Immediate Effect of Mulligan Two Leg Rotation and Bent Leg Raise Techniques on Hamstring Tightness
Condition: Low Back Pain; Hamstring Pulled
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      The aim of this study is to compare the immediate effect of mulligan's two leg rotation and
      bent leg raise for hamstring tightness, core muscle weakness in chronic low back pain, lumbar
      Range of motion. A randomized control trial is being conducted at Women Institute of
      Rehabilitation Sciences Abbottabad. It consisted of 68 participants with moderate chronic low
      back pain 4-6 on VAS scale, weak back extensors, and abdominal muscle weakness .and hamstring
      tightness. 34 patients in Group A is receiving moist heat for the hamstrings muscles prior
      the Mulligan Two leg rotation technique for 10mins .core muscle strenthening exercises for
      back extensors and abdominals. 34 patients in Group B is receiving moist heat for the
      hamstrings muscles prior the Mulligan Bent leg raise technique for 10 minutes.Study duration
      was of 6 months. Sampling technique being applied is purposive.Study includes patients with
      mechanical LBP more than 3 months.Tools being used in the study are Goniometer, Measuring
      tape, Pressure Biofeedback Unit, Visual analogue scale (VAS), Mulligan's belt. Data is being
      analyzed through SPSS 21.
    

Detailed description: 
      The term Low Back Pain (LBP) refers to pain in the lumbo-sacral area of the spine from 1st
      lumbar vertebra to the 1st sacral vertebra. Low back pain (LBP) can be caused by different
      varieties of problems with any parts of the complex, interconnected network of spinal
      muscles, nerves, bones, discs or tendons in the lumbar spine.The stability and support of the
      trunk area is mainly dependent on strength of supporting structures, the muscles. Weak back
      extensor muscles can result improper vertebral alignment which may lead to undue loading on
      the spine. Causes of low back pain can be due to many factors, for example: individual
      characteristics, working environment such as heavy physical work, awkward static and dynamic
      working postures, as well as manual handling and lifting, lifestyle factors and psychological
      factors. It can also be caused because of muscle sprain, ligament sprain, poor posture, age,
      disc bulge, other causes of low back pain include bladder/kidney infection, endometriosis,
      cancer, or ovarian problems Hamstring muscles are comprised of three semitendinosus,
      semimembranosus and biceps femoris. They are located on the posterior compartment of the
      thigh. Hamstring muscles are two joint muscles of body its function is hip extension and knee
      flexion. Injury rate within hamstring muscle, is the long head of biceps femoris that is
      frequently injured and accounts for approximately 80 % of all hamstring injuries. Flexibility
      is the most important component of physical fitness. Normal flexibility allows the person to
      move smoothly and safely . For normal movement and locomotion flexibility of muscle is
      important. It will help a person for normal body function. The flexibility of hamstring
      muscle is always emphasized more. The Hamstring muscle is the most common muscle to always go
      for tightness. The tightness of this muscle apparently increases from childhood up to the age
      of 40-49 years. Tight hamstring muscles causes a major effect on body's normal postural
      alignment. Till date studies have shown that tightness of hamstring always led to low back
      pain with lumbar intervertebral disc pathologies. Biomechanically tightness of hamstring
      muscle is thought to increase patellofemoral joint compressive forces because of increase in
      passive tension at the time of the swing phase of ambulation under rapid and stressful
      situations hamstring muscles fails to pass through full physiological amplitude when
      specifically this muscle goes for tightness.

      The "core" has been described as a muscular box with the abdominals in the front, Para
      spinals and gluteal in the back, the diaphragm as the roof, and the pelvic floor and hip
      girdle musculature as the bottom. Chronic low back pain (CLBP) is a complex condition which
      is mainly associated with back (multifidus) abdominal (transversusabdominis) and hip (Gluteus
      Maximus) muscles dysfunction along with reduced lumbar flexibility Mulligan Bent Leg Raise is
      a newer technique which has been developed to manage hamstring tightness. This stretching
      technique is painless and is recently utilized in the management of hamstring tightness with
      limitation of straight leg raise. The Mulligan bent leg raise (BLR) technique has been
      described as a means of improving range of straight leg raise (SLR) in subjects with LBP
      and/or referred thigh pain (Mulligan, 1999). The intention of this technique is to restore
      normal mobility and reduce LBP and physical impairment. Impairment is defined as
      abnormalities of structure or function, as indicated by signs or symptoms .

      Mulligan's Two Leg Rotation Technique(TLR) is also a painless technique, and it can be
      applied to any subjects having hamstrings tightness, low back pain or limited and/or painful
      straight leg raise (SLR).It can be extremely useful in patients who have a gross bilateral
      limitation of straight leg rising. TLR Technique is a new technique that has been developed
      by Dr. Brain R Mulligan and colleagues.

      Toby Hall ,Sonja Hardt ,Axel Schäfer, Lena Wallin conducted a study in 2006 to investigate
      the immediate effects, on range of motion and pain, of Mulligan's bent leg raise (BLR)
      technique in subjects with limited straight leg raise (SLR) and low back pain (LBP). the
      study reveals that there was a significant increase in the range by 7° in the BLR group,
      which may be clinically important.

      Pratik A. Phansopkar and Vijay Kage in 2014 conducted a study to evaluate the effectiveness
      of Mulligan's TLR technique for hamstrings flexibility in acute non-specific low back pain.
      The Results of the study were focused on Pain relief, decrease in the functional disability
      due to low back pain. Their study demonstrates that, Mulligan's Two Leg Rotation technique is
      effective in increasing the hamstrings flexibility in subjects with low back pain in terms of
      pain, range of motion and functional disability In 2015 Tarun Kumara, Suraj Kumarb, Md.
      Nezamuddinc and V.P. Sharmad conducted a study to evaluate the Efficacy of core muscle
      strengthening exercise in chronic low back pain patients. This study concluded that core
      muscle strengthening exercise is an effective rehabilitation technique for all chronic low
      back pain patients.

      A study conducted in 2018 to investigate the Effectiveness of bent leg raise v/s two leg
      rotation in patients with low back pain. The study was designed to compare the immediate
      effects of two manual techniques in patients with low back pain. The study showed that both
      BLR and TLR techniques were equally effective in reducing LBP. But clinically group A bent
      leg raise technique showed more effective in reducing low back pain and improving ROM than
      group B two leg rotation.

      In 2016, Parag P Kulkarni., Ankita Devasthali., Ajay Kumar and Satish Pimpale conducted a
      study to compare effectiveness of mulligan bent leg raise v/s knee to chest McKenzie for
      hamstring tightness. Their study concluded that Bend Leg raise technique of Mulligan was
      found to be more effective than Knee to the chest of McKenzie.

      A study conducted by Shrinivas Vinayakrao Shinde, Smita Bhimrao Kanase showed that the active
      knee extension and straight leg raise was statistically extremely significantly improved in
      participants treated with mulligan bent leg raise. This improvement is mainly attributed to
      change in stretch tolerance of the hamstring muscle. It may also be assumed that bent leg
      raise triggers neurophysiological responses influencing the muscle stretch tolerance.Thus,
      there was improvement in active knee extension and straight leg raise range in participants.

      Rina, Shamima Nasrin in 2016 conducted a study to investigate the Effectiveness of bent leg
      raise exercise along with conventional physiotherapy comparing with conventional
      physiotherapy alone for the patients with chronic radiating low back pain. Their experimental
      study showed that Bent Leg Raise Exercise with conventional physiotherapy was more effective
      than conventional physiotherapy alone for patients with chronic radiating Low Back Pain C
      Romani-Ruby investigated that the performance of core stability would result in increased
      flexibility of the hamstring musculature and vice versa. Core stability exercise programs
      target these muscles to help improve the overall function of the spine and body during
      activities of daily living, where it provides "proximal stability for distal mobility. More
      recent research demonstrates a significant correlation between core stability and the range
      of motion of the Lower extremities, specifically the hamstrings.
    

Intervention name(s): Mulligan two leg rotation core muscle strengthning exercises; mulligan bent leg raise technique, core muscle strengthning exercises
Intervention type(s): Other; Other
Intervention description(s): Group A :is receiving moist heat for the hamstrings muscles prior the Mulligan Two leg rotation technique for 10mins.Hold the position for 30 seconds, relax for 1 minute. Reps are given 3 repetitions. And 3 Sets at each session .core muscle strenthening exercises for back extensors and abdominals i.e Bridge curls ,table top ,abdominal crunches,back extension with arms supporting, is being performed. Position is being held for about 10 seconds and each exercise are performed with 10 repititions. Patient is being relaxed for 3 seconds between repetitions and 60 second rest between each exercise; Group B is receiving moist heat for the hamstrings muscles prior the Mulligan Bent leg raise technique for 10 minutes. Hold the position for 30 seconds, relax for 1 minute. Reps are 3 repetitions. And 3 Sets at each session .Subject is being receive 2 weeks protocol. core muscle strenthening exercises for back extensors and abdominals i.e Bridge curls ,table top ,abdominal crunches,back extension with arms supporting, are being performed. Position is held for about 10 seconds and each exercise is performed with 10 repititions. Patient is being relaxed for 3 seconds between repetitions and 60 second rest between each exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment