international journal of athletic therapy & training november 2012 27

© 2012 Human Kinetics - IJATT 17(6), pp. 27-30

lexibility is an attribute that may positively influence athletic performance, and there is a widespread belief that it is important for injury prevention. Consequently, stretching

exercises are frequently used in injury rehabilitation, and flexibility is viewed as a component of overall physical fitness.1,2 The hamstring muscle group is particularly susceptible to injury, especially during par-ticipation in activities that involve sprinting and other explosive motions.3-6 Inadequate muscle flexibility, inadequate warm-up, lack of hamstring strength, and muscle fatigue are factors that may contribute to the occurrence of a hamstring injury.7

Hamstring stretching has long been used both in hamstring rehabilitation programs as well as warm-up and injury prevention programs. Numerous stud-ies have assessed the possible benefits and liabilities associated with stretching.4,6-8 Muscle warm up prior to static stretching has been shown to enhance muscle extensibility,1,9 and increased joint ROM has been asso-ciated with increased muscle extensibility.10-11 Optimal

Effects of Different Heating Modalities on Hip Flexion Passive Range of Motion

THERAPEUTIC MODALITIES

Matthew Hanson, EdD, ATC, LAT and James Day, MEd • Buena Vista University

flexibility is believed to decrease the frequency and severity of injuries. Subjects with a history of previ-ous hamstring injury exhibit reduced flexibility, which makes them more susceptible to reinjury.2

Heat application has been shown to increase blood flow, increase the extensibility of connective tissues, decrease reflexive muscle excitability, and decrease pain.12-13 Thus, elevating the tissue temperature can increase the amount of elongation produced by stretch-ing.1 Superficial heat therapy, deep heat therapy, and active exercise are different options for elevation of intramuscular temperature. Examples of superficial heat include paraffin wax, moist heat pack, warm whirlpool, and infrared radiation. Ultrasound and short wave diathermy are examples of deep heating modali-ties. Active exercise is another commonly used method for elevation of tissue temperature.1

Numerous thermotherapy approaches have been combined with stretching exercises, including warm whirlpool,1 active exercise,1 moist hot pack,3,9,14-15 short wave diathermy,14,16-18 and ultrasound.1,19-22 The effects

context: Therapeutic modalities are routinely administered to increase flexibility, but the relative effects of different modes of tissue heating on passive range of motion (PROM) are unknown. objective: To assess the relative effects of active exercise on a stationary bicycle, moist hot pack treatment, and warm whirlpool treatment on hip flexion PROM. Design: Repeated measures. Subjects: 24 males and 20 females between the ages 18 and 24 years. main outcome measure: Hip flexion PROM measured by an inclinometer. results: Repeated measures analysis of variance identified a significant difference among the heating methods, F(1, 43) = 32.41; p < .001. Active exercise produced the greatest change in hip flexion PROM. conclusions: All three treatment methods produced an increase in hip flexion PROM, but active exercise produced a significantly greater increase than moist hot pack and warm whirlpool treatments.

F

28 november 2012 international journal of athletic therapy & training

of different heat modalities need to be assessed with-out stretching to determine the relative effectiveness of each one for increasing ROM.10 Heat application is known to increase tissue extensibility, which should increase joint ROM without administration of a stretch-ing protocol. Furthermore, there is a lack of information in the literature on the comparative effectiveness of deep and superficial heating modalities for promotion of muscle extensibility.14 The purpose of this study was to assess change in hip flexion passive range of motion (PROM) attributable to the administration of common heat modalities, including active exercise on a station-ary bicycle, moist hot pack, and warm whirlpool.

Procedures and FindingsSixty-one subjects initially volunteered to participate in the study, which was approved by an Institutional Review Board. Prospective subjects who had a history of hamstring injury in the past two years, or who had greater than 100 degrees of hip flexion PROM, were excluded. Other exclusionary criteria included a his-tory of a thermoregulatory disorder involvement in a strenuous exercise regimen. Nine potential subjects were excluded and seven subjects were discontinued participation. Thus, 45 subjects (24 male, 20 female, age = 19.83 ± 1.02 years, mass = 80.47 ± 26.12 kg, height = 180 ± 5.27cm) completed the study. Pretreatment hip flexion PROM was measured by an inclinometer, using previously validated methods.23

With the subject in a supine position, the right knee was extended and the extremity was passively lifted to the end-range of hip flexion. The average of the three trials was recorded. All measurements were obtained by the same researcher. Piva et al. reported this method to have an intersession correlation of .88 and an intertester reliability of .99.23

Subjects received the various heat treatments on different days, each of which were 10 minutes in duration and which were administered in a random-ized order. To avoid any possible carry-over effects, treatments were not administered on consecutive days. Water temperature was 44˚C (+/- 1˚C) for the warm whirlpool treatment.10 Subjects stood motion-less for 10 minutes with the extremities submerged in water to the level of the gluteal fold. The moist hot pack was 71 ˚C, which was covered with terry cloth and placed on the subject’s hamstring muscles.2 The active exercise condition involved a stationary bicycle. Subjects were instructed pedal at an intensity level of

100 W (75-85 RPM) for 10 minutes.11 Hip flexion PROM measurements were obtained immediately following the administration of each treatment.

Repeated measures analysis of variance was used to analyze the data for differential treatment effects on hip flexion PROM (SPSS version 19.0). Pretreatment hip flexion PROM values are presented in Table 1. Tables 2 and 3 present pretreatment to posttreatment change in hip flexion PROM values. A significant differ-ences (p < .05) was found among the heating methods,

Table 1. Pretreatment Hip Flexion PROM (Degrees)

Population N Mean SDOverall 44 76.3 8.8

Male 24 70.9 5.8

Female 20 82.8 7.2

Table 2. Change in Hip Flexion PROM (Degrees)

for Each Treatment

Treatment Type Mean SDWarm whirlpool 1.4 1.5

Moist hot pack 1.6 1.3

Active exercise 3.8 2.2

Table 3. Change in Hip Flexion PROM (Degrees) for Each

Treatment by Gender

Treatment N Mean SDWarm whirlpool

Male 24 1.5 1.7

Female 20 1.2 1.3

Total 44 1.4 1.5

Moist hot pack

Male 24 1.8 1.4

Female 20 1.4 1.2

Total 44 1.6 1.3

Active exercise

Male 24 3.8 2.1

Female 20 3.9 2.4

Total 44 3.8 2.2

international journal of athletic therapy & training november 2012 29

F(1,43) = 32.41; p < .001. Active exercise produced a larger change in hip flexion PROM compared to the effects of the warm whirlpool and the moist hot pack treatments.

DiscussionA greater increase in hip flexion PROM was observed following active exercise compared to warm whirlpool and moist hot pack treatments. Active exercise has previously been advocated as the best mechanism to generate a deep heating effect.1

Our female subjects demonstrated pretreatment hip flexion PROM that was over 10 degrees greater than that for the male subjects, which was consistent with the findings of other researchers.7,25 However, we found no difference in average change of hip flexion ROM between genders for any of the treatments. Previ-ous research has demonstrated that multiple methods of therapeutic heat application increase PROM.1,26 The purpose of this study was to identify the mode of thermotherapy that would increase hamstring extensibility to the greatest extent. Our results clearly indicated that active exercise produced a significantly greater increase in hip flexion PROM than the other heat treatments, without the performance of hamstring stretching exercises.

Superficial heating modalities can only raise tissue temperature to a maximum depth of 2 cm.13 Active exercise increases blood flow to the exercising muscles, which warms the adjacent subcutaneous tissues from the inside out.8,25 Consequently, heating derived from active exercise is not hindered by the thickness of the layer of adipose tissue surrounding the muscle. Most studies have combined thermotherapy with stretch-ing exercises.1,9,15-21 Robertson et al.14 reported that a deep heating modality (i.e., short wave diathermy) was more effective than superficial modes for increasing muscle extensibility. However, Boone et al.22 found that continuous ultrasound without stretching did not affect hip flexion PROM. Therefore, the results of studies that have demonstrated an increase in PROM following superficial heating and stretching may have been due to an alteration of the stretch reflex or an analgesic effect that promotes muscle relaxation.

SummaryThe findings of this study suggest that low-intensity active exercise will increase hip flexion PROM without

stretching, which lends support to the performance of warm-up activities before athletic competition.28-31

Combining superficial heating with a deep-heating modality (i.e., ultrasound) has been shown to provide an incremental increase in muscle temperature.27

Future research should assess the effect of combining superficial heating with active exercise.

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heat, deep heat, and active exercise warm-up on the extensibility of the plantar flexors. Phys Ther. 2001;81:1206-1214.

2. George J, Tunstall A, Tepe R, Skaggs C. The effects of active release technique on hamstring flexibility: a pilot study. J Manipulative Physiol Ther. 1994;29:224-227.

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7. Gribble PA, Guskiewicz KM, Prentice WE, Shields EW. Effects of static and hold-relax stretching on hamstring range of motion using the Flexability LE1000. J Sport Rehabil.1999;8:195-208.

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13. Draper DO, Hopkins TJ. Increased intramuscular and intracapsular temperature via ThermaCare knee wrap application, Med Sci Monit. 2008;14(6):P17-11.

14. Robertson, VJ, Ward A, Jung P. The effect of heat on tissue extensibility: a comparison of deep and superficial heating. Arch Phys Med Rehabil. 2005;86:819-825.

15. Funk D, Swank A, Adams K, Treolo D. Efficacy of moist heat pack application over static stretching on hamstring flexibility. J Strength Cond Res. 2001;15:123-6.

16. Peres E, Draper D, Knight K, Ricard M. Pulsed shortwave diathermy and prolonged long-duration stretching increases dorsiflexion range of motion more than identical stretching with diathermy. J Athl Train. 2002;37:43-50.

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30 november 2012 international journal of athletic therapy & training

18. Draper DO, Castro JL, Feland B, Schulties, S, Eggett D. Shortwave diathermy and prolonged stretching increase hamstring flexibility more than prolonged stretching alone. J Orthop Sports Phys Ther. 2004;34:13-20.

19. Akbari A, Moodi H, Moein A, Nazok R, The effect of therapeutic ultrasound and duration of stretching of the hamstring muscle group on passive knee extension. J Med Sci. 2006;6:968-973.

20. Draper DO, Anderson C, Schulthies SS, Ricard MD. Immediate and residual changes in dorsiflexion range of motion using an ultrasound heat and stretch routine. J Athl Train. 1998;33:141-144.

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23. Piva SR, Fitzgerald K, Irrgang JJ, Jones S, Hando BR., et al. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskelet Disord. 2006;7(33):1-13.

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25. Fonseca RMC, Franca NM, Praagh EV. Relationship between indicators of fitness and bone density in adolescent Brazilian children. Pediatr Exerc Sci. 2008;20:40-49.

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27. Draper DO, Harris ST, Schulthies S, Durrant E, Knight KL, Ricard M. Hot-pack and 1-MHz ultrasound treatments have an additive effect on muscle temperature increase. J Athl Train. 1998;33:21-24.

28. McMillian DJ, Moore JH, Halter BS, Taylor DC. Dynamic vs. static-stretching warm up: the effect on power and agility performance. J Strength Cond Res, 2006;20:492-499.

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Matt Hanson is an assistant professor of exercise science and the Human Performance Program Director at Buena Vista University in Storm Lake, Iowa.

James Day is an instructor of exercise science and the Head Athletic Trainer at Buena Vista University, Storm Lake, IA.

Tricia Turner, PhD, ATC, University of North Carolina at Charlotte, is the Report Editor for this article.

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