The Effect of Heat and Stretching on the Range of Hip Motion*

Transcription

1 /84/0602-Ol10$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association The Effect of Heat and Stretching on the Range of Hip Motion* ANDERS S. HENRICSON, MD,t KURT FREDRIKSSON, PT,* INGELA PERSSON, PT,* RODNEY PEREIRA, PT,* YNGVE ROSTEDT, PT,* NILS E. WESTLIN, MDt Flexion, abduction, and external rotation of the hip joint were recorded in 30 volunteers randomized into three groups of 10. The measurements were taken before, immediately after, and 30 minutes after treatment of heat, stretching and a combination of heat plus stretching. Heat only did not improve the range of motion of the hip joint. Stretching increased flexion and external rotation, and heat plus stretching in combination gave the greatest increase in flexion motion, and also significantly increased abduction. External rotation after stretching treatment, and flexion and abduction after heat plus stretching treatment were still significantly increased after 30 minutes. Heat followed by stretching is commonly used in the treatment of joint stiffness in rheumatoid arthritis or following joint surgery, but also for prevention or treatment of joint contracture in bedridden or otherwise immobilized patients, and in patients with neurological disorder^.'^.^^ In sports medicine, externally applied heat is used in the treatment of muscle soreness, muscle injuries, "short muscles," and soft tissue injuries. Also, active warming up is being practiced with the purpose of increasing lithness, range of motion, and strength. Heat is used in therapy because of its effect on the physical properties of connective tissue: increased extensibility of ~ ollagen,~~~~~~~~ decreased joint stiffnes~,'~~~~~.~~ relieved muscle ~ pasm,~.~~~~ and pain relief.4112 The effect of stretching of various types: swing, ballistic, passive, active, fast, slow, hold-relax, contract-relax, or contract-relax antagonist contraction on the range of motion has been meas- ured in healthy volunteers but not in patients.2-5.7, 8.11,16,18. 22,26,27 ~h~ range of motion in- creases irrespective of stretching method, except that hold-relax, contract-relax, and contract-relax antagonist contraction seem to give better results. Heat and stretching combined for treatment of stiff joints or short muscles has not been studied Fig. 1. Measurement of flexion. clinically, nor are there any data on the effect of ' Financial support was obtained from the Swedish Medical Research Council (project NO. B 82-17x ). externally applied heat and stretching on the t Department of Orthopaedic Surgery, Malmb General Hospital, Unirange of joint motion in patients or volunteers. versity of Lund. Malmb, Sweden. $ Department of Physical Therapy, University of Lund. Lund, Sweden. The aim of the present study Was to investigate

2 JOSPTSept/Oct 1984 EFFECT OF TREATMENTS ON RANGE OF HIP MOTION 111 the effect of externally applied heat, stretching, and heat and stretching combined on the range of motion in the hip joint in healthy individuals. MATERIAL Thirty healthy volunteers selected from hospital personnel, students in the Department of Physiotherapy, and athletes (15 men and 15 women) in the age range (30 years + 6 months) were randomized into three groups, 5 men and 5 women in each. Fig. 2. Measurement of abduction. Fig. 3. Measurement of external rotation. METHODS Flexion, abduction, and external rotation in the right hip joint were measured on three occasions: one measurement was taken before, one immediately after, and one 30 min after treatmentheat, stretching, and heat followed by stretching. The range of motion was recorded with a goniometer; the force in the testing was controlled by a dynamometer. The treatments and the measurements were all carried out by the same investigator. Flexion (Fig. 1) was measured with the subject

3 112 HENRICSON ET AL JOSPT Vol. 6, No. 2 in the supine position with the contralateral knee in 90 flexion and the foot resting on the table. The greater trochanter and the head of the fibula were indicated. The leg was then raised with a straight knee to maximal flexion with a pulling force of 5 kg. Abduction (Fig. 2) was measured with the subject in the supine position. The anterior iliac spine and the anterior edge of the tibia were indicated. The leg was pulled in maximal abduction with the force of 5 kg. The external rotation (Fig. 3) was recorded with the subject in the supine position. The anterior superior iliac spine and the anterior edge of the tibia were marked. The external rotation was measured with the hip and the knee joint in 90' flexion and with a 5-kg force pulling on the lower leg in the medial direction. TREATMENT Fig. 4. Electric heating pad on the back and the sides of the thigh. In combined treatment the heat application was immediately followed by the stretching. The error of the measurements of the ranges of motion was estimated from repeated measurements to be 6% for flexion and external rotation, and 7% for abduction. Heat (Fig. 4) was given with the subject in the prone position. An electric heating pad covering the lateral, medial and posterior portion of the thigh was applied for 20 min. The temperature of the pad was 43OC. Stretching (Fig. 5) was applied with the subject in the supine position with the contralateral knee in 90' flexion and the foot resting on the table. The volunteers used modified contract-relax techniques for stretching their hamstrings; they contracted their hamstrings for 7 sec, relaxed for 7 SeC, followed by stretching for 7 SeC. Fig. 5. Position of the subject in the stretching procedure.

4 JOSPTSeptlOct 1984 EFFECT OF TREATMENTS ON RANGE OF HIP MOTION 113 Degrees Before treatment 1 Immediately after veatment 30' after treatment I Degrees 751 lild Before treatment Immediately after treatment 30' after treatment Heat Stretching Heat and stretching Fig. 6. The range of flexion motion in the hip joint after heat, stretching, and heat plus stretching before, immediately after, and 30 rnin after treatment. (Bracket = f 1 SE). Degrees n " Before treatment Immediately after 30' after treatment Heat Stretching Heat and stretching Fig. 7. Range of abduction motion in the hip joint after heat, stretching, and heat plus stretching before, immediately after, and 30 min after treatment. (Bracket = f 1 SE). Heat Stretching Heat and stretching Fig. 8. Range of external rotation motion in the hip joint after heat, stretching, and heat plus stretching before, immediately after, and 30 min after treatment. (Bracket = f 1 SE). STATISTICS For comparisons between groups, t-test was used; for comparison within groups, from time to time, the t-test of paired observations. Also, the range of motion after treatment was compared between treatment groups with analysis of covariance with range of motion before treatment as covariant factor. RESULTS The range of flexion motion was significantly greater in women than in men, but there were no differences in abduction and external rotation between the sexes (Table 1). The use of heat did not increase the range of flexion, abduction, or external rotation immediately after treatment nor 30 min after treatment (Table 2). Stretching caused a significant increase in range of motion for flexion and external rotation in the measurement immediately after treatment. The external rotation range of motion was still increased in the measurement taken 30 min after treatment (Table 2). Heat followed by stretching significantly increased the flexion and abduction range of motion immediately after treatment, and flexion was still increased 30 min after treatment (Table 2). The relative increase of the range of motion is presented in Table 3. Analysis of covariance with pretreatment range of motion as a correcting co-

5 HENRICSON ET AL JOSPT Vol. 6, No. 2 TABLE 1 hi^ i~int.'~~'~ The effect of decreased blood flow Range of hip motion in men and women on the temperature can be demonstrated by ap Range of motion degrees m + SD plying a tourniquet which will result in an increase Motion N Men N Women t p of the skin temperature only.13 Stretching alone Flexion ,6 <O.OO1 increased the joint motion signficantly-in com- Abduction 15 44k k8 0.2 NS* bination with heat, the flexion motion increased External rotation k NS further but not significantly. Externally applied heat does not influence the temperature and elas- - NS, not sianificant. variant factor did not change the outcome of the analysis. DISCUSSION Heat applied on the back of the thigh did not effect the range of motion in the hip joint. The temperature in superficial muscles increases a few degrees after application of the heat pad.13 The subcutaneous fat and natural vascular cooling system prevents further increases in temperature of the muscles and the connecting tissue of the ticity of the muscles and connective tissues and, therefore, the combination of heat and stretching cannot be expected to increase the range of motion more than stretching alone. Heat, how- ever, may reduce ~ain,~.'~ which is explained by the gate inhibition effect.'' Heat may therefore reduce muscle spasm-increased muscle tonus-secondary to pain or physical In conclusion, heat may be useful in the treatment of activity- or pain-induced muscle spasm, and. heat combined with strecthing may be better than stretching alone for treatment of muscle spasm in otherwise healthy individuals. Heat also reduces activity-induced increased muscle tonus. TABLE 2 Flexion, abduction, and external rotation in the hip joint after treatment with heat, stretching, and a combination of heat and stretching. Range of motion (deg) Significance of difference Treatment Immediately After 30 Before and Before and Immediately after Before after min immediately after after 30 min and after 30 min Heat Flexion NS* NS NS Abduction k 6 45 * 4 NS NS NS External rota NS NS NS tion Stretching Flexion p<o.ool NS NS Abduction t 4 NS NS NS External rota- 57 & > p > > p > NS tion Heat and Flexion 93k O.Ol>p>O.OOl 0.05>p>0.01 NS stretching Abduction t > p > > p > 0.01 NS External rota- 58 -t t NS NS NS tion NS, not significant. Flexion Abduction External rotation TABLE 3 Percentage of increase in range of motion Stretching Heat and stretching Before-immediately Before-after Before-immediately Before-after after 30 min after 30 min

6 JOSPTSept/Oct 1984 EFFECT OF TREATMENTS ON RANGE OF HIP MOTION 115 REFERENCES 1. Backlund L, Tiselius P: Objective measurement of joint stiffness in rheumatoid arthritis. Acta Rheum Scand 13: de Vries HA: Evaluation of static stretching procedures for improvement of flexibility. Res Q 33: , Fountain FP, Gersten JW, Sengir 0: Decrease in muscle spasm produced by ultrasound, hot packs and infrared radiation. Arch Phys Med Rehabil41: , Gammon GD, Starr J: Studies on the relief of pain by counterirritation. J Clin Invest 20:13-20, Grahn R, Nordenborg T, Wallin D. Nystr6m J, Ekblom B: Improvement of muscle flexibility-a comparison between two techniques. Am J Sports Med (in press) 6. Harris R: Physical methods in the management of rheumatoid arthritis. Med Clin North Am 52: , Henricson A, Larsson A, Olsson E, Westlin N: The effect of stretching on the range of motion of the ankle joint in badminton players. J Orthop Sports Phys Ther 5:74-77, Holt LE, Travis TM. Okita T: Comparative study of three stretching techniques. Percept Mot Skills 31 : , Hunter J, Kerr EH, Whillians MG: The relation between joint stiffness upon exposure to cold and the characteristics of synovial fluid. Can J Med Sci 30: , Johns RJ, Wright V: Relative importance of various tissues in joint stiffness. J Appl Physiol 17: Kottke FJ, Panley DL, Ptak RA: The rationale for prolonged stretching for correction of shortening of connective tissue. Arch Phys Med Rehabil47: , Lehmann JF, Brunner GD, McMillan JA, Silverman DR, Johnsson VC: Modification of healing patterns produced by microwaves and the frequencies of 2456 and 900 mc. by physiologic factors in human. Arch Phys Med Rehabil45: , Lehmann JF, Silverman DR, Baum BA, Kirk NL, Johnston VC: Temperature disiributions in the human thigh produced by infrared, hot pack and microwave applications. Arch Phys Med Rehabil 47: , Lehmann JF, Masock AJ, Warren CG: Effect of therapeutic temperatures on tendon extensibility. Arch Phys Med Rehabil51: , Lehmann JF, Lateur BJ: Therapeutic Heat. In: Lehmann JF (ed), Therapeutic Heat and Cold. Ed 3, pp Baltimore: Williams & Wilkins, Markos PD: lpsilateral and contralateral effects of proprioceptive neuromuscular fascilitation techniques on hip motion and electromyografic activity. Phys Ther 59: , Melzack R. Wall PD: Pain mechanisms: a new theory. Science 150: , Moore MA, Hutton RS: Electromyografic investigation of muscle stretching techniques. Med Sci Sports 12: , Prentice WE Jr: An electromyografic analysis of the effectiveness of heat and cold and stretching for inducing relaxation in injured muscle. J Orthop Sports Phys Ther 3: , Sapega AA, Quedenfeld TC, Moyer RA, Butler RA: Biophysical factors in range-of-motion exercise. Phys Sportsmed 9:57-65, Stillwell GK: General principles of thermotherapy in: Therapeutic heat and cold. Waverly Press, Baltimore , Tanigawa MC: Comparison of hold-relax procedure and passive mobilisation on increasing muscle length. Phys Ther 52: Warren CG, Lehmann JF, Koblanski JN: Heat and stretch procedures: an evaluation using rat tail tendon. J Appl Physiol 17: , Warren CG, Lehmann JF Koblanski JN: Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med Rehabil 52: , Weidenbacher RA, Smith C: Does heat cause relaxation. Phys Ther Rev 40: , Weber S, Kraus H: Passive and active stretching of muscles. Phys Ther Rev 29: , Wiktorsson-Moller M, Oberg M. Ekstrand J, Gillquist J: Effects of warming up, massage, and stretching on the range of motion and muscle strength in the lower extremity. Am J Sports Med 11: , Wright V, Johns RJ: Quantitative and qualitative analysis of joint stiffness in normal subjects and in patients with connective tissue diseases. Rheum Dis 20:36-46, 1961