Lenghtening the hamstring muscles.pdf

Lengthening the Hamstring Muscles

Without Stretching Using “Awareness

Through Movement”

Background and Purpose. Passive stretching is widely used to increase muscle

flexibility, but it has been shown that this process does not produce long-term

changes in the viscoelastic properties of muscle as originally thought. The

authors tested a method of lengthening hamstring muscles called “Awareness

Through Movement” (ATM) that does not use passive stretching. Subjects.

Thirty-three subjects who were randomly assigned to ATM and control groups

met the screening criteria and completed the intervention phase of the study.

Methods. The ATM group went through a process of learning complex active

movements designed to increase length in the hamstring muscles. Hamstring

muscle length was measured before and after intervention using the Active

Knee Extension Test. Results. The ATM group gained significantly more

hamstring muscle length (

7.04°) compared with the control group

1.15°). Discussion and Conclusions. The results suggest that muscle length

can be increased through a process of active movement that does not involve

stretching. Further research is needed to investigate this finding. [Stephens J,

Davidson J, DeRosa J, et al. Lengthening the hamstring muscles without

stretching using “Awareness Through Movement.” Phys Ther . 2006;86:1641–

1650.]

Key Words: Awareness Through Movement, Feldenkrais method, Hamstring, Muscle lengthening, Stretching.

James Stephens, Joshua Davidson, Joseph DeRosa, Michael Kriz, Nicole Saltzman

Physical Therapy . Volume 86 . Number 12 . December 2006

1641

(

tors to the control of human movement and are

involved in a wide range of activities from

running and jumping to forward bending dur-

ing sitting or standing and a range of postural control

actions. Hamstring muscle strains are the most common

muscle injuries in athletes. 1 The proposed etiology

includes insufficient flexibility, strength (force-

generating capacity) impairment or imbalance, and dys-

synergic contraction that can place excessive strain on

the hamstring muscles. 2 Static stretching of the ham-

string muscles, to maintain flexibility and improve per-

formance, 2– 4 has been proposed as a proactive and

preventive strategy and is now in common use. Studies

with collegiate football players 5 and military basic train-

ees 2,6 document the success of this strategy in reducing

the rates of lower-extremity injuries.

A variety of methods have been used to increase ham-

string muscle flexibility, including static stretch, 14 pro-

prioceptive neuromuscular facilitation, 15 dynamic range

of motion, 16 and active motion in the neural slump

position. 17 None of these methods, however, uses a

process of active motion without pushing or holding at

end-range to achieve its intended results.

“Awareness Through Movement” (ATM) is a process of

verbally guiding a person through an activity during

which movements usually are performed slowly and

gently. It is thought that this process facilitates the

learning of strategies for improving organization and

coordination of body movement by developing spatial

and kinesthetic awareness of body-segment relationships

at rest and during motion, awareness of ease of move-

ment, reducing effort in action, and learning the feeling

of longer muscles in action. 18,19 This process has been

shown to improve balance and coordination in people

with multiple sclerosis 20 and balance and mobility in

people with chronic cardiovascular accident. 21

Reduced hamstring muscle flexibility has been impli-

cated in lumbar spine dysfunction, with a number of

studies 7–10 showing a strong positive correlation between

decreased hamstring flexibility and low back pain. Other

researchers 10 –13 have suggested that hamstring muscle

function in a variety of movements is part of a coordi-

nated motor program and thus the appropriate periods

of lengthening and shortening and perhaps even the

degree of lengthening itself may be a learned part of the

motor control process.

There has been limited study of this approach to ham-

string muscle lengthening. Researchers in Australia

found no effect of ATM on hamstring muscle length

with a very brief intervention. 22,23 The purpose of our

study was to test the hypothesis that ATM can be used

effectively to increase the active length of the hamstring

J Stephens, PT, PhD, CFP, is Assistant Professor, Physical Therapy Department, College of Health Professions, Temple University, 3307 N Broad

St, Philadelphia, PA 19140 (USA). Dr Stephens is a Certified Feldenkrais Practitioner (CFP) and member of the Feldenkrais Guild of North

America (FGNA). He has served as Chair of the Research Committee of FGNA. There are no financial ties. Address all correspondence to Dr

Stephens at: jstephen@temple.edu.

J Davidson, PT, DPT, CSCS, is Sports Physical Therapist, Golf Performance Specialist, and Certified Strength and Conditioning Specialist, The

Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia, King of Prussia, Pa.

J DeRosa, PT, MSPT, is Owner/Physical Therapist, Eastern Shore Physical Therapy, Linwood, NJ.

M Kriz, PT, MSPT, is Staff Physical Therapist, Bonita Springs Sports and Physical Therapy, Bonita Springs, Fla.

N Saltzman, PT, MSPT, is Physical Therapist, Physical Therapy Consultant Group, Scottsdale, Ariz.

Dr Stephens provided concept/idea/research design and institutional liaisons. Dr Davidson provided data collection. Dr Stephens, Dr Davidson,

and Mr Kriz provided writing, data analysis, project management, facilities/equipment, clerical support, and consultation (including review of

manuscript for submission). Assistance with writing, data analysis, and clerical support also was provided by Mr DeRosa and Nicole Saltzman. The

authors acknowledge the assistance of Melinda Bartscherer, who facilitated institutional relations in her role as Acting Chair of the Institute for

Physical Therapy Education at Widener University when the study was done and Jeff Lidicker, PhD, at the College of Health Professions, Temple

University, for his assistance with statistical analysis.

This study was approved by the Widener University Committee for the Protection of Human Subjects.

This research, in part, was presented as a poster at PT 2000: Annual Conference and Scientific Exposition of the American Physical Therapy

Association; June 5–8, 2000; Cincinnati, Ohio.

This article was received July 1, 2004, and was accepted August 11, 2006 .

DOI: 10.2522/ptj.20040208

1642 . Stephens et al

Physical Therapy . Volume 86 . Number 12 . December 2006

T he hamstring muscles are important contribu-

muscles. We chose to look at active length because we

believe that this measure is more meaningful than

passive length in relation to normal functional move-

ment and motor control.

ATM group was made up of 7 male and 11 female

subjects who ranged in age from 22 to 36 years

(25.9

7.89 degrees. The con-

trol group was made up of 6 male and 9 female subjects

who ranged in age from 21 to 27 years (23.9

Method and Materials

1.9) and

had a pretest hamstring muscle length measurement of

140.66

Subjects

Fifty-one subjects were recruited using posters and word

of mouth from the population of graduate students and

faculty at the Widener University, Chester, Pa, campus.

The purpose of the study was explained, and volunteers

signed an informed consent form approved by the

Widener University Committee for the Protection of

Human Subjects.

8.19 degrees. There were no statistically signifi-

cant differences between ATM and control groups based

on age, sex, or pretest hamstring muscle length.

Instrumentation

Active knee extension hamstring muscle length was

measured as the highest value in the range of knee

extension using a PEAK Motus motion analysis system.*

Accuracy of angle measurement for this system has been

reported to be less than 0.1 degree, with an intraclass

correlation coefficient (ICC) of .99. 24 An S-VHS Pana-

sonic CL-700 digital video camera was placed 7.6 m

(25 ft) from each subject and centered on a line

perpendicular to the plane of motion of the subject’s

knee. Movement was recorded on a Sanyo editing S-VHS

recorder at 60 frames per second and digitized using

PEAK Motus software. An alignment apparatus similar to

that described by Scholz and Millford 24 was constructed

of 3.81-cm (1.5-in) diameter PVC pipes. Two vertical

uprights 0.91 m (3 ft) in length were connected by a

crossbar. The footings of each upright were secured to a

standard plinth by 2 Stanley Quick Grips. † Reliability of

knee angle measurements was determined using ICCs

(2,3). A set of 3 repeated measurements from each

subject was used for pretest and posttest calculations.

The pretest ICC was .976, and the posttest ICC was .995.

Subjects qualified for the study if they did not have a

history of orthopedic problems, including surgery or

injury to the back, pelvis, or lower extremities or neuro-

logic dysfunction (eg, multiple sclerosis, cerebral palsy,

or peripheral neuropathy) within 1 year from the begin-

ning of the study. Subjects also were excluded from the

study if they had an active knee extension angle greater

than 165 degrees (full extension

Seven of the 51 subjects did not meet the screening

criteria because their hamstring muscle length exceeded

the maximum standard. Six subjects withdrew for per-

sonal reasons before group assignment. The remaining

38 subjects were randomly assigned to a group that

received ATM intervention (ATM group [n

Experimental Procedures

20]) or a

group that received no intervention (control group

Measurement protocol. The hamstring muscle length of

all subjects who met the screening requirements was

measured using the Active Knee Extension Test

(AKET) 25 1 week prior to beginning the intervention.

Hamstring muscle length was measured again 1 to 2 days

after the end of the intervention period. Subjects were

positioned supine on a standard 0.9-

18]). Five subjects (2 in the ATM group and 3 in the

control group) were dropped from the study after group

assignment. Two of these subjects left the graduate

program, 2 subjects missed the final data collection

because of sickness or travel commitments, and 1 subject

withdrew because of an acute ankle sprain sustained

while running during the period of the study. Thirty-

three subjects (18 in the ATM group and 15 in the

control group) met the screening criteria and com-

pleted the intervention phase of the study.

6-ft)

plinth under the alignment apparatus. A 10.2-cm-wide

(4-in-wide) Velcro strap ‡ was placed around the subject

at the level of the anterior superior iliac spine to stabilize

the pelvis and lumbar spine. An additional 10.2-cm-wide

Velcro strap was placed over the left thigh to stabilize the

pelvis and left lower extremity. The subjects’ right hip

was flexed to 90 degrees until the anterior thigh was just

touching the crossbar of the alignment apparatus.

1.8-m (3-

All subjects were asked to refrain from beginning any

new physical activity, including hamstring muscle

stretching, that had not been part of their regular

activity prior to the 3-week period of the intervention.

Subjects in the ATM group were asked to perform a

15-minute ATM session 5 times per week guided by an

audiotaped ATM lesson sequence. Subjects in the con-

trol group performed their regular daily activities. The

* Peak Performance Technologies Inc, 7388 S Revere Pkwy, Suite 901, Centen-

nial, CO 80112. The Panasonic camera and Sanyo VCR were obtained as part of

the PEAK Motus system.

† Stanley Tools Group, 480 Myrtle St, New Britain, CT 06053.

‡ Velcro USA Inc, 406 Brown Ave, PO Box 5218, Manchester, NH 03103.

Physical Therapy . Volume 86 . Number 12 . December 2006

Stephens et al . 1643

SD) and had a pretest hamstring muscle

length measurement of 141.96

3.8) (X

180 degrees) mea-

sured using a quick-screen active knee extension test in

which the subject lay supine with the hip flexed to 90

degrees and actively extended the knee. 17 If active knee

extension was judged to fall outside of the desired range

as marked on a plexiglass template, based on visual

assessment, subjects were excluded.

continued for the collection of 6 full repetitions for the

pretest and posttest for each subject. Repetitions 4

through 6 only were used as measures of hamstring

muscle length to allow all subjects the same amount of

practice and warm-up time before the measured trials.

Subject data were identified by number only, and the

researcher responsible for determining knee angle from

the PEAK data was not aware of the group to which each

subject was assigned.

Figure 1.

Setup for measuring hamstring muscle length using PEAK Motus motion

analysis system.

Intervention. The ATM intervention was given over a

3-week period and consisted of an initial group training

lesson and a home practice program. All subjects in the

ATM group participated in the initial 30-minute class-

room lesson targeting movements of the right lower

extremity. The lesson consisted of an introduction plus 3

movement segments, with each segment covering varia-

tions of movements requiring lengthening of the ham-

string muscle in different postural configurations. This

lesson was recorded on audiotape, and a copy was given

to each subject in the ATM group for independent

home practice during the course of the study. The

Appendix gives a description of the audiotaped ATM

lessons.

Reflecting markers 2.54 cm (1 in) in diameter were

placed on the subjects’ right lower extremity over the

greater trochanter, the middle of the lateral joint line of

the knee, and the lateral malleolus. Proper alignment of

the right thigh parallel to the vertical post of the

alignment apparatus and perpendicular to the horizon-

tal surface of the plinth was verified using the video

monitor (Fig. 1).

Each segment of the lesson began and ended with a body

scan in the supine position. This scan was designed to

make subjects aware of their quality of neuromuscular

control, including the rate and depth of breathing, the

level of neuromuscular system tension throughout the

body from the jaw to the feet, and the effort involved in

simple movements such as rolling the leg left and right.

The first movement segment began with the subjects

lying on their left side. In the second movement seg-

ment, subjects sat in a long-sitting position. The third

movement segment was done in the standing position,

beginning with the hips and knees flexed and the pelvis

posteriorly tilted. In each segment, movements were

suggested in which subjects flexed and extended the

right knee, tilted the pelvis forward and back, and

rotated the right hip with the head and upper extremi-

ties in various positions. The goal was for subjects to

learn to extend the knee, medially (internally) rotate the

extending leg, and anteriorly tilt the pelvis at the same

time, an organization of movements designed to

lengthen the hamstring muscle from both ends.

Subjects were told to maintain the position of the

anterior thigh in light contact with the crossbar of the

alignment apparatus. They were permitted to use a towel

wrapped around the posterior right thigh just proximal

to the knee throughout the test procedure to maintain

anterior thigh contact with the crossbar. The starting

position for the test was with the anterior thigh touching

the crossbar of the alignment apparatus and the right

knee in a relaxed and fully flexed position. One repeti-

tion of a knee extension movement consisted of moving

the knee into extension until a feeling of resistance from

the stiffness of the hamstring muscle stopped the move-

ment and then returning to the starting position. Sub-

jects were told to begin a series of extension movements

when one of the researchers gave a “go” signal and to

continue until a “stop” signal was given. Movements were

paced at one per 2 seconds using a watch and giving

verbal cues of “up” during the extension phase and

“down” during the flexion phase of the movement. The

timer gave a “ready” signal 3 seconds before the begin-

ning of the procedure. The researcher responsible for

data collection began recording with the PEAK system

just before the beginning of the first repetition and

As with all other movements in the lesson, these move-

ments were done slowly and continuously, with the

subjects resting when tired, and within a comfortable

range of movement, noticing when effort in other areas

of the body interfered with these specific movement

intentions and trying to reduce those efforts and breathe

easily through the entire process. Subjects were told

explicitly not to push into the end-range of knee exten-

sion as they might if they were doing active or passive

1644 . Stephens et al

Physical Therapy . Volume 86 . Number 12 . December 2006

end-range stretching. Variations of the options of rotat-

ing the hip medially and laterally (externally), extending

and flexing the knee, and tilting the pelvis were sug-

gested. Subjects in the ATM group were asked to use the

guidance of the audiotaped ATM lesson sequence until

they were comfortable with the process of exploring the

movements suggested, at which time they could proceed

without the guidance of the audiotape. All subjects were

asked to keep an activity log that included leisure and

exercise activities and for the ATM group also included

the frequency and duration of their ATM practice.

Table 1.

Change in Hamstring Muscle Length Measured in Degrees a

Group

Time

ATM (n

18)

Pretest

141.96

7.89

Posttest

149.00

7.40

Control (n

15)

Pretest

140.66

8.19

Posttest

141.81

7.61

a Full extension

180 degrees. ATM

Awareness Through Movement.

Table 2.

Two-Factor Analysis of Variance With One Repeated Measure (Time)

and Hamstring Muscle Length as the Dependent Variable

Data Analysis

The dependent variable of interest was hamstring mus-

cle length as measured by the maximum active knee

extension angle. Three trials per subject from each

measurement session were recorded, and the mean was

used for data analysis. A 2-factor repeated analysis of

variance (ANOVA) (group

Group

2.807

.104

Time

17.779

.001 a

Group

time

9.177

.005 a

time) was used with time as

the single repeated measure. 26 An alpha level of .05 was

used as the criterion for significance of difference.

a Significant difference.

Subjects in the ATM group practiced independently

over a period of 3 weeks and differed widely from each

other in their number of practice sessions and total

minutes practiced. Furthermore, because all subjects in

the ATM group did not follow the same practice sched-

ule, their postintervention hamstring muscle length

measurements were done with different periods of delay

following the time of their final practice session. To

assess the possible effects of these practice and delay

variables on the outcome measure of hamstring muscle

length, a post hoc multiple regression analysis was done. 26

The number of practice sessions, total minutes of prac-

tice, and delay (in days) were used as independent

variables with the dependent variable of hamstring mus-

cle length change within the ATM group. In this analysis,

a significance level of

9.1°–17.5°). One person representing

each of these levels was interviewed using open-ended

questions to assess their understanding of and experi-

ence and strategies in practicing the ATM lessons. These

qualitative data were used to help interpret the quanti-

tative data collected.

12.9°, range

Results

The mean change in hamstring muscle length in the

ATM group was

1.15 degrees (Tab. 1). There

was a significant increase in hamstring muscle length

over time and an interaction of group

time, indicating

an increase in hamstring muscle length in the ATM

group compared with the control group ( P

.005)

.05 would indicate that the

independent variable made a significant contribution to

the prediction of the outcome measure of hamstring

muscle length change. All statistical analyses were done

using SPSS version 11.0.4 for Macintosh. §

(Tab. 2, Fig. 2).

Table 3 shows the number of practice sessions, total

minutes of practice, and change in hamstring muscle

length for each subject in the ATM group. There was

wide variation in the amount of practice among subjects.

The range for number of sessions was 7 to 18, and total

minutes of practice ranged from 80 to 300 over the

3-week period of the intervention. The delay between

the last practice session and the final hamstring muscle

length measurement ranged from 1 to 10 days. The

regression analysis (Tab. 4) showed that there was no

significant effect on hamstring muscle length change in

the ATM group as a result of number of practice

sessions, the total number of minutes of practice, or

amount of delay between the last practice session and

the final hamstring muscle length measurement.

At the end of the intervention period, subjects in the

ATM group were asked the question: “From your expe-

rience of ATM, would you say that this process is

different from stretching, as you understand it?” After

the hamstring muscle length change analysis was com-

pleted, subjects in the ATM group were divided into 3

levels based on the amount of muscle length change.

F iv e subjects achieved no change in muscle length

4.6°–

6.8°). Seven subjects achieved a large amount of change

6.1°, range

§ SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Physical Therapy . Volume 86 . Number 12 . December 2006

Stephens et al . 1645

7.04 degrees compared with the

control group change of

3.4°–2.6°). Si x subjects achieved a

moderate amount of change (X

0.1°, range

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