Clinical
Clinical
Claudio Gil Soares de Araújo
Claudio Gil Soares de Araújo
FLEXITEST – AN OFFICE
METHOD FOR EVALUATION
OF FLEXIBILITY
CLAUDIO GIL SOARES DE ARAÚJO
ASSESSMENT OF FLEXIBILITY IS
IMPORTANT FOR
RHEUMATOLOGISTS AND
ORTHOPAEDISTS AS WELL AS
SPORTS PHYSICIANS; A SIMPLE
CLINICAL ROUTINE GIVES RELIABLE
AND REPRODUCIBLE MEASURES
lexibility may be defined as the
maximal passive physiological range
of motion in a given joint movement.
However, flexibility is not a general
trait, being rather specific for both joints and
movements. In consequence, a single arc of joint
motion will not probably reflect the individual’s
overall mobility or suppleness, an important
issue in flexibility testing. It is also likely that
there are certain ranges of joint motion that
seem to be more associated with health and
performance needs. Indeed, low and high
extreme levels of range of motion are commonly
associated with unhealthy conditions. This
characteristic makes flexibility quite distinct
from other health-related physical fitness
components, such as maximal aerobic power
and maximal muscle strength and power, in
which higher values are typically related to high
standards of health and physical performance in
all age groups.
Flexibility is a highly adaptable component of
physical fitness and it should be always
considered in exercise prescription for both
healthy and unhealthy individuals of all ages.
Appropriate levels of flexibility are potentially
relevant for simple and complex movements in
daily life, as well as for sports performance and
health maintenance. Despite the consensus on
flexibility exercises as part of any physical
activity programme there are comparatively few
data available concerning measurement and
evaluation of body flexibility. The likely major
reasons for this paucity of scientific data are the
widely recognised limitations and lack of
standardisation of the most commonly used
evaluation
methods,
i.e.
sit-and-reach,
goniometer, etc. Notwithstanding, there are
good practical reasons for routine assessment of
flexibility [Table1].
F
PHOTO DISC
034 l Sport & Medicine Today l Autumn 2001
050 l Sport & Medicine Today l April 2001
N E W S
A S
I T
N E W S A S
B BR RE EA AK KS S
I T
Over the last 20 years, we developed and
validated a new and practical although quite
complete
method
for
the
systematic
measurement and evaluation of body flexibility.
This method is named Flexitest and it can be
easily performed in an office setting. The
Flexitest has been thoroughly evaluated in the
past and the results showed very high inter- and
intra-evaluator reliability. Many published
studies in Latin America and some European
countries have used this method and age- and
gender-percentiles are currently available from
five to 85 years based in over 2,500 noncompetitive subjects. In addition, over 400 data
were obtained in male and female elite athletes
from about 30 sports modalities.
FLEXITEST
Flexitest evaluates the maximal passive range of
motion of 20 joint movements. The movement is
always initiated at the base figure (typically that
equivalent to value 0) towards greater joint
amplitude. All the movements are performed
passively up to either physical limitation or the
subject’s complaint of discomfort. For scoring,
the range of motion passively obtained for each
...FLEXIBILITY TENDS
TO PEAK AT ABOUT
THREE TO SIX YEARS
OF AGE..THEN
PROGRESSIVELY
BUT NOT LINEARLY
DECLINES...THERE
IS SUBSTANTIAL
LOSS AROUND
SCHOOL YEARS
AND PUBERTY...
movement is compared with a reference chart.
Figure 1 provides instructions and an evaluation
chart for movement and detailed positioning of
subject and evaluator as well as additional
comments or hints for interpretation. The
written description should be used in
conjunction and as a complement to the maps.
The evaluation strategy by visual comparison is
widely applied in medicine,
Tanner’s
maturation drawings probably the best known.
Discontinuous values ranging from 0 to 4 are
assigned to each movement, and no
intermediate values are allowed. For example, all
range of motions located between the chart
positions 1 and 2 are graded 1 and so forth. It is
then possible to study the flexibility level in any
of 20 individual movements or seven joints. In
addition, since flexibility scores for all individual
N E W S
N E W S
TABLE 1: POTENTIAL AND PRACTICAL USES OF FLEXIBILITY TESTING
1.
2.
3.
4.
5.
6.
7.
Physical fitness assessment
Pre-participation medical and/or functional evaluation in exercise programmess
Assessment of injury risk potential
Baseline information for assessment of intervention (either physical training or rehabilitation) results
Diagnosis of causes for poor or limited specific sport or daily living activities
Assessment of outstanding potential for specific sport modalities
Clinical diagnosis and follow-up of hypo- or hypermobility conditions
movements present a normal distribution –
median of 2 –, it is possible to add them to
obtain a global or overall body flexibility
dimensionless score, that is called Flexindex
(range: 0 to 80). For individual movements in
adults, extreme scores – 0 and 4 – are quite rare,
most of the time associated, respectively, with
clinically significant joint motion limitation or
hyperlaxity. Based on our experience, we had
arbitrarily established Flexindex limits of 20 and
70 points, respectively, for characterising general
hypomobility and hypermobility. Numbering of
movements starts at ankle and proceeds towards
shoulder, i.e. from distal to proximal. Normally,
all movements that are bilateral, by
standardisation, are performed on the subject’s
right side [Table 2]. A sequence of movements
was established that has proved to require the
least consecutive changes in the subject’s
positions. The suggested sequence of
movements is the following: I, II, V, III, VI, X, XI,
XVII, XVIII, XIX, XX, VIII, IX, VII, XVI, XII, XIII,
XIV, XV, IV. Typically, it takes three to four
minutes for an experienced evaluator to gently
perform the 20 passive movements. Since
previous physical activity may affect flexibility,
in order to standardise the conditions of
application, no warming-up is allowed
immediately before the evaluation. So far, we
have never seen or known any musculoskeletal
lesion provoked by application of the Flexitest
following these instructions.
SPORTS AND CLINICAL
APPLICATIONS
Typically, there is an inverse trend for flexibility
with ageing. Flexibility tends to peak at about
three to six years of age and then progressively
but not linearly decline. Normally, there is
substantial loss around school years and
puberty, followed by a less impressive decrease
from 16 to 40 years of age and then again a trend
to faster reduction with further ageing which
can be interrupted or even partially reversed by
appropriate physical training. Female subjects
tend to be about 15% more flexible than male
counterparts, especially after six or seven years
of age. Despite the fact that flexibility profile
seems to be under strong genetic influence,
physical activity pattern significantly affects it,
A S
A S
I T
I T
B R E A K S
B R E A K S
especially at middle age and seniority.
A number of clinical conditions are
accompanied by specific flexibility profiles.
Long-term insulin-dependent diabetes mellitus
adversely affects conjunctive tissue inducing
limited range of motion in small and large body
joints, which correlates well with the incidence
of microvascular changes. In women with mitral
valve prolapse, overall hypermobility and
specific hyperlaxity signs are at least three or
four times more frequent.
Despite a belief that flexibility is very relevant
for high-level sports performance, this seems not
to be exactly correct, at least as a general
concept. In fact, it should be recognised that
competitive sport represents a very broad area,
TABLE 2: FLEXITEST – MOVEMENTS
Number
Joint
Action
I
Ankle
Dorsal flexion
II
Ankle
Plantar flexion
III
Knee
Flexion
IV
Knee
Extension
V
Hip
Flexion
VI
Hip
Extension
VII
Hip
Adduction
VIII
Hip
Abduction
IX
“Trunk”
Flexion
X
“Trunk”
Extension
XI
“Trunk”
Lateral flexion
XII
Wrist
Flexion
XIII
Wrist
Extension
XIV
Elbow
Flexion
XV
Elbow
Extension
XVI
Shoulder
Posterior Adduction
[from 180(Abduction]
XVII
Shoulder
Extension and
Posterior Adduction
XVIII
Shoulder
Posterior Extension
XIX
Shoulder
Lateral Rotation
XX
Shoulder
Medial Rotation
Autumn
April 2001 l Sport & Medicine Today l 035
051
Clinical
Clinical
Claudio Gil Soares de Araújo
Claudio Gil Soares de Araújo
maximal aerobic power.
When evaluating flexibility in athletes it is of
importance to measure general flexibility as
well as mobility of different joints and
movements, that is, specific flexibility. This
information may have potential implications for
sport training. If a wide joint range of motion is
relevant for a given modality, we could expect
to find scores of 3 and 4 in these athletes. On
the other side, if low mobility is not a handicap,
it would be more suitable to identify below
average scores for some movements (2 or less).
In practice, overall hypomobility and
hypermobility seem not to be a common finding
in high-level sport athletes. However, some
cases of hypermobility in female athletes are
sometimes seen in modalities where
graciousness plays a relevant role, such as
gymnastics, figure skating, synchronised
swimming and dance.
FIGURE 1
MOVEMENT II (ANKLE PLANTAR FLEXION
0
1
CONCLUSION
Flexibility is a relevant issue both for exercise
prescription and assessment. Flexitest is a
simple and practical, albeit quite complete,
method for flexibility testing; easy to learn,
safe, non-invasive and non-equipment
dependent, rapid, reliable and valid seeming to
be a useful tool for an office where sports
medicine is practiced.
2
Authors
Claudio Gil S. Araújo, MD, PhD, FACSM
Clínica de Medicina do Exercício
Rua Siqueira Campos, 93/101
22031-070 - Rio de Janeiro - RJ - Brazil
e-mail: [email protected]
3
Allsport
4
Subject:
seated on the floor with a relaxed and fully extended
right leg
Evaluator: kneeling on a place perpendicular to Subject.
Right hand placed above the right knee of Subject. Left
hand placed in the anterior region of Subject’s right foot,
in order to produce an ankle plantar flexion, while keeping
a right angle between his hand and Subject’s foot;
Comments:
Position of the Subject’s toes is not relevant for the
measurement. Score 4 is given when the metatarsal
region touches the ground. Attention must be given to
keep the Subject’s right knee fully extended
036 l Sport & Medicine Today l Autumn 2001
encompassing many different modalities,
which may considerably vary in the
performance-related physical fitness profiles.
While long distance runners may significantly
rely on their maximum aerobic power for top
performance, judo players may primarily
depend on their muscle power and strength,
and synchronised swimmers may need
outstanding levels of body flexibility.
Furthermore, the expression athlete is very
imprecise, being used to designate individuals
with quite distinct levels of energy
requirements such as marathon runners or
those competing in shooting. It is also possible,
for some sport activities, to observe low levels
of general flexibility in the athlete, while a
larger range of motion would be exclusively
observed in specific joint movements relevant
N E W S
A S
I T
for the biomechanical characteristics of the
modality. This could be nicely exemplified by
one male athlete who won an Olympic gold
medal in one of heaviest categories in judo,
having a low average general flexibility
(Flexindex score of 36), even lower than a
typical untrained subject of his age, but
showing relatively high scores in ankle plantar
flexion, hip extension and trunk flexion which
helped him to use his favourite techniques of
uchi-mata, tai-otoshi and soto-gari. Looking
from a different point of view, it seems that
there is an inverse relationship between
running economy and ankle flexibility in adult
male athletes, which may help to explain why
adolescent and young adults are not top
performers at the elite level in this particular
event despite of their presumably higher
B R E A K S
...WHEN EVALUATING
FLEXIBILITY IN
ATHLETES IT IS
IMPORTANT TO
MEASURE GENERAL
FLEXIBILITY AS WELL
AS MOBILITY OF
DIFFERENT JOINTS
AND MOVEMENTS...
Allsport
N E W S
A S
I T
B R E A K S
Autumn 2001 l Sport & Medicine Today l 037