and

lengthy recovery times.11,12 Development of pathology and movement dysfunction has

been attributed to many intrinsic and extrinsic factors.13 Such factors include: flexibility,

strength, stability, timing, endurance, previous injuries, psychosocial aspects, equipment

and environmental conditions.

Hamstring muscle injuries are one of the most common musculotendinous injuries in the

lower extremity.14 They occur primarily during high speed or high intensity exercises and

have a high rate of recurrence.15,16Lack of hamstring flexibility was the single most

important characteristics of hamstring injuries in athletes.17Hamstring injuries are

commonplace in many mainstream sports and occupations involving physical activity.18

Hamstring muscle injury is a complex problem for athletes, physicians, physical therapists,

and athletic trainers. This injury tends to recur and to limit participation in athletic

competition.103 The initial Football Association Audit of Injuries study19 found that 12% of

all injuries reported over two seasons were hamstring strains. The causes of hamstring

injuries are complicated and multifactorial.20 Recent evidence has suggested that the

hamstring muscles are most vulnerable to injury in the late swing phase of running, where

there is a rapid change from eccentric to concentric function, where the leg is decelerating

to strike the ground.21 Indirect trauma can also result from an overstretch of the

musculotendinous unit leading to a strain, tear or avulsion.22 It is generally claimed that

strain injuries most often occur near the musculotendinous junction.23

Players taking more than 1 day to walk pain-free were significantly more likely to take

longer than 3 weeks to return to competition. Players experienced an injury recurrence, all

involving the biceps femoris. Recurrence was more likely in players who reported a

hamstring injury in the past 12 months.24 The data on hamstring strain injuries remain

consistent with what we know about the biomechanical demands of the hamstring muscle

group during sprinting and acceleration. Biomechanical research demonstrates the

posterior thigh is at greatest risk for injury in the latter stages of the swing phase of

sprinting as the hamstring muscle group reaches its maximal length and rapid eccentric

muscle action occurs prior to and during foot strike.25, 26, 27

The hamstring muscles are the most commonly injured muscles in athletes and are usually

injured during running and jumping.28 Hamstring muscle injury is a complex problem for

athletes, physicians, physical therapists, and athletic trainers. This injury tends to recur and

to limit participation in athletic competition.29Hamstring injuries are common in athletes

and often become a troublesome chronic condition. Hamstring injuries are also notorious

for reinjury, often because of inadequate rehabilitation and premature return to competition

before complete recovery of the hamstring muscle group.30

PREVELANCE:

Male college athletes were 62% more likely to sustain a hamstring injury than female

athletes and more common in field sports than in court sports.31 Injury rates varied by

position, with it being the highest percentage of total injuries among running backs (22%),

defensive backs (14%), and wide receivers (12%).32 Soccer teams revealed that 12% of all

injuries were hamstring strains.33 Hamstring injuries are also seen in Australian Rules

football,34,35 hurling,36 cricket 37and touch football .38

Hamstring muscle injuries have been reported to account for 12% of all injuries in

professional football. Inadequate hamstring muscle length has historically been thought of

as a possible cause of hamstring injury.39Epidemiology studies have revealed that

hamstring injuries alone account for between 6 and 29% of all injuries reported in

Australian Rules football, rugby union, soccer, basketball, cricket and track

sprinters.23,33,34,40,41,42,43 Frustration with hamstring strains is not only explained by the

high prevalence of these injuries, but also by the prolonged duration of symptoms, poor

healing responses and a high risk of re-injury rate of 12–31% .44 Serious concerns arise by

the fact that hamstring injury and re-injury rates have not improved over the last three

decades.45,46,47,48,49,50

In an official audit of injuries in English professional football, hamstring injuries has been

shown to account for 12%–15% of all injuries sustained.19,33 The study of 2376 players

showed a total of 13,116 days and 2029 matches missed over the course of two seasons

due solely to Hamstring injuries33 It is claimed that 10% of all major league soccer players

sustain a hamstring injury during any one season.51 In the English Premier Football League

season 2005–2006, one premiership club had sustained 16 hamstring injuries within the

first three months of the season. In Australian Rules Football hamstring injuries has also

been highlighted as the most common and prevalent injury, accounting for six injuries per

club, per season and resulting in 21 missed matches per club, per season.34 A study found

that 47% of all muscle strains encountered by soccer players during training and/or

matches were injuries to the hamstring muscles.51

FLEXIBILITY:

Flexibility is the ability to move a single joint or series of joints smoothly and easily

through an unrestricted, pain-free range of motion. Muscle length in conjunction with joint

integrity and the extensibility of periarticular soft tissues determine

flexibility.52Zachezeweskil has defined muscle flexibility as" the ability of a muscle to

lengthen, allowing one joint (or more than one joint in a series) to move through a range of

motion and a loss of muscle flexibility as "a decrease in the ability of the muscle to

deform," resulting in decreased ROM about a joint.53

Restricted flexibility can be related to a number of variables, including joint capsule or

other soft tissue restrictions.54 Good muscle flexibility will allow muscle tissue to

accommodate to imposed stress more easily and allow efficient and effective movements.55

Flexibility is defined as “the range of motion available in a joint or a group of joints that is

influenced by muscles, tendons, ligaments and bones”.56 Flexibility is an important

attribute of a healthy as well as of a physically fit muscle.57Clinicians have generally

considered flexibility training to be an integral component in the prevention and

rehabilitation of injuries as well as method of improving one’s performance in daily

activities and sports.58

A sedentary life style often results in diminished flexibility.59The literature reports a

number of associated benefits of flexibility including improved athletic performance,

reduced injury risk, prevention or reduction of post-exercise soreness and improved co-

ordination.60,61Particularly in the field of rehabilitation, flexibility of the muscle is

important in postural balance, complete maintenance of the range of motion of knees and

hips, injury prevention and optimization of musculoskeletal function.62Good muscle

flexibility will allow muscle tissue to accommodate to imposed stress more easily and

allow efficient and effective movements.55

Flexibility increases body awareness, better posture and enhances performance of skill

movements.63 Mainly hamstring flexibility may prevent acute and chronic musculoskeletal

injuries, low backache problems, postural deviations, gait limitations and risk of fall.64

Flexibility refers to the achievable range of motion at a joint or group of joints without

causing injury.65 Muscle flexibility has been defined as “the ability of a muscle to lengthen,

allowing one joint or more than one joint in a series to move through a range of motion”. 66

It is an essential element of normal biomechanical functioning in sports.67 Flexibility is an

intrinsic property of the body tissues that determines the range of motion achievable

without injury at a joint or group of joints.68 Poor hamstrings flexibility has been associated

with low back pain in cross-sectional studies in both adolescents and adults. Poor

hamstring flexibility is also considered a risk factor for the development of patella

tendinopathy and patellofemoral pain,69,70 hamstring strain injury70 and symptoms of

muscle damage following eccentric exercise.71

IMPORTANCE OF HAMSTRING FLEXIBILITY:-

Hamstring is one of the most important muscles during walking.72 Hamstring flexibility is

always given a greater concern while looking for athlete’s overall physical fitness as

hamstring injuries are common and have a significant impact on the performance of an

athlete. The hamstring muscles are important contributors to the control of human

movement and are involved in a wide range of activities from running and jumping to

forward bending during sitting or standing and a range of postural control actions.73

Hamstring muscles tightness is present in almost all population of the world.74 Several

conditions commonly seen by physiotherapist have been link to hamstring muscle

tightness.75Inadequate flexibility is a contributing factor to injury to the hamstring muscle

group. Hamstring strains are a common athletic injury with a tendency to recur. Lack of

flexibility has been suggested as a predisposing factor to hamstring strains. Clinicians have

generally considered flexibility training to be an integral component in the prevention and

rehabilitation of injuries, as well as a method of improving one’s performance in daily

activities and sports. As clinicians, we often provide stretching protocols to athletes with

the expectation that flexibility gains will last long enough to have at least temporary

beneficial effect.58

Hamstring flexibility is always given a greater concern while looking for athlete’s overall

Physical fitness as hamstring injuries are common and have a significant impact on the

performance of an athlete. The hamstring muscles are important contributors to the control

of human movement and are involved in a wide range of activities from running and

jumping to forward bending during sitting or standing and a range of postural control

actions.73Particularly in the field of rehabilitation, flexibility of the hamstring muscles is

important in postural balance, complete maintenance of the ROM of the knee and hips,

injury prevention and optimization of musculoskeletal function.62 Without proper

hamstring flexibility, individuals will not be able to perform simple daily activities which

require extending at the hip or bending at the knee.76

Various stretching techniques and warm up procedures are often suggested prior to sports

or physical exercises that are believed to have beneficial effects over flexibility and

increase in joint ROM.77,78 A variety of stretching activities has been presented in the

literature in order to regain or maintain muscle flexibility and avoid a decrease in ROM

that can impair functional activities in an individual.55 Different methods used to increase

hamstring flexibility are ballistic stretching, dynamic stretching, active stretching, passive

stretching, static stretching, PNF stretching, muscle-energy technique, active release

technique, Dynamic soft tissue mobilization technique and Bowen technique.

STRETCHING:

Among the methods of stretching are ballistic stretching, static stretching, and variations of

proprioceptive neuromuscular facilitation (PNF) techniques.53,79,80,81,78,82 Ballistic

(bouncing) stretching is a rapid, jerky movement in which a body part is put into motion

and momentum carries the body part through the ROM until the muscles are stretched to

their physiological limit.80,81,78 Static stretching is performed by placing muscles at their

greatest possible length and holding that position for a period of time.79,80Proprioceptive

Neuromuscular facilitations a method of promoting or hastening the response of a

neuromuscular mechanism through stimulation of the proprioceptors. Frequently, PNF

techniques involve isometric contractions of a lengthened muscle, followed by further

lengthening, either actively or passively.82

A 30-second duration is an effective amount of time to sustain a hamstring muscle stretch

in order to increase ROM. No increase in flexibility occurred when the duration of

stretching was increased from 30 to 60 seconds or when the frequency of stretching was

increased from one to three times per day by static stretching.83

The intervention study comparing the effects of static and dynamic stretching routines in

the warm-up on hamstring flexibility demonstrated that dynamic stretching enhanced static

as well as dynamic flexibility. Static stretching on the other hand did not have an impact on

dynamic flexibility. This has implications for the use of static stretching in the warm-up for

dynamic sport. The role of static stretching for injury prevention in dynamic sport is also

being questioned.84

Warm-up significantly increased hamstring flexibility. Static stretching also

increasedhamstring flexibility, whereas dynamic did not, in agreement with previous

findings on uninjured controls. The effect of warm-up and static stretching on flexibility

was greater in those with reduced flexibility post-injury, but this did not reach statistical

significance. 85

MUSCLE ENERGY TECHNIQUE:

Muscle energy technique is a manual technique developed by osteopaths that is now used

in much different manual therapy professions.86 Muscle energy technique is considered as a

gentle manual therapy for restricted motion of the spine and extremities and is an active

technique where the patient, not the clinician, controls the corrective force. This treatment

requires a patient to perform voluntary muscle contraction of varying intensity, in a precise

direction, while the clinician applies a counter force not allowing movement to occur.87

Such approach which targets the soft tissues primarily (although it makes a major

contribution towards joint mobilization) has been termed as MET and this is also known as

active muscular relaxation technique.88

Muscle energy technique produced an immediate increase in passive knee extension. This

observed change in range of motion is possibly due to an increased tolerance to stretch as

there was no evidence of visco-elastic change.86

ACTIVE RELEASE TECHNIQUE:

Active Release Technique (ART) is a manual therapy for treating soft tissue problems in

muscles, joints and connective tissue. Providers use palpation to locate areas of tension or

adhesion in a specific tissue, then the tissue is taken from a shortened position to a

lengthened position while using a manual contact to maintain tension along the fibers of

that tissue. Active Release Technique used in combination with joint mobilization is an

effective treatment for soft tissue related problems. The technique involves specific skilful

movement that consists of more than 500 types of specific moves targeted on a case by

case basis. The time period for the treatment differ on a case -by-case basis.0n an average

4-11 visits(each lasts about 15 -30 mins) are enough for correcting soft tissue problems. A

single ART treatment increased hamstring flexibility in a group of healthy, active male

participants. 89

DYNAMIC SOFT TISSUE MOBILIZATION:-

The effect of massage on restoring muscle flexibility has not been extensively researched;

however, several studies have investigated the use of massage as a treatment option for

delayed onset muscle soreness (DOMS).90-95These studies have evaluated the use of

massage to prevent strength losses, reduce muscle soreness, and maintain joint range of

motion. Few of these studies have shown positive effects and many contain major

methodological flaws, such that a clear picture of the effectiveness of massage on DOMS

cannot be generated.91 Existing studies on massage describe significant variation in the soft

tissue techniques, which makes direct comparison between these studies difficult.96 It is

evident that an effective method of influencing flexibility has yet to be identified.

Dynamic soft tissue mobilization was developed with the aim of increasing muscle length.

It utilizes a combined technique of classic massage followed by a dynamic component,

where the limb is moved through its range. Determining a specific area of tightness, where

the treatment is concentrated, proceeds the dynamic component. In addition the DSTM

model has standardized massage parameters for the most time effective clinical use.97

Significant increase in hamstring length could be achieved by identifying a specific area of

hamstring tightness and targeting treatment to this specific area within 8 minute time

frame, in a single treatment by Dynamic soft tissue mopbilization.60 It is hypothesized that

incorporating active contraction into a massage protocol may increase muscle perfusion

and decrease muscle stiffness.98

BOWEN TECHNIQUE

Bowen addresses the body as a whole unit rather than just the presenting symptoms. This

therapy involves short gentle rolling moves over muscle, nerves, ligaments and tendons of

human body utilizing the hand, finger and thumb. Sequence of receiving bilateral rolling

moves are over segments of the erector spinae from the lumbar towards the cervical spine,

latissimus dorsi, the gluteals, the hamstring muscles proximally and distally, tensor fasciae

latae (TFL) and a medial hip adductor move. Moves themselves involve about same kind

of pressure your eyeball might tolerate through a closed eyelid. First the skin is pulled to

side of structure. Gentle pressure is then applied to edge of muscle to a point of resistance.

This challenges the muscle and pushes it out of its normal position. Next a gentle rolling

move is done over structure while maintaining gentle pressure on medial site. Application

of technique involves stimulation of precise points on body, in group of 2-8 points at a

time. Minimum wait of 2 min between certain movements to allow the body to respond the

moves. During this time therapist leaves room to allow the patient maximum space to fully

relax. It has been recently proved that a single treatment of Bowen technique significantly

increases the flexibility of hamstring muscle and maintains the increase for a period of one

week. The absence of any form of tissue loading, stretching, loading or exercise invalidates

explanation of tissue creep viscoelastic theories .Bowen studies provide implication of

fascially induced plasticity following stimulation of mechanoreceptors. Further research is

required into such proprioceptive mechanisms in relation to manual therapy techniques.99

NEED OF THE STUDY:

There have been studies done to check effectiveness of various stretching procedure to

increase hamstring flexibility. Most studies have proved the effectiveness of individual

stretching technique. Among these techniques, Dynamic soft tissue mobilization has been

proved to produce a very significant improvement in increasing hamstring flexibility.

The recent study has shown that that Bowen technique has an effective intervention in

increasing hamstring flexibility. There are no studies done pertaining to the comparative

effectiveness between Bowen technique and Dynamic soft tissue mobilization technique

and hence the need of study arises to check for the superior form of technique in a

treatment of hamstring flexibility.

AIMS AND OBJECTIVES

AIMS AND OBJECTIVES OF STUDY:

1) To find the efficacy of Bowen Technique in improving hamstring flexibility.

2) To find the efficacy of Dynamic soft tissue mobilization in improving hamstring

flexibility.

3) To compare the efficacy of Bowen Technique and Dynamic soft tissue mobilization to

increase hamstring flexibility.

Hypothesis:

Null hypothesis:

There will be no significant difference between Bowen technique and Dynamic soft tissue

mobilization in improving hamstring flexibility.

Alternative hypothesis:

There will be significant difference between Bowen technique and Dynamic soft tissue

mobilization in improving hamstring flexibility.

REVIEW OF LITERATURE

REVIEW OF LITERATURE

ANATOMICAL AND PHYSIOLOGICAL PROPERTIES OF HAMSTRING:-

Tate C M, Williams G N, Barrance, Pater J, Buchanan, Thomas (2006) studied lower

extremity morphology by using Magnetic Resonance Imaging (MRI). The aim of the study

was to describe lower extremity muscle morphology (volume and peak cross sectional

area) in young athletes and compare these with previously reported values. A second aim

was to determine if muscle morphology values differ significantly between sides, implying

that unilateral measurements cannot represent both limbs accurately. They found that mean

volumes and CSA for the current sample of athletes were larger than previously reported

values (primary 8 from cadaver studies of nonetheless). The ratio of total quadriceps

volume to total hamstrings volume averaged nearly 3:1 (2.9 +/- 0.2), whereas previous

reports have been closer to 2:1(2.1 +/- 0.2). The relative contribution of each muscle group

(hamstrings or quadriceps) volume was also different for these athletes. It was finally

concluded that the morphology data presented in this should be used instead of data from

the cadaver when studying young athletic people. These data should improve the accuracy

of biomechanical modeling in the athletic population.100

Dahmane R, Djordjevic S, Smerdu V (2007) tried to estimate the ability of biceps

femoris muscle, a hamstring muscle crucial for biarticulate movement, to adapt to changed

functional demands using mechano myographical methods. They demonstrated that, biceps

femoris muscle has a strong potential to transform into faster contracting muscle after

sprint training, than in the sedentary group. The results of the histochemical and immune

histochemical analysis of biceps femoris muscle also imply a high adapting potential of

this muscle. Beside type 1,2a and 2x (2b) fibres a relatively high proportion of intermediate

type 2c fibres, which co-expressed MyHC and -2a, was found. Therefore, type 2c might

represent a potential pool of fibres capable of transformation either to slow type 1 or to fast

type 2a in order to tune the function response of biceps femoris muscle according to the

actual functional demands of the organism.101

Ripani M, Continenza MA et al. (2006) aimed to describe the anatomy correlated to the

normal magnetic resonance imaging (MRI) images of the proximal thigh region and the

ischial tuberosity. They found that, the anatomical specimens were directly correlated with

MRI scans. Coronal scans showed well the hamstring muscles, both in length and

thickness. Both MRI images and cadaver dissections showed the ischial tuberosity as an

interesting intersection area that could be determined as follows: on the dorsal border the

gluteus maximus and its bursa, on the dorso-medial side the hamstring muscle origin and

on the antero-lateral side the quadrates femoris muscle with its in constant bursa and the

ischial tuberosity. These anatomical and MRI descriptions are very useful to give a

contribution to the right explanation of sciatic symptoms caused by those sports

specifically overloading the hamstring muscles frequently.102

SJ Woodley, Kennedy E, SR Mercer (2005) conducted a review of anatomical literature

to determine what muscles are commonly associated with sacrotuberus ligament. They

reported that via its attachment to the sacrotuberus ligament, the long head of biceps

femoris muscle is capable of influencing the motion or stability of the sacroiliac joint.

However explanations of this mechanism focus primary on these two structures and do not

address the potential influence of surrounding tissues.103

Crosiers JL, Malnati M et al. (2007) conducted a study on quadriceps and hamstring

isokinetic strength and electromyographic activity measured at different ranges of motion

and concluded that testing of knee muscles at short (30 degrees) range of motion (ROMs)

does not compromise the reproducibility of the strength or EMG scores derived from the

commonly used ROM of 90 degrees. However, strength was reproducible within the

accepted clinical standards; a wider error band characterized by corresponding EMG

scores.67

R.L. Gajdosik, C.A. Giuliani, R.W. Bohannon (1990) conducted a study on passive

compliance and length of the hamstring muscles of healthy men and women. This study

examined the passive compliance and length of the hamstring muscles of 15 healthy men

and 15 healthy women (ages 21-37) with passive straight-leg-raising between65° and 80°

and shows that the absolute hamstring muscle lengths differed between genders, they were

not different when standardized as a percentage of the femur length.4

Onishi H, Yagi R et al. (2002) conducted a study on EMG-angle relationship of the

hamstring muscles during maximum knee flexion. Ten healthy subjects performed

maximum voluntary isometric and isokinetic knee flexion. The isometric tests were

performed for 5 s at knee angles of 60 and 90 degrees. The isokinetic test, which consisted

of knee flexion from 0 to 120 degrees in the prone position, was performed at an angular

velocity of 30 degrees /s (0.523 rad/s). With isometric testing, the knee flexion torque at 60

degrees knee flexion was greater than that at 90 degrees. The mean peak isokinetic torque

occurred from 15 to 30 degrees knee flexion angle and then the torque decreased as the

knee angle increased. The EMG activity of the hamstring muscles varied with the change

in knee flexion angle except for the short head of the biceps femoris muscle under

isometric condition. With isometric contraction, the integrated EMGs of the

semitendinosus and semimembranosus muscles at a knee flexion angle of 60 degrees were

significantly lower than that at 90 degrees. During maximum isokinetic contraction, the

integrated EMGs of the semitendinosus, semimembranosus and short head of the biceps

femoris muscles increased significantly as the knee angle increased from 0 to 105 degrees

of knee flexion. On the other hand, the integrated EMG of the long head of the biceps

femoris muscle at a knee angle of 60 degrees was significantly greater than that at 90

degrees knee flexion with isometric testing. During maximum isokinetic contraction, the

integrated EMG was the greatest at a knee angle between 15 and 30 degrees, and then

significantly decreased as the knee angle increased from 30 to 120 degrees. These results

demonstrate that the EMG activity of hamstring muscles during maximum isometric and

isokinetic knee flexion varies with change in muscle length or joint angle, and that the

activity of the long head of the biceps femoris muscle differs considerably from the other

three heads of hamstrings.3

Warren P, Gabbe BJ, Schneider-Kolsky M, Bennell KL.(2010) conducted a study on

Clinical predictors of time to return to competition and of recurrence following hamstring

strain in elite Australian footballers .59 players who suffered a hamstring strain in 2002

season was participated and result was that Players taking more than 1 day to walk pain-

free were significantly more likely (p=0.018) to take longer than 3 weeks to return to

competition (adjusted odds ratio 4.0; 95% CI 1.3 to 12.6). Nine players (15.2%)

experienced an injury recurrence, all involving the biceps femoris. Recurrence was more

likely in players who reported a hamstring injury in the past 12 months (adjusted odds ratio

19.6; 95% CI 1.5 to 261.0; p=0.025).They concluded that Time to walk pain-free and

previous hamstring injury are predictors of time to return to competition and recurrence,

respectively, and should be included in a clinical assessment to aid in prognosis.24

FLEXIBILITY:-

D Hopper, S Deacon et al. (2005) concluded that there are a number of associated

benefits of flexibility including improved athletic performance, reduced injury risk,

prevention or reduction of post-exercise soreness, and improved coordination. Some

studies have shown that decreased hamstring flexibility is a risk factor for the development

of patella tendinopathy and patellofemoral pain, hamstring strain injury, and symptoms of

muscle damage following eccentric exercise.60

Donald E. Hartigand John M. Henderson (1999) conducted a study. The purpose of the

study was to prove that increasing flexibility of the hamstring musculotendinous unit

would decrease the number of lower extremity overuse injuries that occur in military

infantry basic trainees. Two different companies going through basic training at the same

time were used. Hamstring flexibility was checked at the beginning and at the end of the

13-week infantry basic training course. The control company (N = 148) proceeded through

normal basic training. The intervention company (N = 150) followed the same program but

added three hamstring stretching sessions to their already scheduled fitness program. All

subsequent lower extremity overuse injuries were recorded through the troop medical

clinic. Hamstring flexibility increased significantly in the intervention group compared

with the control group. The number of injuries was also significantly lower in the

intervention group. Forty-three injuries occurred in the control group for an incidence rate

of 29.1%, compared with 25 injuries in the intervention group for an incidence rate of

16.7%. Thus, in this study, the number of lower extremity overuse injuries was

significantly lower in infantry basic trainees with increased hamstring flexibility.104

Youdas JW, Krause DA et al. (2005) conducted a study on the influence of gender and

age on hamstring muscle length in healthy adults. The study design was cross-sectional

descriptive study. The purpose of the study wasto examine the factors of gender and age,

stratified by 10-year increments, on hamstring muscle length (HML) as measured by

passive straight-leg raise (PSLR) and popliteal angle (PA). Two hundred fourteen adults

(108 women, 106 men; age range, 20-79 years) with no known history of hip or knee joint

disease and no history of recent hamstring strain participated in the study. PSLR (trunk-

thigh angle) and PA(thigh-leg angle) were estimated with a goniometer. The result

suggests that HML differed significantly (P<.001) between genders for both methods of

measurement, with females demonstrating greater flexibility than their male counterparts.

This study provides physical therapists with typical values of HML in healthy men and

women.105

Mark B. Levin and Timpthy J. Patrik-miller (2002) in their article on children’s

distance running stated that, in male’s strength and flexibility increases by about 20% with

each stage of puberty. In females, the major increase in strength and flexibility occurs just

before mid puberty. In female runners, menstrual periods may be delayed or absent.

Current thought holds that exercise-induced menstrual irregularities carry little medical

risk.106

HAMSTRING TIGHTNESS:-

Akinpelu, Aderonke O, Bakere U, Adegoke Boa (2005) conducted a study to investigate

the influence of age on hamstring tightness in apparently healthy Nigerians. Hamstring

tightness was measured using the active knee extension test (AKET) in 240 apparently

healthy male and female subjects, aged 5-59 years. The subjects were recruited into 6 age

groups using the purposive sampling technique. Hamstring tightness was compared across

the age groups using one-way analysis of variance (ANOVA). The independent t-test was

used to compare hamstring tightness on both lower limbs in male and female subjects.

They found that all subjects had hamstring tightness (absolute extension lag) and this

increased with age up to age group 40-49 years. The male subjects had significantly higher

hamstring tightness than the females in all the age groups.107

Youdas JW, Krause DA et al. (2005) conducted a Cross-sectional descriptive study to

examine the influence of gender and age on hamstring muscle length in healthy adults.

Two hundred fourteen adults (108 women, 106 men; age range, 20-79 years) with no

known history of hip or knee joint disease and no history of recent hamstring strain

participated in the study. Passive straight-leg raise (PSLR) and Popliteal angle (PA) were

estimated with a goniometer. A 2-way ANOVA was used to analyze the effects of 2

independent variables (gender and age) on 2 dependent variables (PSLR and PA).

Statistical significance was established at alpha<.05. They found that hamstring muscle

length (HML) differed significantly (P<.001) between genders for both methods of

measurement, with females demonstrating greater flexibility than their male counterparts.

The difference between genders was 8 degrees for PSLR and 11 degrees for PA. HML was

not influenced by age.105

Erik Witvrouw, Lieven Danneels et al. (2003) conducted a prospective study on muscle

flexibility as a risk factor for developing muscle injuries in male professional soccer

players. They examined 146 male professional soccer players before the 1999–2000

Belgian soccer competition. None of the players had a history of muscle injury in the lower

extremities in the previous 2 years. The flexibility of the hamstring, quadriceps, adductor,

and calf muscles of these players was measured goniometrically before the start of the

season. All of the examined players were monitored throughout the season to register

subsequent injuries. Players with a hamstring (N = 31) or quadriceps (N = 13) muscle

injury were found to have significantly lower flexibility in these muscles before their

injury compared with the uninjured group. No significant differences in muscle flexibility

were found between players who sustained an adductor muscle injury (N = 13) or a calf

muscle injury (N = 10) and the uninjured group. They concluded that soccer players with

an increased tightness of the hamstring or quadriceps muscles have a statistically higher

risk for a subsequent musculoskeletal lesion.108

Odunaiya N.A, Hamzat T.K., Ajayi OF (2005) evaluated the effects of duration of a

static stretching protocol (Intervention) on hamstrings tightness. Their study shows that

statically stretching tight hamstrings for any duration between 15 and 120 seconds on

alternate days for 6 weeks would significantly increases its flexibility. The effect was also

sustained for up to 7 days post intervention.109

Gurkan Erkula, Fahir Demirkan, B.Aiper (2002) conducted a study on hamstring

shortening in healthy adults where they mentioned about hamstring tightness that is present

in most of the population; causes changes in posture and walking ability. This studies

accounts for the fact that the knee extensions deficit is sure with a tight hamstring muscle.

This literature provided the basic focus for the study.74

HAMSTRING INJURY:-

Agre JC (1985) conducted a study on proposed aetiological factors, prevention, and

treatment of hamstring injuries. Several aetiological factors have been proposed as being

related to injury of the hamstring musculotendinous unit. They include: poor flexibility,

inadequate muscle strength and/or endurance, dyssynergic muscle contraction during

running, insufficient warm-up and stretching prior to exercise, awkward running style, and

a return to activity before complete rehabilitation following injury. The best treatment for

hamstring injuries is prevention, which should include training to maintain and/or improve

strength, flexibility, endurance, co-ordination, and agility.22

Nikolaos Malliaropoulos, Emmanuel Papacostas et al (2010) conducted a study on

Posterior Thigh Muscle Injuries in Elite Track and Field Athletes. One hundred sixty-five

track and field athletes with acute, first-time, unilateral posterior thigh muscle injuries were

prospectively evaluated regarding knee active range of motion deficit. This was compared

with the uninjured side 48 hours after injury. A control group was also examined.

Ultrasound was used to image the muscle lesion. All athletes were managed non

operatively with the same rehabilitation protocol. The “full rehabilitation time” (interval

from the injury to full athletic activities) was recorded. They found that range of motion of

the affected leg was decreased in the 165 injured athletes compared with the uninjured side

and the control group. Sonography identified abnormalities in 55% (90 of 165) of the

injured athletes. The biceps femoris was the most commonly affected muscle (68 of 90

[75%]). The musculotendinous junction (proximal or distal) was involved in 93% (85 of

90) of lesions. Eighty-one percent (133 of 165) of athletes had active range of motion

deficit of less than 20°.110

Asklings C, Saartok T, Thorstensson A (2006) investigated possible links between

etiology of acute, first time hamstring strain in sprinters and dancers and recovery of

flexibility, strength, and function as well as time to return to pre injury level. They found

that there appears to be a link between the etiologies of the two types of acute hamstring

strain in sprinters and dancers and the time to return to pre injury level. Initially, sprinters

have more severe functional deficits but recover more quickly.111

Zeren B and Oztekin HH (2006) compared a self performed diagnostic test called

“Taking of the shoe test” (TOST), with other commonly used clinical tests for biceps

femoris muscle strain injuries and concluded that, TOST had a sensitivity and specificity

of100%, and a positive predictive value and an negative predictive value of 100% for

biceps femoris injury as found on ultrasound. The other muscle tests had an average

sensitivity of 57%, specificity of 100%, accuracy of 79%, and negative predictive value of

70%. So TOST is found to be more reliable than other commonly used clinical tests for

hamstring tears. The clinical value of this easy to perform test should be evaluated in a

prospective fashion.112

Rahnama N, Lees A, Bambaecichi E (2005) did a study to determine whether asymmetry

in strength and flexibility are present in the legs of soccer players. Forty-one elite and sub-

elite soccer players (age 23.4 +/-3.8 years; height 1.81 +/- 0.06 m; body mass 81.7+/- 9.9

kg) were studied (data are presented as mean +/- SD). The dynamic strength of knee

flexors (hamstrings) and knee extensors (quadriceps) was measured using an isokinetic

dynamometer at angular velocities of 1.05, 2.09, 5.23 rad/s (in a concentricmode) and2.09

rad/s (in an eccentric mode). The concentric strength ratio (hamstrings(conc)/ quadriceps

(conc) and the dynamic control ratio (hamstrings (ecc)/quadriceps(conc) were computed.

Hip joint flexibility (in flexion) was measured using a goniometer. It is concluded that the

lower strength of the knee flexor muscles of the preferred leg may be associated with the

differential use of these muscle during the kicking action and thus constitutes a unique

training effect associated with soccer. This in turn can lead to muscular imbalance which is

generally regarded as an injury risk factor.113

Kujala UM, Orava S, Jarvinen M (1997) studied currents trends in treatment and

prevention of hamstrings injuries and stated that pre-exercise stretching and adequate

warm up are important in prevention of hamstring injuries. Experimental studies have

shown that a short period of immobilization is needed to accelerate formation of

granulation tissue matrix following injury. The length of immobilization is, however

dependant upon the grade of injury. Mobilization on the other hand, is required in order to

regain the original strength of the muscle and achieve good final results in the reabsorption

of the connective tissue scar and re-capillarisation of the damaged area. Important role of

mobilization in sports field is to avoid muscle atrophy and loss of strength and

extensibility. Complete rupture with loss of function should be operated on, as should

cases resistant to conservative therapy in which, in the late phase of repair, the scar and

adhesions prevent the normal function of the hamstring muscle.114

Hartig DE and Henderson JM (1999) studied the effect of increasing hamstring

flexibility on lower extremity overuse injuries in military basic trainees. This study found

that stretching the hamstrings four times per day resulted in a significant increase in

hamstring flexibility and a significant decrease in lower extremity injuries. Thus, stretching

can help to prevent injuries, but only if it is done properly and frequently throughout the

day.104

Thacker S.B, J Gilchrist, D.F. Stroup, C.D. Kimsey JR (2004) conducted a systematic

review to assess the evidence for the effectiveness of stretching as a tool to prevent injuries

in sports and to make recommendations for research and prevention and concluded that,

there is not sufficient evidence to endorse or discontinue routine stretching before or after

exercise to prevent injury among competitive and recreational athletes. Further research,

especially well conducted randomized controlled trials, is urgently needed to determine the

proper role of stretching insports.115

Dadebo B, White J, George K.P (2004) aimed to investigate the relation between current

flexibility training protocols, including stretching, and hamstring strain rates (HSRs) in

English professional football clubs. They concluded that the flexibility training protocols in

the professional clubs were variable and appeared to depend on staffing expertise.

Hamstring stretching was the most important training factor associated with HSR. The use

of standard stretching protocol (SSP), stretching technique (STE), and stretching holding

time (SHT) are probably involved a complex synergism which may reduce hamstring

strains. Modification of current training patterns, especially stretching protocols, may

reduce HSRs in professional footballers.9

HAMSTRING STRETCHING IN DIFFERENT POSITIONS

L.C. Decoster, Rebecca L Scanlon, Kevin D Horn, Cleland J (2004) conducted a study.

The purpose of the study was to evaluate the relative effectiveness of standing and supine

hamstring stretching in increasing hamstring flexibility as measured by increasing range of

motion at the knee. The trial was randomized, and the setting was local academic physical

therapy and physical therapist assistant programs. Twenty-nine healthy subjects who

exhibited limited hamstring muscle flexibility bilaterally (22 women, 7 men, 25.9 ± 6.13

years of age) volunteered to participate in this study. Subjects were randomly assigned a

different stretch for each leg .Each leg was stretched 3 days per week for 3 weeks (3 × 30

seconds). Stretching sessions were supervised. Measurements were taken before and after

the 3-week stretching phase by the same investigator. They concluded that the standing and

supine hamstring stretches were comparably effective in improving flexibility.54

Ross, Michael (1999) did a study on Effect of Lower-Extremity Position and Stretching

on Hamstring Muscle Flexibility. Twelve healthy subjects with limited hamstring

flexibility stretched one leg with a stance phase stretch (SPS) and the other leg with a

forward swing phase stretch (FSPS) 5 days per week for 2weeks. They concluded that the

SPS was significantly more effective at increasing hamstring flexibility than the FSPS (p

= 0.016). Although both the SPS and FSPS resulted in significant gains in hamstring

flexibility, it was Concluded that the SPS was more effective at increasing hamstring

flexibility in subjects with limited hamstring flexibility.116

DYNAMIC SOFT TISSUE MOBILIZATION:-

D Hopper, S Deacon et al. (2005) conducted a study. The purpose of this study was to

investigate the effect of dynamic soft tissue mobilisation (STM) on hamstring flexibility in

healthy male subjects. Forty five males volunteered to participate in a randomised,

controlled single blind design study. Volunteers were randomised to control, classic STM,

or dynamic STM intervention. The control group was positioned prone for 5 min. The

classic STM group received standard STM techniques performed in a neutral prone

position for 5 min. The dynamic STM group received all elements of classic STM

followed by distal to proximal longitudinal strokes performed during passive, active, and

eccentric loading of the hamstring. Only specific areas of tissue tightness were treated

during the dynamic phase. Hamstring flexibility was quantified as hip flexion angle (HFA)

which was the difference between the total range of straight leg raise and the range of

pelvic rotation. Pre- and post-testing was conducted for the subjects in each group. It was

concluded that Dynamic Soft Tissue Mobilization (DSTM) significantly increased

hamstring flexibility in healthy male subjects.60

Diana Hopper, Mairead Conneely et al.(2005) conducted a study. The primary purpose

of this study was to evaluate the effect of Dynamic Soft Tissue Mobilization (DSTM) in

comparison with classic massage on hamstring muscle length in competitive female field

hockey players. A randomized,self controlled comparative clinical trial, with a blinded

measurer. 39 players were recruited and randomly allocated in 2 groups. One group

received classic massage and the other DSTM. Passive straight leg raise (PSLR) and

passive knee extension (PKE) were used to measure indirect hamstring length before,

following and 24 hour post intervention. It was concluded that both classic massage and

DSTM had an immediate, significant effect on hamstring length in competitive female

field hockey players.97

Russell T. Nelson, William D. Bandy (2004) suggested a better option for maintaining or

increasing flexibility of a muscle is through active contractions using dynamic range of

motion, thereby adding a fourth type of stretching. Dynamic range of motion is a technique

that allows the muscle to elongate naturally in its relaxed state. This elongation is achieved

by having the subject concentrically contract the antagonist muscle to move the joint

through the full available range in a slow, controlled manner to stretch the agonist muscle

group. It has been theorized that, as dynamic range of motion is performed, metabolic

processed increases. These increases cause an increase in temperature that leads to

decreased muscle viscosity and allows for a smoother contraction. This warmed muscle is

more pliable and more accommodating to the forces placed on the muscle, leading to

increased flexibility gains.117

Brian Hemmings, Marcus Smith, Jan Graydon, Rosemary Dyson (2000) conducted a

study. The purpose of the study was to investigate the effect of massage on perceived

recovery and blood lactate removal, and also to examine massage effects on repeated

boxing performance. Eight amateur boxers completed two performances on a boxing

ergometer on two occasions in a counter balanced design. Boxers initially completed

performance 1, after which they received a massage or passive rest intervention. Each

boxer then gave perceived recovery ratings before completing a second performance,

which was a repeated simulation of the first. Heart rates and blood lactate and glucose

levels were also assessed before, during, and after all performances. These findings

provide some support for the psychological benefits of massage, but raise questions about

the benefit of massage for physiological restoration and repeated sports performance.118

D Hopper, S Deacon et al. (2005) also mentioned that some techniques commonly used

by athletes to increase flexibility include static and ballistic stretching as well as

proprioceptive neuromuscular facilitation but recent literature reviews have indicated that

stretching does not provide significant benefits. Similarly, despite a lack of supporting

evidence, it is widely believed amongst athletes, coaches, and therapists that massage is an

effective treatment modality for increasing flexibility.60

DYNAMIC SOFT TISSUE MOBILISATION & DOMS

D Hopper, S Deacon et al. (2005) also concluded that the effect of massage on restoring

muscle flexibility has not been extensively researched; however, several studies have

investigated the use of massage as a treatment option for delayed onset muscle soreness

(DOMS). There are studies which have evaluated the use of massage to prevent strength

losses, reduce muscle soreness, and maintain joint range of motion (ROM). Few of these

studies have shown positive effects and many contain major methodological flaws, such

that a clear picture of the effectiveness of massage on DOMS cannot be generated.

Existing studies on massage describe significant variations in the soft tissue techniques,

which makes direct comparisons between these studies difficult. It is evident that an

effective method of influencing flexibility has yet to be identified.60

J Hilbert, G Sforzo, T Swensen (2003) conducted a study. The purpose of this study was

to investigate the physiological and psychological effects of massage on delayed onset

muscle soreness (DOMS). Eighteen volunteers were randomly assigned to either a massage

or control group. DOMS was induced with six sets of eight maximal eccentric contractions

of the right hamstring, which were followed 2 h later by 20 min of massage or sham

massage (control). Peak torque and mood were assessed at 2, 6, 24, and 48 h pos exercise.

Range of motion (ROM) and intensity and unpleasantness of soreness were assessed at 6,

24, and 48 h post exercise. Neutrophil count was assessed at 6 and 24 h post exercise. It

was concluded that massage administered 2 h after exercise induced muscle injury did not

improve hamstring function but did reduce the intensity of soreness 48 h after muscle

insult.93

BOWEN TECHNIQUE:

Michelle Marr, Julian Baker, Nicky Lambon, Jo Perry (2011) conducted a study on the

effects of the Bowen technique on hamstring flexibility over time: a randomized controlled

in a sample of 120 asymptomatic volunteers. They concluded that a single treatment of the

Bowen technique demonstrated immediate significant increases in the flexibility of the

hamstring muscles in asymptomatic subjects, maintaining improvements for one week

without further treatment.99

Dr. Bernie Carter, Rick Minnery& Bran Clarke (2002) performed a study when 20

participants diagnosed with frozen shoulder were given three to six treatments of the

Bowen Technique. Participants claimed a high level of satisfaction with the therapy. 70%

of participants regained full mobility (equal to the non affected side) by the end of the

treatment. The other participants showed significant improvement in shoulder mobility and

associated function.119

Dicker A. (2005) conducted a study on Using Bowen technique in a health service

workplace to improve the physical and mental wellbeing of staff. He concluded that a six

week program using Bowen Technique treated 31 Hospital and Community Health Service

staff in a group setting providing an innovative way to reduce stress and improve physical

health. Quantitative and qualitative data indicated that Bowen Technique was successful in

reducing pain, improving mobility, reducing stress, and improving energy, well being and

sleep.120

Dicker A. (2001) conducted a study on Using Bowen Therapy to improve staff health and

concluded that Positive results from the administration of Bowen Therapy to staff while at

work has prompted an innovative project addressing the lowering of stress levels and

preventing burn-out for all staff, in and beyond nursing.121

Duncan B,McHugh P,Houghton F,Wilson C.(2011) conducted a study on Improved

motor function with Bowen therapy for rehabilitation in chronic stroke: a pilot study.A

case series of 14 people with chronic stroke were offered 13 sessions of Bowen therapy

over athree-month period. Motor assessments of the 13 people who participated showed

improvements--gross motor function trended to improvement; SF-36 role-physical,

physical health summary scale and total SF-36 scores showed statistically significantly

improvements. However, grip strength reduced. In this pilot study, Bowen therapy was

associated with improvements in neuromuscular function in people with chronic stroke. At

this stage of study, it is not possible to conclude that there is definite benefit; however the

results suggest that exploration through further research is appropriate.122

Dicker A. (2005) conducted a study on Bowen technique--its use in work related injuries.

A program in Byron Shire in 2002 offered Health Service staff treatments with Bowen

Technique. The program was evaluated after 9 months. The evaluation explored the effect

of the treatment on work related injuries. The responses indicated that the provision of

Bowen Therapy for staff might be an effective way of reducing workcover claims. 123

Smith et al (2008) also reported significant increases in hamstring length using two groups

of varying length contraction using Muscle Energy Technique (MET). Increases in

hamstring flexibility were evident immediately post-test, with improvements can only

account for changes in flexibility of the hamstring muscles and did not evaluate movement

control characteristics or injury statistics. Therefore, increases in flexibility cannot be

correlated with changes in stability, efficiency or strength.124

Glen M. DePino William G. Webright, Brent L. Arnold (2000) conducted a study to

determine duration of hamstring flexibility gains as measured by an active knee extension

test, after cessation of an acute Static Stretch Protocol in a sample of 30 male subjects with

limited hamstring flexibility. They concluded that 4 consecutive 30 seconds static stretches

enhances hamstring flexibility but this effect lasted only 3 minutes after cessation of the

stretching protocol.58

OUTCOME MEASURES:

Richard Gajdosik and Gary Lusin (1983) did a study on intratester Reliability of an

Active-Knee-Extension Test in measuring Hamstring Muscle Tightness. The test measures

the angle of knee flexion with a pendulum goniometer after active knee extension with the

hip stabilized at 90 degrees flexion. The angle of knee flexion represents hamstring

tightness. After an instruction session for the subjects, the hamstring muscle tightness of

both extremities of 15 men was measured during test and retest sessions. The

reliability coefficients for test and retest measurements were 0.99 for the left extremity and

0.99 for the right extremity. High reliability resulted from strict body stabilization

methods, a well-defined end point of motion, and accurate instrument placement. They

concluded that if conducted properly, the test should provide therapists with an

objective and reliable tool for measuring hamstring muscle tightness.125

Belinda J Gabbe, Kim L Bennell, Henry Wajswelner, Caroline F Finch (2004)

conducted a study on Reliability of common lower extremity musculoskeletal screening

tests. Fifteen participants (n=9 female, n=6 male) were tested by two raters on two

occasions, 1 week apart to establish the inter-rater and test–retest reliability of the chosen

measurement tools. The tests of interest were Sit and Reach, Active Knee Extension,

Passive Straight Leg Raise, slump, active hip internal rotation range of movement (ROM),

active hip external rotation ROM, lumbar spine extension ROM and the Modified Thomas

Test. All tests demonstrated very good to excellent (Intraclass correlation coefficient, ICC

0.88–0.97) inter-rater reliability. Test–retest reliability was also shown to be good for these

tests (ICC 0.63–0.99). They concluded that these simple, clinical measures of flexibility

and ROM are reliable and supported their use as pre-participation screening tools for sports

participants.126

Teddy W. Worrell, Michael K. Sullivan, Joseph J. DeJulia (1992) conducted a study.

They examined the intratester and three testers performed repeated AKET measurements

on 22 subjects. Intraclass correlation coefficients (ICC) were used to calculate intratester

and intertester reliability. Also, standard error of measurements (SEM) was calculated. The

ICC and SEM were .96 and 1.82°, respectively, for Tester 1, .99 and 1.75° for Tester 2,

and .99 and 1.80° for Tester 3. Intratester 95 % confidence intervals ranged from 60.54 to

69.82°. Intertester ICC and SEM for two testers were .93 and 4.81°, respectively. A 95 %

intertester confidence interval ranged from 56.35 to 75.21°; this reveals that intertester

AKET values contained more error and suggests that only intratester AKET values should

be used when comparing hamstring flexibility values intertester reliability of an active-

knee- extension test (AKET) for determining hamstring muscle length (flexibility).127

C. M. Norris and M. Mathews (2005) did a study to assess inter-tester reliability of two

testers using a novel self monitored active knee extension (AKE) test in the clinic setting

and concluded that the AKE test used in conjunction with goniometry, accurate surface

marking, and manual monitoring of the test leg is a reliable measure of hamstring muscle

length.128

Rakos DM,Shaw KA et al. (2001) determined the inter-rater reliability of the active knee

extension test (AKET) using a stabilizing apparatus to measure hamstring length. One

hundred one subjects with no knowm neuromuscular problems participated in their sturdy.

The AKET was performed with subjects lying supine with hip flexed to 90 degrees with a

stabilization device attached to a plinth. Next, subjects were instructed to actively extend

the knee until therafter detected myoclonuis. Then the rater flexed the knee until

myoclonus subsided and the knee angle eas measured with a blinded goniometer. This

procedure was repeated by each of three raters. Their results suggest that the AKET, when

used with the stabilizing apparatus, demonstrates good inter-rater reliability.129

LC. Decoster, Joshua Cleland, CarolannAltieri, Pamela Russell (2005) have used

standard double arm plastic goniometer to measure active knee extension when the subject

is in supine which is an indicator of hamstring flexibility. In supine hip & knee kept at 90

degree of hip flexion, subjects were asked then to actively extend the knee as far as

possible. It is stopped once the subject no longer extends the knee or when hip begins to

lose it’s 90 degree. The reliability and validity of this test & equipment is mentioned in

most of the literature. That’s the reason it’s intended in the study.130

Jagodzinski M, Kleemann V et al.(2000) analyzed the accuracy of commonly used

techniques for the measurement of knee extension and to compare them with a new

measurement device and concluded that, a precision goniometer that utilizes bony

landmarks of tibia and femur is superior in accuracy compared with standard and long arm

goniometer techniques.131

Gajdosik RL, Rieck MA, Sullivan DK, Wightmam SE (1993) compared four clinical

tests for assessing hamstrings muscle length and concluded that different testing

procedures probably had a minimum influence on test results. However the difference

between Active Knee Extension (AKE) and Passive Knee Extension (PKE) tests suggested

that AKE test and PKE test may represent an “Initial length” and “Maximal

length”respectively.72

Russell PJ and Decoster LC (2006) studied the impact of foot position on supine Active

Knee Extension (AKE) assessment and suggested that clinicians should be aware that foot

Position influences hamstrings extensibility as determined by AKE test and reminded that

gastrocnemius tautness influences knee extensibility. Interventions addressing knee

pathology should be consider the influence of gastrocnemius tautness.132

Yvonne Kane and Jay Bernasconi (1992) described the effect of contralateral hip flexion

on pelvic rotation in the sagittal plane and ipsilateral active knee extension during a

modified active knee extension test. Twenty seven normal subjects were tested, yielding 54

sets of data. Active knee extension was performed in five positions of contralateral hip

flexion and was videotaped. Measurements of pelvic and knee joint angles were obtained

from the film. The results indicated the least amount of pelvic rotation was 5.50 which

occurred at maximum contralateral hip flexion. Analysis of variance revealed a difference

between test positions that was statistically significantfor pelvic rotation and knee

extension (p < .05). Pelvic rotation can be effectively controlled during an active knee

extension test by maximally flexing the contralateral hip. The active knee extension test

can be used as an accurate assessment tool to evaluate hamstring muscle length.133

Brosseau , Tousignant M et al.(1997) examined the intra and intertester reliability of the

universal goniometer (UG) and parallelogram goniometer (PG), and to assess the criterion

validity of the same instruments on subjects with knee restrictions. They concluded that

both intra and intertester reliability were high for both the goniometers. The results for the

criterion validity varied. Their study also suggested that it is preferable to use goniometer

rather than visual estimations when measuring AROM. It is recommended that the same

therapist take all the measurements when assessing AROM for UG and PG goniometric

measurements on patients with knee restrictions.134

Mayerson NH and Milano RA (1984) examined the reliability of placing and reading a

universal goniometer under controlled conditions. Major joints of the upper and lower

extremities were chosen, and for each, multiple positions representing different partsof full

range of motion were designated. A healthy young adult man was assessed using a rigidly

standardized procedure for positioning his joints. Their analysis indicated that, regardless

of whether difference scores are derived from within or between observers, repeated

measurements under controlled conditions can confidently be expected to fall within

appropriately four angular degrees of each other. Results were compared to those from

other studies, limitations of generalizability were discussed, and recommendations for

future research were preferred. The authors suggested that the present findings be

constructed as global upper limit estimates of applied goniometric reliability.135

Wendy Rheault, Michelle Miller et al. (1988) conducted a study. This study was

designed 1) to determine the intertester reliability of the universal goniometer and the

fluid-based goniometer and 2) to establish the concurrent validity of the fluid-based

goniometer. Two testers measured active knee flexion of 20 healthy subjects (15 women, 5

men) using both instruments. The subjects had a mean age of 24.8 years (s = 5.5) and

reported no previous history of pathological conditions of the right lower extremity. Using

a correlational design, high intertester reliability was established for each instrument

(universal goniometer, r =.87; fluid-based goniometer, r = .83). The concurrent validity of

the fluid-based goniometer was also good for both testers (tester A, r = .83; tester B, r =

.82). When the data were subjected to t tests, significant differences were found between

the instruments for each tester (p < .05). The results suggest that similar measurements will

be obtained between therapists using the universal and fluid-based goniometers; however,

the two instruments cannot be used interchangeably in the clinic.136

METHODOLOGY

METHODOLOGY

SOURCE OF DATA

Sample Size of 60 students in the age group of 18 to 30 years with 30 in each of the two

groups from Dr. M.V Shetty College of Physiotherapy, Mangalore were there for the

study.

METHOD OF COLLECTION OF DATA:

In this comparative study, 60 asymptomatic healthy individuals fulfilling the inclusion

criteria were selected using purposive sampling method and randomly divided in to 2

groups i.e. group A and group B, each group consists of 30 members. Informed consent

was obtained from them.

Pre test was conducted on group A and group B by using universal goniometer for

measuring active knee extension range of motion.

Group A subjects received Bowen technique; Group B subjects received Dynamic soft

tissue mobilization technique.

Post test was conducted on group A and group B by using universal goniometer for

measuring active knee extension range of motion immediately after the intervention.

The results were recorded and statistically analyzed.

This study was conducted over duration of 12 months.

CRITERIA FOR SELECTION

INCLUSION CRITERIA

1) Asymptomatic subjects aged 18-30 years.

2) Male and Female.

3) 20-40 degrees active knee extension loss with hip in 90 degree flexion.

4) Stretch end feel during complete range of motion.

5) Dominant right lower limb

EXCLUSION CRITERIA

1) Fractures of the hip and knee.

2) Dislocations of lower limb.

3) Hamstring injuries.

4) Hypermobility of lower limb joint.

5) Muscle imbalance of lower limb.

6) Nerve lesions of lower limb.

7) Subjects have low back pain in last 2 month.

8) Straight leg, hip flexion ROM was greater than 100 degrees.

9) Metal pins, plates or screw in femur.

10) Neurological abnormalities.

MATERIALS USED

1)A universal double arm goniometer.

2)Treatment couch.

3)Assessment format.

OUTCOME MEASURE

Active Knee Extension Test using Universal Goniometer

PROCEDURE

GROUP A ( BOWEN TECHNIQUE)

Starting position: subjects assumed the full-prone lying position on a plinth. A Bowen

treatment lasts 20-30 minutes. Each subject received a single treatment of the following

documented Bowen treatment techniques. Bowen addresses the body as a whole unit rather

than just the presenting symptoms. This therapy involves short gentle rolling moves at

level of superficial fascia over muscle, nerves, ligaments and tendons of human body

utilizing the hand, finger and thumb. Sequence of receiving bilateral rolling moves were

over segments of the erector spinae from the lumbar towards the cervical spine, latissimus

dorsi, the gluteals, the hamstring muscles proximally and distally, tensor fasciae latae

(TFL) and a medial hip adductor move. Moves themselves involve about same kind of

pressure your eyeball might tolerate through a closed eyelid. First the skin was pulled to

side of structure. Gentle pressure was then applied to edge of muscle to a point of

resistance. This challenges the muscle and pushes it out of its normal position. Next gentle

rolling moves were done over structure while maintaining gentle pressure on medial site.

Application of technique involved stimulation of precise points on body, in group of 2-8

points at a time. Minimum wait of 2 min between certain movements to allow the body to

respond the moves. During this time therapist leaved room to allow the patient maximum

space to fully relax.

GROUP B (DYNAMIC SOFT TISSUE MOBILIZATION)

To assess the hamstring muscle group, the subject was remained in the prone position and

deep longitudinal strokes were applied to this entire muscle group. Once the specific area

of hamstring muscle tightness was located, the remaining treatment was limited to this

target area. To execute the dynamic intervention, the subject had moved into a supine

position with the hip and knee flexed to 90˚. In this position, all dynamic techniques

worked the hamstring muscle length from three quarter to end ROM.

Deep longitudinal strokes were applied in a distal to proximal direction to the area of

hamstring tightness when the leg was passively moved to the hamstring lengthened

position. Five strokes were applied and 20 seconds of shaking was performed at the

completion of this technique. The specific area of hamstring tightness was reassessed to

determine whether the surface area of the site of muscle tightness was reduced. If this

reduction had occured, then the next progressive dynamic technique was applied.

However, if the area of muscle tightness didn’t reduced, the treatment was stopped. This

criteria was applied for all dynamic technique. The same sequence was implemented for

the next dynamic technique. During this technique, the subjects were required to actively

extend their leg, in order to achieve reciprocal inhibition of the hamstrings. In the final

technique, the subjects were required to work the hamstring muscle group eccentrically by

creating tension in the therapist’s hand as the muscle was elongated to the end ROM.

During this movement, the therapist performed five deep distal to proximal longitudinal

strokes over the reduced hamstring area of muscle tightness.

Post test was conducted on group A and group B using universal goniometer for measuring

active knee extension range of motion.

The results was recorded and analyzed.

ACTIVE KNEE EXTENSION TEST:

Each subject was positioned in left side lying on examination table for bony landmark

identification. The lateral femoral condyle, head of fibula and lateral malleolus of the right

leg were marked to ensure that the same reference points were used for repeated

measurements.

Once the landmarks were identified, subjects were instructed to lie in supine position. The

subject flexed right hip to 900 and grasps behind the right knee to stabilize hip at 900. A

goniometer was then used to position right knee at 900. A stationary arm along lateral

femur and movable arm aligned with lateral fibula keeping lateral femoral condyle as axis.

Patient actively extended the right knee as much as possible without moving the thigh from

vertical position. Active knee ROM was measured by goniometer. This procedure was

used for flexibility measures in all the groups.

STATISTICAL TEST USED:

Mean, standard deviation and paired and unpaired t- test.

FIGURE 4.1 : HAMSTRING TIGHTNESS

FIGURE 4.5: INSTRUMENT USED

1.Universal goniometer

FIGURE 4.5: ACTIVE KNEE EXTENSION TEST

FIGURE 4.3: DYNAMIC SOFT TISSUE MOBILIZATION

FIGURE 4.6: BOWEN TECHNIQUE

FIGURE 4.7: BOWEN TECHNIQUE

RESULTS

RESULTS:

TABLE 5.1 DEMOGRAPHIC REPRESENTATION OF DATA

5 5 1016.7% 16.7% 16.7%

25 25 5083.3% 83.3% 83.3%

30 30 60100.0% 100.0% 100.0%

F

M

Sex

Total

Dynamic softtissue

mobilizationBowen

technique

Group

Total

Table 5.1

Table 5.1 shows that group A (Bowen Technique) consists of 5 females and 25 males

subjects with hamstring tightness. Group B (Dynamic Soft Tissue Mobilization) consists of

5 females and 25 males with hamstring tightness.

FIGURE 5.1 DEMOGRAPHIC REPRESENTATION OF DATA

Figure 5.1

Figure 5.1 shows that 16.7% subjects with hamstring tightness in Group B(Dynamic soft

tissue mobilization) were female , 83.3% subjects with hamstring tightness in Group

B(Dynamic soft tissue mobilization) were male. 16.7% subjects with hamstring tightness

in Group A (Bowen technique) were female , 83.3% subjects with hamstring tightness in

group A (Bowen technique) group were male.

TABLE 5.2 AGE WISE DISTRIBUTION OF SUBJECTS

14 17 3146.7% 56.7% 51.7%

10 9 1933.3% 30.0% 31.7%

6 4 1020.0% 13.3% 16.7%

30 30 60100.0% 100.0% 100.0%

18 - 20

21 - 23

24 - 25

Age

Total

Dynamic softtissue

mobilizationBowen

technique

Group

Total

Table 5.2

Table 5.2 shows that out of 30 subjects with hamstring tightness in Group A(Bowen

Technique) 17 subjects with hamstring tightness were in age group of 18-20 year,9

subjects with hamstring tightness were in the age group of 21-23 year and 4 subjects with

hamstring tightness were in age group of 24-25 year. Out of 30 subjects with hamstring

tightness in Group B(Dynamic Soft Tissue Mobilization) 14 subjects with hamstring

tightness were in age group of 18-20 year,10 subjects with hamstring tightness were in the

age group of 21-23 year and 6 subjects with hamstring tightness were in age group of 24-

25 year.

FIGURE 5.2 AGE WISE DISTRIBUTION OF SUBJECTS

X2=.743, p=.690, NS

Figure 5.2

Figure 5.2 shows that 46.7% of subjects with hamstring tightness in group B (Dynamic

soft tissue mobilization) were of age group 18-20 year, 33.3% of subjects with hamstring

tightness in group B (Dynamic soft tissue mobilization) were of age group 21-23 year and

20% of subjects with hamstring tightness in group B (Dynamic soft tissue mobilization)

were of age group 24-25 year , 56.7% of subjects with hamstring tightness in group A

(Bowen technique) were of age group 18-20 year, 30% of subjects with hamstring

tightness in group A (Bowen technique) were of age group 21-23 year and 13.3% of

subjects with hamstring tightness in group A (Bowen technique) were of age group 24-25

year.

TABLE 5.3 COMPARISON OF PRE MEASUREMENTS BETWEEN GROUPS

Group N Minimum Maximum Mean Std.

Deviation t value p value Dynamic soft tissue mobilization 30 22 37 28.87 4.629 .644 .522

Bowen technique 30 22 37 29.63 4.590 NS Total 60 22 37 29.25 4.587

Table 5.3

Table 5.3 shows that Active knee extension test in group B (Dynamic soft tissue

mobilization) was 28.87 + 4.629 and that of group A (Bowen technique) was 29.63 +4.59.

t test shows that there is no significant difference between two group with respect to active

knee extension test before treatment as p=0.522>0.05

Chi square test shows that there is no significant different between group A (Bowen

Technique) and group B (Dynamic soft tissue mobilization) as p=0.690>0.

TABLE 5.4 T0 FIND EFFECTIVENESS WITHIN THE GROUPS

30 22 37 28.87 4.629 7.133 1.383 24.71 28.251 .000

30 13 30 21.73 4.727

30 22 37 29.63 4.590 11.233 3.148 37.91 19.546 .000

30 10 27 18.40 4.753

Pre

Post

PrePost

GroupDynamic softtissuemobilizationBowentechnique

N Minimum Maximum MeanStd.

DeviationMean

differences.d of

differencePecentage

change t valuep

value

Table 5.4

Table 5.4 shows that in group B (Dynamic soft tissue mobilization); mean active knee

extension before treatment was 28.87+4.629 and after treatment it was 21.73+4.727

showing 24.71% improvement after treatment which is statistically significant as

p=0.000<0.01

In group A (Bowen technique); mean active knee extension before treatment was

29.63+4.590 and after treatment it was 18.40+4.753 showing 37.91% improvement after

treatment which is statistically significant as p=0.000<0.01

So both the treatments are effective in improving hamstring flexibility

FIGURE 5.4 T0 FIND EFFECTIVENESS WITHIN THE GROUP

Figure 5.3

Figure 5.4 shows that in group B (Dynamic soft tissue mobilization); mean active knee

extension before treatment was 28.87+4.629 and after treatment it was 21.73+4.727

showing 24.71% improvement after treatment which is statistically significant as

p=0.000<0.01

In group A (Bowen technique); mean active knee extension before treatment was

29.63+4.590 and after treatment it was 18.40+4.753 showing 37.91% improvement after

treatment which is statistically significant as p=0.000<0.01

So both the treatments are effective in improving hamstring flexibility

TABLE 5.5 COMPARISON OF EFFECT BETWEEN THE GROUP

7.133 1.383 24.71 6.531 .000

11.233 3.148 37.91 HS

GroupDynamic soft tissuemobilizationBowen technique

change

Meandifference

s.d ofdifference

Pecentagechange t value

pvalue

Table 5.5

Table 5.5 shows that average change in group B (Dynamic soft tissue mobilization) after

treatment was 7.133+1.383 with a change of 24.71% and in that of group A (Bowen

technique), average change was 11.233+3.148 with a change of 37.91%.Test shows that

there is high significant difference between groups with respect to treatment effect as

p=0.000<0.01 so Bowen technique is significantly better compared to Dynamic soft tissue

mobilization.

FIGURE 5.4 COMPARISON OF EFFECT BETWEEN THE GROUP

Figure 5.4

Figure 5.4 shows that average change in group B (Dynamic soft tissue mobilization) after

treatment was 7.133+1.383 with a change of 24.71% and in that of group A (Bowen

technique), average change was 11.233+3.148 with a change of 37.91%.Test shows that

there is high significant difference between groups with respect to treatment effect as

p=0.000<0.01 so Bowen technique is significantly better compared to Dynamic soft tissue

mobilization.

TABLE 5.6 TO FIND EFFECT OF AGE ON THE ON THE TREATMENT

EFFECT

Correlations

.254 .175 NS

.113 .552 NS

change

change

AgewithAgewith

GroupDynamic softtissue mobilizationBowen technique

Karl pearsoncorrelation

coefficient r value p value

Table 5.6

Table 5.6 shows correlation analysis which shows that there is no significant correlation

between age and treatment effect so age has no influence on treatment.

TABLE 5.7 T0 FIND AN EFFECT OF GENDER ON THE TREATMENT

7.16 1.375 .232 .8187.00 1.581 NS

11.16 3.313 .281 .78111.60 2.408 NS

SexMFMF

change

change

GroupDynamic softtissue mobilization

Bowen technique

MeanStd.

Deviation t value p value

Table 5.7 Table 5.7 shows that treatment effect is not significantly different between male and

female as p>0.05 in both groups so there is no influence of gender on treatment.

DISCUSSION

DISCUSSION

The hamstring muscles are commonly linked with movement dysfunction at the lumbar

spine, pelvis and lower limbs, and have been coupled with low back pain and gait

abnormality. Hamstring strains are regularly cited as a sport-related injury, with high risk

of recurrence and lengthy recovery times.

Hamstring muscle injuries are one of the most common musculotendinous injuries in the

lower extremity. They occur primarily during high speed or high intensity exercises and

have a high rate of recurrence. Lack of hamstring flexibility was the single most important

characteristics of hamstring injuries in athletes.

Muscle tightness is one of the limiting factors for restricted range of motion and reduced

flexibility of joint. Hamstring muscles are more prone for tightness causing

Musculoskeletal problems. This study focused on checking effects of Bowen technique and

Dynamic soft tissue mobilization in increasing ROM and flexibility of subjects with

hamstring tightness.

The aim of my study was to compare the effectiveness of Bowen technique and Dynamic

Soft Tissue Mobilization (DSTM) in increasing hamstring flexibility. 60 subjects from

Dr. M. V. Shetty College of physiotherapy fulfilling the inclusion criteria were assigned

for this study by Purposive Sampling Technique. The subjects were divided into two

groups of 30 subjects each. Informed consent was taken from the subjects and the

procedure was explained. Group A received Bowen technique and group B received

Dynamic Soft Tissue Mobilization. Pre and post intervention measurements were taken by

Active Knee Extension Test with the help of universal goniometer.

In the present study the subjects were chosen from age group 18 to 30 years which is well

suported by a study done by Akinpelu, Aderonke O, Bakere U, Adegoke B.O.A. who

conducted a study to investigate the influence of age on hamstring tightness in apparently

healthy Nigerians. They had concluded that hamstring tightness increases with age from

childhood up to 40-49 years, more in males than females and common in age group of 15-

30 years in adults.

The data’s obtained from the study was statistically analysed using paired and unpaired t-

test. Group A had pre treatment mean value of 29.63 and Group B had pre treatment mean

value of 28.87 for active knee extension. The result of the study revealed that there was an

immediate gain in active knee joint extension range of motion in both groups, Group A and

B after the respective protocol. Group A showed post treatment mean value of 18.40 and

Group B showed post treatment mean value of 21.73. There was significant increase in

active range of motion for knee in both the group’s subjects immediately after the protocol.

The range of motion gain in Group A which received Bowen technique was significantly

higher than Group B which received Dynamic Soft Tissue Mobilization.

Michelle Marr, Julian Baker, Nicky Lambon, Jo Perry conducted a study on the effects of

the Bowen technique on hamstring flexibility over time: a randomized controlled in a

sample of 120 asymptomatic volunteers. They concluded that a single treatment of the

Bowen technique demonstrated immediate significant increases in the flexibility of the

hamstring muscles in asymptomatic subjects, maintaining improvements for one week

without further treatment. In the present study the group which received Bowen technique

had significant effect on hamstring flexibility which is well supported by the previous

article.

In the present study it’s also proven that Dynamic Soft Tissue Mobilization has an

immediate, significant effect on hamstring length. This result is well supported by a study

carried out by D Hopper, S Deacon, S Das, A Jain, D Riddell, T Hall, K Briffa who

investigated the effect of Dynamic Soft Tissue Mobilization on hamstring flexibility in a

sample of 45 males. They had concluded that Dynamic Soft Tissue Mobilization

significantly increases hamstring flexibility in healthy male subjects when compared to

control group and classic soft tissue mobilization group.

Diana Hopper, Mairead Conneely, Fiona Chromiak, Emanuela Canini, Jeanette Berggren,

Kathy Briffa conducted a study to evaluate the effect of Dynamic Soft Tissue Mobilization

in comparison with classic massage on hamstring muscle length in competitive female

field hockey players. It was concluded that both classic massage and DSTM had an

immediate, significant effect on hamstring length in competitive female field hockey

players. In the present study the group which received DSTM also showed a significant

improvement in hamstring flexibility which is in accordance with the previous article.

In the present study active knee extension test was used as an outcome measure. The use of

AKET for the present study was well supported by a study carried out by Richard

Gajdosik and Gary Lusin who measured intratester reliability of an Active-Knee-Extension

Test in measuring Hamstring Muscle Tightness. The reliability coefficients for test and

retest measurements were .99 for the left extremity and .99 for the right extremity. High

reliability resulted from strict body stabilization methods, a well-defined end point of

motion, and accurate instrument placement. They concluded that if conducted properly, the

test should provide therapists with an objective and reliable tool for measuring hamstring

muscle tightness.

C. M. Norris and M. Mathews did a study to assess inter-tester reliability of two testers

using a novel self monitored active knee extension (AKE) test in the clinic setting and

concluded that the AKE test used in conjunction with goniometry, accurate surface

marking, and manual monitoring of the test leg is a reliable measure of hamstring muscle

length.

Hence the result of this study proves that Bowen technique is more effectiveness than

DSTM in increasing hamstring flexibility.

Daniel J DJ Cipriani, Megan E ME Terry, Michelle A MA Haines, Amir P AP

Tabibnia, Olga O Lyssanova conducted a study on Effect of stretch frequency and sex on

the rate of gain and rate of loss in muscle flexibility during a hamstring-stretching

program: a randomized single-blind longitudinal study. The results revealed no significant

differences in the rate of gain or the rate of loss between the different stretching protocols

(2-way analysis of variance, F = 2.60, p > 0.05). All the stretching groups gained in hip

ROM from pre to week 4 (F = 269.24, p 0.05). Stretching appears to be equally effective,

whether performed daily or 3 times per week, provided individuals stretch at least 2 times

each day. Moreover, although women are more flexible than men are, there was no sex

difference in terms of stretching response. Similarly in present study showed that

Treatment effect is not significantly difference between male and female as p>0.05 in both

groups so there is no influence of gender on treatment.

The present study Correlation analysis shows that there is no significant correlation

between age (18-30) and treatment effect so age has no influence on treatment.

LIMITATIONS

1) As this study was limited to the effect of Dynamic Soft Tissue Mobilization on the

hamstring muscle, other studies are needed to evaluate the effect of Dynamic Soft Tissue

Mobilization on other muscle groups such as gastrocnemius, soleus and iliotibial band.

2) The result of this study cannot be generalized to all population of having hamstring

tightness. Further research examining the effects of Bowen technique and Dynamic soft

tissue mobilization on individual in other age groups would be of interest.

3) The hamstrings were the only muscles to be assessed in Dynamic soft tissue mobilization

and in the Bowen Technique study, but the Bowen technique involved treating the

paraspinal muscles, latissimus dorsi, gluteals,TFL, hip adductors as well as the

hamstrings.

4) The right side hamstrings were the only muscles to be assessed in Dynamic soft tissue

mobilization and in the Bowen Technique study, but the Bowen technique involved

treating right as well as left side the hamstrings.

5) Post analysis was done immediately after treatment in both groups but its effects after

one week would have been interesting. So further research is required for longer effect.

CONCLUSION

CONCLUSION

The result of this study showed that Bowen Technique is more effective than Dynamic Soft

Tissue Mobilization in increasing hamstring flexibility.

In Dynamic soft tissue mobilization group; mean active knee extension before treatment

was 28.87+4.629 and after treatment it was 21.73+4.727 showing 24.71% improvement

after treatment which is statistically significant as p=0.000<0.01

In Bowen technique group; mean active knee extension before treatment was 29.63+4.590

and after treatment it was 18.40+4.753 showing 37.91% improvement after treatment

which is statistically significant as p=0.000<0.01

Average change in Dynamic soft tissue mobilization group after treatment was

7.133+1.383 with a change of 24.71% and in that of Bowen technique group, average

change was 11.233+3.148 with a change of 37.91%.test shows that there is high significant

difference between groups with respect to treatment effect as p=0.000<0.01 so Bowen

technique is significantly better compared to Dynamic soft tissue mobilization.

Therefore after analyzing the data the following conclusions were drawn:

There is a significant effect of Bowen Technique and Dynamic Soft Tissue Mobilization in

improving the flexibility of the hamstring muscles.

Bowen Technique is comparatively more effective than Dynamic Soft Tissue Mobilization

in improving flexibility of hamstring muscles.

SUMMARY

SUMMARY

The Semitendinosus, Semimembranosus and the Biceps Femoris muscles are collectively

known as the Hamstrings. They form the posterior compartment of the thigh. All except

the short head of biceps femoris cross both the hip and knee joints. As a group, the

hamstrings flex the leg at the knee joint and extend the thigh at the hip joint. They are also

rotators at both joints.

Hamstring tightness is a common condition found in both symptomatic and asymptomatic

subjects. Tightness of the hamstrings results in limitations in knee extension ROM when

the hip is flexed. Large amount of hamstring tightness can produce knee flexion

contractures, an inability to reach full knee extension. A tight hamstring causes increased

patellofemoral compressive force, which may eventually lead to patellofemoral syndrome.

Poor hamstrings flexibility has been associated with low back pain in cross-sectional

studies in both adolescents and adults.

Dynamic Soft Tissue Mobilization and Bowen Technique both helps in improving

hamstring flexibility. The aim of this study is to compare the efficacy of Bowen Technique

and Dynamic Soft Tissue Mobilization in increasing hamstring flexibility. This will help us

to find out the most effective intervention to improve hamstring flexibility.

60 healthy college students aged 18-30 years from Dr. M.V. Shetty College of

Physiotherapy, Mangalore were recruited in this study after obtaining informed consent.

The subjects were divided into two groups of 30 each: Group A and Group B. Pre test

measurements were taken by Active Knee Extension Test.

Group A subjects received Bowen technique and Group B subjects received Dynamic Soft

Tissue Mobilization . Post test measurements were taken by Active Knee Extension Test.

Data was statistically analyzed using paired and unpaired t-test. Average change in

Dynamic soft tissue mobilization group after treatment was 7.133+1.383 with a change of

24.71% and in that of Bowen technique group, average change was 11.233+3.148 with a

change of 37.91%.test shows that there is high significant difference between groups with

respect to treatment effect as p=0.000<0.01 so Bowen technique is significantly better

compared to Dynamic soft tissue mobilization.

The result of this study shows the two groups showed significant increase in hamstring

flexibility after receiving the technique. However, there was a significant improvement

following the application of Bowen Technique than compared to Dynamic Soft Tissue

Mobilization in improving flexibility of hamstring muscle as determined by Active Knee

Extension Test.

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ANNEXURES

ANNEXURES

ANNEXURE I

TREATMENT CONSENT FORM

I, ______________________________voluntarily declare to participate in the research study

entitled “COMPARATIVE STUDY BETWEEN THE EFFECTIVENESS OF BOWEN

TECHNIQUE AND DYNAMIC SOFT TISSUE MOBILIZATION IN INCREASING

HAMSTRING FLEXIBILITY”.

I have been explained about the study, risk of participation and the researchers have

answered all my questions and queries regarding the study to my satisfaction.

Signature of the subject: ____________________________

Signature of the Investigator: _________________________

Subject is fit or unfit to participate in the study:

Date:

ANNEXURE II

DATA COLLECTION SHEET

Date:

Name:

Age:

Sex:

Musculoskeletal screening test; (AKE for hamstring flexibility)

Active Knee Extension ROM:

Group A:

Group B:

OUTCOME MEASURE PRE-TEST

MEASUREMENT

POST-TEST

MEASUREMENT

Active Knee Extension Test

ANNEXURE III

DEFINITIONS

FLEXIBILITY Flexibility is the ability to move a single

joint or series of joints smoothly and easily

through an unrestricted, pain-free range of

motion. Muscle length in conjunction with

joint integrity and the extensibility of

periarticular soft tissues determine flexibility.

DYNAMIC SOFT TISSUE

MOBILIZATION

Dynamic soft tissue mobilization was

developed with the aim of increasing muscle

length. It utilizes a combined technique of

classic massage followed by a dynamic

component, where the limb is moved through

its range. Determining a specific area of

tightness, where the treatment is

concentrated, proceeds the dynamic

component.

BOWEN TECHNIQUE Bowen addresses the body as a whole unit

rather than just the presenting symptoms.

This therapy involves short gentle rolling

moves at level of superficial fascia over

muscle, nerves, ligaments and tendons of

human body utilizing the hand, finger and

thumb. Moves themselves involve about

same kind of pressure your eyeball might

tolerate through a closed eyelid. First the

skin is pulled to side of structure. Gentle

pressure is then applied to edge of muscle to

a point of resistance. This challenges the

muscle and pushes it out of its normal

position. Next a gentle rolling moves is done

over structure while maintaining gentle

pressure on medial site. Application of

technique involves stimulation of precise

points on body, in group of 2-8 points at a

time. Minimum wait of 2 min between

certain movements to allow the body to

respond the moves. During this time

therapist leaves room to allow the patient

maximum space to fully relax.

TIGHT HAMSTRING It is defined as a 200 of knee extension deficit

with the hip at 900

RANGE OF MOTION It is the degree of movement from a defined

neutral zero point (anatomical position) for

each joint.

GONIOMETER It is an instrument for measuring angles or

ROM of a joint.

ANNEXURE IV

MASTER CHART

Dynamic soft tissue mobilization

Bowen technique

Sl no

Sex

Age

Pre intervention measurement

Post intervention measurement

Sl no

Age

Sex Pre intervention measurement

Post intervention measurement

1 M 18 30 22 1 18 F 25 10

2 M 18 25 16 2 18 F 30 17

3 M 18 33 28 3 18 F 33 23

4 M 19 29 23 4 18 F 29 18

5 M 19 23 16 5 19 F 23 14

6 M 19 27 20 6 19 M 35 27

7 M 20 37 28 7 19 M 26 16

8 M 20 35 29 8 19 M 29 20

9 M 20 24 17 9 19 M 25 17

10 M 21 28 23 10 20 M 37 27

11 M 21 34 25 11 20 M 24 13

12 M 21 25 20 12 20 M 27 17

13 M 22 36 29 13 21 M 34 19

14 M 22 22 14 14 21 M 30 21

15 M 22 32 26 15 21 M 22 14

16 M 23 26 18 16 21 M 28 17

17 M 23 30 21 17 23 M 35 22

18 M 23 37 30 18 23 M 25 15

19 M 24 23 15 19 23 M 32 20

20 M 24 29 20 20 23 M 36 13

21 M 24 24 18 21 23 M 27 18

22 M 25 32 24 22 24 M 35 25

23 M 25 26 19 23 24 M 29 14

24 M 25 33 25 24 24 M 24 16

25 M 18 25 20 25 24 M 34 23

26 F 19 27 22 26 19 M 37 24

27 F 18 22 13 27 18 M 27 12

28 F 19 29 23 28 19 M 31 20

29 F 20 28 21 29 20 M 25 13

30 F 21 35 27 30 20 M 35 27