Mobilization Effect on Hamstring Length
Condition: Knee Osteoarthritis
MeSH terms: Osteoarthritis; Osteoarthritis, Knee
Study type: Interventional

Summary: 
      The aim of this research is to determine the effect of knee joint mobilization in patients
      with knee osteoarthritis having hamstring tightness. Tibiofemoral and tibiofibular joint
      mobilization and knee traction effect on hamstring muscle length and pain. A randomized
      controlled trial will be done at Benazir Bhutto Hospital Rawalpindi. The sample size is 44.
      The Participants are divided into two groups, 22 participants in experimental group and 22 in
      control group. The study duration is 6 months. Sampling technique applied is purposive non
      probability sampling technique, patients having Minimum 20% hamstring length shorting, NPRS
      more than 3,both gender of age 40-65,Pain more than 3 months and with mild to moderate knee
      OA are included. Tools used in this study are Numerical pain rating scale (NPRS), Goniometer
      and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale. Data analyzed
      through Statistical Package for the Social Science (SPSS)version 23.
    

Detailed description: 
      Knee Osteoarthritis is a type of joint disease or common rheumatologic disease that result
      from breakdown of joint cartilage and underlying bone which is characterized by pain,
      stiffness, and decreased range of motion. Knee OA is more important not only for its high
      prevalence rate compared with other types of OA but also for its presentation at earlier age
      groups particularly in younger age groups of obese women. Symptoms of knee OA progress slowly
      over years. The incidence of knee OA increases by age and further increase with longer
      lifetime and higher average weight of the population.

      Symptoms of knee OA progress slowly over years. Pain and other symptoms of OA may have a
      profound effect on quality of life affecting both physical function and psychological
      parameters. Knee OA is not a localized disease of cartilage alone but is considered as a
      chronic disease of the whole joint, including articular cartilage, meniscus, ligament, and
      peri-articular muscle that may result from multiple pathophysiological mechanisms. It is
      painful and disabling disease that affects millions of patients.

      Common symptoms are progressive knee stiffness, pain, difficulties in performing activities
      such as walking, stair climbing, squatting. Reduction in functional capacity associated with
      muscular imbalance of lower extremity with pain. Muscles act as brace for knee joint,
      quadriceps muscle weakness and hamstring inhibition effect this bracing. Muscle dysfunction
      may actually precede and accelerate the cartilage deterioration. Evidence showed muscle
      dysfunction is involved in pathogenesis of knee OA. Osteoarthritis (OA) is the most prevalent
      joint disease and a leading source of chronic pain and disability in the United States. Knee
      OA accounts for more than 80% of the disease's total burden and affects at least 19% of
      American adults aged 45 years and older.

      Clinical strategies exist for treatment of knee osteoarthritis with aim to reduce symptoms
      like pain, delay disease progression i.e. pharmacological, physiotherapy and surgical
      strategies. Patients experience chronic pain that cause reduction in ability to use their
      joint. Due to prolong inactivity of joint to move through complete range cause muscle
      shortness along with capsule tightness that leads for further increasing pain and disability.
      Physical therapy interventions are first line of choice for the treatment of knee OA.
      Treatment varieties i.e. modalities, therapeutic exercises, manual therapy along with
      neuromuscular training to improve mechanical environment of knee joint

      It is indicated at least 15-30 degree loss of active knee extension with 90 degree of hip
      ﬂexion account as hamstring shortening. Hamstring muscle tightness and poor flexibility is
      associated with knee OA. Hamstring flexibility is higher in healthy individual as compared to
      subjects with knee OA.A statistically significant relationship was found between hamstring
      tightness and proximal tibiofibular joint grade of arthritis (χ2 test, p=0.004) Recent study
      reported 97.6% of middle aged men with hamstring muscle tightness Hamstring flexibility is
      greater in females than males. Research showed that ischio-tibial flexibility reduce pain
      stiffness and significant functional limitation in knee OA. Joint mobilizations are most
      widely used in treatment of knee OA having various neuro-physiological effects including
      decrease in pain, stiffness, activation and inhibition of muscles.The muscular system
      reflects sensorimotor system it receives information from musculoskeletal and central nervous
      systems. Changes occur in tone within the muscle are the first responses to nociception by
      the sensorimotor system. Many studies reported effect of joint pathology on muscle tone for
      example the presence of knee effusion causes reflex inhibition of the vastus-medialis and
      multifidus has been shown to atrophy in patients with chronic low back pain. In this study we
      aim to increase hamstring muscle length through activation of mechanoreceptors by
      mobilizations.

      There is no study conducted yet to determine effect of joint mobilization on adjacent muscle
      length other than soft tissue techniques which are mainly stretches.

      Literature review: randomized control trail (2019) conducted for comparing effectiveness on
      Proprioceptive Neuromuscular Facilitation(PNF) stretching verses static stretching on
      hamstring flexibility in knee OA patients showed PNF stretching was better in outcome
      measures

      A study compared static verses intermittent stretching for increase of hamstring muscle
      length concluded that intermittent stretching is more effective for hamstring flexibility.

      A pre-post study (2019) find out effect of unilateral posteroanterior mobilization(UPA) on
      lumbar spine observed in his study that UPA lumbar mobilizations increased lumbar Range of
      Motion and hamstring extensibility by a moderate magnitude and this effect remained for 10-15
      minutes post treatment.

      Study reported Joint manipulations reduce nociceptor stimulus, depress responsiveness of
      alpha motor neurons causing changes in muscle tone.

      Study on active stretching and passive mobilization of cervical spine for neck pain concluded
      there was increase range of motion in both groups.

      comparing Muscle Energy Technique(MET) with conventional treatment for hamstring flexibility
      in knee OA patients reported that MET was better than conventional treatment.

      A randomized control trail(2014)compared immediate effects of neurodynamics slider technique
      verses static stretch concluded neurodynamics slider technique is more effective for
      improving hamstring flexibility.

      Therapeutic effect of joint mobilization that joint mobilization may promote muscles
      relaxation thereby increasing joint range of motion

      Joint mobilization and traction allows for selective stretching of selected tissue and can be
      expected to change both elastic and plastic component of stiffness. The intermittent
      compression and distraction of joint distribute fluid into soft tissue decreasing spasm
      allowing for easier movement and increase range of motion.

      Joint mobilization cause stimulation of Golgi tendon organ activity, and reflex inhibition of
      the muscle at the end of the passive joint mobilization.

      A study concluded that joint mobilization decreases muscle activity, reducing muscle
      concentric activation, pain, and muscle tension in periarticular-tissue
    

Intervention name(s): knee joint mobilization and traction; Post isometric relaxation
Intervention type(s): Other; Other
Intervention description(s): Grade 3 traction (Kaltenborn)from knee fully flexed to end of available Range of motion(ROM). Traction 30 sec, 10 sec rest period, 4reps, total 2 min of traction.3 sets for a total of 6 min of traction mobilization.Grade3 keltonborn tibiofemoral and tibiofibular anterior, posterior mobilization 3 sets10glides/set, 3 times/week on alternative days for 4 weeks.
TENS for 20 mins in sitting and strengthening exercises i.e. Quadriceps Setting10 reps, air Cycling 2 min for a bout, straight leg raise (SLR) with weight , Full arc extension 10 reps of each exercise will be carried per session except for full-arc extension and air cycling. Air cycling cont. for 2 min for 1 bout of exercise. Measurement will be taken at base level, after first and last session. Treatment will be given for 3 times/week on alternative days for 4 weeks; Control group include Post isometric relaxation technique on hamstring muscle will be performed in supine lying, hip flexed to 90 degrees knee extended until the point of resistance 20% of maximum effort will be used by patient to create isometric contraction. Patient will be asked to breathe in and hold for 5 to 8 seconds and release both breath and effort then move to new barrier point and process was repeated three times per session
TENS and strengthening exercises as mentioned above.
This treatment regime will be given for 3 times/week on alternative days for 4 weeks.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Knee Mobilization; muscle length; knee Osteoarthritis