Theron White. Clinical Case Report Competition. Utopia Academy. Second Place Winner. Spring 2011

Transcription

1 Massage Therapists Association of British Columbia Clinical Case Report Competition Utopia Academy Spring 2011 Second Place Winner Theron White The effects of massage to the hamstring muscle group on length and sprinting speed P: F: massagetherapy.bc.ca MTABC 2011

2 Table of Contents Abstract 1 Introduction 2 Case History 3 Assessment 5 Treatment 7 Remedial Exercises and Hydrotherapy 8 Results 8 Discussion 10 Conclusion 11 Acknowledgements 13 References 14 Appendix A Treatment Protocol 13 Appendix B Toe-Touch results (Photographs) 14 Appendix C Toe-Touch and Range of Motion data 15 Appendix D Record of 200 Meter Sprints 16 Appendix E Participant workout log during the case study 17 [1]

3 Abstract Objective The Effect of Massage to the Hamstring Muscles on Length and Running Speed To evaluate the effects of massage applied to the hamstrings on sprinting speed over 200 meters (m). The two goals of this case study are 1. To increase the hamstring length of the participant. 2. To evaluate the relationship of an increase in hamstring length and changes in running performance. Methods The case study involved nine days of consecutive, 75 minutes massage treatments. A specific protocol of manual techniques was applied to the hamstrings group Swedish massage, myofascial release, various neuromuscular techniques were applied during the study.. To greater highlight the influence of massage on the results neither remedial exercises nor hydrotherapy were not prescribed. Results There was a significant increase in hamstring length and range of motion antagonistic to shortened hamstrings. Objective results show a 130% increase in functional hamstring length and increased hip flexion and knee extension were experienced bilaterally. During the case study there was a 2.86 second decrease in average 200m sprinting time. Conclusion For this individual the application of massage to the hamstrings was effective in increasing hamstring length. While there may be some apparent correlation between the decreased running times and the increase in hamstring length, there is insufficient evidence in this study to show a direct link. The biomechanics of running is very complex and further research into the application of massage on specific structures and their affect on running and athletic performance needs to be compiled. Key words: Hamstrings flexibility, Sprinting, Length Testing, Massage protocol [2]

4 Introduction The hamstring group is comprised of three muscles: bicep femoris, semitendinosus and semimembranosus. The group gets the name because their tendons have string like appearance as they pass through the popliteal area. The bicep femoris is the largest muscle in the group and has two portions. Proximally the long head originates from the ischial tuberosity and the sacrotuberous ligament and the short head originates from the lateral lip of the linea aspera and lateral supracondylar line of the femur. Distally both heads share a common tendon and attach to the posterolateral tibial condyle and the head of the fibula. Bicep femoris receives dual innervation from both branches of the sciatic nerve; the tibial branch to the long head and the fibular branch to the short head. The origin of semimembranosus is the medial ischial tuberosity (deep to the semitendinosus) and it inserts on the posteromedial tibial condyle. Semimemtendinosis originates from the ischial tuberosity and inserts into the pes anserine tendon on the proximal part of the medial shaft of the tibia. Both of these receive innervation from the tibial branch of the sciatic nerve. a. b. Figure 1. (a) Netter 477A, Figure 1. (b) Netter 477B The hamstrings are biarticular muscles and cross both the hip and knee and respectively extend and flex those joints. The hamstrings can act upon one of these joints at a time or both simultaneously. They play an important role as postural muscles. In weight bearing the quadriceps and the hamstrings are the predominant muscles that support the knee with dynamic co-contraction. (Kessler, p. 346) During the gait cycle of walking and running the hamstrings act upon both joints and contract concentrically and eccentrically during different phases. Electromyographic (EMG) studies shows; the hamstrings and hip extensors extend the hip in the second half of swing phase and the first half of stance phase. The hamstrings also decelerate the momentum of the tibia as the knee extends just prior to initial contact. (Novacheck, p. 80) Typical EMG activity for running is shown in figure 2. The hamstrings also play an important [3]

5 role in the management of stride length during running. If the stride length is longer, then fewer contraction cycles are needed to cover the same distance. (Barlow et al, 2004) Figure 2. EMG (adapted from Mann and Hagy) Case History The participant is a twenty-nine year old, non smoking female in good health with good dietary habits. She is regularly involved in a high volume strength and metabolic conditioning regime (see Appendix E). Over the past two years her work out regime has been widely varied and involves compound olympic lifts, body weight exercises and aerobic activities such as skipping rope and running. On average she completes five to six workouts in a seven day span. Her main complaint is that her hamstrings always feel tight during her workouts and she experiences delayed onset muscle soreness (DOMS) regularly. Presently she does not incorporate any specific flexibility training or stretching protocol on a consistent basis into her exercise regime. She has reported that running is her weakest area of competence based on speed. In an attempt to improve this she has made an effort to complete a 200m timed sprint at the end of her workouts. Assessment Hamstring length was measured using the functional toe-touch test, hip flexion ROM and the straight-leg raise test. Toe-touch measurements were made with a tape measure before and after each treatment with a follow up measurement fourteen days after the final massage. Hip flexion and the straight-leg raise test measurements were taken by goniometer before the first, fifth and after the ninth treatment. A timed 200m sprint was performed after the participant s workout. [4]

6 Toe Touch Test To perform the test the participant was instructed to bend forward at the waist, reach towards the floor with her fingertips while keeping the knees extended. No specific warm-up was required before attempting the test. A tape measure was used to determine the distance from the tip of the middle finger closest to the ground. The level of the ground is represented by a value of zero. Negative numbers indicate the participant was not able to touch the ground and positive numbers indicate that she was able to reach beyond the bottom of her toes. Figures 3 and 4 illustrate negative and positive values respectively. Initial measurements were centimeters (cm). Figure 3. Negative toe-touch number Figure 4. Positive toe-touch number Range of Motion assessment Hip flexion measurements were taken in the supine position. The hip was passively flexed while the knee was allowed to flex passively until resistance to further motion was felt and attempts at overcoming resistance caused posterior tilting of the pelvis. (Norkin and White, p.194) Figure 5 depicts the goniometer alignment for measuring hip flexion. Figure 5. Norkin and White. (p ) The fulcrum was centered over the greater trochanter of the femur. Align the proximal arm with the lateral midline of the pelvis. Align the distal arm with the lateral midline of the femur, using the lateral epicondyle for reference. [5]

7 Knee extension was measured using the straight-leg raise test. In this test the patient flexes the hips to 90 and grasps behind the knee with both hands. The examiner then extends the knee through the available range. (Hertling and Kessler, p. 297) The end of the testing motion occurs when resistance is felt from tension in the posterior thigh and further knee extension causes the hip to move toward extension. (Norkin and White, p.238). Figure 6 depicts the goniometer alignment for measuring knee extension. Figure 6. Norkin and White. (p. 239) The fulcrum is centered over the lateral epicondyle of the femur. Align the proximal arm with the lateral midline of the femur, using the greater trochanter for a reference. The distal arm is aligned with the lateral midline of the fibula using the fibular head and lateral malleolus for a reference. 200 meter sprint The sprint was completed in a straight line and consisted of a 100 meter turn around. The running surface was a typical city sidewalk. The shoes the participant used were two months old and are only used during workouts and sprints. The same person timed all the runs with the same watch. The participant chose this route for convenience and to avoid crossing the street. The record of sprints performed between January 16, 2011 and March 2, 2011 is shown in appendix D. Treatment The treatment goals were to increase hamstring length by decreasing intermuscular fascial restrictions, reduce muscle tone and decrease intramuscular adhesions. The case study involved nine treatment sessions and a tenth meeting, fourteen days after to reassess the toe-touch test. The first, fourth and ninth sessions included ROM assessments of the hip and knee. Treatments one through nine were performed on consecutive days at approximately ten pm and the same protocol was repeated at each treatment. See appendix A for detailed description of the treatment protocol. A summary of the treatment protocol in order of application follows. Positioning - Prone [6]

8 Full body compressions (introductory technique) Sacrotuberous ligament release Following techniques were applied exclusively to the hamstring group. o Superficial myofascial release (MFR) to the hamstring group o Neuromuscular attachment frictions (proximal attachments) o Insertion to origin muscle separation (biceps femoris and semitendinosus muscle bellies) o Tendon bowing (distal tendons of bicep femoris, semitendinosus and semimembranosus) General Swedish techniques were used as a transitional bridge between techniques. Treatment notes The participant was asked to maintain her regular activities and to refrain from any stretching activities of the upper or lower body, including the two week period after the ninth treatment. Prior to treatment six (Feb 27, 2011), the participant complained of moderate lumbar soreness and stiffness resulting from her workout that day. The soreness was described as moderate prior to treatment seven and minimal before treatment eight. It should be noted that no therapeutic or self care interventions were taken to mitigate the lumbar complaint between treatment six and the tenth reassessment session. The participant continued her workout regime irrespective of the soreness. Remedial Exercise and Hydrotherapy There were no remedial exercises or hydrotherapy protocols given to the patient. Results Overall the treatments successfully produced an increase in hamstring length. The participant showed steady increases in all assessment areas during the case study. Additionally the participant recorded her fastest 200 meter sprint and decreased her average completion time during the study. [7]

9 Toe Touch Test The standing toe-touch produced incremental positive results with each treatment. Initial assessment showed a reach cm from the bottom of her toes, increases peaked after the eighth treatment at +5.72cm. This value was replicated at the end of the ninth treatment (See Figure 7). On reassessment after fourteen days the participant was able to reach +4.45cm. Appendix C.1 contains the accompanying data. Cen1meters Standing Toe-Touch measurements pre and post treatments Pre- treatment Post- Treatment Reassment 4.45 Figure 7. Pre and post treatment results for forward bend test. Range of Motion Range of motion values for bilateral hip flexion and knee extension are depicted in figure 8. Increases of ROM over the course of the study were right (R) and left (L) hip flexion were R 22 and L 12. Knee extension increases were R 9 and L Range of Mo1on Assessments ROM values - Degrees R Hip Flexion L Hip Flexion R Knee Extension L Knee Extension 0 Feb 22, Tx 1 Feb 26, Tx 5 Mar 02, Tx 9 ROM Assessment Dates Figure 8. Hip and Knee Range of Motion measurements. [8]

10 200 m Sprints There were 31 recorded sprint times from January 16, 2011 to March 2, Analysis of the data showed a mean of seconds, a median and mode of 46 seconds with a range of 7 seconds. The highest value in the set was 50; the lowest value, 43 was recorded four times during participation in the case study. On Feb 5 th, 2011 the day a high of 50 seconds was recorded, the participant reported feeling very tired. This run was completed on a day that the participant reported only getting four hours of sleep the previous night. The average 200m completion time from January 16 th February 17 th was seconds. The average completion time during the case study period February 24 th - March 2 nd was 43.5 seconds. Figure 9 depicts the individual run times and the ongoing average before and during the case study. Time - Seconds Timed 200m Sprints 200m Jan 16 - Feb17 Avg Jan 16 - Feb m Feb 24 - Mar 2 Avg Feb 24 - Mar Mar Mar Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan- 11 Run Dates (Jan 16 - Mar 2) Figure 9. Individual sprint times (seconds) with ongoing average completion times. Feb 24 Mar 2 represent sprints completed during the case study. Discussion The effect of massage on hamstring muscle length and evaluating any changes in running performance was the primary focus of this study. Factors that may have influenced the results of this study are The validity of the assessment techniques The length of treatments The timing of the massage treatments The starting hamstring length of the participant Points of contention to the validity of the toe-touch test as a true measurement of hamstring flexibility include the influence of vertebral mobility, anthropomorphic variability among test [9]

11 subjects. The measurements were taken with the same individual so anthropomorphic variance is not a factor in the results. With respect to vertebral mobility; in test subjects with good hamstring extensibility; if the trunk is inclined well past the horizontal plane as a result of pelvic movement, maximum reach may be achieved by less than maximal vertebral flexion. The contribution of hip flexion to trunk flexion is greater than that achieved by vertebral flexion. (Kippers & Parker, p. 1683) Although the position of the fingertips does not supply information about vertebral flexion, some clinicians may argue that the technique is valid for following a patient's progress. (Kippers & Parker, p. 1683) As mentioned previously the participant reported lumbar soreness and stiffness with trunk flexion but results of the toe touch test continued to show improvements. It s plausible that the assessed gains were due more to an increase in hamstring length than that of vertebral involvement. A review of three studies showed increases in hamstring length or ROM post massage treatment. The protocols were widely varied and ranged from a single nine to twelve minute application (Crossman, 1984) to a five minute applications twice a week for three weeks. (Vennard, 2005) The nine hours of hands on time in this study is much greater than the time dedicated in the reviewed studies. This difference might account for the significant changes in hamstring length. Some studies have reported that massage; post treatment may induce a transient loss of muscle strength or a change in the muscle fiber tension-length relationship. (Arroyo-Morales et al, 2008) The treatments were performed at night and all workouts and timed runs were performed the following day to mitigate the possible detrimental effects of massage on performance. Normal hamstring flexibility during the straight-leg raise test should be within 20 of full extension. (Magee, p.634) Full extension being 180 ; the participant s initial results of 135 and 132 for the right and left knee extension respectively were below the normal range of hamstring flexibility. These finding may indicate that the flexibility and running gains were representative of her initial lack of flexibility and may not be a true representation of the efficacy of the treatment protocol on a normal population base. Other assessment techniques that could have been implemented to add further insight on the efficacy of the treatments. The use of a detailed questionnaire or a participant journal could have provided subjective findings during the case study. A greater correlation between the treatments and an increase in sprinting speed could have been made if assessment methods included stride length and rate measurements over the 200m distance. Conclusion The massage protocol applied in the case study was effective in increasing the hamstring length of the participant. The increase in hamstrings length and corresponding ROM changes appear to have positively influenced the participants sprinting speed. Based on the assessment methods used, this study cannot directly attribute the decreasing sprint times recorded during the study to the ROM changes observed. Further research involving the specific application massage to the hamstrings and its effect on athletic performance, running mechanics and speed and running should be completed. Suggestion for future studies include a population base that falls within [10]

12 normal flexibility ranges and the inclusion of sprinting stride length and rate over a fixed distance as assessment methods. [11]

13 Acknowledgements I would like to acknowledge the participant for pushing your mind and body daily. To her partner, you patience and assistance was exemplary. To Ben Ngui case supervisor extraordinaire, thanks for attention to detail and encouragement. A huge thank you to Kirti and Takaya White for enduring many evenings away from home. [12]

14 References 1. Arroyo-Morales M, Olea N, Martínez M M, Hidalgo-Lozano A, Ruiz-Rodríguez C,Diazrodriguez L. (2008) Psychophysiological effects of massage-myofascial release after exercise: a randomized sham-control study. Journal of alternative and complementary medicine. 2008; Dec 14(10): Biceps Femoris - Wheeless' Textbook of Orthopaedics. Retrieved March 1, 2011 from Duke Orthopedics online Caplan, N., Rogers, R., Parr, M.K., Hayes, P.R. (2009). The effect of proprioceptive neuromuscular facilitation and static stretch training on running mechanics. Journal of Strength and Conditioning Research. 2009; Jul 23(4): Chumanov, E.S, Heiderscheit, B.C, Thelen, D.G. (2007). The effect of speed and influence of individual muscles on hamstring mechanics during the swing phase of sprinting. Journal of Biomechanics. 2007; 40(16): Epub 2007 Jul Colby, L. & Kisner, C. (2007). Therapeutic Exercise - Foundations and Techniques. Philadelphia, PA. F.A. Davis Company. 6. Crosman, L.J. BS, PT, Chateauvert, S.R, MTh, Weisberg, J, PhD, RPT. (1984) The Effects of Massage to the Hamstring Muscle Group on Range of Motion. The Orthopaedic and Sports Physical Therapy Sections of the American Physhcal Therapy Association. 1984; 6(3): Gajdosik, R & Lusin, G., (1983) Hamstring Muscle Tightness: Reliability of an Active-Knee- Extension Test. Physical Therapy Journal. 1983; 63 (7) Hertling, D. and Kessler, R.M. (2006). Management of Common Musculoskeletal Disorders Physical Therapy Principles and Methods. Philadelphia, PA: Lippincott Williams & Wilkins. 9. Kippers, V., Parker, A.W. (1987) Toe-Touch Test A Measure of Its Validity. Journal of the American Physical therapy Association. 1987; Nov 67 (11) Magee, D. (2008). Orthopedic Physical Assessment. (pp ). Edmonton, AB:Saunders. 11. Mann R.A, Hagy J. (1980). Biomechanics of walking, running, and sprinting. American Journal of Sports Medicine. 1980; Sep 8(5): [13]

15 12. Mann, R.A., Moran, G.T., Dougherty, S.E. (1984) Comparative electromyography of the lower extremity in jogging, running, and sprinting. American Journal of Sports Medicine. 1984; Dec 14(6) Netter, F.H. (2006). Atlas of Human Anatomy 4 th Ed. Elsevier. 14. Norkin. C.C, White, D.J.(2003). Measurement of Joint Motion: A guide to goniometry 3 rd Ed. Philadelphia, PA. F.A. Davis Company. 15. Novacheck. T.F. (1998). The biomechanics of running. Gait and Posture. 1998; 7(1) %29%207%281%29,% pdf 16. Simonsen, E.B., Thomsen, L, Klausen, K. (1985) Activity of mono- and biarticular leg muscles during sprint running. European Journal of Applied Physiology and Occupational Physiology. 1985; 54(5) Sloniger, M.A., Cureton, K.J., Prior, B.M., Evans, E.M. (1997) Lower extremity muscle activation during horizontal and uphill running. Journal of Applied Physiology. 1997; Dec 83(6) Stephens, J., Davidson, J., DeRosa, J., Kriz, M., Saltzman, N. (2006) Lengthening the Hamstrings Muscles Without Stretching Using Awareness Through Movement. Journal of the American Physical Therapy Association. 2006; Dec 86 (12) Tortora, G. J. & Derrickson, B. (2009). Principles of Anatomy and Physiology 12th Ed. Hoboken, NJ. John Wiley & Sons. 20. Vennard, K, J. (2005).The Effects of Massage on Hamstring Flexibility: A Thesis presented to The Faculty of the Department of Health and Kinesiology: Sam Houston State University. [14]

16 Appendix A Treatment Protocol: Introductory techniques - Full body rocking and full body compression Myofascial Release o Cross hand MFR to increase superficial fascial mobility proximally between the gluteals and hamstring, over the hamstring muscle bellies and distally across the popliteal fossa between the hamstrings and gastrocnemius. o Intermuscular myofascial separation Between the adductor group and semitendinosus and semimembranosus Between biceps femoris and the iliotibial band - MFR adductors/hams, hams/it band. Sacrotuberous ligament release o Performed with the olecronon process just proximal and medial to the ischial tuberosity. (held for 90 sec) o Followed by multiple 2 second olecranon compressions along length of the sacral attachments of the sacrotuberous ligament. Neuromuscular Attachment release o Performed on the proximal attachment site of the hamstring groups on the Ischial tuberosity. o Static compression with the olecronon for 90 seconds on bicep femoris attachment site. The patient s knee is flexed to 90 and passively extended. This action was repeated in 10 second cycles (flexion to extension and back to flexion). o The process was repeated at the semitendinosus and semimembranosus attachment site. Intra muscular separation from insertion to origin o Performed unidirectionally from distal insertion to proximal origin with reinforced thumb pressure and minimal emollient. o Three full traversals of the muscle belly of bicep femoris was made each separated by 5 effleurage strokes. o At the rate of 30 seconds from insertion to origin o The techniques was repeated on the muscle bellies of semitendinosus and semimembranosus. Tendon bowing o Patient s knee was flexed to 90 and asked to perform gentle resisted knee flexion to landmark the distal tendons. The tendons were accessed for bowing on the medial and lateral sides of the popliteal fossa. o The bicep femoris tendon was bowed laterally. The hip was slightly externally rotated by using the leg as a lever. Finally the knee was passively extended to increase the tensile load on the tendon. At a rate of 30 seconds from knee flexion to knee extension. o Process was repeated three times on the each with a starting position of 90 knee flexion. Effleurage was performed between o The process was replicated on the distal tendons of semitendinosus and semimembranosus. The variation being a medial bow of the tendons Swedish massage techniques of effleurage, open Cs and muscle jostling were applied as transitional work between specific techniques. [15]

17 Appendix B Photographs of toe touch test. All photographs were taken by the author. Treatment 1 Feb 22 Pre Post Treatment 2 Feb 23 Pre Post Treatment 3 Feb 24, 2011 Treatment 4 Feb 25, 2011 Treatment 5 Feb 26, 2011 Treatment 6 Feb 27, 2011 Treatment 7 Feb 28, 2011 Treatment 8 Mar 1, 2011 Treatment 9 Mar 2, 2011 Reassessment March 16, 2011 [16]

18 Appendix C C.1 Standing Toe Touch Results All results are measured in inches. o ( ) values represent fingertip distances above floor level o (+) values represent fingertip distances below floor level Date Standing forward bend TX # Pre treatment Post treatment Reassessment % change 1 22-Feb % 2 23-Feb % 3 24-Feb % 4 25-Feb % 5 26-Feb % 6 27-Feb % 7 28-Feb % 8 1-Mar % 9 2-Mar % 10 16th Mar 4.45 C.2 Hip and Knee Range of Motion results All values are degrees Right Hip Flex Right Knee Ext Left Hip Flex Left Knee Ext Pre tx Pre tx Pre tx Pre tx Treatment #1 Feb Treatment #5 Feb Treatment #9 Mar [17]

19 Appendix D Times for 200 meter runs Run # Date 200 m time Jan 16-feb 17 Feb 24-mar 2 Average Average 1 16-Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Mar Mar [18]

20 Appendix E Conditioning workouts during the case study E.1 [19]

21 E.2 [20]

22 E.3 [21]

23 [22]