Author Names

MS YilDirim, S Ouyrek, OÇ Tosun, S Uzer, and N Gelecek

Reviewer Name

Nikol Papa, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

The aim of this study was to compare the effects of static stretching, proprioceptive neuromuscular facilitation (PNF) stretching and Mulligan technique on hip flexion range of motion (ROM) in subjects with bilateral hamstring tightness. A total of 40 students (mean age: 21.5±1.3 years, mean body height: 172.8±8.2 cm, mean body mass index: 21.9±3.0 kg · m-2) with bilateral hamstring tightness were enrolled in this randomized trial, of whom 26 completed the study. Subjects were divided into 4 groups performing (I) typical static stretching, (II) PNF stretching, (III) Mulligan traction straight leg raise (TSLR) technique, (IV) no intervention. Hip flexion ROM was measured using a digital goniometer with the passive straight leg raise test before and after 4 weeks by two physiotherapists blinded to the groups. 52 extremities of 26 subjects were analyzed. Hip flexion ROM increased in all three intervention groups (p<0.05) but not in the no-intervention group after 4 weeks. A statistically significant change in initial–final assessment differences of hip flexion ROM was found between groups (p<0.001) in favour of PNF stretching and Mulligan TSLR technique in comparison to typical static stretching (p=0.016 and p=0.02, respectively). No significant difference was found between Mulligan TSLR technique and PNF stretching (p=0.920). The initial–final assessment difference of hip flexion ROM was similar in typical static stretching and no intervention (p=0.491). A 4-week stretching intervention is beneficial for increasing hip flexion ROM in bilateral hamstring tightness. However, PNF stretching and Mulligan TSLR technique are superior to typical static stretching. These two interventions can be alternatively used for stretching in hamstring tightness.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

  • Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

  • Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

  • Yes

Were study participants and providers blinded to treatment group assignment?

  • Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

  • No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

  • Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

  • No

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

  • Yes

Was there high adherence to the intervention protocols for each treatment group?

  • Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

  • Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

  • Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

  • No

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

  • Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

  • Yes

 

Key Finding #1

Mulligan TSLR technique was significantly more effective than typical static stretching, but no significant difference was found between Mulligan TSLR technique and PNF stretching

Key Finding #2

No statistically significant difference was found between typical static stretching and the no-intervention group, although typical static stretching led to significant improvement in hip flexion ROM within the group

 

Please provide your summary of the paper

The authors experimented with three different mobility interventions compared to a control group to determine which intervention had the greatest impact on hip flexion ROM after four weeks. All three interventions demonstrated statistically significant increases in the participants’ hip flexion ROM with the most robust improvements found after using the Mulligan TSLR technique and PNF stretching.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study suggests that all three approaches can be effective, but clinicians may help patients gain more hip flexion ROM by using either the Mulligan TSLR technique or PNF stretching. One way to implement the findings of this literature is to educate patients experiencing limited hip flexion on how to correctly perform PNF stretching in the clinic and make that a part of their HEP rather than static stretching to maximize gains in mobility.