INDIAN JOURNAL OF PHYSICAL THERAPY, VOLUME 4 ISSUE 1 (JANUARY JUNE 2016)

NIRALI KAMANI1, JINKAL ZALAVADIYA1, NISHANT NAR2, ASHISH KAKKAD3

1. MPT student, Shri K. K. Sheth Physiotherapy College, Rajkot
2. Consultant physiotherapist, civil hospital, Rajkot.
3. Assistant professor, Shri K. K. Sheth Physiotherapy College, Rajkot.

ABSTRACT
Background: Work-related musculoskeletal disorders (WMD) in health professionals especially physiotherapist are
more common. They are exposed to many of the some occupation related risk factors leading to WMD, especially with
regard to the low back. Hamstring tightness causes many abnormalities in human body e.g. anterior knee pain,
increase in lumbar lordosis and lower cross syndrome. Its tightness causes alteration in pelvic tilt, which can affect
back muscle is moment arm. As there is lack of research in this aspect, the aim of this study is to correlates the
relationship in between hamstrings flexibility and back extensors endurance.
Purpose: Purpose of this study is to determine the relationship between hamstring flexibility and back extensors
endurance.
Study design: A cross-sectional observational Study
Material and Methods: A cross-sectional observational study was conducted on 50 healthy female physiotherapy
students (Age:-18-24 years). Hamstrings flexibility was measured by modified sit and reach test with the subjects in
long sitting position foot against wooden flexometer. Subjects were supposed to lean forward with fingertip slides on
its top, score was recorded (i.e. stretch difference). Back extensors endurance was measured by Beiring Sorenson test
performed by subjects in the prone position. They were asked to hold the test position while time recorded.

0.07411) between hamstrings flexibility and back extensors endurance.

Conclusion: This study shows moderately positive association between hamstring flexibility and back extensor muscle
endurance, which may lead to Low Back Pain.

KEYWORDS: Healthy Female Physiotherapy Students; Back Extensors Endurance; Hamstrings Flexibility; Low
Back Pain (LBP); Beiring Sorenson test; modified sit and reach test

movement sequencing (dynamic posture) are

INTRODUCTION considered to be common risk factors for low back
pain. Alteration in movement patterns could lead
Work-related musculoskeletal disorders to excessive loading of lumbar tissues
(WMD) are common among health care workers1. predisposing the subject to LBP3.
The relationship of the disorder with employment Low back pain is defined as a pain or
can be complex: individuals may experience discomfort localized below the costal margin and
impairment or disability at work because of back above the inferior gluteal fold with or without
disorders whether the later was directly caused by referred leg pain4. It is among the most prevalent
job-related factors or not. The degree to which musculoskeletal disorders affecting a large
ability to work is impaired that often dependent on proportion of the population with prevalence rate
the physical demands of the job. Furthermore, 60 85%5.
when an individual experiences a back disorder at Previous episodes of LBP, health and
work, it may be a new occurrence or an lifestyle, physical attributes, lifting technique,
exacerbation of an existing condition2. psychosocial state, and work environment are the
Physiotherapists are also exposed to risk factors of the low back pain6. Jensen et al
some occupational risk factors leading to WMD, (2012) found that the risk of developing LBP is
especially with regard to the low back. Byron E. greatest among the newly educated health care
Bork reported that about 2.8% of physiotherapists workers7. Physical attributes those have been
unable to practice due to low back pain during 12 implicated are erector spinae muscular endurance,
month period1. quadriceps strength and endurance, abdominal
McKenzie (1981) found changes in body muscle endurance and hamstring flexibility.
alignment (static posture) and alteration of Goel et al, (1993) showed the back
muscles reduce load on passive structures and
For Correspondence maintain the erect posture of the spine throughout
Nirali Kamani the day and active during many manual handling
Email: [email protected] procedures including lifting and load carrying8. A

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reduction in back extensors endurance has been HYPOTHESIS

found to be significantly predictive for new
episodes of LBP8. Null hypothesis: There is no correlation
Muscle tightness is caused by a decrease between the hamstring flexibility and the back
in the ability of the muscle to deform. It could extensors endurance.
make the musculotendinous units more Experimental hypothesis: There is
susceptible to injury and increased resistance to correlation between the hamstring flexibility and
various anatomical structures which may lead to back extensors endurance
overuse syndrome. Some pathological conditions
at the joint on which the muscle acts especially,
METHODOLOGY
muscles like the hamstrings which pass over two
joints9.
MATERIAL
Hamstring tightness generates posterior
pelvic tilt and decreases lumbar lordosis, due to
the attachments of it to the ischial tuberosity
which puts the spine at a disadvantage when it
comes to the ability to hold body upright against
gravity. According to isometric length-tension
relationship, when a muscle fiber is lengthened
beyond optimal length, its ability to generate
amount of active tension reduces10. Due to
attachment of back extensor muscles on the
pelvis, the posterior pelvic tilt may put these FIGURE 1: MATERIAL (Pen, Paper, Stopwatch, Two
muscles in to lengthen position. So, Back stabilizing belts, Scale, Custom made wooden flexometer)
extensors have to work harder.
If the constant pulling of the shortened Study population: healthy female physiotherapy
muscles happens for a prolonged time, the students
muscles in the low back become weak and start to Sample size: 50 Healthy female physiotherapy
get tired sooner 11. Back extensor muscle with students.
reduced endurance may over load the soft tissue Source of data: Shri K.K. Sheth, Physiotherapy
and passive structure of spine may cause LBP 12. College, Rajkot.
Study design: Cross-sectional observational study
NEED OF THE STUDY Method of sampling: Purposive sampling
LBP is the most prevalent INCLUSION CRITERIA
musculoskeletal disorders affecting a large Age group: 18 to 24 years
proportion of the population prevalence rate 60 Gender : Female
85%. A reduction in back muscle endurance has Volunteered to participate
been found to be significantly predictive for new
EXCLUSION CRITERIA
episodes of LBP7, but there is less studies
available shows correlation between back Professional sports players
extensors endurance and hamstring flexibility. So History of Low Back Pain
the need of this study is to find out relation Previous fractures or surgery to their back,
between hamstring flexibility and back extensors pelvis, hips or knees.
endurance in healthy female physiotherapy During menstruation
students. Unwillingness to perform the test
MEASUREMENT PROCEDURE
AIMS OF STUDY
50 healthy female physiotherapy
To find out relation between hamstrings students, age-18-25 (mean=20.48). Who all fulfill
flexibility and back extensors endurance in the inclusion criteria was selected. All individuals
healthy female physiotherapy students. were provided informed consent and agreed to
participate in the study. Age was recorded prior to
OBJECTIVES the testing and oriented to the study. After the
hamstring flexibility was checked through custom
To obtain hamstring flexibility in centimeter. made wooden flexometer, the subjects were asked
To obtain back extensors endurance in to performed Beiring Sorenson test. Then, the
seconds. correlation had established between hamstrings
To correlate the hamstring flexibility and flexibility and back extensors endurance.
back extensor muscle endurance.

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MODIFIED SIT AND REACH TEST

FIGURE 4: BEIRING SORENSON TEST

FIGURE 2: MODIFIED SIT AND REACH TEST

STATISTICAL ANALYSIS
(START)
Data from sample of 50 healthy female
Subjects were asked to take a long sitting physiotherapy students was taken and Correlation
position with back and head against a wall. Then, was done between hamstring flexibility and back
extensor endurance by using Pearson's correlation
while keeping the back straightened (fig. 2) co-efficient test by software SPSS 14.0 version.

RESULTS
Hamstring flexibility and back extensor
muscle endurance shows moderately positive
correlation (r= 0.0741) at 95% confidence interval
(-0.2086 to 0.3454) with two tailed p-value
(t=0.60). Results of this study were not
statistically significant.

FIGURE 3: MODIFIED SIT AND REACH TEST (END)

Subjects were instructed not to jerk or

bounce to reach further. Adjust the sliding ruler so

the subject to place her hands side by side, and

lean forward slowly as far as possible (head and
shoulders can come away from the wall) keeping
FIGURE 5: CORRELATION BETWEEN HAMSTRING
the fingertips level with each other and the legs
FLEXIBILITY AND BACK EXTENSION
flat (fig 3). Hold the full reach position for two
ENDURANCE
seconds, and score (i.e. reach distance) was
recorded. Score was recorded to nearest13.
DISCUSSION
BEIRING-SORENSEN TEST
This study was designed to correlate
The test was performed for assessment of between hamstring flexibility and back extensors
trunk extensor endurance. The subjects lied in the endurance in healthy female physiotherapy
prone position on the examining table with the students. Results showed the moderate positive
upper edge of the iliac crests positioned on the correlation between hamstring flexibility and
upper edge of the table. The knees and ankles back extensors endurance. However, the results
were fixed to the table by two stabilizing belts and were not found statically significant.
arms were bent across the chest. The subjects were C. M. Morris studied on 29 students
asked to isometrically maintain the upper body in participating in sport activities. No association
a horizontal position (fig. 4). A chair was provided was found between hamstring muscle length and
for safety purpose. The time during which the total angle of pelvic tilt in people with
patient keeps the upper body straight and extensibility of the hamstrings within normal
horizontal was recorded by stopwatch14. limits14. Mohammad Reza Nourbakhsh et al,
(2002) studied on symptomatic LBP and
asymptomatic 600 subjects on relationship
between mechanical factor and incidence of LBP

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and found moderate correlation between Retrospective analysis can be done for back
hamstring length and pelvic tilt12. extensors endurance in LBP patient.
Effect of BMI on back extensor endurance
back muscle endurance and correlated to can be done. Studies over the abdominals
increased periods of sitting and lower physical strength and hip flexor tightness are
activity. That is shown a relationship between recommended.
passive slumped sitting postures and reduced back The study can be done with active knee
muscle activity. The findings of this study suggest extension angle, as it is more specific for
hamstrings flexibility.
posture relative to their end of range may be a
more significant factor than simply comparing CLINICAL IMPLICATION
spinal flexibility (back extensor endurance) or
posture8. Kendall et al, (1993) theoretically There is moderately positive correlation
explained the relation between hamstring between hamstring flexibility and back muscles
flexibility and back extensors endurance. Because endurance .So, the hamstring tightness may alter
the hamstring muscles attach to the ischial the back extensors endurance. This may lead to
tuberosity, it is hypothesized that tightness of LBP.
these muscles may induce posterior pelvic tilt,
resulting in a flat back and LBP 14.
However, this study shows moderately
CONCLUSION
positive relation in between two variables. First
reason is hamstring length, if it influences on The prevalence of WMD among physical
pelvic tilt, only one of many factors that may lead therapy students was higher in the low back.
to LBP as seen as lower cross syndrome. Several studies were shown that decreased back
Second possible reason, the line of action extensor muscle endurance is an important factor
of the hamstrings is almost vertical and the in chronic LBP. This study shows that there is
attachment to the ischial tuberosity is only slightly moderate association between hamstring
flexibility and back extensor endurance. So,
posterior to the femoral head. This minimal
posterior force tends to rotate the pelvis hamstring flexibility may affect back extensor
endurance, hence low back pain.
posteriorly. This is likely to be outweighed by
activity of the hip flexors which will rotate the
pelvis anteriorly. Therefore, any change in the CONFLICT OF INTEREST
length of the hamstrings may not alter the total
range of pelvic tilt14. There was no personal or institutional
So, the length tension relationship does conflict of interest for this study.
not alter as there is no change in the sagittal plane
motion of the pelvis during normal standing ACKNOWLEDGMENT
position. Ultimately there is no or moderate
reduction in back extensor muscle endurance. We would like to thank god, our parents
and sister for their blessing. We would like to
LIMITATIONS thank our respected teacher Dr. Paras Joshi for
their guidance. We also acknowledge to our
The person with less physical fitness cannot friends Dr. Radhika Karia, Dr. Parul Rakholiya,
perform back extensor endurance test Dr. Priyanka Makwana, Dr. Mittal Shanishwara,
effectively though the hamstrings are not Dr. Janki Aghera, Dr. Vaidehi Udeshi, and Dr.
tight. Kajal Anadkat and Dr. Anandi Chalalia for their
Obesity may affect the back extensor support and encouragement.
endurance, but Body Mass Index is not taken
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