Grand Valley State University
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Masters Theses
Graduate Research and Creative Practice
1996
Effect of Thirty Second Static Stretch on Hamstring
Muscle Flexibility in Subjects Over Age 65
Erin Bloomquist
Grand Valley State University
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EFFECT OF THIRTY SECOND STATIC STRETCH ON HAMSTRING MUSCLE
FLEXIBILITY IN SUBJECTS OVER AGE 65
By
Erin Bloomquist
THESIS
Submitted to the D epartm ent of Physical Therapy
a t Grand Valley S tate University
Allendale, Michigan
in partial fulfillment of the requirem ents
for the degree of
MASTER OF SCIENCE IN PHYSICAL THERAPY
1996
THESIS COMMITTEE APPROVAL
/
Ja n e Toot, Ph D
K-
Katherine Kim, Ph D
Date
4 /Z3/4 h
Date
Gordon Alderink, M.S. Date
EFFECT OF THIRTY SECOND STATIC STRETCH ON HAMSTRING MUSCLE
FLEXIBILITY IN SUBJECTS OVER AGE SIXTY-FIVE
ABSTRACT
T he p u rp o se of this study w as to determ ine the effect of a thirty second
static stretch on ham string m uscle length in a sam ple of healthy people over ag e
sixty-five. Twelve individuals betw een th e a g e s of 65 and 89 w ere randomly
assig n ed to two groups: a treatm ent group which performed one repetition of a
thirty seco n d static stretch of the ham strings, o n e time per day for four w eeks,
and a control group which did not perform a hamstring stretch. ANCOVA results
w ere calculated a s p=.046, implying a significant treatm ent effect. Overall power
w as calculated a s .541. The results su g g e st th at in the healthy elderly, thirty
se c o n d s is an ad e q u ate duration to apply a static stretch and achieve
therapeutic effects.
Dedication
This m anuscript is dedicated to my family, who m ade it possible for m e to
com plete th e work, and especially my daughter, who inspired m e to p ersev ere.
TABLE OF CONTENTS
Page
ABSTRACT........................................................................................................
i
DEDICATION........................................................................................................ ii
LIST OF TA B LE S.................................................................................................v
LIST OF F IG U R E S .........................................................................................
vi
CHAPTER
1. INTRODUCTION.............................................................................. 1
2. REVIEW OF LITERATURE..............................................................6
Basic D efinitions....................................................................... 6
Biom echanics of S tretch in g .......................................................8
Neurologic Control of S tretc h in g ............................................ 10
Correlation Between Flexibility and F a lls .......................... 12
Biologic and Physiologic Effects of A g in g ........................ 15
Effects of Exercise in the E lderly........................................ 16
Studies on Static S tre tc h ...................................................... 17
3. METHODOLOGY
D e s ig n ....................................................................................... 20
Population and S a m p le ......................................................... 20
E q u ip m en t................................................................................ 21
P ro c e d u re s ...................................................................................22
D ata A n aly sis........................................................................... 24
4. R E S U L T S ............................................................................................ 25
5. DISCUSSION AND CONCLUSIONS
D iscussion of R e s u lts ................................................................ 28
Discussion of Results Within Theoretical Framework . . . 30
Discussion of Results C om pared to Literature
............ 31
C o n c lu s io n s ................................................................................ 32
Limitations of Study ............................................................. 32
R ecom m endations for Further R e s e a rc h ............................. 33
iii
Page
R E F E R E N C E S ................................................................................................... 34
APPENDIX A - MEDICAL HISTORY Q U ESTIO N N A IR E.....................
39
APPENDIX B - INFORMED CONSENT TO PA R T IC IPA TE................
42
APPENDIX C - PHYSICAL EXAMINATION F O R M ................................... 45
APPENDIX D - INSTRUCTIONS FOR HOME ST R E T C H IN G .................48
APPENDIX E - EXERCISE L O G ..................................................................
IV
50
LIST OF TABLES
Table
Page
1. P retest, one-w eek, and p o sttest m e asu res of hamstring
flexibility of all subjects
...........................................................
25
2. M ean and standard deviation values for pretest, posttest
and adjusted po sttest of ham string flexibility
for both groups
.......................................................................
26
3. Analysis of covariance for adjusted m eans: Com parison
of knee flexion m easu rem ents for treatm ent
and control groups
.......................................................................
27
LIST OF FIGURES
Figure
Page
1. International classification of impairment,
disability and handicap
.......................................................
3
2. Biobehavioral-environmental model
of falls .............................................................................................
13
VI
CHAPTER 1
INTRODUCTION
It is widely accepted in the clinical setting th at range of motion, or
flexibility, is d e c re a se d in the elderly. Certainly th ere are proven histologic and
physiologic c h a n g e s that occur in the hum an m usculoskeletal system that
support such a loss. The research that h a s a d d re sse d identification of the norms
of range of motion in the elderly, however, show s minimal or no d e c re a se from
th e g eneral population (Roach & Miles, 1991; W alker, S ue, Miles-Elkousy, Ford
& Trevelyan, 1984). This research, however, h a s neglected a s se s sm e n t of the
flexibility of th e two joint m uscles that potentially limit motion a t a joint, it is my
belief th at a s s e s s m e n t of this asp ect of range of motion would indeed show
significant d ecrem en t in the elderly population.
D ebate exists in the identification of norm s of flexibility. In her invited
com m entary of th e research of Bandy and Irion (1994, 59), Jo an Walker, Ph.D.,
FT, questioned th e research ers’ criterion for d e c re a se d range of motion a s
"having g reater than 30 d e g rees loss of knee extension m easu red with th e femur
held at 90 d e g re e s of hip flexion” (the 90/90 te st position). S h e su g g ested that in
th e a b s e n c e of pathology, th ose subjects with g reater than 30 d eg rees of knee
flexion a t termination of the 90/90 test (57 out of 75 initial subjects) w ere merely
expressing a slightly lower, but normal, range of motion. S h e su g g ested that
2
m uscle flexibility of th e ham strings is a trait with a normal distribution, and that
individuals with knee flexion above 30 d eg rees are simply on th e low end of that
distribution. A question arises a s to the validity of this statem ent, b a se d on the
relatively small num ber of individuals (14 out of 75 original subjects in the study)
who, to carry W alker’s analogy further, represent the entire left side of the
distribution curve. In addition, a sam ple can be normally distributed and still be
pathologic for th e trait m easured. Finally, the Bandy and Irion study in no way
attem pted to conclude th at it's sam ple w as representative of th e population. A
much more com prehensive study would be required to identify the norm s of
sco res of ham string flexibility using the 90/90 test.
In th e a b se n c e of normative d ata regarding flexibility of th e ham strings,
research ers m ust rely on th e clinical experience of others. Bandy and Irion
(1994) ch o se -30 to zero d eg rees of knee extension with 90 d e g re e s of hip
flexion, a s their range of normal hamstring length, without citing a rationale for
this choice of range. M agee's (1992) orthopedic a s se s sm e n t text, a s well a s
Scully and B arnes' (1989) general text, cite S uadek (1990), who proposed the
90/90 test a s an a s se s sm e n t of hamstring length, and ran g es of g reater than 20
d eg ree s of knee flexion a s less than normal hamstring length. Kendall and
McCreary (1983) a s s e s s ham string length with the supine straight leg raise test.
They consider normal hamstring length to allow 70 d e g re e s of hip flexion with full
knee extension. Neither S audek or Kendall rem ark on the consideration of ag e
in developing their norms.
The impact of flexibility loss in th e elderly population m ay b e b est
understood in light of th e International Classification of Impairments, Disabilities
and H andicaps (ICIDH), the disablem ent m odel proposed by th e World Health
Organization (Jette, 1994). Disablement, a concern which is prom inent in th e
elderly population, is defined by Je tte a s "the various im pacts of chronic and
acute conditions on the functioning of specific body system s, on basic hum an
perform ance, and on people's functioning in n ecessary, usual, expected and
personally desired roles in society." (Jette, 1994,11) The ICIDH attem pts to
"delineate th e m ajor pathw ays from d isea se...to functional con seq u en ces"
(Figure 1)(Jette, 199 4 ,1 2 ).
FIGURE 1 from Je tte , 1994
INTERNATIONAL CLASSIFICATION OF IMPAIRMENT, DISABILITY & HANDICAP
DISEASE
the intrinsic
pathology
or disorder
IMPAIRMENT
—^
loss or
abnormality
of
psychological.
physiological
or anatomic
structure or
function
at organ level
HANDICAP
DISABILITY
—^
restriction
or lack of
ability to
perform an
activity in a
normal
m anner
—^
disadvantage
due to
impairment
or disability
that limits
or prevents
fulfillment of
a normal role
Applying th e age-related ch an g es in flexibility to this model, the "intrinsic
pathology" would be the aging p rocess occurring in th e m usculoskeletal tissues.
4
T he im pairm ents th at would be noted include th e primary impairm ents of
d e cre ase d flexibility of th e joints and m uscles, and th e secondary im pairm ents of
faulty balance and gait disturbances. The disabilities that could result from the
effects of th e im pairm ents on normal activities might include a d ecrease d ability
to bath e and d re ss safely, and an increased risk of falls. T he associated
handicaps could include a d ecrease d quality of life, increased likelihood of
requiring atten d an t care or institutionalization, and increased financial burdens
asso ciated with co st of treatm ent or loss of professional roles.
Falls are a m ajor so u rce of morbidity in th e elderly, and thus are the
subject of m any studies. R esearch ers are trying to identify and isolate the
factors m ost im portant in causing or predicting falls, such a s vision, vibration
se n s e , strength, balance, aerobic capacity, postural sway, and proprioception.
The relationship of th e s e factors is complex, and also influenced by social,
psychological, tem poral and environmental factors. The faller is not merely the
sum m ation of his various risk factors, and an individual's level of impairment may
not b e a valid predictor of his or her predisposition to falling. Only consideration
of all factors, intrinsic and extrinsic, and design of an individualized treatm ent
plan that includes correction, adaptation and practice, can reduce a patient's
likelihood of falling. O ne a re a of impairment that can readily be ad d ressed by
physical therapy is flexibility, which has been correlated with an increased
incidence of falls (G ehlsen & Whaley, 1990; Tinetti, 1988).
5
Physical therapists have th e education in anatom ic structure, physiology,
neural control m echanism s, and pathologic and normal age-related changes,
which particularly qualifies them to treat the asp ects of function and mobility, of
which flexibility is a part. In addition, physical therapists spend a g reat am ount of
time with th e patient, often seeing them in the environm ents in which they
function, such a s their hom e or a long term care facility. This time allows
physical therapists to a s s e s s all com ponents of functional activities, to determ ine
im pairm ents and design a specific corrective or adaptive treatm ent plan.
A sound theoretical basis for evaluation and treatm ent techniques is
required in order to maintain the integrity of the physical therapy profession.
Physical th erap ists’ lack of co n sen su s about ad eq u ate duration of stretch has
been a problem a re a in exercise prescription for a long time. This study
proposes to extend the question of duration of stretch to the elderly. Age-related
ch an g es in m uscle and connective tissue structure su g g e st that the elderly may
need to hold a stretch longer than a younger person. This study will a s s e s s the
effects of a thirty seco n d stretch, which h as been identified a s an optimal
duration of stretch in a younger population, on a group of healthy, communityliving elderly.
CHAPTER 2
REVIEW OF LITERATURE
BASIC DEFINITIONS
FLEXIBILITY
A nderson and Burke (1991, 63) define flexibility a s "range of motion in a
joint or series of joints that are influenced by m uscles, tendons, ligaments, bones
an d bony structures." They further identify two kinds of flexibility: static and
dynamic. Static flexibility is th e available range of motion of the joint, easily
m easu red in d eg rees. Dynamic flexibility is m ore difficult to define and m easure.
It is the ability of th e joint to move in it’s available range - a quantitative and
qualitative m ea su re of th e relative “stiffness" of th e joint. T he soft tissue
structures surrounding the joint contribute to it’s dynam ic flexibility. Kendall and
M cCreary also consider flexibility a s joint range of motion and all the structures
which might limit it (1983). Kisner and Colby (1990) define it a s a tissu e’s ability
to yield to a stretch force. It ap p ears that flexibility is a general term, not
exclusively applied to m uscle.
SHORTNESS OR TIGHTNESS
T h e se term s ap p ear interchangeable, and are m ore specific to description
of m uscle length. Kendall and M cCreary (1983) describe their te sts of hamstring
length with this terminology, and cite m uscle sh o rtn ess a s a c a u se of faulty
postural alignm ent and d e creased mobility. M agee (1992) u s e s the vocabulary
of tightness, a s well a s contracture, in his a s se s sm e n t of hamstring length.
Kisner and Colby define contracture a s "shortening or tightening" of m uscle or
other tissue, and go on to identify several types of contracture: "myostatic
contracture" is the adaptive shortening of a m usculotendinous unit in th e
a b se n c e of pathology (1990).
STRETCHING
Kisner and Colby (1990) define stretching a s any technique designed to
lengthen shortened soft tissue structures, and in crease range of motion. They
identify two ty p es of stretching; passive stretch and active inhibition. P assive
stretch utilizes an externally applied force, either m anual or m echanical, to
elongate th e m uscle. Active inhibition requires active participation of th e subject
to m ove th e limb into a lengthened position, thus theoretically decreasing tone,
or resistan ce to stretch, in the m uscle being stretched.
A nderson and Burke identify ballistic stretch and static stretch a s two
m ethods to stretch m uscles and other soft tissues, and proprioceptive
neurom uscular facilitation a s a m ethod of increasing length of a m uscle by
actively inhibiting the m uscle in conjunction with applying a static stretch (1991).
8
S tatic stretch in this c a s e is essentially identical to passive stretch a s described
by Kisner and Colby. Ballistic stretch is a rapidly applied stretch to a m uscle at
its en d range, which is rep eated several tim es (bouncing).
BIOMECHANICAL RESPONSE TO STRETCH
P assiv e stretch of a m usculotendinous unit s tre s s e s both th e contractile
an d noncontractile elem ents. T he noncontractile elem ents include th e parallel
elastic com ponent, which com prises th e fascial layers surrounding th e m uscle
belly, th e fasciculi and th e individual m uscle fibers, and the series elastic
com ponent, of which th e tendon is th e primary structure (P alastanga, Field, &
S o am es,1989; Taylor, Dalton, S eab er, & G arrett, 1990; Kisner & Colby, 1990).
T h e contractile elem ents are th e actin and m yosin filaments.
T he reaction of the m uscle to passive stretch is described a s having both
an elastic com ponent, described by its p assiv e tension curve, and a viscous
com ponent which includes the stre s s relaxation response, th e creep response,
hysteresis, and strain rate d ep en d en ce (Taylor e t al., 1990; Herbert, 1988;
Lehmkuhl & Smith, 1983). With any type of stretch, however, th e goal is th e
sam e ; perm anent ch an g e in th e length of th e tissue. T here is research to
support th at the tension developed in passively stretched m uscle results from the
properties of the parallel elastic com ponent, and alternatively, research that
attributes th e tension to the contractile elem ent, th e m uscle fiber itself (Herbert,
1988). W hether th e tension is concentrated in th e intram uscular connective
tissu e or in the myofilaments, th e resp o n se of th e m uscle to a low-load
9
prolonged stretch h as b ee n m easured. W hen th e stretch Is applied, tension rises
in the m uscle. If th at tension is high enough and th e stretch is held, th e tissu es
will undergo c re ep and stress-relaxation, resulting in a d e crease d tension in the
m uscle and a new resting length. T he cumulative effects of repeated low-load
stretch to a m uscle will be a perm anent change in the m uscle length.
B ecau se tendon h a s a much higher stiffness than m uscle, w hen a relaxed
m uscle is stretched the in crease In length always results from th e m uscle
lengthening, not th e tendon. Herbert (1988) cites research th at su g g e sts that the
gains in flexibility achieved after stretching are d u e to th e viscous properties of
th e m uscle and a re tem porary, lasting only eight m inutes to twenty four hours.
T he validity of this argum ent is called into question in light of th e research by
Bandy and Irion (1994), in which subjects who participated in a flexibility program
w ere given two d ay s rest before the post-test m easurem ent, and yet show ed
significant im provem ents in flexibility. The work of Taylor e t al.(1990) supports
th e ten et that increased m uscle length after stretching results from the
viscoelastic properties of m uscle, and correlates this with clinically relevant
stretching p aram eters such a s rate of stretch, duration of stretch, num ber of
repetitions, and preconditioning effects.
How long the gains resulting from a stretching program persist h a s not
been specifically studied, but it should vary depending on th e individual's activity
level and type, an d w hether a m aintenance program for flexibility w as initiated.
Both Herbert (1988), and G ossm an, S ahrm ann and R ose (1982) a g re e that
10
pathologie length c h an g e s in m uscle are correctable, and require both restoring
normal length and providing active m ovem ent and strengthening in th e new
range to maintain it. No studies, that this investigator is aw are of, com pare the
biomechanical properties of m uscle and tendon in young adult and elderly adult
subjects. B ased on current information on th e physiologic ch an g es that occur in
m uscle and tendon with age, however, it m ay be that older tissu es would have
different biom echanical properties and resp o n ses to stretch.
NEUROLOGIC CONTROL OF STRETCH
There are two primary so u rces of afferent neural information about m uscle
position and movement: the Golgi tendon organ and th e m uscle spindle. The
Golgi tendon organ (GTO) is the sensory organ receptive to ch an g es in tension
of a muscle. It is m ost receptive to ch an g es th at result from active m uscle
contraction. It is only sensitive to passive tension, due to stretch of a relaxed
m uscle, w hen the stretch is n ear th e end of the physiologic range of the muscle.
If the m uscle is suddenly stretched or exposed to an excessive tension in this
end range, the GTO will be activated. The resp o n se in this c a se would be
twofold: increased activity of Group lb afferents synapsing disynaptically or
polysynaptically on lb inhibitory interneurons, would inhibit the alpha motor
neuron of th e agonist and synergist m uscles. Simultaneously, increased
stimulation of lb excitatory interneurons would facilitate th e alpha motor neurons
to the antagonists. This would effect a joint m ovem ent aw ay from the maximally
stretched position. Obviously, this is not a therapeutic u se of th e GTO to
11
increase m uscle length, how ever It m ay result from an inappropriate stretching
technique (Moore, 1984).
T h e m uscle spindle is the sensory organ that h a s traditionally been
considered to control a m uscle's resp o n se to stretch. Information regarding
m uscle spindle structure and function can b e found in Sholz and Cam pbell's
(1980) review of th e m uscle spindle, a s well a s Kandel, Schwartz, and Jessell's
neurology text (1991). Historically, it h a s b een believed th at a s a m uscle is
passively lengthened, th e ch ange in length is se n se d by the spindle, and through
it's afferent and efferent connections, facilitation of th e hom onym ous and
synergist m uscles and inhibition of the antagonist m uscles would occur. The
quantity and rate of stretch effect the m agnitude of th e response, so that g reater
ch an g es in length or g reater velocities of stretch produce rapid recruitm ent of
larger num bers of alpha motor neurons to resist th e stretch. T he tension
produced during th e stretch w as supposed to be primarily th e result of this neural
control loop. Today, it is believed that the primary functions of th e m uscle spindle
and GTO are to provide proprioceptive input to the central nervous system , but
resp o n se to th at information is controlled by higher neurologic centers. This
d o esn 't m ean th at th e connections described earlier don't exist or function. It
d o es m ean that their function can be modified by higher centers, which m ay in
fact override their reflex actions depending on the situation. This change in
perception of th e function of th e m uscle spindle com es a s a result of research on
electrom yography (EMG) resp o n se to lengthening of m uscle, and characteristics
12
of innervated and denervated m uscle in resp o n se to stretch (Sholz & Campbell,
1980; Taylor e t al., 1990).
Additional information about m uscle and joint position and m ovem ent is
received by both joint m echanoreceptors and cu tan eo u s m echanoreceptors.
T h e se receptors are stim ulated by th e m echanical deformation of non-m uscular
tissu e s th at acco m p an ies m ovem ent of a joint o r by the m echanical deformation
of the skin a s a joint m oves through a range of motion. Information from th e se
receptors can either facilitate or inhibit the reflex activity of a m uscle or tendon,
th u s influencing tone in th e m uscle (Isaacs, 1993). Kandel cites a study by
G andeviam , McCloskey e t al. which found that for b est position sensation,
cutaneous, joint and m uscle spindle afferents n eed to b e working together
(1991).
CORRELATION BETWEEN FLEXIBILITY AND FALLS
According to Hornbrook, S tev en s and Wingfield (1983, 309), falls are "a
com plex equation of th e interactive elem ents of impaired physical and sensory
function, reduced health status, risk-taking behaviors, and environmental
hazards." They describe a model for understanding th e etiology of falls,
stressing that interventions need to be both deficit specific and functional (S ee
Fig 2).
13
FIGURE 2 from Hornbrook, 1993 (310)
BIOBEHAVIORAL-ENVIRONMENTAL MODEL OF FALLS
PHYSICAL STRUCTURE
Strength
Jo in ts-ran g e , pain
S en ses-v isio n , vestibular, so m atosensory
Brain structure
PHYSIOLOGIC FUNCTION
Balance
Reaction time
Coordination/pm pnoception
Gait
Cognitive function
BEHAVIOR
Risk taking
Preventative/protective behaviors
Adaptive behavior
ENVIRONMENT
Gradient of surface
Texture of surface
Lighting
R esilience of surface
O bjects in pathway
Extemal forces-gravity, moving object
OUTCOME
Fails
Injuries
Medical c a re use
Death
Quality of life
14
Theorized benefits of exercise include a reduced risk of falling, and a
reduced incidence of injury given a fall (Buchner & Colem an, 1994). Tinnetti,
S peechley and Ginter (1988) studied risk factors associated with falls, and while
they did not ad d re ss flexibility specifically, they did a s s e s s gait and balance
disturbances, attributing th e se to underlying neurologic and m usculoskeletal
impairments. They found that deficits in balance and gait significantly increased
risk of falling. Risk of falling w as found to in crease linearly a s the num ber of risk
factors increased. Multiple risk factors for falls are commonly found in the
elderly. G ehlsen and W haley (1990) com pared balance, strength and flexibility
betw een a group of elderly with no history of falls to a group with a history of
falls. They found a significant difference betw een the groups in flexibility
m easu res of hip flexion and knee flexion, with non-fallers having greater range of
motion than fallers.
T he Frailty and Injuries: Cooperative S tudies of Intervention Techniques
(FICSIT) trials, a series of seven independent studies assessin g efficacy of
intervention techniques to reduce incidence of falls in the elderly, included
flexibility training, in conjunction with other interventions such a s strengthening,
balance, en d u ran ce training, medication ch an g es, education, behavioral
changes, functional activity training, and/or nutritional supplem entation. Results
of all studies w ere published a s a M eta-analysis (Province e t al.,1995). Results
show ed significantly reduced risk of falls in two of the seven groups, and near­
significant reduction in falls in another two groups. The other three studies
15
show ed an increase in falls in th e treatm ent group. Overall, assignm ent to a
group that received an exercise intervention led to d ecrease d incidence of falls
at P = .07, which ap p ro a ch e s significance. Attempts to isolate effects of single
exercise types show ed b alan ce training a s the only significant intervention.
However, this finding should be viewed cautiously, a s fall incidence w as the
result of th e interactive effects of th e interventions in th e trials.
BIOLOGIC AND PHYSIOLOGIC EFFECTS OF AGING
In a review of th e literature on age-related m uscular ch an g es, Payton and
Poland (1983) found th at th e aging pro cess resulted in m uscle atrophy d u e to
both a loss in num ber an d size of m uscle fibers, d ecrease d conduction at the
myoneural junction, d e c re a se d mitochondrial activity evidenced by a d e c re a se in
mitochondrial enzym es, and increased fibrofatty deposition in th e m uscle.
Pickles (1989) su g g ested th at there is also a loss of fluid and inorganic
salts, resulting from degeneration of the sarcolem m a, which contributes to
reduced force-production capacity in m uscles, a s well a s sym ptom s of lethargy.
Donatelli and O wens-Burkhart attributed loss of fluid to d e crease d s p a c e
betw een collagen fibers. They su g g ested that this results in d e c re a se d mobility
of collagen fibers a t th e m olecular level and increased collagen fiber crosslink
formation (1981). Dehydration is a common occurrence am ong th e elderly and
potentially in creases th e se normal a g e related effects. The theoretical results of
th e se ch an g es in tissu e composition and structure is a d e c re a se d extensibility of
th e tissu es.
16
In a study of ch an g es In rat tendon properties with aging, Vaiias, Pedrini,
Pedrini-Mille, and Holioszy (1985) found th e following: there w as no significant
difference b etw een young and elderly rats, reg ard less w hether they had
exercised or w ere sedentary, in patellar tendon dry weight. However, there w as
significantly increased collagen content and d e c re a se d ground su b stan ce in the
older rats. If this finding is extended to hum an subjects, the increased proportion
of collagen com bined with d ecreased matrix would se e m to support a loss in
extensibility an d increased stiffness in th e tissues.
W eston (1993) found increased collagen stability, which he concluded
w as not d u e to increased num ber of cross-linkages, but to increased strength of
cross-link bonds. This stability resulted in d e c re a se d collagen com pliance with
increased ag e. This effect is increased by immobility and d ecrease d by exercise
(Donatelli & Owens-Burkhart, 1981; Woo, G om ez, Amiei, Ritter, G elberm an,
A keson,1981).
EFFECTS OF EXERCISE IN THE ELDERLY
In spite of th e many ch an g es th at result with aging, elderly tissu es are still
able to respond to a training stimulus with improved function (Menard, 1993). In
a study by Mills (1994), elderly patients who participated in a low-intensity
aerobic exercise program show ed significant im provem ents in flexibility. Frekany
and Leslie also found improved flexibility in patients over a g e 71 following an
exercise program to improve flexibility (1975). For a review of m any studies on
exercise effects on skeletal m uscle structure and strength, th e read er is referred
17
to Finch an d S chneider's H andbook of th e Biology of Aging (1985). To this
re se a rc h e r's knowledge, no study h a s b een d o n e to d ate to a s s e s s a treatm ent
protocol for improving flexibility, designed for and tested on a younger
population, in an older population, which is th e purpose of this study.
STUDIES ON STATIC STRETCH
D ebate exists a s to th e effectiveness of static stretch to improve flexibility
of the ham strings. Many studies have ad d re sse d the effects of static stretch
(Starring, G ossm an, Nicholson & Lemons, 1984; W essling, DeVane, & Hylton,
1987; Madding, W ong, Hallum & M adeiros, 1987; Gajdosik, 1991; Bandy & Irion,
1994). Bandy and Irion's 1994 study of effect of duration of static stretch on
gains in flexibility is the m ost recent, and is a well designed study. Randomly
assigning fifty-seven m ixed-sex subjects ag ed 20 to 40 y ears to four groups, one
control group which received no stretch, and th ree treatm ent groups which
received 15, 30 or 60 second stretches, th e research ers conducted a six w eek
program of static stretching to the hamstring m uscles. Individuals stretched o n e
time p e r day, five tim es per week, for six w eeks.
P rete st and po sttest m easu res of ham string flexibility, a s s e s s e d by the
90/90 test, w ere com pared using an AN OVA to determ ine any significant
differences betw een th e four groups. It w as found that there w as a significant
difference in final range of motion sco res betw een the groups who had stretched
for 30 or 60 se c o n d s versu s the control or th e group who stretched for 15
sec o n d s. Further, it w as found that th ere w as no significant difference betw een
18
th e group who stretched for thirty seco n d s and th e group who stretched for sixty
seconds. From th e s e findings, it ap p ears that a thirty to sixty second static
stretch repeated daily for six w eeks is sufficient to produce plastic deformation of
the hamstring m uscles.
From this study, the research ers concluded th at a period of at least 30
seco n d s w as optimal for improving flexibility. Stretching durations longer than 30
seco nd s w ere questionable in their ability to improve flexibility more than 30
second stretches. T he findings of Bandy and Irion contradict th e earlier study by
Madding, Wong, Hallum and M adeiros (1987). In a study of 72 male subjects
aged 22-40 years, they found that for a single repetition of passive stretch, 15
seco n d s of stretch produced significant gains in flexibility of th e hip adductors.
S tretches of 45 se co n d s and 2 minutes produced no significant difference in
flexibility com pared to 15 second stretches. The disparity betw een th e se two
studies may be explained with several considerations. The sam ple size used by
Madding e t al. w as only 18, and w as perhaps too small to accurately reflect the
differences betw een the levels of the independent variable. Different m uscle
groups w ere used in the studies, which could have different resp o n ses to stretch.
Also, the Madding e t al. study applied only a one-tim e stretch, m easuring the
gain in flexibility immediately after the stretch. In this case, the resultant increase
in length of the m uscle could be considered com pletely due to the hysteresis
resp o n se of the m uscle. This is not a clinically significant application of
stretching, and it would b e questionable to apply th e findings of the study to a
19
clinical model in which a stretch is repeated several tim es a day, for a prescribed
num ber of d ay s or w eeks, the sum m ative effects of which would be perm anent,
or plastic, length changes. T he Bandy & Irion study attem pted to apply a more
clinically relevant stretching protocol, how ever they did not a d d re ss th e effects of
varying th e num ber of stretch repetitions per day on flexibility.
T h ere a re m any studies which com pare different stretching techniques,
such a s static stretch, PNF stretching techniques, and prolonged stretch (Light,
Nuzik, P erso n iu s & Barstrom, 1984; Etnyre & Abraham, 1986a, 1986b; G odges,
M acR ae, Longdon, Tinberg & M acRae, 1989; Sullivan, DeJulia & Worrell, 1992;
H aibertsm a & G oeken, 1994). T h e se studies all apply th e techniques with
different protocols, making judgm ents a s to th e validity and generalizability of the
results difficult. In all of the studies cited, however, static stretch h a s b een found
to be effective to increase flexibility. It is a technique asso ciated with minimal
risk of injury, it is easy to tea ch and to learn, and can b e reliably reproduced by a
variety of patients in a hom e program. Further, in order to m ake com parisons
betw een stretching techniques, it would b e ad v an tag eo u s to first identify th e b est
protocols for each of the techniques, using th e se a s a basis for com parison.
CHAPTER 3
METHODOLOGY
DESIGN
T he p urpose of this study w as to determ ine th e effect of a thirty second
static stretch on ham string m uscle extensibility in healthy, community-living
elderly in th e W est Michigan area. It is a p retest and posttest control group
experim ental design.
POPULATION AND SAMPLE
This study u sed a convenience sam ple of healthy, community-living
elderly persons, m ale and fem ale, residing in a federally-subsidized housing
complex. All volunteers w ere screen ed on th e criteria for inclusion or exclusion
in th e study. All individuals were: ag e 65 or older; independent in all activities of
daily living; com pleted th e Medical History Q uestionnaire (Appendix A); signed
an informed co n sen t form (Appendix B); undenwent a screen of p resent physical
statu s (Appendix 0); had g reater than 15 d e g re e s of knee flexion while
maintaining 90 d e g re e s of hip flexion (90/90 test); and ag reed not to begin or
esc a la te an exercise program during th e duration of th e experim ent. Criteria for
exclusion from th e study included: requiring so m e level of assisted living; failure
to sign th e informed consent form; previous medical history of low back, pelvis,
20
21
hip or lower extremity fractures, active low back pain or history of laminectomy,
d iab etes, peripheral vascular d ise a se or leg cram ps, stroke, rheum atoid arthritis,
hip or k n ee replacem ent, or any chronic medical condition which might effect
normal re sp o n se of th e lower extremity to stretch; findings on physical screen of
a positive neural tension test, less than 110 d eg re e s of p assiv e hip flexion, less
than 0 d e g re e s of passive knee extension, 90/90 te st of less than 15 d eg rees
knee flexion, an d signs of neurological dysfunction such a s unilateral m uscle
w eak n ess or sen so ry changes; not agreeing to delay Initiating or Increasing the
Intensity of an exercise program for th e duration of th e experim ent; and
unavailability of a watch or clock with a second hand to tim e th e duration of
stretch.
EQUIPMENT
A fifteen-inch, double-arm ed, full-clrcle goniom eter w as used to a s s e s s
ran g e of motion at th e terminal point of the 90/90 test. T h e goniom eter w as
m easu red ag ain st th ree known angles drawn with a protractor, to reduce
system atic error. The ICC value calculated from th e s e m e a su re s w as 1.000.
Testing w as perform ed on a portable plinth. O ne Inch wide cotton belting
m aterial w as provided by the researcher, and used to hold th e leg in a position of
static stretch to the ham strings.
22
PROCEDURES
After completion of the Human Subjects Review pro cess at Grand Valley
S tate University, th e director of the apartm ent complex w as approached and
presented a sum m ary of the proposed experim ent. Upon approval to u se the
site, volunteers w ere recruited by u se of flyers posted around th e building.
Twenty-eight volunteers signed up at the front desk. T he research er contacted
by phone all p erso n s who signed up to answ er any questions they had, and to
adm inister portions of the Medical History Q uestionnaire, to determ ine if they had
any condition which would m ake them ineligible to participate. Subjects who
w ere eligible w ere scheduled a one hour appointm ent with th e researcher. This
appointm ent consisted of signing the informed co n sen t form (Appendix B),
completion of the Medical History Q uestionnaire (Appendix A), the physical
exam ination (Appendix 0), a pretest m easurem ent of th e individual's hamstring
m uscle flexibility a s m easured by the 90/90 test, and instruction in the stretch
technique (Appendix D). The 90/90 test w as performed using th e surface
landm arks described by Norkin and White (1985) a s follows: Subjects were
positioned supine with both th e hip and knee of the leg to be m easured in 90
d e g rees of flexion; the center of the goniom eter fulcrum w as positioned over the
lateral epicondyle of th e femur, the proximal arm aligned with the greater
trochanter, and th e distal arm aligned with the lateral malleolus of the tibia. The
knee w as passively extended to the point w here resistance to further motion w as
felt by th e exam iner or the subject. The right leg w as arbitrarily chosen a s the
23
te st leg, unless th e individual reported a history of previous injury of th e right hip,
knee, or ankle, in which c a s e the left leg b ecam e th e te st leg. The opposite, or
untested leg, w as m aintained in hip and knee flexion with th e foot flat on th e mat,
to flatten the low back, and to eliminate any effect tight hip flexors may have had
on th e m easurem ent.
At this point, any subjects who did not m eet the criteria for inclusion in the
study w ere eliminated. All twelve remaining subjects w ere instructed in th e
stretch technique, although not all w ere subsequently assigned to the group
which perform ed the stretch.
Static self-stretch of th e ham strings w as
performed in a supine position, using one-inch wide cotton belting which w as
held in the su b jects h ands and looped around th e heel of the leg to be stretched,
with the knee held in extension, and with the arm s supporting the weight of the
leg. Subjects u sed their arm s to raise th e leg until th e point w hen a mild
stretching sen satio n w as felt in the back of th e thigh. This intensity rep resen ts a
clinically accep ted low-ioad stretch. An exercise log (Appendix E), to docum ent
daily completion of the stretch, a s well a s a written sh e e t of instructions for
proper perform ance of the stretch, w as delivered and explained to all subjects.
To en su re learning of the proper perform ance of th e stretch, all subjects w ere
required to perform the stretch with no verbal guidance from th e researcher.
O nce initial data collection w as com pleted, each subject w as randomly
assigned to on e of two groups, and th o se two groups w ere randomly designated
a s control group or treatm ent group. S ubjects w ere notified by phone of which
24
group they w ere in an d of th e experim ent start date. Individuals in the control
group (n = 6 ,1 m ale and 5 fem ale, m ean a g e = 76.3, standard deviation = 8.29)
did not perform th e stretch during the experim ent, and individuals in the
treatm ent group (n = 6, 6 fem ale, m ean a g e = 73.5, standard deviation = 4.81)
performed a hom e program of o ne stretch sessio n per day, holding th e stretch
for thirty seco n d s, tim ed by a w atch or clock. They com pleted one repetition of
th e stretch p er sessio n , sev en day s per w eek, for a total of four w eeks. Each
com pleted stretching sessio n w as docum ented in th e exercise log. After four
w eeks, all subjects w ere retested on the 90/90 te st using identical m ethods a s
described for th e pretest.
DATA ANALYSIS
Intratester reliability w as determ ined by a test-retest design on 3 subjects
from th e control group, using the pretest m easu re and a m easu re taken one
w eek later to determ ine th e intraclass correlation coefficient. To determ ine
w hether significant differences betw een th e two groups existed, an analysis of
covariance (ANCOVA) w as performed, using th e p retest m e a su re s of hamstring
flexibility a s th e covariate. Significance for all statistical te sts w as accepted at
th e .05 level (Portnoy & Watkins, 1993).
CHAPTER 4
RESULTS
The results of pretest, one-w eek and p o sttest m easu res of hamstring
flexibility using th e 90/90 te st of all subjects is p resen ted in T able 1. T he m ean s
for p retest and p o sttest m easurem ents, and th e adjusted m ean s from the
ANCOVA, for ea c h group are presented in Table 2.
TABLE 1
PRETEST, ONE WEEK AND POSTTEST MEASURES
OF HAMSTRING FLEXIBILITY OF ALL SUBJECTS (90/90 test)
ID #
1
2
3
4
5
6
7
8
9
10
11
12
GROUP
C
C
T
T
0
C
T
T
0
T
0
T
PRETEST
24
50
49
17
20
23
42
42
49
42
34
36
ONE WEEK
23
29
NA
NA
NT
24
NA
NA
NT
NA
43
NA
POSTTEST
18
47
40
0
19
26
27
41
38
20
40
28
C = control group T = treatm ent group
NA = not applicable, a s th e se w ere subjects in the treatm ent group
NT = not tested, subjects in the control group not included in th e reliability study
25
26
TABLE 2
MEAN AND STANDARD DEVIATION VALUES FOR PRETEST,
POSTTEST, AND ADJUSTED PO STTEST (in d eg rees) OF
HAMSTRING FLEXIBILITY FOR BOTH GROUPS
GROUP
CONTROL (n=6)
TREATMENT (n=6)
PRETEST
33.3 (13.38)
38.0(11.08)
POSTTEST
31.3 (12.03)
26.0 (15.09)
ADJUSTED
PO STEST
33.6
23.7
T he intraclass correlation coefficient (ICC) value for the intrarater reliability
study using pretest and one-w eek m easu res of hamstring flexibility (n = 3) of the
control group w as .88. T he ICC value of pretest and p osttest m easu res of
hamstring flexibility of th e control group (n = 6) w as .92.
All subjects in the treatm ent group show ed im provem ent in 90/90 test
sco res a t posttest, with a m ean gain of 12.0 d eg rees, standard deviation of 7.48
d eg rees, and range of 1-22 degrees. One individual in the treatm ent group
show ed a minimal improvement of only one d egree. T he reason for this is
unclear. It m ay be that the subject w as not compliant with the daily perform ance
of th e stretch, or performed the stretch incorrectly.
T he ANCOVA results (S ee Table 3) show ed no significant interaction
betw een group and treatm ent (p = .316), and a significant difference betw een
treatm ent and control for p retest and posttest m easurem ents of hamstring
flexibility (p = .046). The covariate, pretest range of motion of knee flexion, w as
27
found to be significant at p = .001. Statistical power analysis revealed a power
of .541.
TABLE 3
ANALYSIS OF COVARIANCE FOR ADJUSTED MEANS: COMPARISON OF KNEE FLEXION
MEASUREMENTS FOR TREATMENT AND CONTROL GROUPS
Source of variance
df
SS
MS
F
P
covariate
1
1395.56
1395.56
26.97
.001
betw een
groups (adjusted)
1
277.33
277.33
5.36
.046
within groups
(error)
9
465.77
51.75
11
1946.67
176.97
Totai
CHAPTER 5
DISCUSSION AND CONCLUSIONS
DISCUSSION OF RESULTS
This study a s s e s s e d resp o n se of healthy elderly to a thirty-second static
stretch of th e ham strings m uscles. R esults of the ANCOVA dem onstrated th at
for this sam ple, a thirty-second static stretch of th e ham strings performed once
daily for four w eeks produced a significant im provem ent in 90/90 test
m easu rem en ts of hamstring flexibility.
Pow er w as calculated a s .541, primarily d u e to th e small sam ple size.
T he effect of this low pow er is on th e generalizability of th e findings to the targ et
population. Although the findings w ere significant in spite of the low sam ple size,
th e sco p e of this study m ust b e limited to a pilot study. Reproduction of the
study on a larger population is required in order to m ake predictions to the
population of healthy elderly. Discussion of the findings of this study will only be
ab le to com pare it’s sam ple’s results to previous research.
Intratester reliability for the goniom etric m easurem ents w as high
(ICC = .88), however th ere w as one outlier in the o n e w eek m easurem ent data
which w as excluded. This individual’s p retest knee flexion m easurem ent w as 50
28
29
d eg re es, one-w eek m easurem ent w as 21 d eg rees, and posttest m easurem ent
w as 47 d eg ree s. R easo n s for th e discrepancy in one-w eek m easurem ents w ere
not clear. T he subject reported no m edication ch a n g e s which may have affected
h er flexibility. S h e did, however, report a recent in crease in activity level,
unrelated to exercise. It is possible that her increased activity level, which
required a g re at deal more walking than usual, m ay have had an effect on her
ham string length. Another explanation for th e lower o n e w eek m easurem ent
w as th at s h e w as preoccupied at th at time, and not attending a s much to the
sen satio n of stretch in her hamstring, allowing an increased range of motion a t
the knee. Another possible explanation for th e discrepancy is tester error,
although consistency in technique w as practiced throughout th e study.
T he decision to exclude the m easu rem en t w as b ased on several factors.
T he large difference betw een th e pretest and w eek-one sco res w as not
supported by th e posttest sco re to be a true value. An ICC value w as calculated
using th e p retest and p osttest sco res of th e entire control group and w as found
to support exclusion of this subject from th e reliability study (.92). The reliability
coefficients, with the outlier excluded, fell within th e ranges reported by other
studies which a s s e s s e d intratester reliability (ICC ranges of .80 to .99). Finally,
clinical ex perience did not support such a vast ch an g e in flexibility which w.js
then reversed, a s th e se m easurem ents implied. Exclusion of this subject
however, b e c a u se of the small sam ple size, reduced the value of the reliability
m easu re. By excluding one subject from th e reliability data, one-fourth of the
30
sam ple w as excluded. Inclusion of that subject, however, would lower the
reliability to .34, which is unacceptable for the application of any statistical tests
to the data.
DISCUSSION OF RESULTS WITHIN THEORETICAL FRAMEWORK
Although th ere a p p e a rs to b e a scientifically b a se d c o n se n su s of the
effects of aging on m usculoskeletal tissue structure and biom echanical
properties, th e relationship of th e s e ch an g es to function in th e elderly h a s yet to
be studied. A ge-related ch a n g e s in m uscle and connective tissue would su g g est
a d ec rease d level of flexibility in th e elderly, a s well a s a d e c re a se d re sp o n se to
a stretch stimulus. This study dem onstrates an attem pt to relate known effects of
aging, such a s d e c rea se d connective tissue extensibility and in creased fibrofatty
deposition in th e m uscle, with th e functionally significant attribute of flexibility.
This study a s s e s s e d th e effect of a thirty-second, low load, static stretch program
on ham string m uscle flexibility in subjects over a g e sixty-five, and found a
significant effect in this sam ple. Therefore, it ap p ears th at th e p aram eters of
frequency, duration, and intensity which w ere applied in this study w ere sufficient
to create a perm anent ch an g e in hamstring m uscle length in th e su b jects of this
sam ple. T he impact of this finding on treatm ent of elderly patients with flexibility
loss is suggestive that, for the elderly patient with adaptive m uscle shortening,
therapists n eed not in crease durations of stretch beyond 30 se c o n d s to show
significant improvement. However, the relationship of a g e and intrinsic m uscular
31
or neurologic pathology with stretch h as not b een a d d ressed within this study,
and might h av e significantly different results.
DISCUSSION OF RESULTS COMPARED TO LITERATURE
T he results of this study support previous research nndings that static
stretch im proves flexibility, and su g g ests that in th e healthy elderly it is an
effective treatm en t for improving flexibility. Thirty se c o n d s w as ch o sen a s th e
stretch duration b a sed on the study by Bandy and Irion (1994), which found that
in a healthy younger population, stretch durations of thirty seco n d s w ere a s
effective a s sixty seco n d s in improving flexibility. Thirty seco n d s w as also a
sufficient duration to result in significant im provem ents in hamstring flexibility in
this sam ple of elderly subjects. Another finding of this study is that a four w eek
protocol of stretching, one time per day every day, resulted in significant
im provem ent in flexibility. Clinically, this is significant, for a s time allotted by
insurance com panies for therapy b ased on diagnosis is closely monitored and
often cut, th erapists can improve efficiency by incorporating flexibility exercises
in a hom e program , and still expect significant results in a four w eek period.
This study ad d s to the research differentiating stretch techniques by
providing information on response of healthy elderly to a static stretching
protocol. T he clinical significance of this is that, while the d e b a te about m ost
effective stretching m ethod may continue, therapists should feel confident in the
choice to prescribe a static stretching hom e program to their patients, knowing
that it will result in significantly improved range of motion. In regards to the
32
elderly, this study su g g e sts that in th e a b se n c e of pathology elderly patients will
also benefit from static stretch program s, although additional studies with a
larger sam ple are required to improve th e confidence of that
statem ent,
CONCLUSIONS
This is the first study which h as a s s e s s e d resp o n se of people over ag e
65 to stretch. Although th e sam ple size limits generalizability of th e results of
this study, the finding of significant im provem ent in ham string flexibility in the
treatm ent group affirms th e need for additional studies on th e effect of stretching
procedures on the elderly.
LIMITATIONS OF STUDY
The m ost significant limitation of this study is th e low pow er (.541), which
c re a te s limitations regarding th e generalizability of th e results to th e target
population of healthy elderly. O ther limitations of this study included th e use of a
hom e program to apply th e treatm ent variable, which introduced th e possibility of
communication of information betw een the groups that might have affected th e
results. This risk w as increased b e c a u se all subjects w ere instructed in the
stretch technique. Also, com pliance may have been d e crease d in th e hom e
program, and individuals m ay have falsely stated that they perform ed th e
treatm ents a s required. Subjects learned the stretch technique in o n e session
with no opportunity for the research er to retest to assu re they had retained it.
33
Consequently, subjects could have b een performing the stretch Incorrectly during
the experim ent.
RECOMMENDATIONS FOR FURTHER RESEARCH
T here a re several variables which should b e considered in a study of the
relationship of a g e and flexibility. To ad d re ss within th e sa m e study the effect of
the sam e stretching program on both a younger population and an elderly
population, including a variety of stretching durations a s in th e Bandy and Irion
study, would m ake it possible to m ake direct com parisons betw een older and
younger su b jects’ resp o n se to stretch. It would also be valuable to a s s e s s
resp o n se of elderly subjects to a variety of stretching techniques, such a s lowload prolonged stretch, PNF stretch techniques and static stretch. Finally, further
research to a s s e s s the im pact of d e crease d flexibility of various m uscle groups
on function in both the healthy and patient elderly populations will aid clinicians
•j
in justifying stretching program s for th e se patients.
34
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39
APPENDIX A
40
APPENDIX A
MEDICAL HISTORY QUESTIONNAIRE
Researcher to review with subject
ID#____________________________
Date
_____
page 1 of 2
HAVE YOU EVER HAD OR CONSULTED A PHYSICIAN FOR;
Back injury, back pain, x-rays
Arthritis or gout (which joints_____________ )
Lupus erythem atosus
Brain injury/head injury
Spinal cord Injury
Stroke
Knee pain/injury/surgery
Hip pain/injury/surgery
D iabetes
C ancer,tum or,cyst
Edem a, lym phedem a
Leg cram ps
V ascular d ise a se , claudication, PVD
Cardiopulm onary problem s
CORD
Chronic lung d ise a se
Em physem a
H eart attack
Multiple Sclerosis
Parkinson's d ise a se
H ypertension
Fractures (where__________________________ )
Guillane-Barre
Poliomyelitis
Spina bifida
Vision/eye problem s/glasses
Hearing loss/hearing aid
Com m ent on an y y es answ ers:
y es
__
__
__
__
__
__
__
__
__
__
__
__
__
no
__
__
__
__
__
__
__
__
__
__
__
__
__
_
__
__
__
__
__
__
_
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
41
MEDICAL HISTORY QUESTIONNAIRE
page 2 of 2
ID # ________________ ___________
D ate___________
_Any other p a st or p resen t health problem not listed?
_Have you ev er received physical therapy? If "yes", for w hat conditions?
_List p a st surgeries:
_List m edications currently taking:
_Do you require any a ssista n c e from an o th er individual to perform any of th e
following (circle if yes)
bathing/grooming/toileting
dressing
preparing food/eating
m aintenance of your hom e (light housework)
42
APPENDIX B
43
APPENDIX B
page 1 of 2
INFORMED CONSENT TO PARTICIPATE
Grand Valley S tate University D epartm ent of Physical Therapy study on effect of
duration of static stretch on gains in ham string flexibility in the elderly.
Principal Investigator: Erin Bloomquist,Student FT
1, th e volunteer subject, understand that I am agreeing to participate in a
physical therapy g raduate research study designed to study the effect of duration
of stretch on flexibility of th e hamstring m uscle group, the m uscles in the back of
th e thigh, in p erso n s a g e 65 and older. This study will add to physical therapists
knowledge of how b est to treat elderly patients with loss of flexibility.
I understand that I will be asked to submit to several screen s to determ ine
my eligibility to participate in the study, which include a physical exam , a medical
history questionnaire, and a screen for level of independence in daily activities. I
understand th at I m ay not be chosen to participate in th e study b ased on the
findings in th e screen , and that if chosen, 1 may not be included in the group to
receive th e stretching treatm ent. I understand that the research er will need to
schedule o n e hour for this screen and instruction in the stretching technique. 1
understand th a t I will be asked to w ear a gown during parts of this experim ent,
which will b e provided by th e researcher, in order to allow the researcher to
locate and m easu re my range of motion, and that I will be draped with a s h e e t
for m odesty.
I understand that this is not required of m e for participation in the
study.
I understand that during this study I should not experience any pain; the
stretching procedure should only feel like a mild stretch. I understand th e risks
asso ciated with th e activities performed in this study, though minimal, include
overstretching, which could cau se pain in the m uscle. In the event of an injury in
44
page 2 of 2
the co u rse of this study, I understand it will b e m y responsibility to seek medical
attention through my family physician.
I understand that the information obtained during this study will be kept
confidential. If th e data are used for publication, no n am es or other identifiers
will be used.
I understand that my participation in this study is on a volunteer
b asis and th at 1 may withdraw from th e study at any time. I also understand that
the research er m ay term inate my participation in this study a t any time after sh e
h as explained th e reason for doing so. I understand th at any questions I have
regarding this study will be answ ered a t any time. Erin Bloomquist, the primary
researcher, will b e available a t (616)874-8676, to answ er my questions. I may
also contact the Chair of the R esearch Committee, J a n e Toot, at Grand Valley
S tate University, phone num ber (616)895-2682, or Paul Huizenga, Head of
Human S ubjects Review at G rand Valley S tate University, phone num ber (616)
895-2472.
I have explained t o _____________________________th e purpose of the research,
the p rocedures required, and th e possible risks and benefits to the b est of my
ability.
Investigator
Date
1 confirm th at Erin Bloomquist h as explained to m e th e purpose of the research,
the study procedures, and the possible risks and discom forts a s well a s benefits
that I may experience. I have read and understand this co n sen t form.
Therefore, I a g ree to give my consent to participate a s a subject in this research
project.
Participant
W itness to Signature
Date
Date
45
APPENDIX C
46
APPENDIX C
PHYSICAL EXAMINATION FORM
Date___________ Page 1 of 2
ID#___________________________
DOB_____________
SEX_____
HEIG HT.
WEIGHT
OBSERVATION
Posture:
Gait:
AROM (with overpressure):
L
F=full motion; L=limited motion
peripheral joint scan _________________________________
arm s behind head
__
arm s behind back
__
arm s over opposite shldr.
__
wrist flex/ext
__
hand open/close____________________________ __
sq u a t and recover
stork
lum bar spine and pelvis
__
flexion
extension
__
lateral flexion
__
rotation (sitting)
__
FOR ANY RANGE "L" DESCRIBE ENDFEEL AND PAIN:
47
STRENGTH
C1/C2-CERVICAL FLEX/EXT/ROT/LATFLEX
C3/C4-SH OU LD ER SHRUG
C 5-SH 0U L D E R ABDUCTION
CG-ELBOW FLEXION
C 7 -E L B 0 W EXTENSION
C8-THUMB EXTENSION
T1-F1NGER ABDUCTION
L2-H IP FLEXION
L3-KNEE EXTENSION
L4-ANKLE DORSIFLEXION
L5-EXT. HALLICUS LONGUS
S1/S2-AN KLE PLANTARFLEXION
P ag e 2 of 2
L
R
_
_
_
_
_
_
_
_
_
_
_
__
DERMATOME SCAN (note any assym m etry)
C4-T1;L1-S1
REFLEXES/TONE
BRACHIORADIALIS
C5/C6
BICEPS
C6
TRICEPS
C7
QUADRICEPS
L2-L4
GASTROC-SOLEUS
S1/S2
L
__
_
_
_
_
R
_
_
_
_
_
FLEXIBILITY
ILIOPSOAS (THOMAS TEST)
RECTUS FEMORIS(MOD. THOMAS)
HAMSTRINGS (90/90)
TFL(OBER)
ADDUCTORS
_
____
__
_
_
_
_
_
_
_
_
_
DURAL MOBILITY
STRAIGHT LEG RAISE
PRONE KNEE BENDING TEST
48
APPENDIX D
49
APPENDIX D
INSTRUCTIONS FOR HOME STRETCHING
TO BE PERFORM ED ONE TIME PER DAY, EVERY DAY, FOR FOUR WEEKS
1. LIE ON YOUR BACK ON THE FLOOR.
2. BEND BOTH HIPS AND KNEES SO THAT YOUR FEET ARE ON THE
FLOOR.
3. LOOP THE STRETCH CORD AROUND YOUR RIGHT ANKLE, RAISING
YOUR FOOT OFF THE FLOOR TO DO SO.
4. PULLING WITH YOUR ARMS, LIFT YOUR LEG SO THAT YOUR KNEE
STRAIGHTENS. AT SOME POINT, YOU WILL FEEL A STRETCH IN THE
BACK OF YOUR THIGH.
5. HOLD THE LEG IN THE POSITION AT WHICH YOU FEEL THE STRETCH
FOR THIRTY SECONDS (BY THE CLOCK TIM ER ). IT SHOULD NOT BE
PAINFUL, ONLY A STRETCHING SENSATION. USE YOUR ARMS TO HOLD
YOUR LEG UP.
6. AFTER THIRTY SECONDS SLOWLY LOWER THE LEG DOWN TO THE
FLOOR.
7. MARK O FF ON YOUR EXERCISE LOG AFTER COMPLETING THE
STRETCH.
50
APPENDIX E
51
EXERCISE LOG
INSTRUCTIONS: EACH DAY THAT YOU PERFORM THE EXERCISE, MARK
OFF IN ONE SPA CE IN THE EXERCISE LOG. YOU NEED TO DO ONE
STRETCH P E R DAY FOR FOUR W EEKS. IF YOU MISS A DAY, DO NOT
MARK A SPACE.
DAY
WEEK
1
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
2
3
4