Running Head: NORDIC HAMSTRING EXERCISE 1

Nordic Hamstring Exercise Program Effect on Lower Back Strength

Immaculata University

Thomas Prato
NORDIC HAMSTRING EXERCISE 2

Table of Contents

Introduction………………………………………………………………………………………..3

Purpose Statement…………………………………………………………………...……3

Research Questions………………………………………………………………………..4

Hypotheses………………………………………………………………………...………4

Delimitations and Limitations…………………………………………………………….4

Assumptions………………………………………………………………………………4

Significance of Study……………………………………………………………………..5

Definition of Terms………………………………………………………………………5

Review of Literature……………………………………………………………………………..6

Methodology…………………………………………………………………………………….12

Participants………………………………………………………………………………12

Instruments………………………………………………………………………………12

Procedures……………………………………………………………………………….12

Data Analysis……………………………………………………………………………14

References……………………………………………………………………………………….15

Appendix A: Informed Consent…………………………………………………………………19

Appendix B: Data Collection Sheet……………………………………………………………...20

NORDIC HAMSTRING EXERCISE 3

Among athletes, hamstring injuries are one of the most prevalent injuries evaluated.

These injuries are commonly seen in the sports that involve sprinting, cutting, and explosive

movements (Lategan & Gouveia, 2018). Lower back pain (LBP) has been proven to be very

common among varying populations across the globe. In the Black Sea region, in Turkey, it has

been proven that over 62% of the entire population suffer from LBP (Capkin et al., 2015). Since

there are numerous people that suffer from both conditions there have been many varying

rehabilitation techniques created to help deal with these ailments. In prior research, there has

been a focus on the commonality of LBP and hamstring injuries. One of the studies that was

conducted in the past focused on how flexibility can affect LBP and pain levels experienced

(Bedard, Kyung-Min Kin, Grindstaff, & Hart, 2013).

When dealing with LBP rehabilitation there are numerous exercises to help alleviate this

issue. However, the main reasoning behind these exercises are to strengthen the core which

allows for great lumbar spine stabilization (Thames, 2018). For hamstring injuries there are also

numerous exercises to help strengthen the muscle group, and increase flexibility. One of the

exercises that has been proven to increase hamstring strength as well as act as a preventative

technique for hamstring injuries is the Nordic Hamstring exercise (NHE). The NHE has been

significantly proven to increase hamstring strength and volume (Seymore, Domire, DeVita,

Rider, Seymore, & Kulas, 2017). However, there is a lack of information focusing on how

hamstring strength can impact LBP and muscular endurance.

Purpose Statement

The purpose of this research is to determine the differences in lower back muscle

endurance of college-aged students in a research group following the completion of the Nordic

hamstring exercise program compared to a control group.

NORDIC HAMSTRING EXERCISE 4

Research Question(s)

Will there be an increase in lower back endurance in the research group compared to the

control group following the NHE program?

Will there be an increase in hamstring strength in the research group compared to the

control group following the NHE program?

Hypotheses

It is hypothesized that participation in the NHE program will provide an increase in lower

back muscle endurance. However, with the time limitations of the study there will be no

significant differences seen compared to the control group. It is also hypothesized that

participation in the NHE program will provide an increase in hamstring strength. However, with

the time limitations of the study there will be no significant differences seen compared to the

control group.

Delimitations & limitations

Limitations of this study include the number of individuals that participate in the study.

Time is also a limitation due to the limit of 4 weeks allocated for data retrieval. The ages of the

subjects must be between 18-23, and due to ease of access they will all be Immaculata University

students. The students will be only allowed to participate in the study if they have not had any

hamstring or lower back injury within the past 3 months.

Assumptions

During the NHE it is assumed that the subjects are trying as hard as they can to receive

the best results During the pre and post testing it is also assumed that they are trying their

hardest. It is also assumed that they are completely honest in their injury history related to

hamstring and lower back ailments.

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Significance of the Study

The significance of this research is to potentially give health care providers another

rehabilitation exercise, specifically the NHE, when dealing with lower back pain. Administering

the NHE to college-aged students can potentially show if there is a link between hamstring

strength and lower back endurance. If significant results are seen, this study can also show that

strengthening the hamstring muscles can help alleviate lower back pain.

Definition of Terms

Bilateral. Relating to the right and left and left sides of the body or of a body structure

such as the right and left extremities (Floyd, 2015)

Eccentric. A contraction in which the muscle lengthens in an attempt to control the

motion occurring at the joints that it crosses, characterized by the force of gravity or applied

resistance being greater than the contractile force (Floyd, 2015)

Ischial tuberosity. A bony swelling on the posterior part of the superior ramus of the

ischium that gives attachment to various muscles and bears the weight of the body in sitting

(Merriam-Webster Medical Dictionary)

Linea aspera. A longitudinal ridge on the posterior surface of the middle third of the

femur (Merriam-Webster Medical Dictionary)

Lumbar lordosis. Abnormal lumbar vertebral convexity (Prentice, 2014)

Lumbar spine. The five vertebrae are the major support of the low back and are the

largest and thickest of the vertebrae (Prentice, 2014).

Strain. Extent of deformation of tissue under loading (Prentice, 2014)

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Review of Literature

Hamstring injuries are one of the most commonly seen ailments in the sports world

(Lategan & Gouveia, 2018). Among the populations that are not involved in sports, lower back

pain is the most prevalent injury (Capkin et al., 2015). Previous research has indicated that

hamstring tightness can cause the muscles to pull on the pelvis and can potentially cause defects

in the actual anatomical structure of the pelvis and lumbar spine (Bedard, Kyung-Min,

Grindstaff, & Hart, 2013). Due to this change in anatomical structure, lower back rehabilitation

focuses on increasing core muscle strength to help stabilize the lumbar spine (Thames, 2010).

With the commonality of both hamstring and lower back issues there have been numerous

methods of rehabilitation for each. One of the rehabilitation techniques for hamstrings involves

utilizing the Nordic hamstring exercise (NHE). The NHE has shown the ability to increase

hamstring strength and prevent injury (Seymore et al., 2017).

The hamstring muscle group consists of the biceps femoris, semimembranosus, and

semitendinosus muscles. The semitendinosus muscle originates on the ischial tuberosity and

inserts on the anterior medial surface of the tibia. The semimembranosus also originates on the

ischial tuberosity and inserts on the posteromedial surface of the medial tibial condyle. The

biceps femoris is split into a short head and a long head, where the short head originates on the

lower half of the linea aspera and the lateral condyloid ridge, and it inserts on the lateral condyle

of the tibia. The long head originates on the ischial tuberosity and inserts on the head of the

fibula and the lateral condyle of the tibia. The main function of the hamstring muscle group is

hip extension and knee flexion. Other actions include internal and external rotation of the hip and

knee (Floyd, 2015).

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Hamstring strains are common occurrences in sports that involve constant sprinting,

jumping, kicking, and cutting. Specifically, injury prevalence is 12-17% in soccer players, 29%

in sprinters, 8-23% in football, and 6-15% in rugby players (Lategan & Gouveia, 2018). After an

initial injury there has shown to be between a 20-33% chance of reinjury (Tyler, Schmitt,

Nicholas, & McHugh, 2017). The strains mainly occur due to eccentric contraction of the

hamstring during the terminal swing-phase while sprinting (Lategan & Gouveia, 2018). There

are three different grades of hamstring strains. Grade 1 consists of small tearing of the muscle or

tendon with pain, and minimal to no loss of strength. Grade 2 strains are more complete partial

tears with pain and definite loss of strength. Finally, grade 3 tears are complete ruptures resulting

in complete loss of function and, typically, the development of a hematoma (Copland, Tipton, &

Fields, 2009).

Hamstring rehabilitation and prevention programs often focus on strength and flexibility

improvements. One study found that static stretching, starting 48 hours after injury, four times a

day of the hamstring muscles decreased time to return to unrestricted activity (Copland et al.

2009). Static stretching, in combination with a good warm-up program, has be proven to be able

to reduce the incidences of injuries. However, even though stretching programs are common in

rehabilitation it was stated that eccentric strength exercises should be included when the goal is

prevention and rehabilitation (Kalli & Dimitrios, 2016).

Research has shown that the Nordic Hamstring Exercise (NHE) should be included in

hamstring injury prevention programs due to the ability to reduce hamstring injuries (Cuchna,

Welsch, Meier, Regelski & Van Lunen, 2017). The NHE is done in groups of two in which the

one person is kneeling on both knees while the partner holds their feet down on the ground
NORDIC HAMSTRING EXERCISE 8

(Cuchna et al., 2017). The person kneeling then proceeds to slowly lower their torso to the

ground while using their hamstrings to resist the fall (Cuchna et al., 2017).

Strengthening of the hamstring muscle group is an important deciding factor when

choosing the NHE in rehabilitation exercises. Since the NHE has been shown to significantly

increase hamstring strength, it was compared to other hamstring exercises to see how much

improvement there actually is with the NHE. In a prior study, focusing on muscle activation, the

NHE was compared to hamstring exercises known as cranes. This involves the patient starting on

both knees. They then flex at the hip so they are looking down towards the ground. Once in this

position they then extend their arms forward. This created a forward lean forward, and they are

simultaneously causing a lengthening of the hamstring muscle group with the leans. They then

use their hands to catch their fall. Another exercise done was lying kicks which is done by lying

down supine. The person then raises one heel off the ground while the other heel is on the

ground with the knee slightly flexed. They then use the heel that is on the ground to push off the

ground so both feet are off the ground, and then they land on the same heel as they come down.

This study indicated that the NHE activates the hamstring at high levels and at angles similar to

peak hamstring activation while the other two exercises do not achieve the same success (Van

den Tillaar, Brevik Solheim, & Bencke, 2017).

The reasoning behind utilizing the NHE program is that eccentric strengthening in

hamstring-strain rehabilitation provides the greatest chance of preventing reinjury (Tyler et al.,

2017). One study, focused on the NHE, stated that there was a significant bilateral hamstring

strength improvement when utilizing the NHE (Anastasi & Hamzeh, 2011). Looking internally at

the actual hamstring muscle group shows the benefits that the NHE can provide. In a recent
NORDIC HAMSTRING EXERCISE 9

study, the effect of the NHE was shown to increase hamstring muscle growth and muscle volume

(Seymore et al., 2017).

Low back pain (LBP) is another very common ailment among different populations

across the world. For example, among healthcare providers, the prevalence of LBP has been

found to be 70.99% (Çınar-Medeni, Elbasan, & Duzgun, 2017). Another study looked at the

general population of the Black Sea region of Turkey and the results showed 62.1% of the public

self-reported LBP (Capkin et al., 2015). LBP spans across all ages from teenagers to older adults.

Across the globe it has been found that LBP affects around 23% of the population. Among these

patients 85-95% have a lack of a specific pathology, indicating how difficult it can be to relate

the pain a specific mechanism of injury (Engel, Arampatzis, Català, Kopinski, & Mayer, 2018).

Rehabilitation techniques for low back pain are often aimed around the goal of achieving

greater core strength. Focusing on core strength is important because of the ability of these

muscles to help stabilize the lumbar spine. Deeper trunk muscles should be addressed as the first

step in stabilizing the entire trunk and pelvis. These deeper trunk muscles consist of the

transverse abdominis, lumbar multifidus, and the diaphragm. All three of these muscles on the

anterior aspect of the trunk assist in stabilization of the posterior lumbar muscles known as the

erector spinae and quadratus lumborum. The erector spinae group consists of three different

muscles known as the iliocostalis, longissimus, and spinalis (Floyd, 2015).

There have been prior connections made linking hamstring action and lower back

musculoskeletal activity. The hamstring muscle group has been seen to play a role in

stabilization of the pelvis and spine. Hamstring tightness was shown to cause pulling of the

pelvis which can result in anatomical defects of the pelvis and lumbar spine (Bedard et al.,

2013). Patients that have experienced low back pain are seen to have tighter hamstrings (Arab &
NORDIC HAMSTRING EXERCISE 10

Nourbakhsh, 2014). With a lack of extensibility leading to a reduction in lumbar lordosis it could

potentially result in a forward leaning orientation of the trunk (Bedard et al., 2013). Low back

pain has also been seen among people who have demonstrated paraspinal weakness, and this has

been linked back to hamstring contribution (Bedard et al., 2013). However, when studying

hamstring flexibility relating to lower back pain researchers reported no significant findings

suggesting that flexibility is an important contributor in dealing with low back pain (Kuukkanen

& Malkia, 2000).

With the linkage of hamstring injuries and low back pain, injury prevention and

rehabilitation are very important in the recovery process. Patients with low back pain often are

seen doing abdominal exercises during rehabilitation, and this is due to the fact that core muscles

help stabilize and control the lumbar spine (Thames, 2010). However, even though these

exercises are increasing the stability of the lumbar spine they may not be decreasing pain levels.

As previously studied, stabilization techniques can provide physiological improvements without

showing pain improvements (Hebert, Koppenhaver, Fritz, & Parent, 2008).

The NHE has been studied previously focusing on the effect of the exercise program

relating to LBP levels. In this study, just focused on elite rowers, it was found that the NHE does

decrease pain thresholds while also increasing performance during activity. Lower back

flexibility was also tested, but there were no results that stated any effects on flexibility were

seen (Kasmi, Hammami, Noureddine & Riadh, 2017).

With the amount of hamstring injuries that occur in sports it is important to have effective

rehabilitation and preventative techniques. The NHE has been shown to increase actual growth

and volume of the hamstring while adding a preventative method for further injuries (Seymore et

al., 2017). Low back pain, which is seen across varying demographics, can be treated with core
NORDIC HAMSTRING EXERCISE 11

exercises due to their ability to stabilize the lumbar spine (Thames, 2010). It has been seen that

patients suffering from LBP have experienced hamstring tightness, which can actually cause a

pulling on the pelvis resulting in anatomical defects (Bedard et al., 2013).

NORDIC HAMSTRING EXERCISE 12

Methodology

The aim of this study is to test if the NHE program can lead to an increase in lower back

strength. The purpose is to determine if there is a link between a hamstring strengthening

program, like the NHE, and lower back strength improvements.

Participants

The participants will be college-aged students at Immaculata University. The general

population will be used, and there will be no restrictions due to gender. Those people

experiencing LBP of greater than 3, on a scale of 1-10, will not be allowed to participate. Those

who have injured their hamstring or lower back within the past 3 months will also be excluded

from the study. Participants will be recruited by word of mouth and being asked to participate.

There may be a previous relationship with the researcher.

Instrument

A stopwatch will be used for the pre and post-test procedures. The researcher will be in

charge of the timing and when the time will start and end. All data will be recorded on a data

collection sheet (Appendix B).

Procedures

The research will begin with the participants’ completion of the informed consent sheet

(Appendix A) and the top part of the data collection sheet (Appendix B). Prior to group

assignment, all participants will complete pre-testing. This includes a lower back extension

endurance test, a lateral abdominals endurance test, a plank endurance test, and a hamstring

bridge test to test hamstring, abdominal and lower back strength. The extension endurance test

requires the patient to be lying face down on a table with their hips lined up with the edge of the

table. They are then supposed to hold their torso off the edge of the table keeping their spine in
NORDIC HAMSTRING EXERCISE 13

line with the table while the researcher holds their legs for support (Starkey & Brown, 2015).

This will be done until the patient cannot do it any longer. The total time will be recorded. The

lateral abdominals endurance tests requires the patient to be side-lying with the legs straight and

the body rested on a flexed elbow. They are then supposed to raise their pelvis off the table while

maintaining a neutral spine for as long as possible (Starkey & Brown, 2015). The total time will

be recorded. The plank exercise requires the patient to be lying face down on flexed elbows.

They then lift their body off the ground while maintaining a neutral spine for as long as possible.

The total time will be recorded. For the one-legged hamstring bridge the participant is lying on

their back and places a bent leg on a box while the other leg is straight in the air. They then raise

the hips up off the ground while maintaing neutral posture. This is done as many times as

possible and the score will be recorded.

The participants will be placed into one of two groups, the control or research group. The

decision is made based upon matched pair sampling based on pre-test strength results. The

groups will be made so there are around 5 participants per group. More students will be recruited

if possible. The first patient will be placed into the research group, and then if another participant

has similar pre-test strength results they will be place into the control group so they can be

compared throughout the study. This methodology will continue until the groups are finalized.

However, if enough participants are recruited, more students will be placed in the research group

to make up for the potential of anyone who drops out of the study. The participants will be

assigned a number and letter based upon group. For example, the first person in the research

group will be labeled as 1R, and the first person in the control group will be labeled as 1C.

The subjects placed into the research group are taken through a 5-minute warm-up before each

exercise session. The warm-up consists of lower extremity activities of the participant’s
NORDIC HAMSTRING EXERCISE 14

choosing. They will then proceed to the NHE. The NHE is done in groups of two in which the

one person is kneeling on both knees while the researcher holds their feet down on the ground.

The person kneeling then proceeds to slowly lower their torso to the ground while using their

hamstrings to resist the fall (Cuchna, Welsch, Meier, Regelski, & Van Lunen, 2017). This

procedure is done for a total of 8 repetitions for 3 sets. This procedure is done two days per week

for four weeks. There will be a rest period of 24-48 hours between session, depending on the

subject’s schedule. Following the completion of the program the participants will be asked to

come back and partake in the post-test, which is the same exercises as the pre-test. These results

will be recorded on the same data collection sheet as before.

Those in the control group will be allowed to continue with their activities of daily living

without having to do any exercise. After four weeks they will go through the same tests to

measure their post-test results. The data will be recorded on the same data collection sheet.

Data Analysis

The data will be recorded and then analyzed on the Specific analysis of this research will

be done using t-tests.

NORDIC HAMSTRING EXERCISE 15

References

Anastasi, S. M., & Hamzeh, M. A. (2011). Does the eccentric Nordic Hamstring exercise have

an effect on isokinetic muscle strength imbalance and dynamic jumping performance in

female rugby union players? Isokinetics & Exercise Science, 19(4), 251–260. Retrieved

from

http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN=67467275&site

=ehost-live

Arab, A. M., & Nourbakhsh, M. R. (2014). Hamstring muscle length and lumbar lordosis in

subjects with different lifestyle and work setting: Comparison between individuals with

and without chronic low back pain. Journal of Back & Musculoskeletal Rehabilitation,

27(1), 63–70. Retrieved from:

http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN=94080744

&site=ehost-live

Bedard, R. J., Kyung-Min Kim, Grindstaff, T. L., & Hart, J. M. (2013). Active Hamstring

Stiffness After Exercise in Women With a History of Low Back Pain. Journal of Sport

Rehabilitation, 22(1), 47–52. Retrieved from

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N=84821405&site=ehost-live

Capkin, E., Karkucak, M., Cakırbay, H., Topbas, M., Karaca, A., Köse, M. M., & Gökmen, F.

(2015). The prevalence and risk factors of low back pain in the eastern Black Sea region

of Turkey. Journal of Back & Musculoskeletal Rehabilitation, 28(4), 783–787. Retrieved

from http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN=

111946894&site=ehost-live
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Çınar-Medeni, Ö., Elbasan, B., & Duzgun, I. (2017). Low back pain prevalence in healthcare

professionals and identification of factors affecting low back pain. Journal of Back &

Musculoskeletal Rehabilitation, 30(3), 451–459. Retrieved from

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s3h&AN=122963474&site=ehost-live

Copland, S. T., Tipton, J. S., & Fields, K. B. (2009). Evidence-Based Treatment of Hamstring

Tears. Current Sports Medicine Reports (American College of Sports Medicine), 8(6),

308–314. Retrieved from http://library.immaculata.edu:2052/login.aspx?direct=

true&db=s3h&AN=45347268&site=ehost-live

Cuchna, J. W., Welsch, L., Meier, T., Regelski, C. L., & Van Lunen, B. (2017). The

Effectiveness of Nordic Hamstring Exercises in Reducing Hamstring Injuries in

Competitive Soccer Players: A Critically Appraised Topic. International Journal of

Athletic Therapy & Training, 22(3), 12–17. Retrieved from

http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN

=122803032&site=ehost-live

Engel, T., Arampatzis, A., Català, M. M., Kopinski, S., & Mayer, F. (2018). Perturbations in

Prevention and Therapy of Low Back Pain: a New Approach. / Perturbationsgestütztes

Training in der Prävention und Therapie von Rückenschmerzen. German Journal of

Sports Medicine / Deutsche Zeitschrift Fur Sportmedizin, 69(7/8), 247–253. Retrieved

from http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN=

131063088&site=ehost-live

Floyd, R. T. (2015). Manual of Structural Kinesiology (19th ed.). McGraw-Hill Education.

NORDIC HAMSTRING EXERCISE 17

Hebert, J., Koppenhaver, S., Fritz, J., & Parent, E. (2008). Clinical Prediction for Success of

Interventions for Managing Low Back Pain. Clinics in Sports Medicine,27(3), 463-479.

doi:10.1016/j.csm.2008.03.002

Kalli, K., & Dimitrios, S. (2016). Hamstring Injuries: Prevention and Rehabilitation. Biology of

Exercise, 12(2), 15–34. Retrieved from

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e=ehost-live

Kasmi, S., Hammami, A., Noureddine, G., & Riadh, K. (2017). The effects of Nordic hamstring

exercise on pain and performance in elite rowers with lower back pain. Turkish

Kinesiology,3(2), 22-25. Retrieved from http://dergipark.gov.tr/download/article-

file/320794

Kuukkanen, T., & Malkia, E. (2000). Effects of a three-month therapeutic exercise programme

on flexibility in subjects with low back pain. Physiotherapy Research International, 5(1),

46. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=s3h

&AN=6148587&site=ehost-live

Lategan, L., & Gouveia, C. P. (2018). Prevention of Hamstring Injuries in Sport: A Systematic

Review. South African Journal for Research in Sport, Physical Education & Recreation,

40(1), 55–69. Retrieved from http://library.immaculata.edu:2052/login.aspx?direct=true

&db=s3h&AN=128451155&site=ehost-live

Medical Terms and Abbreviations: Merriam-Webster Medical Dictionary. (n.d.). Retrieved from

https://www.merriam-webster.com/medical

Prentice, W. E. (2014). Principles of athletic training: A competency-based approach. New

York, NY: McGraw-Hill.

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Seymore, K., Domire, Z., DeVita, P., Rider, P., Kulas, A., Seymore, K. D., … Kulas, A. S.

(2017). The effect of Nordic hamstring strength training on muscle architecture, stiffness,

and strength. European Journal of Applied Physiology, 117(5), 943–953. Retrieved from

http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&AN=

122421282&site=ehost-live

Starkey, C., & Brown, S. D. (2015). Examination of Orthopedic and Athletic Injuries the

Orthopedic and Athletic Injury Examination Handbook, 3rd Ed. F A Davis.

Thames, C. (2010). Rehabilitation for Low Back Pain. Hughston Health Alert, 22(2), 7.

Retrieved from http://library.immaculata.edu:2052/login.aspx?direct=true&db=

s3h&AN=57275994&site=ehost-live

Tyler, T. F., Schmitt, B. M., Nicholas, S. J., & McHugh, M. P. (2017). Rehabilitation After

Hamstring-Strain Injury Emphasizing Eccentric Strengthening at Long Muscle Lengths:

Results of Long-Term Follow-Up. Journal of Sport Rehabilitation, 26(2), 131–140.

Retrieved from http://library.immaculata.edu:2052/login.aspx?direct=true&db=s3h&

AN=122551094&site=ehost-live

Van den Tillaar, R., Brevik Solheim, J. A., & Bencke, J. (2017). Comparison of Hamstring

Muscle Activation during High-Speed Running and Various Hamstring Strengthening

Exercises. International Journal of Sports Physical Therapy, 12(5), 718–727. Retrieved

from http://library.immaculata.edu:2052/login.aspx?direct=true&db=

s3h&AN=126498882&site=ehost-live
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Appendix A: Informed Consent

NORDIC HAMSTRING EXERCISE 20

Appendix B: Data Collection Sheet