Classical Guitar and Playing-Related Musculoskeletal Problems
Stretching—An Important Strategy to Prevent Musculoskeletal Aging
Transcript of Stretching—An Important Strategy to Prevent Musculoskeletal Aging
246 www.topicsingeriatricrehabilitation.com October–December 2014
Topics in Geriatric Rehabilitation • Volume 30 , Number 4 , 246 - 255 • Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
DOI: 10.1097/TGR.0000000000000032
This study aimed to review systematically the available
evidence on the effects of stretching exercise on musculo-
skeletal function of the elderly individuals. The search was
performed in 4 databases. Twenty-four controlled clinical
trials were included and the methodological qualities were
measured using the JADAD scale. Stretching exercise
improved gait speed ( P = .04), range of motion of hip
uniarticular fl exors ( P = .02), and ankle dorsifl exion
( P = .003) as compared with control groups. Stretching
exercise can be considered as an intervention for elderly
individuals in counteracting age-related decline in mobility.
However, it is suggested new randomized clinical trials,
focusing on the parameters to prescribe stretching exercise.
Key words: aging , ankle , elderly , exercise , gait , joint range of
motion , muscle stretching exercise
Stretching—An Important Strategy to Prevent Musculoskeletal Aging A Systematic Review and Meta-analysis
Talita Gianello Gnoato Zotz , MSc ; Ana Paula Cunha Loureiro , MSc ; Silvia Regina Valderramas , PhD ;
Anna Raquel Silveira Gomes , PhD
Studies indicate that stretching exercises can improve yield of sports practices in young adults, 11-13 besides improving work-related musculoskeletal pain in adults, 14 increasing fl exibility and torque in older community, 9 improving the muscle-tendon length and fl exibility, and preventing torque loss in the institutionalized elderly indi-viduals. 10 However, the literature on the effects of stretch-ing exercises presents a lot of variation for its prescription and absence of a control group and randomized trials. 5-10
In this sense, a systematic review with meta-analysis of randomized clinical trials could provide more reliable esti-mates of the effectiveness of stretching exercises. There-fore, a meta-analysis of randomized clinical trials on the effects of muscle stretching exercises in institutionalized and community older adults was carried out. The objective of the study was to review the prescription parameters of muscle-stretching exercises and their effects on gait speed, ROM of hip extensors, uniarticular and biarticular hip fl ex-ors, dorsifl exors, and ROM peak of hip extension.
METHODS
Eligibility criteria Randomized and nonrandomized clinical trials that used a stretching protocol for elderly individuals were included in this study, as compared with no treatment, minimal intervention, and other types of intervention or other types of exercises, which assessed the following outcomes: gait speed, hip extension, hip biarticular fl exors, hip uniar-ticular fl exors, peak hip extension, and ankle dorsifl exion. Studies were published in scientifi c journals between 1963 and 2013 and without restriction on language of publica-tion. The exclusion criteria were as follows: (1) presence of many groups with different stretching protocols, (2) lack of prescription parameters for stretching protocol, (3) lack of control group, and (4) lack of data from the control group.
Search strategy and selection of studies The search was performed and in duplicate, from 1963 to June 2013, through the electronic databases PubMed, Lilacs, Medline, and Cochrane Central Register of Con-trolled Trials (Cochrane CENTRAL). 15 The research was
Reduced fl exibility is due to muscular adaptations leading to adaptive shortening of the muscle-tendon, which can affect mobility and equilibrium,
thus modifying the functional impairments in the elderly individuals. 1-3 Changes in skeletal muscle resulting from the aging process occur both radially (in parallel) as decreased muscle mass and longitudinally (in series), by decreasing the fascicle length of the muscle and pennation angle. 4 Therefore, it has been shown that stretching exer-cises can improve muscle-tendon length, range of motion (ROM), torque, equilibrium, and the functionality in the elderly individuals. 5-10
Author Affi liations: Physical Education Department (Ms Zotz), Internal
Medicine Postgraduate Program and Physiotherapy Department
(Dr Valderramas), Physical Education Postgraduate Program and Physi-
otherapy Department (Dr Gomes), Federal University of Paraná; Physio-
therapy Department, Pontifi cal Catholic University of Paraná (Ms Loureiro),
Curitiba, Paraná, Brazil.
The authors declare that they have no confl icts of interest in the research.
T.G.G.Z. is the recipient of CAPES/REUNI PhD fellowship. A.P.C.L. is the
recipient of CAPES PhD fellowship (Process number BEX: 0590-13-4).
A.R.S.G. is the recipient of productivity fellowship from Conselho Nacional
de Desenvolvimento Científi co e Tecnológico-CNPq (Process number
308696/2012-3).
Correspondence: Talita Gianello Gnoato Zotz, MSc, Federal University
of Parana, Odete Laura Foggiato St, Curitiba - PR, 82630-040, Brazil
( [email protected] ).
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 246TGR-D-14-00024_LR 246 15/10/14 9:05 PM15/10/14 9:05 PM
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 247
performed in June 2013 using the following terms: stretch-ing , elderly , aging , and muscle-stretching exercise. The terms were grouped with combination of the words used in the search for randomized and nonrandomized con-trolled trials. 16
Titles and abstracts of all articles identifi ed by the search strategy were evaluated independently by 2 investigators (T.G.G.Z. and A.P.C.L.), in duplicate. All abstracts that did not provide enough information on inclusion and exclu-sion criteria were selected to review the full text. In the sec-ond step, the same reviewers independently assessed the full-text articles to select those in accordance with the eligi-bility criteria. Differences between reviewers were resolved by consensus.
Data extraction Using standardized forms, the previous reviewers per-formed the data extraction independently, concerning the methodological characteristics of the studies, interven-tions and outcomes as well as differences, which were also resolved by consensus. The outcomes of interest were the following: gait speed, ROM, hip extension, ROM of hip biar-ticular fl exors, ROM of hip uniarticular fl exors, peak hip extension, and ROM of ankle dorsifl exion.
Risk of bias’ assessment and JADAD classifi cation The risk of bias’ assessment was performed by the same independent reviewers (T.G.G.Z. and A.P.C.L.) through the JADAD scale. 17 , 18 For each specifi c result, the evidence quality was based on 5 factors: (1) described as rand-omized, (2) described as double blind, (3) described losses, (4) appropriate randomization, and (5) appropriate mask-ing. The quality was reduced by 1 level for each factor not satisfi ed. The JADAD scale results in 2 levels of evidence and classifi es the study as poor quality (0-2) and high qual-ity (3-5). 18
Data analysis The selected articles were analyzed using the software Comprehensive Meta-analysis version 2.2 (Bio-stat Inc, Englewood, New Jersey).
Only continuous data were considered for analysis. The difference in means and their 95% confi dence intervals were calculated for individual trials, and the standardized mean difference was used as a summary effect size esti-mator. According to the Cohen 19 defi nitions, an effect size of 0.2 was considered small; 0.5, medium; and 0.8, large. The random-effects model was used to assess the mean difference measured in the meta-analysis. To assess the degree of heterogeneity, the I 2 test was also used, which describes the percentage of variation in the estimated effect. A value of more than 50% was indicative of substan-tial heterogeneity. 19
RESULTS
Description of the studies The search resulted in 6.265 possibly relevant titles from all databases, of which 42 studies were considered potentially relevant and selected for further analysis. Twenty-four of these studies involving 1.371 subjects met the eligibility cri-teria and were included in the systematic review. However, only 8 studies totalizing 365 elderly patients were included in the meta-analysis ( Table 1 ). Figure 1 shows the fl owchart of the selected studies.
Bias’ risk From the studies included in the systematic review (n = 42), 61.5% (n = 16) presented adequate randomization, 34.6% (n = 9) presented randomization, 26.9% (n = 7) reported blinding of researchers and patients, 19.2% (n = 5) presented a description of the blinding technique, and 65.3% (n = 18) showed losses in monitoring and exclusions ( Table 2 ).
Gait speed Four studies 7 , 26 , 30 , 31 evaluated the effects of a stretching pro-tocol on gait speed of older adults (n = 193). The analysis of those studies has shown that the stretching exercise resulted in a signifi cant improvement in gait speed when compared with the control group ( P = .04) ( Figure 2 ). According to JADAD classifi cation, 2 studies 30 , 31 from this meta-analysis showed high quality, while the other 2 7 , 26 showed poor quality ( Table 2 ). In addition, the studies included in the meta-analysis used different prescription parameters for stretching exercises; however, despite these differences, all studies have chosen to perform the super-vised static stretching exercise.
Stanziano et al 26 used a stretching protocol consisting of 10 repetitions, held for 5 seconds each time, totaling 50 seconds for each elongated muscle group (shoulder fl exors/abductors/extensors, hip extensors/abductors; lat-eral trunk fl exors; trunk rotators; trunk fl exors; ankle plan-tar fl exor muscles), with closed kinetic chain performed once a day, 2 times a week, for 8 weeks. The 50-foot-gait speed test was used to assess the outcomes.
Cristopoliski et al 7 reported a stretching protocol con-sisting of 4 repetitions of 60 seconds each time for the muscle groups of the hip extensors and dorsifl exors, total-ing 240 seconds for each muscle group, with closed kinetic chain, performed 3 times a week for 12 weeks. The method to assess the gait parameters was videotaped using 4 digital camcorders (JVC, GR-D250).
Watt et al 30 presented the following stretching protocol: 1 set of 4 repetitions of 60 seconds each time, with an inter-val of 60 seconds between each repetition; closed kinetic chain for the single joint hip fl exor muscles, performed
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 247TGR-D-14-00024_LR 247 15/10/14 9:05 PM15/10/14 9:05 PM
248 www.topicsingeriatricrehabilitation.com October–December 2014
TAB
LE 1
Chara
cte
rist
ics
of
the S
tudie
s Fro
m t
he P
rese
nt
Revi
ew
Refe
rences
Stu
dy
Desi
gn
Part
icip
ants
Inte
rvention N
um
ber
of
Part
icip
ants
=
Contr
ol N
um
ber
of
Part
icip
ants
=
Variable
s
Zakas
et al 2
0
Not in
form
ed
22 s
edenta
ry h
ealth
old
wom
en
(Pro
tocol 1)
(Pro
tocol
2)
(Pro
tocol 3)
22
part
icip
ants
fro
m
each g
roup
22
RO
M-g
onio
mete
r: T
runk fl e
xion, fl exi
on o
f th
e h
ip join
t,
ext
ensi
on o
f th
e h
ip join
t, a
bduction o
f th
e h
ip join
t,
knee fl e
xion a
nd a
nkle
dors
ifl e
xion
Gallo
n e
t al 1
0
Not in
form
ed
17 inst
itutionaliz
ed
eld
erly
wom
en
89
Left U
L, B
I, L
ysholm
Scoring S
cale
, is
okin
etic
eva
luation, photo
gra
mm
etr
y
Johnso
n e
t al 2
1
Not in
form
ed
20 h
ealth w
om
en
20
0R
OM
of ankle
fl e
xion
Ferb
er
et al 2
2
Not in
form
ed
26 h
ealthy
old
adults
26
0Ele
ctr
ogonio
mete
r, s
urf
ace E
MG
Kerr
igan e
t al 2
3
Double
-blin
ded,
random
ized,
contr
olle
d trial
96 h
ealthy
eld
erly
indiv
iduals
47
49
RO
M o
f hip
ext
ensi
on, hip
join
t m
ove
ment and L
L
bila
tera
lly d
uring g
ait, gait v
elo
city,
kin
etic a
nd
kin
em
atic g
ait, sp
eed, cadence, st
ep length
, hip
ext
ensi
on torq
ue, R
OM
in p
lanta
r fl exi
on,
pla
nta
rfl e
xion forc
e, ante
vers
ion p
elv
ic
Lust
osa
et al 2
4
Quasi
-exp
erim
enta
l st
udy
25 c
om
munity-
dw
elli
ng
eld
erly
wom
en
13
12
Isokin
etic d
ynam
om
etr
y
Rodacki et al 2
5
Not in
form
ed
15 c
om
munity-
dw
elli
ng
eld
erly
wom
en
15
0K
inem
atics
gait a
naly
sis
Sta
nzi
ano
et al 2
6
Not in
form
ed
17 e
lderly
resi
dents
of a r
esi
dential
retire
ment
com
munity
89
Fle
xibili
ty test
: th
e b
ack-s
cra
tch test
(B
S),
RO
M,
functional perf
orm
ance; knee e
xtensi
on in s
upin
e
test
, to
tal body
rota
tion test
. Str
ength
and p
ow
er
of
LL, U
L s
trength
, core
pow
er
Sw
ank e
t al 2
7
Not in
form
ed
43 h
ealthy
eld
erly
indiv
iduals
32
11
RO
M
Batist
a e
t al 9
Not in
form
ed
12 a
ctive
old
er
wom
en
12
0R
OM
, is
okin
etic torq
ue o
f knee fl e
xors
and e
xtenso
rs
and functional perf
orm
ance
Christ
ianse
n
et al 2
8
Random
ized
contr
olle
d trial.
40 h
ealthy
eld
erly
indiv
iduals
20
20
RO
M; kin
em
atics
analy
sis
of gait, st
ep length
, dis
pla
cem
ent of th
e s
egm
ent.
Crist
opolis
ki
et al 7
Not in
form
ed
20 h
ealthy
old
er
wom
en
12
8Thre
e-d
imensi
onal gait a
naly
sis,
photo
gra
mm
etr
y,
length
of m
usc
le-t
endon r
ectu
s fe
moris
and
pso
as
ilium
Fela
nd e
t al 5
Not in
form
ed
62 indiv
iduals
fro
m a
re
tire
ment house
49
13
RO
M
Gajd
osi
k e
t al 6
Not in
form
ed
19 e
lderly
wom
en
10
9G
ait s
peed, bala
nce, grip s
trength
, EM
G
Gurjão e
t al 2
9
Not in
form
ed
23 e
lderly
wom
en
23
0M
usc
le s
trength
(is
okin
etic)
test
, EM
G
(continues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 248TGR-D-14-00024_LR 248 15/10/14 9:05 PM15/10/14 9:05 PM
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 249
TAB
LE 1
Chara
cte
rist
ics
of
the S
tudie
s Fro
m t
he P
rese
nt
Revi
ew
(Continued )
Refe
rences
Stu
dy
Desi
gn
Part
icip
ants
Inte
rvention N
um
ber
of
Part
icip
ants
=
Contr
ol N
um
ber
of
Part
icip
ants
=
Variable
s
Watt e
t al 3
0
A d
ouble
-blin
ded,
random
ized, con-
trolle
d trial
82 h
ealthy
eld
erly
indiv
iduals
43
39
RO
M e
xtensi
on o
f th
e h
ip join
t, length
of m
usc
le-
tendon r
ectu
s fe
moris
and p
soas
ilium
, dyn
am
ic
peak h
ip e
xtensi
on, peak o
f pelv
ic a
nte
vers
ion,
stride length
, gait s
peed (
3D
gait a
naly
sis)
Watt e
t al 3
1
A d
ouble
-blin
ded,
random
ized, con-
trolle
d trial
74 fra
il eld
erly
indiv
iduals
33
41
Dyn
am
ic p
eak h
ip e
xtensi
on, peak p
elv
ic a
nte
vers
ion,
stride length
, gait s
peed in c
om
fort
able
and fast
st
ep, jo
int ext
ensi
on R
OM
in the h
ip
Burk
e e
t al 3
2
Random
ized c
on-
trolle
d trial
50 w
om
en a
ged 6
5
years
or
old
er
17 (
pro
tocol 1)
17 (
pro
tocol 2)
16
Post
ura
l contr
ol, m
usc
le s
trength
with d
ynam
om
ete
r w
ith R
OM
of LL
Lam
et al 3
3
Sin
gle
-blin
d c
lust
er
random
ized c
on-
trolle
d trial
389 s
ubje
cts
at risk
of
cognitiv
e d
eclin
e171 (
Tai chi)
218 (
stre
tchin
g a
nd
to
nin
g e
xerc
ise)
Pro
gre
ssio
n o
f dem
entia, cognitiv
e s
core
, depre
ssio
n,
dyn
am
ic e
quili
brium
Gallo
et al 3
4
Not in
form
ed
57 e
lderly
wom
en fro
m
com
munity
15 (
pro
tocol 1)
14 (
pro
tocol 2)
14
Functional capacity
(fl e
xibili
ty, coord
ination, agili
ty a
nd
dyn
am
ic b
ala
nce, re
sist
ance o
f m
usc
ula
r st
rength
and a
ero
bic
resi
stance, genera
l fu
nctional In
dex
Pom
perm
aye
r and
Gonçalv
es 3
5
Desc
riptive
ex-
post
-fa
cto
23 h
ealthy
eld
erly
wom
en b
etw
een
60-
and 8
0-y
ear
old
2 g
roups—
num
ber
not
desc
ribed p
er
gro
up
LL F
orc
e, U
L P
ow
er, L
L F
lexi
bili
ty, U
L F
lexi
bili
ty, A
gili
ty/
Equili
brium
, A
ero
bic
s R
esi
stance
Gom
es
et al 3
6
Exp
erim
enta
l analy
ti-
cal
83 e
lderly
indiv
iduals
12 (
pro
tocol 1)
21 (
pro
tocol 2)
15 (
pro
tocol 3)
35
Sys
tem
ic B
P, B
MI, D
ynam
ic B
ala
nce, G
ait Index
(dyn
am
ic g
ait),
musc
le s
trength
Vare
jão e
t al 3
7
Not in
form
ed
69 e
lderly
indiv
iduals
36 (
pro
tocol 1)
33 (
pro
tocol 2)
RO
M (
cerv
ical sp
ine r
ota
tion, horizo
nta
l fl exi
on o
f th
e
should
er, h
orizo
nta
l ext
ensi
on o
f th
e s
hould
er
join
t,
fl exi
on o
f th
e s
hould
er
join
t, fl e
xion o
f th
e lum
bar
spin
e, fl exi
on o
f th
e h
ip join
t, fl e
xion o
f th
e k
nee),
Functional A
ssess
ment of daily
liv
ing a
ctivi
ties
(gait s
peed, equili
brium
, fu
nctional perf
orm
ance)
quest
ionnaire W
HO
QL-1
00.
Halle
gra
eff
et al 3
8
A r
andom
ized trial
with c
onceale
d a
l-lo
cation a
nd
inte
ntion-t
o-t
reat
analy
sis
N =
80 e
lderly
indiv
id-
uals
with n
octu
rnal
pain
s in
the L
L, and
cra
mps
N =
40 P
resl
eep
stre
tchin
g; M
ain
tain
usu
al activi
ties
N =
40
BM
I, D
aily
phys
ical activi
ty (
pedom
ete
r), Str
ength
and
LL F
unctionalit
y, n
ight cra
mps,
seve
rity
of cra
mps
(VA
S)
Abbre
viations:
BI, B
art
hel in
dex;
BM
I, b
ody
mass
index;
BP, blo
od p
ress
ure
; EM
G, ele
ctr
om
yogra
phy;
LL, lo
wer
limb; R
OM
, ra
nge o
f m
otion; U
L, upper
limb; VA
S, vi
sual analo
g s
cale
; W
HO
QL, W
orld H
ealth O
rganiz
ation
qualit
y of lif
e a
ssess
ment in
stru
ment.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 249TGR-D-14-00024_LR 249 15/10/14 9:05 PM15/10/14 9:05 PM
250 www.topicsingeriatricrehabilitation.com October–December 2014
daily, for 10 weeks. The gait assessment’s method used was a VICON system. In another study, these authors 31 used the same stretching protocol for the same muscle group and outcome method; however, the study was performed with frail elderly individuals in the community.
RANGE OF MOTION
ROM of hip extension Two studies 7 , 23 evaluated the ROM of hip extension (n = 116). It can be observed that the stretching exercise did not favor intervention groups ( P = 0.26) ( Figure 3 ). According to the JADAD classifi cation, one study showed high qual-ity 23 while other presented poor quality. 7 In the study reported by Kerrigan et al, 23 the exercise prescription was characterized by the absence of supervision, that is, the individuals were trained by a professional and made the stretching protocol at home without supervision. The active static stretching protocol prescribed in this study was 1 set of 4 repetitions of 30 seconds each time at inter-vals of 30 seconds between each repetition; closed kinetic
chain, held twice a week for 8 weeks for uniarticular fl exor hip. ROM of hip fl exion was measured with a goniometer. Cristopoliski et al 7 used the supervised passive static stretching for the hip fl exor muscles with 1 set of 4 repeti-tions of 60 seconds each time, and 60-second interval between each repetition; closed kinetic chain 3 times a week for 4 weeks.
ROM of hip biarticular fl exors and ROM of hip uniarticular fl exors All articles 7 , 10 of this meta-analysis evaluated the ROM of hip biarticular fl exors (n = 37), and no statistical signifi cance was observed ( P = 0.14) ( Figure 4 ). However, a statistical signifi cance was found for the ROM of hip biarticular fl exors in the stretching group ( P = .02) ( Figure 5 ). Both studies were classifi ed as poor quality according to the JADAD quality rating scale.
Gallon et al 10 evaluated the effect of the supervised active static stretching on the ROM of hip fl exors using the follow-ing stretching protocol: 1 set of 4 repetitions of 60 seconds each time, with a 60-second interval between each repetition;
Figure 1. Steps performed in the selection process and reasons for exclusion .
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 250TGR-D-14-00024_LR 250 15/10/14 9:05 PM15/10/14 9:05 PM
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 251
Figure 2. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 4 studies demonstrating the difference between the control and stretching groups.
TABLE 2 Bias’ Risk for the Included Studies and JADAD Classifi cation
References Randomization
Description of Randomization
Method Blinding
Description of Blinding
MethodDescription of Losses
JADAD Classifi cation
Zakas et al 20 Yes No No No Yes Poor quality
Gallon et al 10 Yes No No No Yes Poor quality
Johnson et al 21 No No No No Yes Poor quality
Ferber et al 22 No No No No No Poor quality
Kerrigan et al 23 Yes Yes Yes Yes Yes High quality
Lustosa et al 24 Yes No No No Yes Poor quality
Rodacki et al 25 No No No No No Poor quality
Stanziano et al 26 Yes No No No No Poor quality
Swank et al 27 No No No No Yes Poor quality
Batista et al 9 No No No No Yes Poor quality
Christiansen et al 28 Yes Yes Yes Yes Yes High quality
Cristopoliski et al 7 Yes No No No Yes Poor quality
Feland et al 5 Yes Yes No No Yes High quality
Gajdosik et al 6 Yes Yes No No Yes High quality
Gurjão et al 29 No No Yes No Yes Poor quality
Watt et al 30 Yes Yes Yes Yes Yes High quality
Watt et al 31 Yes Yes Yes Yes Yes High quality
Burke et al 32 Yes Yes No No Yes High quality
Lam et al 33 Yes Yes Yes Yes Yes High quality
Gallo et al 34 No No No No No Poor quality
Pompermayer and Gonçalvez 35 No No No No No Poor quality
Gomes et al 36 Yes No No No Yes Poor quality
Varejão et al 37 No No No No No Poor quality
Hallegraeff et al 38 Yes Yes Yes No Yes High quality
closed kinetic chain, 3 times per week for 8 weeks. Before the stretching exercises, ludic activities were performed for 10 minutes to warm up. The outcomes muscle-tendon length of uni- and biarticular hip fl exors and hamstring fl ex-ibility were assessed by a photogrammetric method.
Cristopoliski et al 7 used the supervised passive static stretching for the hip fl exors, with a set of 4 repetitions of 60 seconds each time, and 60-second interval between each repetition; closed kinetic chain 3 times a week for 4 weeks. Thus, it appears that the stretching technique
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 251TGR-D-14-00024_LR 251 15/10/14 9:05 PM15/10/14 9:05 PM
252 www.topicsingeriatricrehabilitation.com October–December 2014
was similar for all studies, differing only as to the execution mode, active or passive.
Although the prescription parameters of the stretch-ing protocol were the same for both studies, the study of Gallon et al 10 lasted for more than 4 weeks after the study of Cristopoliski et al. 7
ROM peak of hip extension All the articles 30 , 31 of this meta-analysis evaluated the ROM peak of hip extension (n = 156), and no statistical signifi -cance was observed between them ( P = 0.36). The studies showed high quality according to JADAD classifi cation. The limitation parameters of these studies have been cited earlier in the Gait speed outcome. It is noteworthy that the exercises from both studies were supervised for static active stretching ( Figure 6 ).
ROM of ankle dorsifl exion The articles selected 6 , 28 for the meta-analysis evaluated the ROM of dorsifl exion (n = 59) and presented statistical sig-nifi cance for the stretching group ( P = .003) ( Figure 7 ). Christiansen et al 28 observed the effect of the unsuper-vised active static stretching on the ROM of dorsifl exors using the following prescription parameters: a set of 3 rep-etitions of 45 seconds each time, at intervals of 45 seconds between each repetition; closed kinetic chain, performed 2 times a day, every day for 8 weeks. The muscle groups elongated in that study were plantar fl exors and uniarticu-lar hip fl exors. In contrast, Gajdosik et al 6 used a stretching apparatus in which only the right heel could be elongated,
using a set of 10 repetitions of 15 seconds each time. The exercises were supervised static passive stretching, in closed kinetic chain 3 times a week for 8 weeks, and the interval between the repetitions was not reported by the authors.
DISCUSSION In this systematic review, it was found that the stretching exercise was associated with signifi cant improvement in ROM of the uniarticular hip fl exors and dorsifl exors and gait speed in elderly individuals. However, the increase in these outcomes was induced when the muscle-stretching protocol was performed for at least 4 weeks. It is notewor-thy that all studies in the meta-analysis were carried out in closed kinetic chain.
The closed kinetic chain induces co-contraction of the agonist and antagonist muscle groups. 39 Thus, when stretching exercise is performed in closed kinetic chain, it can change the passive elastic components contributing to increase the skeletal muscle-tendon length and joint ROM. 22 , 40
It has been reported that the decrease in musculoten-dinous stiffness induced by the acute effect of a single stretching session may return to baseline within 20 min-utes. 41 Therefore, with respect to the regularity of the stretching exercises, American College of Sports Medicine (ACSM) has recommended between 2 and 3 times per week for increasing fl exibility, while 5 and 1 time per week is recommended for more signifi cant gains and muscle maintenance, respectively. 42
Figure 3. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 2 studies demonstrating the difference between the control and stretching groups.
Figure 4. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 2 studies demonstrating the difference between the control and stretching groups.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 252TGR-D-14-00024_LR 252 15/10/14 9:05 PM15/10/14 9:05 PM
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 253
Statistically signifi cant difference was observed in this meta-analysis with regard to the increased ROM of dorsi-fl exion, due to the regular practice of stretching exercises for 8 weeks in elderly individuals. 6 , 28 Gajdosik et al 6 pre-scribed passive stretching, performed using an isokinetic dynamometer (5 per second) 1 time a day, with a set of 10 repetitions for 15 second each, performed 3 times per week. In the study of Christiansen, 28 the static stretching protocol in closed kinetic chain consisted of 3 repetitions of 45 seconds each, 2 times a day, every day.
The increase in dorsifl exion ROM observed by Gajdosik et al 6 and Christiansen 28 has confi rmed the rec-ommended frequency by ACSM between 2 and 3 times a week. 42 With respect to the number of times the stretch-ing protocol should be done in a day, the effect of stretch-ing exercises on 1 or 3 times per day in young adults has been reported, and no statistically signifi cant difference was detected when the daily frequency was increased. 43 Therefore, further studies are necessary to investigate the effects of stretching protocols performed in different daily frequencies to elucidate this prescription parameter.
The ACSM 42 recommends that physical exercise is nec-essary to improve and maintain health of the elderly pop-ulation, with activities that include aerobic exercises, and strength, fl exibility, and equilibrium training. Evidences for prescribing muscle stretching exercises recommended to gain fl exibility, have 3 to 4 repetitions, with duration between 30 and 60 seconds of each repetition.
In the case of elderly people, an important issue that should be noted is the functional performance, particu-larly gait, 28 which declines with age, increasing the risk of falls. 44
This meta-analysis shows an improvement in gait as a favorable outcome to the stretching protocols. 7 , 26 , 30 , 31 Stanziano et al 26 prescribed a stretching protocol consist-ing of 10 repetitions, lasting 4 to 5 seconds each, and held in 10 different muscle groups, twice a week for 8 weeks. These authors observed an increase in not only ROM but also in the mobility and functionality of elderly living in a residential retirement community. Cristopoliski et al 7 also found an improvement in gait parameters in elderly community after prescription of unsupervised stretching
Figure 5. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 2 studies demonstrating the difference between the control and stretching groups.
Figure 6. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 2 studies demonstrating the difference between the control and stretching groups.
Figure 7. Forest plot (meta-analysis, random-effects model) of standard difference in means and 95% confi dence intervals, for 2 studies demonstrating the difference between the control and stretching groups.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 253TGR-D-14-00024_LR 253 15/10/14 9:05 PM15/10/14 9:05 PM
254 www.topicsingeriatricrehabilitation.com October–December 2014
protocol consisting of 3 repetitions with 45-second dura-tion each, twice a day for 8 weeks. Thus, we suggest studies to verify the duration of the effect of stretching program on gait when acute and chronic protocols are performed as well as the detraining effects.
Costa et al 45 reported the effects of stretching exercises on the major muscle groups of the lower limbs, performed 2 times a week for 12 weeks, and analyzed the detraining effects. The stretching increased hip fl exion and main-tained it after detraining. However, when stretching was associated to resistive training, it increased hip extension after 6 and 12 weeks and maintained after detraining. The authors concluded that although resistive exercise or stretching, performed alone, was suffi cient to increase ROM, the stretching exercise was determinant in an early gain and its maintenance.
The improved gait can be due to the changes in the movement of the pelvis during gait induced by the muscle-stretching exercise in the hip and ankle region 7 together with the increase of ROM of both uniarticular hip 7 , 10 and ankle dorsifl exors. 6 , 28
Batista et al 9 found that muscle stretching performed in an elderly community, using a protocol of 7 repeti-tions 1 minute each, twice a week for 4 weeks increased 45% ROM of knee fl exors and improved functional mobil-ity in older women. Likewise, Christiansen 28 found that muscle stretching also held twice a week in elderly com-munity with 3 repetitions of 45 seconds each, for 8 weeks increased by 11% ROM of dorsifl exion, besides an increase in gait speed. Comparing the outcomes of these studies, it is found that when the stretching exercise carried out for just 4 weeks only 2 times a week was enough to increase ROM and functionality.
According to Soucie et al, 46 aging reduces ROM of joints, and both ROM of hip extension and dorsifl exion suffer a reduction of 7.7% and 15.9%, respectively, which under-mines the proper execution of the gait walk analysis. Thus, as explained by the meta-analysis of this systematic review, the muscle stretching performed in elderly individuals statically supervised at least 2 times a week demonstrated positive effects on gains of ROM of uniarticular hip fl exors and dorsifl exors from 4 weeks protocol.
It is found that the prescription parameters of stretch-ing exercises for elderly people and the evaluation of their effects are not standardized. Thus, further studies are needed, using similar prescription parameters and evalua-tion of outcomes for comparison purposes.
Strengths and limitations of the review A systematic review with meta-analysis was performed, because this type of study can provide more reliable esti-mates of treatment effectiveness than individual tests due to its greater statistical power. 47 However, differences in prescription parameters of stretching exercises used in the
studies, as well as the methods for analyzing the outcomes, have limited the results.
In the systematic review, many studies were method-ologically limited by the degree of bias. Only 5 studies clearly described the blinding technique (patients and therapists). 23,28,30,31,33 In addition, only 9 studies 5 , 6 , 23 , 28 , 30-33 , 38 described the randomization method, which has limited the systematic review with meta-analysis.
CONCLUSIONS This systematic review with meta-analysis suggests that mus-cle-stretching exercise for older people improves both gait speed and ROM of the hip fl exors and dorsifl exors, which can be considered as an intervention for the elderly indi-viduals. However, the methodological quality of the arti-cles suggests that further randomized controlled trials are needed on this subject, with special focus on the prescrip-tion parameters of stretching exercises. Studies should be planned with greater methodological rigor, higher number of individuals, and better-detailed prescription parameters.
REFERENCES 1. Nonaka H , Mita K , Watakabe M , et al. Age-related changes in the
interactive mobility of the hip and knee joints: a geometrical analysis . Gait Posture . 2002 ; 15 ( 3 ): 236-243 .
2. Klein D , Stone WJ , Phillips WT , Gangi J , Hartmam S . PNF training and physical function in assisted-living old adults . J Aging Phys Activity . 2002 ; 81 : 1206-1214 .
3. Holland GJ , Tanaka K , Shigematsu R , Nakagaichi M . Flexibility and physical functions of older adults: a review . Aging Phys Activity . 2002 ; 10 : 169-206 .
4. Narici MV , Maganaris CN . Plasticity of the muscle-tendon com-plex with disuse and aging . Exerc Sport Sci Rev . 2007 ; 35 ( 3 ): 126-134 .
5. Feland JB , Myrer JW , Schulthies SS , Fellingham GW , Measom GW . The effect of duration of stretching of the hamstring mus-cle group for increasing range of motion in people aged 65 years or older . Phys Ther . 2001 ; 81 ( 5 ): 1110-1117 .
6. Gajdosik RL , Vander Linden DW , Mcnair PJ , Williams AK , Riggin TJ . Effects of an eight-week stretching program on the passive-elastic properties and function of the calf muscles of older women . Clin Biomech (Bristol, Avon) . 2005 ; 20 ( 9 ) 973-983 .
7. Cristopoliski F , Barela JA , Leite N , Fowler NE , Rodacki AL . Stretch-ing exercise program improves gait in the elderly . Gerontology . 2009 ; 55 ( 6 ): 614-620 .
8. Bird ML , Hill K , Ball M , Williams AD . Effects of resistance- and fl exibility-exercise interventions on balance and related meas-ures in older adults . J Aging Phys Act . 2009 ; 17 ( 4 ): 444-454 .
9. Batista LH , Vilar AC , De Almeida Ferreira JJ , Rebelatto JR , Salvini TF . Active stretching improves fl exibility, joint torque, and func-tional mobility in older women . Am J Phys Med Rehabil . 2009 ; 88 ( 10 ): 815-822 .
10. Gallon D , Rodacki AL , Hernandez SG , et al. The effects of stretching on the fl exibility, muscle performance and function-ality of institutionalized older women . Braz J Med Biol Res . 2011 ; 44 ( 3 ): 229-235 .
11. Shier I . Does stretching improve performance? A systematic and critical review of the literature . Clin J Sport Med. 2004 ; 14 ( 5 ): 267-273 .
12. Kokkonen J , Nelson AG , Eldredge C , Winchester JB . Chronic static stretching improves exercise performance . Med Sci Sports Exerc . 2007 ; 39 ( 10 ): 1825-1831 .
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 254TGR-D-14-00024_LR 254 15/10/14 9:05 PM15/10/14 9:05 PM
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 255
13. Ferreira GN , Teixeira-Salmela LF , Guimarães CQ . Gains in fl ex-ibility related to measures of muscular performance: impact of fl exibility on muscular performance . Clin J Sport Med . 2007 ; 17 ( 4 ): 276-281 .
14. Marangoni AH . Effects of intermittent stretching exercises at work on musculoskeletal pain associated with the use of a per-sonal computer and the infl uence of media on outcomes . Work . 2010 ; 36 ( 1 ): 27-37 .
15. Moseley AM , Sherrington C , Elkins MR , Herbert RD , Maher CG . Indexing of randomised controlled trials of physiotherapy interventions: a comparison of AMED, CENTRAL, CINAHL, EMBASE, hooked on evidence, PEDro, PsycINFO and PubMed . Physiotherapy . 2009 ; 95 ( 3 ): 151-156 .
16. Robinson K , Dickersin K . Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed . Int J Epidemiol . 2002 ; 1 ( 31 ): 150-153 .
17. Clark HD , Wells GA , Huët C , et al. Assessing the quality of ran-domized trials: reliability of the Jadad scale . Control Clin Trials . 1999 ; 20 ( 5 ): 448-452 .
18. Jadad AR , Moore RA , Carroll D , et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary ? Con-trol Clin Trials . 1996 ; 17 ( 1 ): 1-12 .
19. Cohen J . Power Analysis for the Behavioral Sciences . 2nd ed. New York, NY: Academic Press ; 1988 .
20. Zakas A , Doganis G , Zakas N , Vergou A . Acute effects of active warm-up and stretching on the fl exibility of elderly women . J Sports Med Phys Fitness . 2006 ; 46 ( 4 ): 617-622 .
21. Johnson E , Bradley B , Witkowski K , et al. Effect of a static calf muscle-tendon unit stretching program on ankle dorsifl exion range of motion of older women . J Geriatr Phys Ther . 2007 ; 30 ( 2 ): 49-52 .
22. Ferber R , Osternig L , Gravelle D . Effect of PNF stretch tech-niques on knee fl exor muscle EMG activity in older adults . J Electromyogr Kinesiol . 2002 ; 12 ( 5 ): 391-397 .
23. Kerrigan DC , XenopouloS-Oddsson A , Sullivan MJ , Lelas JJ , Riley PO . Effect of a hip fl exor-stretching program on gait in the elderly . Arch Phys Med Rehabil . 2003 ; 84 ( 1 ): 1-6 .
24. Lustosa LP , Pacheco MG , Liu AL , Gonçalves WS , Silva JP , Pereira LS . Impact of static stretching on the gain in knee-exten-sor strength of community-dwelling older women after a train-ing program . Rev Bras Fisioter . 2010 ; 14 ( 6 ): 497-502 .
25. Rodacki AL , Souza RM , Ugrinowitsch C , Cristopoliski F , Fowler NE . Transient effects of stretching exercises on gait parameters of elderly women . Man Ther . 2009 ; 14 ( 2 ): 167-172 .
26. Stanziano DC , Roos BA , Perry AC , Lai S , Signorile JF . The effects of an active-assisted stretching program on functional perfor-mance in elderly persons: a pilot study . Clin Interv Aging . 2009 ; 4 : 115-120 .
27. Swank AM , Funk DC , Durham MP , Roberts S . Adding weights to stretching exercise increases passive range of motion for healthy elderly . J Strength Cond Res . 2003 ; 17 ( 2 ): 374-378 .
28. Christiansen CL . The effects of hip and ankle stretching on gait function of older people . Arch Phys Med Rehabil . 2008 ; 89 ( 8 ): 1421-1428 .
29. Gurjão AL , Gonçalves R , De Moura RF , Gobbi S . Acute effect of static stretching on rate of force development and maximal vol-untary contraction in older women . J Strength Cond Res . 2009 ; 23 ( 7 ): 2149-2154 .
30. Watt JR , Jackson K , Franz JR , Dicharry J , Evans J , Kerrigan DC . Effect of a supervised hip fl exor stretching program on gait in elderly individuals . PM R . 2011 ; 3 ( 4 ): 324-329 .
31. Watt JR , Jackson K , Franz JR , Dicharry J , Evans J , Kerrigan DC . Effect of a supervised hip fl exor stretching program on gait in frail elderly patients . PM R . 2011 ; 3 ( 4 ): 330-335 .
32. Burke TN , França FJ , Meneses SR , Pereira RM , Marques AP . Pos-tural control in elderly women with osteoporosis: comparison of balance, strengthening and stretching exercises. A rand-omized controlled trial . Clin Rehabil. 2012 ; 26 ( 11 ): 1021-1031 .
33. Lam LC , Chau RC , Wong BM , et al. A 1-year randomized con-trolled trial comparing mind body exercise (Tai Chi) with stretching and toning exercise on cognitive function in older Chinese adults at risk of cognitive decline . J Am Med Dir Assoc . 2012 ; 13 ( 6 ): 568.e15-e20 .
34. Gallo LH , Gonçalves R , Gurjão ALD , et al. Effect of different stretching volumes on functional capacity in elderly women . Rev Bras Cineantropom Desempenho Hum . 2013 ; 15 ( 1 ): 103-112 .
35. Pompermayer MG , Gonçalves AK . Relação entre capacidades motoras de idosas praticantes de hidroginástica e alongamento . Estud Interdiscipl Envelhec. 2011 ; 16 : 473-484 .
36. Gomes ARS , Wischneski P , Rox R . Whether or not to affi liate stretching with resistance training to improve equilibrium in the elderly . Act Fisiatr . 2011 ; 18 ( 3) : 130-135 .
37. Varejão RV , Dantas EHM , Matsudo SMM . Comparação dos efei-tos do alongamento e do fl exionamento, ambos passivos, sobre os níveis de fl exibilidade, capacidade funcional e qualidade de vida do idoso . R Bras Ci e Mov . 2007 ; 15 ( 2 ): 87-95 .
38. Hallegraeff JM , Van Der Schans CP , De Ruiter R , De Greef MH . Stretching before sleep reduces the frequency and severity of nocturnal leg cramps in older adults: a randomised trial . J Phys-iother . 2012 ; 58 ( 1 ): 17-22 .
39. Karandikar N , Vargas OO . Kinetic chains: a review of the con-cept and its clinical applications . PM R . 2011 ; 3 ( 8 ): 739-745 .
40. Gajdosik RL , Vander Linden DW , MCnair PJ , et al. Slow passive stretch and release characteristics of the calf muscles of older women with limited dorsifl exion range of motion . Clin Bio-mech (Bristol, Avon) . 2004 ; 19 ( 4 ): 398-406 .
41. Ryan ED , Beck TW , Herda TJ , et al. The time course of muscu-lotendinous stiffness responses following different durations of passive stretching . J Orthop Sports Phys Ther. 2008 ; 38 ( 10 ): 632-639 .
42. Garber CE , Blissmer B , Deschenes MR , et al. American College of Sports Medicine position stand. Quantity and quality of exer-cise for developing and maintaining cardiorespiratory, muscu-loskeletal, and neuromotor fi tness in apparently healthy adults: guidance for prescribing exercise . Med Sci Sports Exerc . 2011 ; 43 ( 7 ): 1334-1359 .
43. Bandy WD , Irion JM , Briggler M . The effect of time and fre-quency of static stretching on fl exibility of the hamstring mus-cles . Phys Ther . 1997 ; 77 ( 10 ): 1090-1096 .
44. Studenski S , Perera S , Patel K , et al. Gait speed and survival in older adults . JAMA . 2011 ; 305 ( 1 ): 50-58 .
45. Costa TC , Locks RR , Koppe S , Yamaguti AM , Formiga A , Gomes ARS . Strength and stretching training and detraining on fl exibil-ity of elderly . Top Geriatr Rehabil . 2013 ; 29 : 142-148 .
46. Soucie JM , Wang C , Forsyth A , et al. Range of motion measure-ments: reference values and a database for comparison studies . Haemophilia . 2011 ; 17 ( 3 ): 500-507 .
47. Plentz RD , Sbruzzi G , Ribeiro RA , Ferreira JB , Dal Lago P . Inspiratory muscle training in patients with heart failure: meta-analysis of randomized trials . Arq Bras Cardiol . 2012 ; 99 ( 2 ): 762-771 .
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00024_LR 255TGR-D-14-00024_LR 255 15/10/14 9:05 PM15/10/14 9:05 PM