Table 1: Table-Flexibility training studies examining the relationship between flexibility and functional abilities in older adults.

Publication
country/study
type
ObjectivePopulationMethodsOutcomesComments and conclusionsQuality

Barrett and Smerdely,
2002 [9].
Australia.
RCT (single-blinded, assessor).
Focus
Major muscle groups.
To determine whether a resistance training program could improve strength, mobility, and quality of life of community-dwelling elderly people
versus flexibility control group.
.  
Age: 67 yr.
10 males, 30 females.  
Experimental
.  
Age: 64 3 yr.
5 male, 15 female.
Control
Age: 70 3 yr.
5 male, 15 female.
Inclusion criteria
>60 yr, healthy.
Prepost 10 wks.
Both groups attended class 1 hr, twice wk−1, 10 wks.
Intervention
5 min warm-up including stretching, 8–10 resistance exercises (~45 min) with free weights for both upper and lower limbs, followed by 5 min of stretching.
Control
Stretching of major muscle groups (25 min) light cardiovascular (20 min) and low intensity strengthening (15 min).
Assessment
Isometric strength bilaterally with hand dynamometer: biceps, quads; time to stand and sit 5 times for leg strength.
Balance: Functional reach test and step test.
Quality of Life: SF36 Health. Survey self-reported.
Analysis
Independent sample t-tests.
Gender: Chi-square tests.
Bonferroni adjustment.
Progressive resistance training group improved significantly in all physical measurements.   
Flexibility group improved significantly in sit-to-stand (9.6% from 10.2 to 9.2 s) and step test (23.5% from 17 to 20 steps) only.
Progressive resistance training had a greater effect than flexibility training on quadriceps strength, left biceps strength, functional reach test and step test.
Neither group improved significantly in any subscale of quality of life.
Progressive high intensity resistance training produces greater strength, balance, and gait improvements than a nonspecific flexibility group.13/18

Klein et al. 2002 [10].
USA.
Prospective two-stage intervention.
Focus
Major muscle groups.
To examine the impact of PNF on physical function in an assisted-
living population by assessing ROM and isometric strength.
.  
Age: 87 6.5 yr.
Male = 2.
Female = 12.
Inclusion criteria
≥65 yr, no neurological or cognitive impairments, resting BP < 160/100 mmHg, no limiting cardiorespiratory condition or recent surgery
Living in assisted-living facility, frail.
Baseline (T1), pretraining (T2, 5 wks), posttraining (T3, 10 wks).
Pre-training
1 wk−1 visit with trainer to increase rapport and interest in participation.
Training program
40–60 min, 2 wk−1Warm-up, cool down, and flexibility (single set 15–20 min, later 2-3 sets)
Flexibility: 8 exercises using passive contract-relax PNF technique (6 s isometric contraction then passive stretch held for 20 s then 20 s rest). Hamstrings, gluteals, shins, calves and back).
Assessments
Isometric strength (dynamometer), flexibility (bubble inclinometer for shoulders, hips, and ankles, sit-and-reach for spine, functional-reach for shoulder).
Mobility: get-up-and-go test, 5-sit-to-stand.
Analysis
Listwise repeated measures, univariate ANOVA, paired t-tests, and Bonferroni adjustment
  
Statistically significant differences in 6 of 18 variables:
sit-to-stand decreased significantly from 9.33 to 7.91 s ( ).
No change in balance, get up and go, single leg stand.
Ankle-flexion ROM decreased (improved) from 26.25 to 20.27° ( ).
Shoulder-flexion ROM increased from 163.8 to 177.6° ( )
No change in hip flexion, hip extension, ankle extension, functional reach, and sit-and-reach.
Significant increases in strength for hip extension and ankle flexion/extension.
No change in hip flexion, shoulder extension, and shoulder flexion strength
PNF flexibility training can improve ROM, isometric strength, and selected physical-function tasks in assisted-living older adults. Because the training period was short, 10 weeks, the results suggest that continued training might have a greater impact on physical function and the ability to perform routine daily activities.13/18

Brown et al. 2000 [11].
USA.
RCT.
Focus
Major muscle groups.
To examine effects of low-intensity exercise on factors associated with frailty (gait, flexibility, strength, balance, sensation, response time, and coordination)
versus flexibility control group.
.  
Age: 83 4 yr.
Experimental group (exer)
.  
Male = 20,
Female = 28.
Age: 83 4 yr. Control group (home)
.  
Male = 17,
female = 22.
Age: 83 4 yr.
Characteristics
Sedentary, over 78 yrs, living independently but with difficulty.
Inclusion criteria
Medical screening, physical performance test (PPT) for frailty: 17 < score < 32.
Pre-post 3 mo
Intervention
exer
22 low intensity strength and flexibility exercise for upper and lower body
3x/week for total of 36 sessions ( 3 mo)
HOME
9 upper and lower body flexibility exercises.
Conducted at home (self-report), option to participate on site 1 wk−1.
Assessments
Strength: physical performance test, isokinetic dynamometer (knee flexors/extensors, ankle flexors/extensors), and hand-held dynamometer (upper extremities)
ROM: goniometry (shoulders, hips, knees, ankles, and trunk).
Balance: static (Romberg test), dynamic (balance bean, obstacle course, and gait speed), and weight-shift (Berg balance test).
Gait: pressure-sensitive foot switches.
Coordination: Purdue peg board.
Speed of response: red light to green light, stepping on brake and gas pedals.
Sensation: Semmes-Weinstein monofilaments.
Analysis
2 2 ANOVA; paired t-tests for EXER group
only
Physical performance test  
Significant improvements in PPT scores from 29 4 to 31 4; unchanged in control group); improvements were in chair rise, putting on/taking off coat, picking up penny, and Romberg test.
Strength
Significant increases in knee flexor and extensor strength (9% change versus−1% in control) and shoulder abductors.
Range of motion
Flexibility increased in all measurements and in both groups.
Balance
Significant improvements in EXER group for obstacle course, full-tandem of Romberg, Berg balance test, and one-limb standing time. No significant changes in control group
Gait
Significant change in preferred walking cadence in EXER group.
Coordination
Difference between groups was “almost significant.”
Response time
Unchanged in both groups.
Sensation
No apparent differences.
The control group lost a small amount of strength and balance in just 3 months, even though flexibility improved.
These results suggest that the more comprehensive the exercise intervention, the greater the likely scope of improvement in frailty.
14/24

King et al. 2000 [12].  
USA.
RCT.
Focus
Major muscle groups.
To evaluate the effects of two different community-
based physical activity regimens—on one year physical performance outcomes, perceived functioning and well-being in a sample of community-dwelling, sedentary women and men.
  
Age: 70 4 yr
Males = 36, females = 67
Inclusion criteria
>65 yrs, absence of cardiovascular disease or stroke, regularly active no more than 2x/week during the preceding 6 mo, free of musculoskeletal problems that would prevent participation in moderate levels of physical activity.
Pre-post 12 month, 6 month interim assessment  
2 exercise classes/week and home exercise at least 2 wk−1.
Classes one hour, home exercise built up to 40 min sessions.
Experimental group (fit and firm)
Progressive moderate-intensity endurance and strengthening exercises.
5–10 min warm-up, 40–45 min aerobic and strength training circuit, 5–10 min cool-down; target heart rate 60–75% HRR.
Control group (stretch and flex)
Stretching and flexibility exercises.
5–10 min warm-up, 40 min stretching section, 5–10 min relaxation exercises.
Stretching for neck, shoulders, back, chest, waist, hamstrings, calves, and hands.
Assessments
Functional capacity/endurance: Graded treadmill exercise test (GXT).
Strength and flexibility: upper body strength (lift and reach task), lower body strength (sit to stand), and flexibility (sit and reach w/Accuflex 1 sit and reach box.
Self-rated physical performance: a self-efficacy questionnaire.
Perceived functioning and well-being: scales from the Medical Outcomes Study (MOS) incl. physical functioning, bodily pain, emotional well-being,
(values reported separately for men and women for each group).  
Functional capacity/endurance Submax HR: Fit & Firm had significantly greater improvement versus Stretch & Flex
Strength and flexibility
Lift and reach task: Fit & Firm had significantly greater upper body strength than Stretch & Flex.
Sit-to-stand: No significant results.
Sit-and-reach: Men assigned to Stretch & Flex had significantly greater increases than men in Fit & Firm. No statistical difference in women, but trend for greater improvement for women in Fit & Firm versus. Stretch & Flex. Women in Fit & Firm had significantly greater increases in flexibility at 12 mo than men.
Self-rated physical performance
Significantly greater increases in walking distance and self-efficacy for heavy lifting in Fit & Firm than in Stretch & Flex.
Perceived functioning and well-being
Only pain scale had significantly greater effects for Stretch & Flex (also statistically significant within group) than Fit & Firm.
Community-based physical activity regimens focusing on moderate-intensity endurance and strengthening exercises or flexibility exercises can be delivered through a combination of formats that result in improvements in important functional and quality of life outcomes.21/24
energy/fatigue, sleep problems, sense of mastery, and self-esteem.
Analysis  
ANOVA, ANCOVA, MANCOVA, Tukey’s studentized range test, and least-squares means procedure.

Lazowski et al. 1999 [13].   
Canada.
RCT.
Focus
Major muscle groups.
To evaluate group exercise programs in long-term care
versus. flexibility control group.
.  
Age: 80 0.9 yr.
11 male, 57 female.  
Functional Fitness for long-term care program
(FFLTC) group
.  
7 male, 29 female.
Range of motion(ROM) group
.  
2 male, 30 female.
Residents of five long-term care institutions (>3 month)
Inclusion criteria
No recent cardiovascular events, uncontrolled high BP, recent fracture, total blindness, or deafness.
Ability to stand with minimal assistance. Walking devices and wheelchairs allowed.
Pre-post 4 mo  
Intervention   FFLTC group
45 min, 3 wk−1
warm up/stretching (5 min), walking (15 min), progressive upper and lower body strengthening (10 min), balance, and cool down stretching (5 min).
Control group  
Seated range of motion group
vocal exercises, word/memory games, range of motion exercises (fingers, hands, arms, knees, ankles), and relaxation exercises.  
Assessments
Mobility-timed up-and-go (TUG).
Functional balance-Berg Scale.
Stair climbing power.
Functional ability-functional independence measure (FIM).
Flexibility-Modified sit and reach test. shoulder flexion.
Isometric strength: elbow flexion, shoulder abduction, knee extension, hip abduction/adduction.
grip strength.
Isotonic Strength: knee extensors.
86% and 79% compliance
ROM scored lower on several measures at baseline.
Considerable variability within all conditions on all measures.
FFLTC led to significant improvements in mobility, balance, flexibility, and various measures of strength. Functional capacity was unchanged in the FFLTC group and decreased in the ROM group.
No change in grip strength, gait speed and stair-climbing power for either, group.
ROM (control).
Increased TUG time.
No change in balance or lower body flexibility.
Non-significant 3.5% change in shoulder flexion ROM.
21% increase in shoulder abduction strength.
Decline in isotonic leg and hip strength.
The FFLTC is suitable for long-term care residents, feasible for staff to deliver, and low-cost. Most importantly, functional outcomes clearly superior to seated ROM program.
ROM may improve shoulder-abduction strength, but will not prevent declines in lower body strength, mobility, and balance.
21/24

Stanziano et al. 2009 [14].   
USA.
RCT.
Focus
Major muscle groups.
To examine impact of an active-
assisted (AA) flexibility program on ROM and functional performance variables in older persons living in a residential retirement community (RRC).
.  
Age: 88 5.4 yr.
Experimental group
.  
90 4.5 yr.
1 male, 7 female.
Control group
.
88 6.2 yr.
3 male, 6 female.
Inclusion criteriaLiving in an RRC, ability to sit upright in a chair for 30 min (no akathisia, neurological, or osteoporotic limitations).
Pre-post 8 wks 2 wk−1  
Experimental group
10 stretches: back scratch (shoulder flexion/abduction), standing thigh (hip hyperextension), side lunge (hip abduction), overhead back (shoulder hyperflexion), overhead side (lateral trunk flexion), cross chest (horizontal shoulder adduction), seated trunk twist (trunk rotation), seated hamstring (trunk/hip flexion), and seated calf (dorsiflexion).
10 repetitions, 4-5 s each.
Control group
Arts and crafts class with limited physical exertion.  
Assessment
Conducted 1 wk before and after training period.
Flexibility:
back scratch test (BS).
Modified chair sit and reach test (SR).
Supine knee extension test (KE).
Modified total body rotation test (BR).
Strength/power:
30-sec chair stand (CS).
Modified ramp power test (MRPT).
30-sec arm curl (AC).
Gallon jug shelf test (GJST).
Mobility:
50-foot gait speed test (GS).
8-foot timed up and go (UG).  
Analysis
ANCOVA
  
Flexibility
Significant increases in ROM made by experimental group for all measures but left side BS and right side SR.
Control group showed no change in any flexibility measure but a significant loss in ROM for right-side knee extension.
Functionality
Experimental group significantly improved CS and MRPT, while control had significant declines.
Experimental group significantly improved in AC and the GJST, while control had no change.
Experimental group reduced time taken to complete the UG and GS.
Eight weeks of AA stretching may be an effective intervention for improving ROM, mobility, and functional power for older persons living in a RRC.
Data provide clear link between flexibility and functional performance in older persons and support the inclusion of flexibility training in interventions designed to increase independence in older persons.
16/24

Raab et al. 1988 [15].  
USA.
Non-RCT.
Focus
Major muscle groups.
Examine the ability of weighted and nonweighted exercises to increase flexibility in older adults in the hip, shoulder, wrist, ankle, and neck. .  
Female.
Experimental groups
Exercise (no weights, EN).
.  
70 3.9 yr.
Exercise (with weights, EW).
.  
70 3.2 yr.
Control group
No exercise.
71 8.1 yr.
Healthy, active older adults.
Pre-post 25 wks.  
Exercise program
60 min, 3 days/week;
5–10 min treadmill warm-up; 10 min aerobics at 65% HRmax; 25–30 min whole body strength and flexibility exercises; 10–15 mon cool-down.
Exercises involved active and passive stretching held for 20 s, slow circling motions for ROM, and repetitive movements for example, leg curls.
EW had gradual introduction of wrist and ankle weights.
Assessments
Shoulder flexion and abduction.
Neck rotation.
Wrist flexion/extension.
Ankle flexion/extension.
Hip flexion.
Analysis
Two-way ANOVA, Dunn-planned comparisons with two contrasts, one-and two-tailed t-tests.
Flexibility improved significantly for exercise groups in ankle plantar flexion, shoulder flexion abduction, and cervical rotation to the left.  
Hip flexion (reflecting hamstring flexibility) increased for all groups, with no between-groups differences.
The exercise with no weights groups had nearly 2.5x greater increase in ROM than exercise with weights for shoulder abduction. No other flexibility comparisons in the exercise groups were significant.
No functional outcomes.
Exercise can increase flexibility in healthy, older women by improving shoulder flexion and abduction, ankle plantar flexion, and cervical rotation. For shoulder abduction, a nonweighted exercise program can produce greater flexibility gains in older adults than a weighted exercise program, and should be considered if flexibility is the primary goal.13/23

Bird et al. 2009 [16].  
Australia.
Randomized Crossover. Tria.l.
Focus
Major muscle groups.
To determine the effect of community-based resistance- versus flexibility-training programs on balance and related measures. .  
Age: mean 67 yr.
Males = 18,
Females = 14.
Sedentary.
Inclusion criteria
No history of stroke or other neurological disease or current diabetes, cardiovascular disease, or uncontrolled hypertension. No use of walking aids.
Pre-post 16 wks, 4 wk washout, 16 wks (crossover).  
Intervention
Both groups had 3 sessions.wk−1 for 16 wks, then 4 wk washout, then switched to other group for 16 wks.
Resistance training (RT)
2-3 sets of 10–12 reps.
Flexibility training (FT)
40–45 min with 16–20 stretches; two stretches for each of: hamstrings, quadriceps, back, and chest.
Assessments
Balance, force plate.
Timed up-and-go.
10 times sit-to-stand.
Step test.
Lower limb strength (right and left knee-flexion and extension) with an isokinetic dynamometer.
Analysis
Repeated measures ANOVA
Lower limb strength increased significantly in the RT group, but not in the flexibility group and there was a significant difference between the two groups.
Significant improvements were seen in both groups for timed up-and-go, 10 times sit-to-stand, and step test.
Significant improvements in medial-lateral sway range were seen in the flexibility group only.
Significant decreases in sway velocity were seen in both conditions.
Significant improvements in balance performance were achieved with both resistance-training and standing flexibility-training programs in healthy untrained older adults.  
Flexibility program did incorporate some degree of balance training in the nature of the flexibility tasks.
19/24

Swank et al. 2003 [17].  
USA.
Non-RCT.
Focus
Major muscle groups.
To determine the effects of adding modest hand and ankle weights to whole-body stretching exercise on ROM. .  
Age: 55–83 yr.
Body Recall (BR).
n = 18. 
68 5.6 yr; 8 male,
10 female.
BR + Weights.
n = 14. 
68 3.1 yr.
4 male, 10 female.
Control.
.  
69 6.5 yr.
1 male, 10 female.
Participants of body recall older adult low intensity flexibility program.
Inclusion criteriaNo overt disease or any severely limiting orthopaedic problems
Pre-post 10 wks.  
Intervention
Supervised.
BR = pain-free, smooth, rhythmic whole-body movements.
Training group 1 (BR)
60 minutes, 3 wk−1.
Training group 2 (BR  +  W)
60 minutes, 3 wk−1with gradual progression of ankle weights and band exercises.
Control group
No description.
Assessment
ROM (goniometer) for neck (left and right rotation), hip (flexion and extension), shoulder (flexion and abduction), knee (extension and flexion), and ankle (plantar and dorsiflexion).
Analysis
ANCOVA, Levene’s test of equality. Tukey Honestly Significant Difference test, P = ≤ 0.01.
(pre values not given).
Significant differences found for 6 of 10 ROM measures: cervical rotation (left and right), hip extension, ankle flexion/extension and shoulder flexion, for both BR and BR + W in comparison to control  
BR + W showed significantly greater increases in 4 of 6 measures that showed significant change: cervical rotation (left and right), hip extension, and ankle dorsiflexion versus BR.
Found that the addition of weights enhanced effectiveness of stretching exercise. It is likely that a positive effect was noted for 2 reasons: increased resistance during exercise movement and exercises were performed through full ROM.
It seems plausible to hypothesize that greater effects would be shown by addition of weights to stretching routines for nursing home clients or free-living, otherwise sedentary elderly.
14/23

Alexander et al. 2001 [18].
USA.
Non-RCT.
Focus
Major muscle groups.
(1) Analyze the biomechanics of rise performance during chair-rise tasks with varying task demand in more disabled older adults.
(2) To determine whether a strength-training program might improve chair-rise success and alter chair-rise
strategy
versus. flexibility control.
(final).
Training Group.
n = 16.
Age: 82 6.0 yr.
4 male, 12 female.
Control group.
.
Age: 84 7.4 yr.
2 male, 12 female.
Residents of local housing facility.
Inclusion criteria
>65 yr.
No lower extremity hemiplegia or amputations, blindness, acute inflammatory or infectious illness, and no dementia. Must complete the easiest chair-rise task. Cannot be currently involved in formal exercise.
Pre-post 12 wks.
Intervention
Resistance training
1 hour/day, 3 days.wk−1 using HydraFitness hydraulic equipment for lower body exercise. Also weighted chair rise and weighted ankle flexion/extension.
Control group
Participated in series of seated neck, trunk, arm, leg, and foot flexibility exercises.
Assessment
Seven chair rise tasks, biomechanics of tasks
H = using hands
NH = without using hands
60/100/140 are seat heights as
% of floor to knee heights).
Analysis
Two-way ANOVA, repeated measures ANOVA with pairwise post hoc comparisons (Fisher’s PLSD).
Only training group improved ability to complete the most difficult tasks. Controls maintained performances in general, one or two declined.
Only significant decrease was in total rise time for both groups at H-100.
Centre of Pressure (COP) increased significantly in both groups in all tasks but H-140 (highest seat height).
Knee torques increased for both groups significantly for H-100, H-60, NH-100, and NH-100-F.
Mean hip torques increased significantly in controls and decreased significantly in training group in H-60.
Subtle, yet significant changes can be demonstrated in chair-rise performance as a result of controlled, short-term resistance training program.15/23

Takeshima et al. 2007 [19].
Japan.
Non-RCT.
Focus
Major muscle groups.
To compare the effects of a walking-
based aerobic program, a band-based resistance program, a stretching-
flexibility program, a customized balance program, and a Tai Chi program on functional fitness in a group of community older adults.
.  
73 6 yr.
64 male, 49 female.
Aerobic (AER).
.
Resistance (RES).
n = 17.
Balance (BAL).
.Flexibility (FLEX).
.
Tai Chi (T-CHI, Yang Style).
.
Control (CON).
.
Healthy sedentary.
Inclusion criteria
No meds for hypertension, HRT.
No CHD, no regular physical activity.
Pre-post 12 wks.  
Intervention
Supervised  2 days  wk−1 (RES, BAL, FLEX, T-CHI)
3 days per wk (AER).
All had 10–15 min warm-up
60–70 min of specific exercise:
AER-Outdoor walking
RES-Progressive elastic band exercises for all major muscle groups
BAL-Eyes open/closed, exercise on floor, on foam mats
FLEX-15 static stretches for upper and lower body (15–20 s each).
T-CHI- standardized 24 forms.
Assessments
Functional Fitness.
30 s arm curl test.
30 s chair stand time.
8 Ft timed up-and-go.
back scratch test.
chair sit and reach test.
12 min walk test.
Analysis
ANOVA.
Wilk’s criterion.
Kolomogorov-Smirnov test.
Improvement in cardiorespiratory fitness (12 min walk) was limited to AER (16%)
RES, BAL, and T-CHI, resulted in improvements in upper and lower body strength and balance/agility. RES showed greatest upper body strength improvement (31%). BAL showed greatest lower body strength improvement (40%).
Balance/agility was similar across RES, BAL, and T-CHI (10%).
Functional reach, similar improvements for AER (13%), BAL (16%), RES (15%).
No significant changes in either FLEX or CON on any measure.
It is recommended that older adults participate in a well-rounded exercise program vs. single mode.
RES, BAL, and TAI CHI cross domains not specifically targeted in their design.
AER necessitates aerobic-specific activity to improve cardiorespiratory fitness.
With FLEX, lack of improvement suggests that further study is needed to explore the effect of flexibility exercise training in older adults.
18/23

Erickson et al. 2011 [20].
USA.
RCT.
Focus
Major muscle groups.
To evaluate whether 1 year of exercise training increases the size of the hippocampus and improves spatial memory using moderate-intensity aerobic exercise versus a stretching and toning exercise program. .   
Experimental (exp).
n = 60.
Age: 68 yr.
16 male, 44 female.
Control (con).
. Age: 66 yr.
24 male, 46 female.
Community-dwelling, sedentary.
Inclusion criteria
Aged 55–80 yr, no dementia, healthy less than 30 min. of PA in last 6 mo.
Both EXP and CON groups included same 5 min of stretching, both before and after exercise.
Program lasted 1 year.
Aerobic exercise condition (EXP)
Progressed from walking 10 min at 50–60% HRRmax to 40 min at 60–75% HRRmax by week 7, then maintained until program finished.   
Stretching and toning control condition (CON)   4 muscle toning exercises, 2 balance exercises, one yoga sequence, and one exercise of choice. Told to exercise at RPE of 13–15 on 20 pt Borg scale.   
Assessments
max
MRI for hippocampal volume.
Computer-based spatial memory task.
Analysis
Repeated measures ANOVA.
t-tests.
EXP group VO2 max increased 7.78% while CON increased 1.11%.
EXP group had significant group × time interaction for increased hippocampus size (left + 2.12%, right + 1.97%), while CON group declined (left −1.4%, right −1.43%).
Greater increases in aerobic fitness were associated with greater increased in hippocampal volume, suggesting that larger changes in fitness translate to larger changes in volume.
Higher aerobic fitness levels at baseline were associated with better spatial memory.
Aerobic exercise-induced increases in BDNF are selectively related to the changes in anterior hippocampal volume.
Loss of hippocampal volume in late adulthood is not inevitable and can be reversed with moderate-intensity exercise.
19/24

Ceceli et al. 2009 [21].
Turkey.
Non-RCT.
Focus
Major muscle groups.
To determine if performing regular ROM exercises had a beneficial effect on the balance, functional activity, and flexibility of elderly subjects.
.  
Age: 73 yr.
3 males, 43 females.
Group 1.
n = 25.
Age: 74 5.15 yr.
21 female; 3 males.
Rest home residents.
Group 2 (control). .
Age: 72 4.13 yr.
Female.
Inpatient clinic patients, and sedentary housewives.
Inclusion criteria>65 yr.
Able to ambulate without assistive device.
Independent in activities of daily living.
Pre-post; 4 month.
Intervention
Supervised ROM exercises. Supine position with 10 repetitions of each upper and lower extremity joints.
3 wk−1, 20 min.
Flexibility
Lateral trunk flexion (right and left)
distance between middle finger at rest and in max lateral flexion.
Anterior trunk flexion: distance from middle finger tip to the ground.
Balance
Sharpened Romberg (SR) test.
One-legged stance test (OLST).
Both tests performed with eyes open then closed.
Functional activity.
30 m Walking Time.
Functional reach test.
AnalysisMann-Whitney U test.
Significant increase in Group 1 versus 2 in left (10.76 to 13.32 cm, P = 0.035) and right (10.47 to 12.88 cm, ) lateral flexion. No change in anterior flexion (8.66 to 8.24 cm)
30 m walk time decreased significantly from 28.14 to 20 s ( ) in Group 1.
Functional reach increased significantly from 15.95 to 19.6 cm ( ).
No significant difference in balance tests.
Authors stated that participating in daily flexibility group exercise increases ROM and causes some improvement in balance.
When compared to a randomly selected hospital applied group, the rest home group has better balance, trunk flexibility and functional ability.
11.5/23

Christiansen 2008 [22].
USA.
RCT.
Focus
Hips and ankles.
To examine the effects of a hip and ankle static stretching program on freely chosen gait speed of healthy, community-dwelling older people not active in exercise. .  
Age: 72 4.7 yr.
Intervention Group.
. Age: 72 4.7 yr.
3 male, 15 female.
Control group.
.
Age: 72 5.0 yr.
5 male, 14 female.
Independently living.
Inclusion criteria
In desired age range, healthy, no joint or musculoskeletal pain that limited movement in past month, no diagnosed gait or balance disorder, no falls history, has not participated in formal exercise during the previous 6 month, and has not used an assistive device for walking.
Pre-post 8 weeks.
Intervention group
Hip and ankle stretching. 2 static stretches held for 45 seconds and repeated 3 times alternating sides; total 9 minutes (540 s)/session. Stretches are standing calf stretch and standing hip flexor stretch.
Control group
Ensured no changes in current physical activity.
Assessments
Passive ROM: goniometric measurements of hip (hip extension based on Thomas test position) and ankle.
Gait: shoes on; two walking speeds.
Analysis
Independent t tests or chi-square tests, ICC model 2 and form 1, 2-factor repeated measures ANOVA, separate repeated-measures ANOVA, paired t tests, and Bonferroni adjustment.
85% compliance
Gait: significant increase in freely-chosen gait speed for intervention group (1.23 to 1.30 m s−1, +0.7m s−1, and ) versus. control (no change).
joint motion: peak hip extension and knee flexion increased significantly (59.7 to 66.5°) in intervention group, with no change in control (56.2 to 56.1°).
Significant increase in intervention group (7.8 to 11.3°) for passive dorsiflexion, with no change in control.
Other: No significant changes in stride length or joint angular displacement.
Evidence is provided from the results that joint motion is a modifiable impairment that can be effectively targeted for older people with simple, static stretching home-based intervention.19/24

Cristopoliski et al.
2009 [23].
Brazil.
RCT.
Focus
Hips and ankles.
To determine whether a 4 wk supervised stretching program for lower limbs alters gait kinematics in aged population.n = 28.
Female.
Experimental Group.
n = 12.
Age: 66 4.2 y.r
Control Group.
. Age: 65 2.9 yr.
Characteristics
Community dwelling.
Inclusion criteria
Healthy, no gait performance limitations.
Pre-post 4 wks.
Intervention
Experimental group.  3 sessions.wk−1.
Supervised.
5 min walking warm-up.
Hip extensor/flexor muscles, ankle plantar flexor muscles.
Static stretches, 60 s each, 4 times.
Control
no activity.
Assessment
Static ROM of hip extension and flexion and ankle dorsiflexion by photography.
Gait performance
Analysis
Repeated measures ANOVA, univariate analysis, post hoc Scheffe.
Static range of motion changed significantly ( ) in both hip and ankle joints for the experimental group, no change in the control group.
Hip extension (73 to ).
Hip uniarticular flexors (6.3 to 2.0°).
Hip biarticular flexors (7.0 to 2.7°).
Plantar flexor amplitude (39 to 48°).
Experimental group showed increased step length, higher velocity, and reduced double support time after-training.
Supervised stretching program is effective to alter a number of gait variables. Aged participants displayed gait parameters which were similar to those of young adults.17/24

Batista et al. 2009 [24].
Brazil.
Experimental (Pre-post within subjects).
Focus
Hamstrings.
To determine if an active stretching program increases knee-flexor torque and flexibility, antagonistic torque, and functional mobility in older adults, and whether the possible adaptations remain after intervention. .  
Sex: female.
Age: 68 6.4 yr.
Participants in geriatric revitalization program for at least 12 month.
Inclusion criteria
>60–80 yrs, no vascular, inflammatory or lower-limb musculoskeletal disorders.
No uncontrolled hypertension
Flexibility
deficit ≥20°.
4 wks without stretching (A1) followed by 4 wks of stretching intervention (B), followed by 4 weeks without stretching (A2).
Participants were own controls (A1).
Flexibility intervention (B)
2 wk−1; 4 wks.
Standing in front of table, therapist aligned spine with bar, participant flexed knees and trunk until hands reached table. Then extend knee and tilt pelvis anteriorly to max painless tension
Held for 60 s, returned to standing for 30 s. Repeated 7 times (7 60 = 420 s).
Assessments
Knee extension ROM deficit (goniometer).
Isokinetic torque of knee flexors and extensors.
Timed Up-and-Go (TUG), functional capacity.
Analysis
Repeated one-way analysis of variance.
Student’s Newman-Keuls test.
Significant decrease in knee extension deficit after intervention (24.1° to 14.1°, P = 0.0001), but not completely maintained after 4 wks (18.8°).
TUG performance improved (8.4 to 7.2 s, ) and remained at end of program (7.6 s).
Significant increase in concentric and eccentric torque of knee flexors and extensors.
The knee flexor stretching program was effective in increasing the flexibility of this muscle group, increasing knee-flexor and extensor torque and improving functional mobility in older adults. Most improvements lasted at least 4 wks after the stretching ceased. The increase in knee ROM is probably a result of adaptation in the connective tissue caused after the knee-flexor program.13/18

Johnson et al. 2007 [25].
USA.
Experimental (Pre-post within subjects).
Focus
Calves.
To investigate the effects of a static calf MTU stretching program on ankle dorsiflexion ROM in healthy adult women 65 years and older.
.  
Age: 84 4.7 yr.
Female.
Inclusion criteria
>65 yr, healthy.  
No evidence of lower extremity dysfunction (assessed by visual observation of gait).
Less than 10° of passive ankle dorsiflexion ROM.
Functionally independent.
Pre-post, 6 wks.
No control group.
Intervention
Supervised stretching of left and right calf muscle tendon unit (MTU).
Standing with shoes on, placed one foot in front of other in comfortable stepping stance with hands on chair.
Leaned forward on front leg until stretch felt in rear leg.
Held for 60 s and repeated 4x/leg, once daily, 5 days wk−1 for 6 wks.
Assessment
Passive ankle dorsiflexion ROM by goniometry.
Measured prior to stretching protocol and 3 days after-protocol.
Posttesting researcher blind to pretesting data.
Analysis
Paired t-test.
Dorsiflexion ROM increased significantly from −11.1° to 1.2° ( ).A 6-wk stretching protocol significantly improved ankle dorsiflexion ROM in elderly females. The ROM improvements were maintained 3 days after the last day.
Were able to demonstrate a lasting, or plastic change in calf MTU passive ROM.
10/18

Gajdosik et al. 2005 [26].
USA.
RCT.
Focus
Calves.
(1) To examine the effects of an eight-week stretching exercise program on calf muscle length, and on their length extensibility and passive resistive force properties for older women with limited dorsiflexion ROM.
(2) To examine the influence of the stretching program on three functional tests.
.  
Age: 65–89 yr.
Female.
Stretching group
n = 10.
Age: 73 6.8 yr.
Control Group.
.75 8.3 yr.
Community-dwelling.
Inclusion criteria
Active dorsiflexion ≤10°.
Had ability to relax calf muscles and tibialis anterior during passive movements of ankle.
No history of orthopaedic or neurological disorders. Minimally to moderately active.
Pre-post 8 wks.
Stretching group
Held static stretch for 15 s, 10 repetitions (total 150 s) 3x/wk for 8 wks.
Control group
Did not exercise.
Assessments
(Measured barefoot).
Functional
Timed agility course (modification of timed up-and-go).
Timed 10 m walk.
Standing forward functional reach.
Passive
Kin-Com ankle-foot apparatus (dorsiflexion)
Dorsiflexion range of motion.
Passive-electric energy (EMG).
Passive resistive forces.
Analysis
Univariate ANOVA, two-way MANOVA, Pillai’s Trace, two-way ANOVA for repeated measures, and one-way ANOVAs.
Stretching group significantly increased maximal passive dorsiflexion angle (11.1 to 16.2°, ) and full stretch ROM (37.1 to 50.0°, ). No significant changes in control group.
Stretching group showed significant improvement in timed agility course (18.26 to 16.88 s, ) and 10 m walk (6.44 to 5.99 s, ).
No change in control group speed.
No change in functional reach test for either group.
Stretching group increased both absorbed passive-elastic energy and retained passive-electric energy.
MVC: Stretching group increases 14%, while control group increased 3.5% (both nonsignificant).
An 8-week stretching program for short calf muscles of older women increased the maximal DF ROM which indicated increased length of the calf muscles. The stretching program also increased the length extensibility, passive resistive forces and stored and retained passive elastic energy of the calf muscles. These adaptations correspond with decreased agility course and 10m walk times.19/24

Petty et al. 1999 [27].  
USA.
Time-series, quasi-experimental.
Focus
Calves.
(1) To examine the relationship between maximum ankle dorsiflexion ROM and an individual’s ability to move the trunk posteriorly with fixed BOS.
(2) To examine intervention designed to increase gastrocnemius length on maximal ankle DF ROM and the ability to move posteriorly with fixed BOS.
(3) To examine the contributions of maximum ankle DF ROM, age, and height to performance of volitional posterior trunk movement.
.  
82 4.5 yr.
4 male, 3 female.
From audience at retirement community lecture.
Exclusion criteria
Any current neurological symptoms, taking any medications that might affect balance, any visual problems interfering with daily function, significant pain during backward lean test.
Inclusion criteria
>65 yr, no greater than 0° ankle DF ROM, at least 90° of shoulder flexion and 0° of elbow extension, ability to stand without external support for 2 min and perform Backward Lean Test properly, and not currently receiving physical therapy.
Intervention  
4 wk stretching program:
gastrocs stretching in “step-standing” position; point of stretch held for 30 s followed by 15 s rest; 4 repetitions per body part, repeated twice per day.
Assessments  
Maximal ankle dorsiflexion (knee extended).
Backward Lean Test (barefoot).
Analysis
Pearson product moment. correlation coefficient.
Paired t test.
Multiple regression analysis.
Mean pretest DF ROM: −5.9° 2.5° increased to 0.5° 2.9° (significant mean change of 6.4° 2.2°)
Backward Lean pre-test: 5.2 3.5 cm increased to 9.3 3.6 cm (significant mean change of  cm).
The Backward Lean test proved useful for assessing changes in dynamic postural control in a posterior direction.
The positive correlation between maximal ankle DF ROM and distance of posterior horizontal trunk excursion during Backward Lean may be related to the biomechanical requirements of the BL test.
Subjects who performed an exercise program designed to lengthen the gastrocsoleus muscles demonstrated increased range of maximal ankle DF with knee extended and improved ability to lean backward while maintaining a stationary BOS. The significant increase in DF ROM from pretest to posttest supports the efficacy of the stretching protocol.
A significant relationship exists between the degree of available maximal ankle DF ROM with the knees extended and the horizontal distance an individual is able to move the trunk posteriorly while maintaining a fixed BOS.

Kerrigan et al. 2003 [28].
USA.
Double-blind RCT.
Focus
Hip flexors.
To test the effect of a hip flexor stretching program on age-related gait changes about the ankle. .  
Males = 30.
Females = 66.
Treatment.
n = 47.
15 male, 32 women.
Control.
. 
15 men, 34 women.
Inclusion criteria
≥65 yrs old, healthy.
Pre-post 10 wks.  
Protocol  
Home exercises.
Both groups performed warm-up and cool-down; 30 s stretches alternating limbs for 4 sets/8 stretches in total.
2x per day (approximately 5 min).
Treatment group
Hip stretching exercise.
Control group
Deltoid stretching exercise.
Assessment
Static hip extension range, goniometer.
Pelvic and bilateral lower-extremity joint motion and joint kinematics.
Analysis
Unpaired and paired t tests, paired Student t tests, and Bonferroni adjustment.
Only peak ankle dorsiflexion and plantar flexion during swing increased significantly with treatment.
Trend for increased in static peak hip extension (6.1 to 7.7°, ).
No major changes with control group.
Both groups had similar minor increases in comfortable walking speed.
Tendency toward a reduction in anterior pelvic tilt implies that modest improvement in hip extension range allowed for a slight decrease in anterior pelvic tilt. These findings support the hypothesis that an increase in pelvic tilt in the elderly is a compensation for hip contracture rather than a compensation or a direct result of another impairment.
Improvement in peak ankle plantar flexion with hip stretching and a trend toward improved ankle plantar flexor power at comfortable walking speed were found. These results suggest that these outcomes in the elderly may be secondary to proximal impairment rather than to impairment at the ankle or ankle musculature per se.
17/24

Rider & Daly 1991 [29].
USA.
RCT.
Focus
Trunk.
To determine if a flexibility training program could positively influence the spinal mobility of older adults and be conducted in such a way as to facilitate the adoption of such a program by the participants as part of their weekly exercise routine. .  
Females.
Experimental group. n = 10.
Control group.
. Age: mean 72 yr.
Inclusion criteria
No orthopaedic conditions for example, moderate to severe back pain, no osteoporosis or any spinal deconditioning disorders.
Pre-post 10 wks.
Experimental group
Supervised flexibility exercises (sit and reach, knee tuck, pelvic lift, and back extension) 3 times each, held for 10 s each
3 days wk−1.
Control group
Continued current exercise program without flexibility training.
Assessments
Spinal flexion (sit and reach)
Spinal extension.
Analysis
Repeated measures ANOVA.
Experimental group showed significant improvement ( ) pre to post for both spinal flexion (28.36 cm to 32.57 cm) and spinal extension (17.87 cm to 25.04 cm).There is a meaningful positive association between regular flexibility training and spinal mobility in older population studies and may reduce the potential for age-related spinal deconditioning.14/24

Weng et al. 2009 [30].
Taiwan.
RCT (blind assignment).
Focus
Thighs.
To compare the effects of various stretching techniques on the outcomes of isokinetic exercise in patients with knee osteoarthritis (OA). .  
in each of 4 groups.
Age: 64 7.5 yr.
Males = 26, Females = 106.
Inclusion criteria
Bilaterial moderate knee OA (Altman Grade II).
No hip joint OA or any other hip problems with ROM limitations.
Pre-post 8 wks.
Intervention
isokinetic exercise
3x wk−1 for 8 wks at increasing doses.
Active-assisted quadriceps and biceps femoris, holding end-point for 30 s, repeat 10x (10 min).
PNF: HR(hold-relax), CR (contract-relax), CRAC (contract-relax agonist contract), HRAC (hold-relax agonist contract).
Group 1: isokinetic muscular strengthening.
Group 2: bilateral knee static stretching before isokinetic exercise.
Group 3: PNF before isokinetic exercise.
Group 4 (control): warm-up only.
All groups received 10 min (15 min in control) hot packs and passive ROM on stationary bike.
Assessment
ROM: goniometer changes in knee active assisted ROM (flexion and extension).
Pain: VAS scale.
Disability: Lequesne’s index (LI). MPT: flexion and extension with isokinetic dynamometer
Analysis
Weighted kappa statistics, Paired t tests, one-way ANOVA with Tukey’s test, and Dunnett’s test.
.  
Follow-up .  
ROM: significantly increased in groups II and III.
Pain: decreased significantly in all groups, but increased in control. Greater decreases in II and greatest in III.
Disability: average LI scores decreased significantly in all groups, greatest in III.
MPT: average at 60°/second increased significantly in all measurements for groups II and III. All groups increased significantly more than control.
Stretching therapy is recommended as an adjuvant treatment to isokinetic exercise for patients with knee OA.
PNF is more effective than static stretching exercise.
13/24

Yr: year; hr: hour; wk: week; wks: weeks; min: minutes; s: seconds; m: meters; ROM: range of motion; x: times; mo: months; pt: point; HRR: heart rate reserve; cm: centimeters.