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Stretching and Flexibility in the Aging Adult

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Home Health Care Management & Practice
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DOI: 10.1177/1084822309334073
published online 9 April 2009Home Health Care Management Practice
Harvey W. Wallmann
Stretching and Flexibility in the Aging Adult
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Stretching and Flexibility in the Aging Adult
Harvey W. Wallmann, PT, DSc, SCS, LAT, ATC, CSCS
Keywords: flexibility; stretching; alignment; range of motion; aging; movement
Stretching to improve flexibility has long been recog-
nized as an important component of a total fitness
program for generating and maintaining overall flexibil-
ity as well as for sporting events and activities of daily
living (ADLs). Many health care professionals would
agree that stretching is especially important after sustain-
ing an injury, because this may result in compromised
range of motion (ROM) and flexibility due to impaired
mobility. Immobility may lead to shortened muscles,
which may lead to muscular imbalance about a joint,
which, in turn, could lead to faulty postural alignment
that may further lead to injury and joint dysfunction.
Consequently, understanding and incorporating stretch-
ing exercises to restore normal ROM and flexibility is a
crucial component to any rehabilitation program.
What Is Stretching?
Stretching is simply the movement of the muscles and
tendons about a joint to a point of resistance within the
available ROM, at which point a force is applied, gener-
ally past its end range. A stretch is induced as the tissue
is subjected to a tensile (pulling) force, resulting in elon-
gation of the musculotendinous unit and, hence, transient
deformation. Of course, the amount of stretching that
takes place depends on the physiology of the muscles and
connective tissue (e.g., skin, fascia, ligaments, tendons,
joint capsules, and muscle fascia), where the mechanical
behavior is related to the overall property of viscoelastic-
ity (Lederman, 1997; Taylor, Dalton, Seaber, & Garrett,
1990). Viscoelasticity is a combination of the properties
of viscosity and elasticity (Lederman, 1997; Levangie &
Norkin, 2001). Viscosity refers to a material’s ability to
dampen and lubricate elements. Elasticity refers to a
material’s ability to return to its original state following
deformation (i.e., change in dimensions such as length or
shape) after the removal of the deforming load. It is the
springlike element within the tissue.
Stretching may be performed actively, where the indi-
vidual supplies the force for the stretch, or passively,
where a partner or outside entity provides the force for the
stretch. Stretching also affects different sensory receptors
in the muscle and tendon, resulting in important neuro-
physiological phenomena.
What Is Flexibility?
Flexibility has been defined as the ability to move
muscles and joints through a full ROM (Bandy & Sanders,
2001) and generally refers to the degree of normal
motion available. Flexibility is necessary for efficient
movement, as decreased joint mobility and ROM may
lead to incorrect body alignment, chronically tight mus-
cles, faulty compensation patterns, inefficient body
mechanics, and possibly increased risk of injury.
Flexibility can be classified into different categories.
Static flexibility refers to the ROM about a joint as a
result of static stretching (no velocity involved) or pas-
sive movement, whereas dynamic flexibility relates to
the ability to move through an ROM with normal or
rapid velocity using active movements (Alter, 1996;
Holcomb, 2000). However, no evidence substantiates
that flexibility exists as a single general characteristic of
the body. Rather, it is specific to particular joints, joint
actions, or movements (Merni, Balboni, Bargellini, &
Menegatti, 1981). For example, having good gastrocne-
mius flexibility does not mean the hamstrings will also
be flexible. Consequently, it is highly variable among
different individuals, resulting in different levels of
flexibility in various movements.
The flexibility needed for athletic endeavors usually
differs from that needed for ADLs. Just as flexibility is
joint specific, it is also activity or sport specific. Many
studies have identified a functional ROM for specific
joints, which occurs during the performance of certain
functional tasks (Ostrosky, Van Swearingen, Burdett, &
Gee, 1994). For example, depending on the height of the
step, approximately 105° of knee flexion is necessary to
ascend and descend stairs. Another example would be a
baseball pitcher exhibiting increased shoulder ROM with
external rotation and decreased internal rotation ROM in
the throwing arm as compared with the nonthrowing arm.
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Furthermore, a swimmer would require more bilateral
shoulder flexibility than would a sprinter.
Many people consider good flexibility essential for
successful athletic performance and injury prevention.
However, there is virtually no research to substantiate
the claim that increased flexibility can improve athletic
performance. Commonsense suggests that including
stretching activities in rehabilitation and fitness pro-
grams is a good idea. Flexibility is an important part of
any training program, because it dictates movement abil-
ity during sports activities. Decreased flexibility in a
hurdler, for example, could hinder performance. However,
with notable exceptions, maximal flexibility is not vital
in all sports because most sport skills (e.g., shooting a
basketball and playing golf) require an effective balance
between joint flexibility and stability and do not require
full ROM.
Flexibility is maintained through regular and proper
stretching regimens and will diminish over time if tissues
are not stretched or exercised (Alter, 1996). Therefore, a
loss of flexibility would result in a decreased ROM about
a joint secondary to a decreased ability of the muscle to
deform. It stands to reason, then, that the goal of any flex-
ibility program would be to improve ROM at all joints by
enhancing musculotendinous extensibility around those
Limitations to Flexibility
Factors and components other than muscles, tendons,
and their surrounding fascia may be responsible for lim-
iting flexibility and joint ROM. These limitations might
include bony structures, fat, connective tissue lesions,
skin, postural problems, age, or sex (Arnheim & Prentice,
1997) and would be determined as contributing to func-
tional movement limitations during the assessment.
Additionally, given joint specificity, the clinician must
identify the restriction responsible for causing the limita-
tion and then select the appropriate exercise technique to
improve flexibility.
Aging and Flexibility
Children appear to have increased flexibility during
their elementary school years with a leveling off during
adolescence and an eventual decline throughout adult-
hood (Corbin & Noble, 1980). The physiological changes
that occur with aging beyond adolescence can be respon-
sible for the decrease in overall musculoskeletal flexibil-
ity, especially in the elderly. The loss of muscle function,
along with the increase in intramuscular connective tissue
stiffness, results in decreased ROM and a gradual decline
in the efficiency of performance of ADLs. Certain physi-
cal and biochemical changes occur to collagen with aging
resulting in decreased extensibility. These changes include
an increased formation of intramolecular and intermo-
lecular cross-links, which restricts the ability of the
collagen fibers to move past each other.
Despite the fact that collagen is less mobile and
responds slower to stretching in the elderly than in their
younger counterparts, evidence reveals that decreases in
flexibility and ROM can be minimized in those elderly
who remain active in a flexibility training program. Given
some compensation for time, the older person is actually
capable of increasing flexibility (Lewis, 2002). In fact,
ROM increases have been observed in several joints as a
result of various exercise programs in an aging population
(Mills, 1994; Skelton, Greig, Davies, & Young, 1994).
Sex Differences
Women are generally more flexible than men (Alter,
1996). This may be because of physiological and anatomi-
cal differences. For example, pregnancy affects flexibility,
making the pelvic joints and ligaments relaxed and capable
of greater movement. A study examining the differences
between men and women over an 18-year period revealed
that men had less flexibility than women only in their ham-
string muscles (Barnekow-Bergkvist, Hedberg, Janlert, &
Jansson, 1996). Some of the differences in flexibility may
be because of the sex-specific nature of different regular
and social activities. Additionally, although no firm conclu-
sions can be drawn, hormonal fluctuations may play a role
in ligamentous laxity of certain joints, thus potentially pre-
disposing women to greater ROM differences than men.
Pathology and Joint Laxity
The goal of any flexibility program is to improve
the joint ROM by improving the muscle extensibility.
However, musculoskeletal extensibility may also be affected
by skeletal malalignment, thereby altering soft tissue
loading of the joints. Subsequently, compensatory pos-
tures may result in pathology, alongside abnormal joint
load distribution and contact pressures, which can lead to
articular cartilage degeneration.
Joint laxity may affect the way flexibility is assessed.
Although it may seem counterintuitive, some people
with increased joint laxity actually have poor musculo-
tendinous extensibility. Carter and Wilkinson (1964)
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Wallmann / Stretching and Flexibility 3
developed a hypermobility screening method, later modi-
fied by Beighton, Solomon, and Soskolne (1973), which
has been used extensively to examine specific joint flexi-
bility. This method examines the ability to perform the
following movements: (a) to hyperextend the knees and
elbows beyond 10°, (b) to passively extend the fingers so
that they are parallel to the forearm, (c) to passively abduct
the thumb so that it touches the forearm, and (d) to forward
flex the trunk so that the palms easily touch the floor. When
demonstrating a stretching program with hypermobile
individuals, it is necessary to first isolate the muscle to be
stretched and then focus on stretching the muscle only and
not the joint capsule. This produces a more effective
stretch than simply performing a stretch over two or three
joints (Bandy & Sanders, 2001).
Human movement is a carefully orchestrated process
that involves the driving force of the neuromuscular and
musculoskeletal systems. One factor affecting move-
ment is the ability of tissues responsible for both the
generation of motion of joints and limitation of exces-
sive motion that may potentially cause damage to tis-
sues. Therefore, it is critical to understand the basic
biomechanical and physiological properties of tissues
supporting human movement. Knowing these properties
allows the clinician to make decisions regarding thera-
peutic exercise programs impacting flexibility.
For many, the main goal of stretching is to enhance
overall flexibility. However, stretching has also been
shown to help facilitate relaxation, prevent injury, reduce
postexercise soreness, allow quicker recovery from work-
outs, and affect performance. Additionally, a flexible body
may have improved muscle balance and is often seen as
being more efficient and more easily able to undergo
strength and endurance training. Research is currently
ongoing in an attempt to challenge some of the long-held
beliefs about stretching, especially its influence on imme-
diate dynamic muscle performance.
Alter, M. J. (1996). Science of flexibility (2nd ed.). Champaign, IL:
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Arnheim, D. D., & Prentice, W. E. (1997). Principles of athletic
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Bandy, W. D., & Sanders, B. (2001). Therapeutic exercise: Techniques
for intervention. Baltimore: Lippincott Williams & Wilkins.
Barnekow-Bergkvist, M., Hedberg, G., Janlert, U., & Jansson, E.
(1996). Development of muscular endurance and strength from
adolescence to adulthood and level of physical capacity in men
and women at the age of 34 years. Scandinavian Journal of
Medicine and Science in Sports, 6, 145-155.
Beighton, P., Solomon, L., & Soskolne, C. L. (1973). Articular mobil-
ity in an African population. Annals of the Rheumatic Diseases,
32, 413-418.
Carter, C. O., & Wilkinson, J. A. (1964). Genetic and environmental
factors in the etiology of congenital dislocation of the hip. Clinical
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Corbin, C. B., & Noble, L. (1980). Flexibility: A major component of
physical fitness. Journal of Physical Education and Recreation,
51, 23-24.
Holcomb, W. (2000). Stretching and warm-up. In T. Baechle & R. Earle
(Eds.), Essentials of strength training and conditioning (2nd ed.,
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neurology, and psychology. New York: Churchill Livingstone.
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ciplinary approach to assessment and rehabilitative management
of the elderly (4th ed.). Philadelphia: F. A. Davis.
Merni, F., Balboni, M., Bargellini, S., & Menegatti, G. (1981).
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growth. Medicine and Sport, 15, 168-175.
Mills, E. M. (1994). The effect of low-intensity aerobic exercise on
muscle strength, flexibility, and balance among sedentary elderly
persons. Nursing Research, 43, 207-211.
Ostrosky, K. M., Van Swearingen, J. M., Burdett, R. G., & Gee, Z.
(1994). A comparison of gait characteristics in young and old
subjects. Physical Therapy, 74, 637-644.
Skelton, D. A., Greig, C. A., Davies, J. M., & Young, A. (1994).
Strength, power and related functional ability of healthy people aged
65-89 years. Age and Ageing, 23, 371-377.
Taylor, D. C., Dalton, J. D., Seaber, A. V., & Garrett, W. E. (1990).
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Harvey W. Wallmann, PT, DSc, SCS, LAT, ATC, CSCS, is
an associate professor, chair of the Department of Physical
Therapy, and the founding director of the Physical Therapy
Program at the University of Nevada, Las Vegas. He also
served 1 year as the interim dean for the School of Health and
Human Sciences. He received a BA in movement and sports
science from Purdue University in 1985, an MS degree with an
emphasis in exercise physiology from Purdue University in
1986, an MS degree in physical therapy from the University of
Indianapolis in 1989, and a doctor of science degree from
Loma Linda University in 2000. He has advanced training and
skills in manual techniques of the spine and extremities, with
his primary work experience being in orthopedics and sports
physical therapy. In addition to being a certified athletic trainer
and a certified strength and conditioning specialist, he is also
a board certified clinical specialist in sports physical therapy
and serves as the chair of the sports specialty council under the
American Board of Physical Therapy Specialists. Areas of
interest include foot and ankle, foot orthotic fabrication, gait
training, the effects of stretching on performance, muscle
fatigue, sports nutrition, and balance assessment.
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... Although the aims of the present study did not include the assessment of possible aetiological mechanisms affecting joint ROM, according to scientific literature, flexibility improvements are mainly attributed to alterations in the extensibility of the connective tissue, as adequate/poor joint flexibility is considered to be dependent on the length and elasticity of the connective tissue surrounding individual muscle fibres and the muscle in total (Sapega et al. 1981, Warren et al. 1976, Alter 1996, Wallmann 2009). However, the positive impact of connective tissue on flexibility appears overestimated by researchers, whereas the effects myogenic constraints in determining ROM appear underestimated (Hutton 1992). ...
Technical Report
Full-text available
The aim of the present study was to assess the acute effect of selected mat Pilates exercises on the lower extremities joint flexibility of female amateur soccer players. Eighteen volunteers, all female amateur soccer players, with a mean age of 25.6±3.5 years old, mean height of 168.3±2.8 cm, mean body mass equal to 66.4±6.2 kg and mean training age of 13.5 years, lacking prior Pilates knowledge, formed the study's sample. All players performed two different mat Pilates protocols on non-consecutive sessions, in random order. The first protocol included initial flexibility measurements, selected mat Pilates exercises performed in full ROM and final flexibility measurements. The second protocol was similar to the first, expect for the mat Pilates exercises, where the joints were not in full ROM. Ten repetitions were performed for each exercise (1x10) before equal repetitions were performed on the alternate leg (2x10). Range of motion (ROM) was measured passively on hip flexion, hip extension, hip abduction, knee flexion and ankle dorsiflexion on the right side of the body, with the use of a flexometer. A 2x2 Analysis of Variance for repeated measures was used in order to verify differences between pre-and post-measurements for both mat Pilates protocols. The study revealed that the selected mat Pilates exercises produced significant effects on the joint flexibility only when performed in full ROM. The findings suggest the use of mat Pilates exercises as an alternate training method for improving joint flexibility among soccer players, only when performed in full ROM.
... Famisis (2015) failed to record improvements in the lower extremities joint ROM of soccerplayers, while using a session of calisthenics exercises with restricted ROM, but reported significant improvements in flexibility, when calisthenics exercises were performed in full ROM as an extra session. Additionally, although in the elderly collagen appears less mobilised and adapts slower during stretching, according to literature, reductions in joint ROM can be minimized via systematic stretching training (Alter 1996, Wallmann 2009). Further research is needed in order to assess the degree of involvement of age or the performance of restricted ROM activities on the reduced ROM demonstrated in the elderly. ...
Technical Report
Full-text available
The effect of the duration of static stretching as well as that of the number of repetitions in acute stretching protocols on flexibility has not been extensively examined in the elderly. The aim of the present study was to investigate the acute effects of stretching duration on the range of motion (ROM) of the lower extremities and the trunk in elderly women, when stretching is performed once or in multiple repetitions while controlling the total amount of the time spent in one stretching session. Twenty sedentary women aging 65-85 years old (mean age=75.9) participated in this study. Subjects performed three static stretching protocols lasting for 60 s each, in non-consecutive training sessions. The first stretching protocol comprised of a 60 s stretch (1x60), the second of two 30 s stretches (2x30), whereas the third was of four 15 s stretches (4x15). ROM was determined during hip flexion, extension and abduction, knee flexion, and ankle dorsiflexion, as well as during trunk flexion, using a flexometer and a goniometer. An analysis of variance (ANOVA) with repeated measures revealed no significant differences between the stretching protocols. Further statistical analysis indicated significant (p<.001) improvements after the stretching exercises, in all flexibility protocols. The findings suggest that a single 60 s static stretch of the lower extremities and trunk’s muscles produced the same effect as two 30 s and four 15 s stretches during a flexibility training session involving sedentary elderly women.
Exercise prescription is an important part of clinical decision making for rehabilitation professionals. Evidence-based practice encourages rehabilitation professionals to have strong rationale based on the current literature for all elements of practice including therapeutic exercise. Prescribing what “has seemed to work in the past” or “what seems right” may accomplish some positive outcomes for patients; however, using sound prescription principles from current research more consistently produces optimal outcomes. This article presents a framework for exercise prescription based on levels or phases. These include Tissue Healing, Mobility, Performance Initiation, Stability, Motor Control, Performance Improvement, Advanced Coordination, Agility, and Skill. Available research is used to substantiate the framework and guide the rehabilitation professional's decision-making process when prescribing exercise.
The aim of this study was to determine the effects of workplace manual technique interventions for female participants on the degree of joint range of motion and on the level of musculoskeletal ache, pain, or discomfort experienced when performing workplace responsibilities. Nineteen (19) female volunteers were given chair massages on-site twice per week for 1 month. Participants included individuals in administration and management from a company in Ljubljana, Slovenia. A total of 19 female volunteers 40-54 years of age enrolled for this study. Fifteen (15) of them completed all measurements. The Cornell Musculoskeletal Discomfort Questionnaire was used, and range-of-motion measurements in degrees were taken. Subjects completed a series of self-report questionnaires that asked for information concerning musculoskeletal discomfort for the neck, upper back, and lower back in the form of a body diagram. A range-of-motion test (to compare the change in joint angles) was performed with a goniometer to assess cervical lateral flexion, cervical flexion, cervical extension, lumbar flexion, and lumbar extension. Between the first and the last measurements, a significant difference (p<0.05) was found in increased range of motion for cervical lateral flexion (28.8%). Wilcoxon signed rank test showed a significant increase (p<0.05) in range of motion for cervical lateral flexion (42.4±6.3 to 48.3±7.3), cervical extension (63.2±12.4 to 67.2±12.3), and a significant decrease (p<0.05) in the Cornell Musculoskeletal Discomfort Questionnaire values for the neck (2.7±0.8 to 1.9±0.6) and the upper back (2.7±0.7 to 2.2±0.8) from the phase 2 to 3. Significant reductions were also shown in the Cornell Musculoskeletal Discomfort Questionnaire values for the neck (2.8±0.8 to 1.9±0.6) and the upper back (2.7±0.8 to 2.2±0.8) from the phase 1 to 3. On-site massage sessions twice per week for 1 month are the most effective interventions (compared to one session or no massage intervention) for decreasing the duration of musculoskeletal ache, pain, or discomfort and for increasing range of motion.
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This cross-sectional study was designed to examine the effects of healthy ageing on muscle strength, power, and potentially related functional ability. Subjects were recruited through local and national newspapers and inclusion was based on strict health criteria, by questionnaire. Isometric knee extensor, isometric elbow flexor and handgrip strength, leg extensor power, timed rise from a low chair, lifting a weighted bag on to a surface, and stepping unaided on to boxes of different heights were measured in 50 men and 50 women, evenly distributed over the age range 65–89 years. The differences in isometric strength and leg extensor power over the age range were equivalent to ‘losses’ of 1–2% per annum and ∼ 3½% per annum, respectively. The decline of explosive power was faster than the decline of knee extensor strength in men (p = 0.0001), but not significantly so in women (p = 0.08). Power standardized for body weight influenced chair rise time and step height. Isometric knee extensor strength standardized for body weight influenced chair rise time.
Most muscle stretching studies have focused on defin ing the biomechanical properties of isolated elements of the muscle-tendon unit or on comparing different stretching techniques. We developed an experimental model that was designed to evaluate clinically relevant biomechanical stretching properties in an entire muscle- tendon unit. Our objectives were to characterize the viscoelastic behavior of the muscle-tendon unit and to consider the clinical applications of these viscoelastic properties. Rabbit extensor digitorum longus and tibialis anterior muscle-tendon units were evaluated using methods designed to simulate widely used stretching tech niques. Additionally, the effects of varying stretch rates and of reflex influences were evaluated. We found that muscle-tendon units respond viscoelastically to tensile loads. Reflex activity did not influence the biomechani cal characteristics of the muscle-tendon unit in this model. Experimental techniques simulating cyclic stretching and static stretching resulted in sustained muscle-ten don unit elongations, suggesting that greater flexibility can result if these techniques are used in the clinical setting. With repetitive stretching, we found that after four stretches there was little alteration of the muscle- tendon unit, implying that a minimum number of stretches will lead to most of the elongation in repetitive stretching. Also, greater peak tensions and greater energy absorptions occurred at faster stretch rates, suggesting that the risk of injury in a stretching regimen may be related to the stretch rate, and not to the actual technique. All of these clinically important considera tions can be related to the viscoelastic characteristics of the muscle-tendon unit.
Joint mobility was measured in 1,081 members of a Tswana community in the Western Transvaal, as part of an epidemiological survey of bone and joint conditions. The method, using an assessment of the range of movements of a predetermined set of joints, was easy to carry out and gave reproducible results. Joint mobility diminished with ageing, falling rapidly as childhood progressed, and more slowly throughout adult life. Marked differences were present between the sexes, females having a greater degree of joint laxity than males of the same age. A positive correlation existed between the mobility score and the degree of passive hyperextension which could be achieved by the fifth finger. The range of movements of the fifth finger was greater on the nondominant side in both left and right handed individuals. Arthralgic complaints were positively related to joint laxity in both sexes. Physique, as expressed by ponderal index and metacarpal length, was not found to bear any relation to joint mobility.
The purpose of this study was to describe and compare active range of motion during free-speed gait in younger and older people. Sixty volunteers in good health were studied. Thirty subjects (15 male, 15 female) were between 20 and 40 years of age, and 30 subjects (15 male, 15 female) were between 60 and 80 years of age. Subjects were videotaped walking down a 6-m walkway with reflective markers at six locations along their right side. The videotape was analyzed for nine gait characteristics using a two-dimensional video motion analysis system. Differences in gait characteristics between the two groups were examined using a multivariate analysis of variance, followed by univariate F tests. Two gait variables--knee extension and stride length--were significantly different between groups, and differences in velocity approached significance. For individuals in good health, the gait of older people differs from the walking pattern of young people for selected variables. Older people demonstrate less knee extension and a shorter stride length compared with younger people. Differences in self-paced walking velocity between old and young people may have influenced the gait characteristics measured.
An experimental group of 20 elderly subjects participated in 8 weeks of low-intensity aerobic exercise while 27 subjects in a comparison group maintained their usual level of activity. The program consisted of stretching and strengthening chair exercises. A significant difference between the groups was found for flexibility of the ankles and the right knee. No significant difference was found between the groups for muscle strength or balance, although the experimental group improved their balance by 22%.