Bowen's Technique and Muscle Energy Technique on Hamstrings Tightness
Condition: Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      The aim of this research is to find and compare the effect of Bowen's technique and Muscle
      energy technique on intensity of pain, active knee extension, limited forward bending and
      active straight leg raise on hamstrings tightness in patients with chronic non-specific low
      back pain. A randomized control trial is conducting at Railway General Hospital, Rawalpindi
      and Al-Ain Hospital, Wah Cantt. The sample size is calculated through open epi is 24. The
      subjects are divided in two groups, 12 subjects in Bowen's technique group and 12 in Muscle
      energy technique group. Study duration is of 6 months. Sampling technique applied is
      non-probability convenient sampling for recruitment and group randomization using sealed
      envelope method. Only 18-35 years individuals of hamstrings tightness with chronic
      non-specific low back pain are included. Tools used in the study are Numeric pain rating
      scale (NPRS), Active knee extension, Sit and reach test, Active straight leg raise and
      Goniometer. Data will be analyzed through SPSS 21.
    

Detailed description: 
      Hamstring muscles are well known for their immense tendency to tightness which is due to
      their multi-joint function, their tonic postural character, and considerable amount of
      tensional forces to which they are constantly submitted. The ability of the muscle to
      lengthen allowing one joint (or more than one joint) to move through the range of motion is
      due to the flexibility of the muscle. If a muscle has good flexibility it will allow muscle
      tissue to accommodate to imposed stress more easily and allows efficient and effective
      movement and will assist in preventing or minimizing injuries and enhance performance of the
      muscle.

      The length of the hamstring muscles is considered to play an essential role in both the
      effectiveness and efficiency of fundamental human movements such as walking and running.
      Particularly 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. Tight hamstrings have been involved
      in lumbar spine dysfunction and shows strong positive correlation between low back pain and
      reduced hamstring flexibility. Hamstring muscle tightness leads to decreased range of motion
      of lumber flexion and pelvic tilt. This can alter the biomechanics of lumbar spine and may
      lead to back pain. Mainly hamstrings flexibility may prevent acute and chronic
      musculoskeletal injuries, low backache problems, postural deviations, gait limitations and
      chances of fall.

      Low back pain (LBP) is described as the pain located in the lower part of the spine
      (lumbo-sacral region), coming from this area and optionally radiating to one or both lower
      limbs. It occurs in a great amount of the population, in about 80% of people and it has a
      different intensity. Non-specific LBP (low back pain) is defined as low back pain not
      attributable to a known cause there is no pathology within the spine such as cancer,
      osteoporosis, trauma or fracture. It represents 90-95% of the cases of Low back pain. There
      are several factors which are responsible for development of Low back pain. Various factors
      include increased lumber lordosis, reduced abdominal muscle strength, and decreased back
      extensor muscle endurance, back extensor muscle flexibility, length of iliopsoas and
      hamstring muscle flexibility.

      Muscle energy technique (MET) is a manual technique developed by osteopaths that is now used
      in much different manual therapy professions. It is gentle manual therapy technique for
      restricted motion of the spine and extremities and is an active technique where the patient,
      not the clinician, controls the corrective force.

      One of the two techniques is 'Post-isometric relaxation technique (PIRT)' which uses
      controlled, voluntary isometric contractions up to 20% of a target muscle group. MET is
      claimed to be useful for lengthening a shortened muscle, improving range of motion at a joint
      and increasing drainage of fluid from peripheral regions. This approach which targets
      primarily the soft tissue is also known as 'active muscular relaxation'.

      Bowen's technique (BT) was developed by Thomas Bowen in the 1950s in Geelong, Australia which
      is a dynamic system of muscle and connective tissue therapy. Bowen's Technique is a
      technique, based on a delicate movement and a series of manipulation of soft tissues. It is a
      soft tissue therapy, in which therapist uses fingers or thumb to apply gentle rolling moves
      over muscles, tendons, and other connective tissues in specific parts of the body. Minimum of
      2 minutes will be allowed between moves to allow the body to respond and then the whole
      procedure will be repeated again. Sequence of receiving bilateral moves are applied over
      segments of erector spinae ,latissimus dorsi, gluteals,the hamstrings muscles proximally and
      distally, Tenser fascia latae, hip adductors are many more. A classic Bowen's technique
      session usually lasts from 15 to 45 minutes.

      In general, the mechanism of action of Bowen's Technique is based mainly on the concept of
      proprioception. The skin is innervated tissue and has various types of receptors that detect
      changes during the position of touch, pressure, vibration, temperature or pain. The fascia
      also plays the role of a system for collecting, transmitting and processing information.
      There is even less data on the physiological effects of Bowen's Therapy. There are largely
      unsubstantiated claims that it acts through effects on fascia, muscle, and cutaneous sensory
      receptors that give rise to a rebalancing of autonomic nervous system (ANS) activity, muscle
      relaxation, altered myofibroblast activity, and changes in the type of collagen. Adipocytes
      and fibroblasts, on the other hand, are responsible for mechano-transduction and lead to a
      wide range of sensory sensations and communication signals. Therefore, it has been suggested
      that the contact of the therapist's hands with the patient's skin initiates communication
      with structures lying deeper. Bowen's studies provide implications of fascially induced
      following stimulation of mechanoreceptors. The effect of rolling moves that are
      characteristic of this method is muscular and fascial loosening.

      There have been many studies done to check the effectiveness of stretching techniques to
      increase the flexibility of Hamstrings amongst the most common is MET. Bowen's technique is a
      specific form of therapy and the concept of treatment of patient according to Bowen's is
      significantly different from the commonly known methods. There are no studies done pertaining
      to the comparison of MET and Bowen's Technique for hamstrings flexibility in patients with
      non-specific low back pain and hence the need of the study arises to check for the more
      superior form of technique in the treatment of hamstrings flexibility. Until now, the effects
      of Bowen's Technique therapy have been most often described in the form of a case study. It
      is difficult to find research conclusions from such works only.

      A research was conducted in 2020 entitled as "The effect of muscle energy technique on
      flexibility of hamstring muscle in Futsal Players" and concluded that Muscle energy technique
      increased flexibility of hamstrings among futsal players by improving ranges of knee
      extension. This study also shows the implacability of Muscle Energy Technique in a clinical
      setting, where it can be performed as a treatment technique for patients who come in for
      physiotherapy relating to reduced hamstring flexibility.

      A research was conducted in 2018 entitled as "Bowen Technique for patients with low back
      pain" concluded that there were clearly noticeable results in the severity of pain, the range
      of motion and the degree of disability of respondents referring Oswestry standardized scale.
      It can be concluded that subsequent treatments would still eliminate pain and improve the
      health of patients as well.

      A research was conducted in 2017 entitled as "Effect of Bowen Technique versus Muscle Energy
      Technique on Asymptomatic Subjects with Hamstring Tightness" concluded that 3 sessions on
      alternate days for a week proved to be effective in improving popliteal angle and sit and
      reach test for flexibility measurements in both Bowen technique as well as muscle energy
      technique but Bowen technique has shown more improvement in hamstring flexibility and ROM
      than muscle energy technique.

      A research was conducted in 2013 entitled as "Comparative study between the effectiveness of
      Bowen technique and dynamic soft tissue mobilization in increasing hamstrings flexibility"
      concluded that 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 Extension Test.
    

Intervention name(s): Bowen's Technique; Muscle Energy Technique
Intervention type(s): Other; Other
Intervention description(s): In Bowen's Technique, sequence of short gentle moves are applied over Hamstrings. Skin slack is taken to the lateral side of muscle. The muscle is hooked by the thumbs from its lateral edge. Skin is carried along and thumb is flattened in a medial direction, the muscle plucks under the thumbs. Three alternate sessions per week are given for 4 weeks. The treatment time for each session is 20 minutes.; Isometric contraction of hamstrings is performed by the patient being employing 20% of the strength. This contraction is resisted by the practitioner for 7-10 s. A three second relaxation period is given. This technique is repeated for three times. Three alternate sessions per week is given for 4 weeks.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: physical therapy; Hamstring; flexibility; Muscle Energy Technique