Post Facilitatiion Stretch and Dry Needling on Hamstring Tightness in Chronic Low Back Pain

Comparison of Post Facilitatiion Stretch and Dry Needling on Hamstring Tightness in Chronic Low Back Pain

The aim of this research is to compare the effects of post-facilitation stretch and dry needling on hamstring flexibility, pain, lumbar range of motion, pelvic tilt, and functional status in patients with chronic low back pain. This randomized clinical trial will be conducted at Spine Care Physical Therapy and Rehabilitation Centre (SPRC), Peshawar. The sample size will be 36 participants, who will be randomly divided into two groups: 18 participants in the post-facilitation stretch group and 18 participants in the dry needling group. The study duration will be 3 weeks, with interventions applied three times per week. The sampling technique used will be non-probability purposive sampling, followed by random allocation using the sealed opaque envelope method. Participants aged 20-50 years diagnosed with chronic nonspecific low back pain and having hamstring tightness will be included. Outcome measures used in the study will be Active Knee Extension Test (goniometer) for hamstring flexibility, Numeric Pain Rating Scale (NPRS) for pain, goniometer for lumbar flexion and extension, pelvic inclinometer for pelvic tilt, and Modified Oswestry Disability Index (MODI) for functional disability.

Study Overview

• Status: Not yet recruiting
• Conditions: Low Back Pain
• Intervention / Treatment: Other: Dry Needling along with Conventional Therapy; Other: Post Facilitation Stretch along with Conventional Therapy

Detailed Description

Chronic low back pain (CLBP), defined as pain persisting for more than 12 weeks, represents one of the leading causes of long-term disability worldwide. In the absence of a clearly identifiable structural pathology, the majority of cases are classified as chronic non-specific low back pain, which poses significant challenges for accurate diagnosis and targeted management. The Global Burden of Disease (2023) report highlights low back pain as the highest-ranking musculoskeletal condition in terms of disability, affecting approximately 7.5% of the global population, with lifetime prevalence estimates reaching up to 80% and projected to rise further by 2050.Chronic low back pain is closely associated with musculoskeletal dysfunctions, including impaired trunk muscle control, altered pelvic mechanics, and compensatory movement strategies involving the hip and lower extremities. Disruption of normal movement patterns and muscle imbalances contributes to abnormal load distribution across the lumbar spine, thereby perpetuating pain and functional limitation. In particular, restricted pelvic mobility during trunk flexion and extension results in excessive lumbar spine motion, increasing mechanical stress on spinal structures.Lifestyle and behavioral factors play an important role in the development and progression of CLBP. Emerging evidence suggests that regular moderate physical activity has a protective effect against chronicity. A recent prospective cohort study (2025) demonstrated that individuals engaging in more than 100 minutes of daily walking exhibited a significantly lower risk of developing chronic low back pain. In contrast, psychosocial factors such as depression have been shown to negatively influence pain severity, disability levels, and recovery outcomes, emphasizing the multifactorial nature of CLBP.

Hamstring muscle tightness is a commonly observed impairment in individuals with CLBP and has been identified as a key contributor to altered lumbopelvic rhythm. The hamstring muscle group comprising the semitendinosus, semimembranosus, and long head of the biceps femoris originates from the ischial tuberosity and plays a crucial role in regulating hip and knee mechanics. Reduced hamstring flexibility limits anterior pelvic tilt during forward bending, leading to compensatory lumbar spine motion and increased repetitive loading. Chronic hamstring tightness is frequently accompanied by weakness of the gluteus maximus and deep core stabilizers, resulting in posterior chain imbalance and reliance on superficial stabilizers such as the erector spinae, further aggravating pain persistence.Improving hamstring flexibility is therefore considered an important therapeutic target in the management of chronic non-specific low back pain. Various stretching techniques, including static stretching, have demonstrated effectiveness in increasing range of motion and reducing musculotendinous stiffness. Improved flexibility has been associated with favorable changes in muscle activation patterns and a more balanced distribution of movement between the pelvis and lumbar spine, potentially reducing mechanical strain.

Among manual therapy interventions, Dry Needling (DN) has gained increasing attention as an invasive technique designed to deactivate myofascial trigger points, normalize muscle tone, and reduce nociceptive input. DN has shown effectiveness in reducing pain sensitivity, relieving muscle tightness, and improving functional movement, particularly when combined with exercise-based rehabilitation. Evidence from systematic reviews and meta-analyses supports its short- to mid-term benefits in reducing pain and disability in individuals with CLBP.Similarly, Muscle Energy Technique (MET), particularly in the form of post-facilitation stretch (PFS), has demonstrated strong efficacy in improving hamstring flexibility. PFS utilizes a maximal voluntary contraction followed by an immediate stretch to enhance muscle extensibility through neuromuscular mechanisms such as post-isometric relaxation and reciprocal inhibition. Compared to conventional stretching, MET has been shown to produce superior improvements in range of motion, reduce muscle stiffness, and enhance functional performance.Although both DN and PFS are effective in reducing pain and improving flexibility, they operate through distinct physiological mechanisms. PFS primarily modulates neuromuscular tone through voluntary contraction and reflex inhibition, whereas DN directly targets localized myofascial dysfunction to interrupt pain cycles and restore tissue perfusion. Despite their individual benefits, limited evidence exists directly comparing these two interventions within a standardized rehabilitation framework for chronic non-specific low back pain associated with hamstring tightness.However, no evidence exists comparing post-facilitation stretch and dry needling when combined with conventional physiotherapy in chronic non-specific low back pain associated with hamstring tightness.Therefore, the present randomized clinical trial aims to compare the effects of post-facilitation stretch and dry needling, each combined with conventional physiotherapy treatment, in individuals with chronic non-specific low back pain accompanied by hamstring tightness. The primary objective of the study is to determine which intervention leads to greater improvement in hamstring flexibility. Secondary objectives include comparison of lumbar range of motion, pelvic tilt, pain intensity, and functional disability between the two intervention groups.

• Study Type: Interventional
• Enrollment (Estimated): 36
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Imran Amjad PT, PhD; Phone Number: 03324390125; Email: imran.amjad@riphah.edu.pk

Study Locations

• Pakistan
  • Khyber Pakhtunkhwa
    • Peshawar, Khyber Pakhtunkhwa, Pakistan, 25000
      • Spine Physical Therapy and Rehabilitation Center
      • Contact: Aiman Basheer, DPT; Phone Number: +92 318 945 8557; Email: aimanbasheer444@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosed with chronic non-specific low back pain of more than 12 weeks' duration.
• Positive Straight Leg Raise (SLR) test or Active Knee Extension Test showing hamstring tightness (<80° hip flexion with knee extended).

Exclusion Criteria:

• History of spinal surgery, fracture, or neurological deficit.
• Radiculopathy or red flag signs (tumor, infection, inflammatory disorders).
• Recent steroid injection therapy for low back pain (within 3 months).
• Contraindications to dry needling (bleeding disorders, infection at site, needle phobia).
• Pregnancy.
• Severe needle phobia (for DN group).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Dry Needling along with Conventional Therapy; Needle retention 30-60 seconds per point. 5 minute moist heat pack applied to posterior thigh before treatment Static hamstring stretches 3 reps × 20 seconds post-session.	Other: Dry Needling along with Conventional Therapy; Patient in prone position with pillow under ankle. After skin antisepsis, a sterile filiform needle (0.25 × 40 mm) will be inserted into identified myofascial trigger points in the hamstrings. Local twitch responses will be elicited with 5-10 positioning movements. Needle retention 30-60 seconds per point for 3 weeks 3 session per week.The patient was positioned in supine lying on the treatment plinth with the contralateral limb extended and the treated limb raised with the knee extended for static hamstring stretching. The pelvis was stabilized to prevent compensatory movements.For the moist heat pack, the patient remained in prone lying, with the heat pack applied over the posterior thigh (hamstring region) and properly secured for comfort and safety
Active Comparator: Post-Facilitation Stretch along with Conventional Physiotherapy; maximal isometric contraction for 7-10 seconds, followed by complete relaxation for 1-2 seconds, rapid, controlled stretch for 15-20 seconds 3-5 reps 5-minute moist heat pack Static hamstring stretches 3 reps × 20 seconds post-session.	Other: Post Facilitation Stretch along with Conventional Therapy; Post-Facilitation Stretch with Conventional Physiotherapy. Participants in this group will receive post-facilitation stretch combined with conventional physiotherapy. Post-facilitation stretch will be performed with the patient in supine lying. The therapist will passively stretch the hamstring muscle to the point of first resistance, followed by a maximal isometric contraction (100% effort) for 7-10 seconds. After a brief relaxation period of 1-2 seconds, a rapid, controlled stretch will be applied and held for 15-20 seconds. This sequence will be repeated 3-5 times per session. Conventional physiotherapy will include a 5-minute moist heat pack applied to the posterior thigh before treatment, followed by static hamstring stretching (3 repetitions × 20 seconds) after the session. Sessions will be conducted three times per week for 3 weeks, with a total of 9 sessions, each session lasting approximately 30 minutes.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hamstring Flexibility (Active Knee Extension Test)	Changes from baseline hamstring flexibility will be assessed using the Active Knee Extension (AKE) test measured with a universal goniometer. The AKE test evaluates hamstring extensibility by measuring the degree of active knee extension with the hip maintained at 90° flexion. It is a reliable and valid clinical measure for assessing hamstring tightness in individuals with low back pain.	baseline,1 week, 2 week, 3 week

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Numeric Pain Rating Scale (NPRS)	Changes from Baseline pain values will be taken with the help of Numeric Pain Rating Scale measures level of pain. Scoring is done by selecting a point from zero to ten as the current level of pain. Zero means minimum pain and 10 denotes maximum pain.	Baseline, 1 week, 2 week, 3 week
Lumbar Range of Motion	Changes from baseline lumbar flexion and extension range of motion will be measured using a universal goniometer following standardized assessment procedures with the participant in standing position.	Baeline ,1 week, 2 week, 3 week
Pelvic Tilt	Changes from baseline pelvic alignment will be assessed using a pelvic inclinometer by measuring the angle between the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS). This measure provides an objective assessment of anterior or posterior pelvic tilt.	Baeline, 1 week, 2 week, 3 week
Functional Disability (Modified Oswestry Disability Index MODI)	Changes from baseline functional disability will be assessed using the Modified Oswestry Disability Index (MODI). MODI is a validated questionnaire used to evaluate the impact of low back pain on daily activities and functional status, with higher scores indicating greater disability.	Baeline, 1 week, 2 week, 3 week

Collaborators and Investigators

• Sponsor: Riphah International University
• Investigators: Principal Investigator: Muhmmad Affan Iqbal, PhD*, Riphah International University, Islamabad

Study record dates

Study Major Dates

• Study Start (Estimated): February 2, 2026
• Primary Completion (Estimated): July 31, 2026
• Study Completion (Estimated): August 31, 2026

Study Registration Dates

• First Submitted: February 17, 2026
• First Submitted That Met QC Criteria: February 17, 2026
• First Posted (Actual): February 23, 2026

Study Record Updates

• Last Update Posted (Actual): February 23, 2026
• Last Update Submitted That Met QC Criteria: February 17, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Dry Needling; Chronic Low Back Pain; Post Facilitation Stretch
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Back Pain; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Low Back Pain
• Other Study ID Numbers: RCRAHS-ISB/REC/MS-PT024437

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No