EBP 3 Project Plan Title: In young adults, are three repetitions of target-muscle PNF more effective than a single repetition of target-muscle PNF for improving acute extensibility of the hamstring muscles? European School of Physiotherapy Semester 3 Year 2016

Tamara Bonarrigo Sonia Cristovão Karit Kaljusto Rebecca Lau Abigael Read

Cristovao et al._EBP3_Project Plan

Contents Contents ...........................................................................................................................................2 Introduction .......................................................................................................................................3 Methods (of the research) ................................................................................................................. 5 Group organization ........................................................................................................................... 9 Planning ......................................................................................................................................... 13 References ..................................................................................................................................... 16 Appendix 1 – Detailed planning – Project plan ................................................................................ 18 Appendix 2 – Detailed planning – Research Paper ......................................................................... 18

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Cristovao et al._EBP3_Project Plan

Introduction Maintenance of adequate muscle flexibility is important in rehabilitation from illness or injury, since immobility often leads to a reduction in flexibility. It is also considered to be important in injury prevention - a short, tight muscle can inhibit normal joint range of motion, and is also more easily over-extended and strained (Wan et al. 2016). As hamstring injury is a common sport injury, and stretching has been recommended to prevent this type of injury (Franklin et al. 2000, Thacker et al. 2004, Orchard et al. 2005), it is important to consider how to best optimize flexibility of the hamstring muscles in healthy individuals. Furthermore, hamstring flexibility has been regarded as important in clinical rehabilitation for the maintenance of muscular and postural balance (Worrell et al. 1992), as well as in the rehabilitation of osteoarthritis (Weng et al. 2009). Stretching may also alter outcomes such as: range of motion (ROM), maximal isometric torque, passive resistive torque, muscle and tendon stiffness, fascicle length, and pennation angle (Konrad et al. 2016).

Various techniques to increase hamstring muscle flexibility have been described, including proprioceptive neuromuscular facilitation (PNF), ballistic stretching and static stretching (Etnyre et al. 1988, Franklin et al. 2000, Decoster et al. 2005). In PNF, passive muscle stretching is performed alternately with isometric muscle contraction. There are different types of PNF - some involve isometric contraction of the target muscle, and some involve isometric contraction of the muscle antagonistic to it (Maddigan et al. 2012). “Contract-Relax” PNF involves passive stretch of the target muscle, then an isometric contraction of the same muscle, followed by relaxation and passive movement into further stretch (Feland et al. 2004). This technique will thereafter be referred to as target muscle proprioceptive neuromuscular facilitation (TM-PNF).

Previous studies have reported that PNF stretching is more effective at increasing joint range of motion (ROM) than static and ballistic methods (Feland et al. 2004, O’Hora et al. 2011), while other studies have demonstrated that all forms of stretching yield similar results (Behm et al. 2016). In terms of hamstrings PNF, there is evidence of an acute temporary increase in flexibility (Etnyre et al. 1988, Decoster et al. 2005, O’Hora et al. 2011), but the varying stretching protocols make it difficult to determine the most effective and efficient methods for improving hamstring extensibility in a single stretching session.

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Cristovao et al._EBP3_Project Plan Spernoga et al. (2001) suggest that frequency and duration of stretching can influence flexibility gains. In clinical practice there are time constraints, so determining the optimal frequency and duration for a single stretching session is important. Bonnar et al. (2004) found there to be no significant difference in hamstring flexibility gains, whether the isometric contraction of the target muscle is held for 3, 6 or 10 seconds. Therefore isometric contractions as short as 3-seconds can be effective and efficient during a single stretch session in the clinical setting. Meanwhile, O’Hora et al. (2011) demonstrated that a single bout of TM-PNF is more effective than a single bout of static stretching (SS) in increasing hamstring flexibility. However, to our knowledge, previous research has not focused on the effect of the number of repetitions of TM-PNF stretching on the extensibility of hamstring muscles, after a single session. Further knowledge about this would be beneficial in the clinical setting, by assisting therapists in finding a balance between time-efficiency and maximising benefits from the PNF session.

This RCT addresses the question: In young adults, are three repetitions of TM-PNF more effective than a single repetition of TM-PNF for improving acute extensibility of the hamstring muscles, as measured by the sit-and-reach test (SRT)?

P: young adults, aged 18-40 I: 3 repetitions of TM-PNF stretching of the hamstring muscles C: 1 repetition of TM-PNF stretching of the hamstring muscles O: difference in hamstring extensibility in as measured by sit and reach test, when comparing the pre- and post-exercise measurements. T: immediately following the intervention (within 1 minute)

We will test the following hypotheses: H0 – There is no difference in reach distance between 3 repetitions of TM-PNF and 1 repetition of TM-PMF. H1 – There is a difference in reach distance between 3 repetitions of TM-PNF and 1 repetition of TM-PMF.

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Cristovao et al._EBP3_Project Plan

Methods (of the research) Participants Target Participants Young adults will be recruited on a voluntary basis from the international student population of the European School of Physiotherapy, or the Dutch Physiotherapy programme at Hogeschool van Amsterdam. Inclusion & Exclusion Criteria To be eligible participants must also be: 1. Between 18 to 40 years of age, regardless of gender and nationality. 2. Able to understand written and spoken English. The following are exclusion criteria: 1. Injury to the lumbar spine or lower extremity in the past three months (including dislocations, fractures, muscle tissue damage (whether grade 1, 2 or 3), structural damage to the joints and wounds on the hamstrings). 2. Having participated in an exercise activity 12 hours prior to the trial. 3. Inability to reach the slider on the Sit and Reach box for the baseline measurement. 4. Informed consent not obtained.

Procedure(s) Subject Recruitment The recruitment drive will mostly be conducted via Facebook, and through appearances and short presentations at school lectures in the first academic week of the semester (February 6th to 10th). An online sign-up form will be used for registration. Randomisation and Concealed Allocation Allocation of participants to the two intervention groups will be randomised. Upon signing up for the trial, participants will receive a confirmation. Identity codes will be created in a numerical order, and assigned to each participant when they arrive to the trial The assigned identity codes are randomised by inscription to an intervention group by the Principle Investigator using the “randBETWEEN” function on Microsoft® Excel. The interventions will be named Group 0 or 1 for one or three repetitions of TM-PNF. All this information will be recorded as a table in a Microsoft® Excel sheet. After receiving informed consent to participate in the study via a signed form, the Principal

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Cristovao et al._EBP3_Project Plan Investigator will reference the individual’s identity code against the corresponding group it was randomly allocated to, to decide allocation. The Principal Investigator will ensure allocation is concealed from all other investigators involved in the trial. The participant will be blinded to the intervention received by the alternative intervention group. Blinding Triple-blinding will be achieved with participants, data collectors and assessors by naming the two interventions Group 0 and 1. These labels will be used consistently for participants, data collection and data analysis, and will remain until data analysis is complete. The two interventions will be performed in two separate rooms by two different physiotherapists; SRT measurement will be conducted in an adjacent room. If it is not feasible to obtain a third room for measurement, one of the interventions rooms will be wholly sectioned off with a privacy screen. The data collector will not be present when interventions are carried out.

Equipment/quality of measurement tools The Sit and Reach Test (SRT) is a field test commonly used to measure flexibility of (both) the hamstrings and low back (Baltaci et al. 2003). Meta-analysis by Mayorga-Vega and colleagues (2014) showed the SRT has a moderate mean correlation coefficient of criterion-related validity (gender, age and level of extensibility of hamstrings of participants) for estimating hamstring extensibility (rp range= 0.46-0.67). 4 cm is the minimal clinically important difference (MCID) in SR (Lopez-Miñarro et al. 2010). The reliability coefficient of the SRT is 95% (Mayorga-Vega et al. 2014). All participants will perform the SRT both pre- and post-intervention. The test will then be repeated three times and the mean average will be calculated. Distance will be measured to the nearest 0.5 centimetre (cm). There will be one unrecorded trial attempt before the pre-test measurement is taken. A standard SRT box will be used. The dimensions of the box are as follows: length of base 35 cm, width 45 cm, height 32 cm and length 55 cm. On top of the box, a standard meter ruler is attached with the reading of 23 cm in line with the heel position. A metal slider is placed at a tangent to the ruler, to assist with accuracy of measurement. In the event that a standard SRT box is not located, a box will be built to this specification.

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Cristovao et al._EBP3_Project Plan

Variables According to the research question, the independent variable is the duration of stretching intervention (one versus three repetitions of TM-PNF) and the dependent variable is hamstring extensibility as measured by the SRT in centimetres (cm). At the time of measurement, physical (paper) records will be made of results. Within 24 hours of the trial ending, all data will be entered into a Microsoft® Excel spreadsheet by the data collector, resulting in a second copy of the data, which is formatted ready for data analysis. Additional descriptive variables will be recorded by the Principal Investigator during the sign-up or registration process prior to the trial, for the purpose of exploring possible confounding factors. These include, but are not limited to: gender, age, height, weight, nationality, and sports participation (type and frequency). These data will be entered into a Microsoft® Excel spreadsheet by the Principal Investigator, for use in analysis.

Measurement protocols Protocol Sit-and-Reach Test 1. Participant is asked to take off his/her shoes. 2. Participant is asked to sit with his/her legs straight and the soles of his/her feet against the box. 3. Data collector ensures that the participant has both knees flat against the floor, and that one palm is placed on top of the other hand, so that both palms are facing the floor and the corresponding fingertips are level. 4. Data collector asks the participant to bend slowly forward, as far as they can, so that the hands reach over the box and are in contact with the slider. Any jerky movement needs to be avoided. 5. The participant is asked to exhale while bending forward and asked to lower the head between the arms. a. Measurement is taken at the level the slider has been pushed to, rounded to the nearest 0,5 centimeters (cm). b. Participant is allowed one free trial before taking the pre-intervention baseline measurement. c. Test needs to be performed three times both pre- and post-intervention, and the mean result is calculated. Protocol 1 X TM-PNF group 1. Participant is asked to lie supine on the therapy table, flex the left hip and knee and keep their back flat against the table to prevent excessive pelvic tilt.

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Cristovao et al._EBP3_Project Plan 2. Physiotherapist passively stretches the right hamstring muscle without rotating the leg until the participant first reports a mild stretch sensation. This position is held for 2 seconds. 3. Participant is asked to isometrically contract the hamstrings with a maximum voluntary contraction by trying to extend the leg at the hip, against the resistance of the physiotherapist, for 5 seconds (Sharman et al. 2006). 4. Repeat points 2 and 3 with the left leg. Protocol 3 X TM-PNF group 1. Participant is asked to lie supine on the therapy table, flex the left hip and knee and keep their back flat against the table to prevent excessive pelvic tilt. 2. Physiotherapist passively stretches the right hamstring muscle without rotating the leg until the participant first reports a mild stretch sensation. This position is held for 2 seconds. 3. Participant is asked to isometrically contract the hamstrings with a maximum voluntary contraction by trying to extend the leg at the hip, against the resistance of the physiotherapist, for 5 seconds (Sharman et al. 2006). 4. After the contraction, the participant relaxes while the physiotherapist applies a gentle (passive) stretch to the hamstring, until the participant feels a mild stretch once more. 5. Repeat points 3 and 4 twice more. 6. Repeat points 2-5 with the left leg.

Statistical comparisons Statistical analysis will be performed using IBM® SPSS® version 22.0, incorporating an intent-totreat analysis. Comparison of the difference between pre- and post-intervention measures will be achieved using the dependent T-test. Comparison of the difference between intervention groups will be achieved through using the independent T-test. Effect size will be taken using Cohen’s d, with the mean difference between two groups (for both pre- and post-test and between intervention groups) divided by the pooled standard deviation, using Cohen’s d. A Cronbach’s alpha coefficient of 0.05 will be used. Variables will be coded first in Microsoft Excel, before importing the data into SPSS; where relevant, nominal (gender, nationality) or ordinal scales (frequency of sport) will be numerically transformed. Possible confounding factors will be explored by investigating correlations between the dependent variable and the other descriptive variables with Pearson’s correlation test.

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Cristovao et al._EBP3_Project Plan

Group organization Different roles – project The division of roles is reported in the table hereunder. Allocation was based on areas of expertise, and on self-development goals of individuals. Role

Description

Name

Back-up

Captain



Responsible for communication with our coach (Jesse)

Sonia

Abigael



Leads group meetings



Contact person in case of delays



Addresses group- or work-related issues in meetings (missed

Rebecca

Karit

Tamara

Sonia

Abigael

Rebecca

Rebecca

Tamara

deadlines, poor quality deliverables)

Secretary



Monitors quality of output



Responsible for monitoring compliance to the organization rules



Writes and publishes meeting minutes (within 24 hours of each meeting ending)



Sends agenda to all group members at least 48 hours prior to each meeting

Project



Records attendance and lateness



Manages via email: information concerning the project and

Manager

research 

Keeps track of deadlines and sends reminders 24 hours prior to delivery



Contact person in case of delays



Monitors quality of output



Produces a back-up of the Google Drive folder, where all work is stored, on a weekly basis

Editor (text) and



proof reading

Editor (visual)

Reviews coherence and consistency of output, when the work of all group members is compiled



Checks grammar and syntax of final document



Corrects spelling and typing errors



Responsible for the visual presentation of the research paper

Division of tasks – Project Plan The division of tasks is reported in the table below.

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Cristovao et al._EBP3_Project Plan Section

Name

Back-up

Introduction

Sonia

Karit

Participants

Rebecca

Sonia

Procedures

Rebecca

Sonia

Karit

Tamara

Karit

Tamara

Variables

Rebecca

Sonia

Statistical comparisons

Rebecca

Sonia

Group organization

Tamara

Abigael

Planning

Tamara

Abigael

Quality (extra)

Tamara

Abigael

Editing

Abigael

Rebecca

References

Everyone is responsible for substantiating their work with relevant references.

Appendices

Everyone is responsible for substantiating their work with relevant references.

Methods

Quality of measurement tools Measurement protocols

Division of tasks – research Below is an overview of the division of tasks for the research project itself, based on the skills the various group members have shown during preparation of the project plan. Task Recruitment of participants

Interventions

Description Randomisation and concealed allocation

Roles

Name

Back-up

Sonia

Tamara

Abigael

Rebecca

Karit

Sonia

Data collector 1

Rebecca

Abigael

Principal Investigator

TM-PNF of intervention group 0

Physiotherapist 1

TM-PNF of intervention group 1

Physiotherapist 2

Performs measurement of hamstring extensibility Measurements

(pre- and post- intervention) and records them on record sheet

Data input

Enters data into “Raw data” excel sheet

Data collector 2

Rebecca

Karit

Data analysis

Performs statistical analysis in SPSS

Assessor

Tamara

Sonia

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Cristovao et al._EBP3_Project Plan

Division of tasks – research paper For the write-up of the research paper, the following assignment of tasks has been agreed: Section

Name

Back-up

Abstract

Sonia

Abigael

Introduction

Sonia

Abigael

Methods

Karit

Rebecca

Results

Tamara & Sonia

Karit

Conclusion & Discussion

Rebecca & Abigael

Tamara

Editing of layout

Rebecca

Sonia

References

Everyone is responsible for substantiating their work with relevant references.

Appendices

Everyone is responsible for substantiating their work with relevant references.

Role of coach We expect our coach, Jesse Aarden, to answer questions we may have concerning the project (via email or during meetings), and to guide us if we have concerns with regard to our group work or the group dynamic. We also expect our coach offer constructive feedback following progress updates, and we expect him to inform us promptly if he has concerns regarding our research question. We expect our coach to provide timely grading of the take, and to quickly agree on a clarification meeting in case of a grade below 8.

File management Drafts of the research paper sections and of the complete document will be stored in their own dedicated folder in the Google Drive folders. Detailed rules are listed in a separate document: “Cristovao et al._Project Plan_EBP3_2016_File Management”.

Collaboration For online communication we use Google Drive (see structure in Appendix 1 – Google drive folders). The group folder includes the main research question, back-up questions, templates, project plan and meeting minutes. We also communicate via email, especially regarding updates and concerns. We have had four meetings so far as a group, plus extra subdivision meetings. In group meetings we update each other with progress, discuss any relevant matters, and seek to

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Cristovao et al._EBP3_Project Plan answer any questions. Minutes are recorded and uploaded to the Google Drive subfolder “Meeting minutes”. There is also a Whatsapp group for quick and brief communication.

SMART goals Sonia Cristovão My goal is to improve my communication skills for conflict resolution throughout the group work for EBP 4. This goal is realistic as resolving conflicts is a skill necessary for academic and professional careers, and it is attainable as I will be the Team Captain for EBP4 project and this is one of my responsibilities. This goal will be measured by asking my group colleagues to complete a behavioural feedback form at the end of EBP4. Tamara Bonarrigo My goal is to go out of my comfort-zone and start developing skills in statistical analysis. I believe this goal is achievable, given the role I have taken on for the research paper, and relevant for future career development. It will be measured by the timely delivery of statistical analysis (which will be reviewed by the back-up). I will achieve this goal based on the agreed deadlines. Rebecca Lau I aim to drastically boost my organisational skills by the end of EBP4, and I will be given the opportunity to achieve this through my role as secretary in the team. Organisation is an essential skill to possess as a professional, in terms of organising collaborations to administrative matters. I will ask for feedback on this from my teammates when we conduct the group process evaluation at the end of the project. Karit Kaljusto To improve my knowledge on conducting a scientific research, I want to deliver high quality protocols for this project. To achieve this, I need to read different protocols and research papers, and to practice critical thinking, in order to make the best choices and find the most recent evidence available. My achievement of this goal will be measured by my team on the group process evaluation form, under content and quality. I find doing searches is time-consuming, therefore I need to practice, in order to be able to filter through the large amount of information available. Abigael Read My goal is to improve my organisational skills, in order to meet all deadlines decided for this project. The evidence of whether I meet this goal will be the meeting minutes. This goal should be achievable, since I have carefully reviewed group schedules for any clashes with my own personal

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Cristovao et al._EBP3_Project Plan schedule, and then put time in my diary in order to work on the project plan. The goal is relevant for me, because I find it tricky to keep up-to-date with all the many emails and Whatsapp conversations, meaning that I can lose track of deadlines. Group Goal Our goal is to further improve our skills in working with a team. This goal is measurable by timely addressing any conflict and delay within the team – as it will be reported in the minutes. It is attainable as all group members are deeply committed to the project and relevant for our future professional career. It will be attained by the end of the project.

Planning Realistic time-table – project plan The time-table followed to deliver this project plan can be found in Appendix 2 – Detailed planning – Research Paper.

Realistic time-table – research paper The table hereunder only contains the milestones of the project.

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Cristovao et al._EBP3_Project Plan The detailed planning including deliverables is included in Appendix 2 – Detailed planning – Research Paper)

Deadline of sub-products: Sub-products are the deliverables mentioned in the detailed planning in Appendix 3 – Detailed planning). Here deadlines are also specified.

Buffer weeks There are no buffer weeks. ESP now requires 2nd year students to do the same amount of work as in previous years but in less time. The consequence of this is that there is no buffer week, which could result in missing the deadline for the take and / or the retake with consequent risk of failing EBP4.

Safety net planning – rules and regulations Rules and regulations concerning meeting attendance, deliverables and deadlines, and quality assurance are listed in a separate document: “Cristovao et al._Project Plan_EBP3_2016_Safety net planning”.

Start and final end date See table above.

What if…? “What if” scenario

Likelihood

Threat value

Mitigation

H

- The Project Manager is responsible for

Produced work is

sending reminders in the run-up to deadlines

rushed and of

for deliverables.

poor quality

- In the instance of a missed group deadline,

of occurring The group falls behind on

H*

deadlines.

the group will meet to re-discuss commitments running in parallel with the project, and priorities in terms of study-load. The group may have

H

H

-We

emphasize

that

any

feedback

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Cristovao et al._EBP3_Project Plan “What if” scenario

Likelihood

Threat value

Mitigation

difficulty separating

The group may

exchanged within the group is not on a

personal from

avoid addressing

personal level and is strictly work-related.

professional

important issues.

-We encourage open and honest

of occurring

communication to resolve any issues with

relationships.

group dynamics. The group gets a grade below 8.

L**

H

The group will give priority to improving the grade for the retake, by following up on the feedback provided by the coach - in the grading form and subsequent clarification meeting.

*H stands for high ** L stands for low

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Cristovao et al._EBP3_Project Plan

References 

Alonso FJ, Heck A, Petrides C, Sigel K. The immediate effects of agonist vs. antagonist PNF stretching on hamstring extensibility measured by sit-and-reach test: RCT. European School of Physiotherapy. 2016.



Baltaci G, Un N, Tunay V, Besler A, Gerceker S. Comparison of three different sit and reach tests for measurements of hamstring flexibility in female university students. Br J Sports Med. 2003;37:59-61



Behm D, Blazevich A, Kay A, McHugh M. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Appl Physiol Nutr Metab. 2016;41:1-11.



Bonnar B, Deivert R, Gould T. The relationship between isometric contraction durations during hold-relax stretching and improvements of hamstring flexibility. J Sports Med Phys Fitness. 2004;44(3):258-61.



Decoster L, Cleland J, Altieri C, Russell P. The effects of hamstring stretching on range of motion: a systematic literature review. J Orthop Sports Phys Ther. 2005;35:377-387.



Etnyre BR, Lee EJ. Chronic and acute flexibility of men and women using three different stretching techniques. Res Q Exerc Sport. 1988;59(3):222–228.



Feland J, Marin H. Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching. Br J Sports Med. 2004;38(18):1-2.



Franklin B, Whaley M, Howley E, Balady G, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2000.



Konrad A, Stafilidis S, Tilp M. Effects of acute static, ballistic, and PNF stretching exercise on the muscle and tendon tissue properties. Scan J Med Sci Sports. 2016.

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Lopez-Minarro PA, Vaquero-Cristobal R, Muyor JM, Espejo-Antunez L. Criterion-related validity of sit-and-reach test as a measure of hamstring extensibility in older women. Nutr.Hosp. 2015;32(1):312-31.



Maddigan M, Peach A, Behm D. A comparison of assisted and unassisted proprioceptive neuromuscular facilitation techniques and static stretching. J Strength Cond Res. 2012;26(5):1238-1244.

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Mayorga-Vega D, Merino-Marban R, Viciana J.Criterion-related validity of sit-and-reach tests for estimating hamstring and lumbar extensibility: a meta-analysis. J Sports Sci Med. 2014;13(1):1-

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Cristovao et al._EBP3_Project Plan 14. 

O’Hora J, Cartwright A, Wade C, Hough A, Shum G. Efficacy of static stretching and proprioceptive neuromuscular facilitation stretch on hamstrings length after a single session. J Strength Cond Res. 2011;25(6):1586-1591.

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Orchard J, Best T, Verrall G. Return to play following muscle strains. Clin J Sport Med. 2005;15(6):436–441.

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Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mechanisms and clinical implications. Sports Med. 2006;36(11):929-939.

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Spernoga S, Uhl T, Arnold B, Gansneder B. Duration of maintained hamstring flexibility after a one-time, modified hold-relax stretching protocol. J Ath Train. 2001;36(1):44-48.

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Thacker S, Gilchrist J, Stroup D, Kimsey C. The impact of stretching on sports injury risk: A systematic review of the literature. Med Sci Sports Exerc. 2004;36(3):371–378.

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Wan X, Qu F, Garrett W, Liu H, Yu B. Relationships among hamstring muscle optimal length and hamstring flexibility and strength. J Sport Health Sci. 2016. doi: http://dx.doi.org/10.1016/j.jshs.2016.04.009

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Weng M, Lee, C, Chen C, Hsu J, Lee W, Huang M, Chen T. Effects of different stretching techniques on the outcomes of isokinetic exercise in patients with knee osteoarthritis. J Med Sci. 2009;25(6):306–315.

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Worrell T, Perrin D. Hamstring muscle injury: The influence of strength, flexibility, warm-up, and fatigue. J Orthop Sports Phys Ther. 1992;16(1):12–18.

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Appendix 1 – Detailed planning – Project plan

Appendix 2 – Detailed planning – Research Paper

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