Grand Valley State University

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1996

Effect of Thirty Second Static Stretch on Hamstring Muscle Flexibility in Subjects Over Age 65 Erin Bloomquist Grand Valley State University

Follow this and additional works at: http://scholarworks.gvsu.edu/theses Part of the Rehabilitation and Therapy Commons Recommended Citation Bloomquist, Erin, "Effect of Thirty Second Static Stretch on Hamstring Muscle Flexibility in Subjects Over Age 65" (1996). Masters Theses. Paper 269.

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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.

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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

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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

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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.

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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

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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

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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.

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Kisner, C., & Colby, L A (1990). Therapeutic Exercise: Foundations and techniques (2nd ed.)(pp 109-146). Phiadelphia: F.A. Davis Company. Lehmkuhl, L.D., & Smith, L.K. (1990). Brunnstrom's Clinical Kinesiology (4th ed.)(pp 69-146). Philadelphia: F.A. Davis Company. Light, K.E., Nuzik, S., Personius, W., & Barstrom, A. (1984). Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Physical Therapy.64(3). 330-333. Madding, S.W., Wong, J.G ., Hallum, A., & Madeiros, J.M. (1987). Effect of duration of passiv e stretch on hip abduction range of motion. The Journal of O rthopaedic and S p o rts Physical Therapy. &(8), 409-416. M agee, D.J. (1992). O rthopedic Physical A ssessm ent (2nd ed.)(pp 333-371). Philadelphia: W.B. S au n d ers Company. Menard, D. (1993). N eurom uscular considerations. In C.B. Lewis, K.A. Knortz (Eds.), O rthopedic_assessm ent and treatm ent of th e geriatric patient (pp 25-42). St.Louis: Mosby. Mills, E.M. (1994). The effect of low-intensity aerobic exercise on m uscle strength, flexibility, and balance am ong sedentary elderly persons. Nursing R e sea rch . 43(4), 207-211. Mohr, T. (1989). M usculoskeletal analysis: The hip. In R.M. Scuuly, M.R. B arnes (Eds.), Physical therapy (pp 369-396). Philadelphia: J.B. Lipincott Company. Moore, J.C . (1984). T h e Golgi tendon organ: A review and update. T he AmeiLgaD-J.Qurnal...pf .0.c.cup.atlorial .The rapy, 36(4), 227-236. P alastanga, N., Field, D., & S oam es, R. (1989). Anatomy and hum an movement: Structure and function (pp20-21L Oxford: Heinem ann. Payton, D.D., & Poland, J.L. (1983). Aging process: implications for clinical practice. Physical T herapy. 62 .4 1 -4 8 . Pickles, B. (1989). Biological a sp e c ts of aging. In O.L. Jack so n (Ed.), Physical therapy of th e geriatric patient (2nd ed.)(pp 27-76). New York: Churchill Livingstone.

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Portnoy, L G ., & W atkins, M.P. (1993). Foundations of clinical research: Applications to practice (pp 350-352, appendix c). Norwalk: Appleton & Lange. Province, M.A., Hadley, E.G., Hornbrrok, M.C., Lipsitz, L.A., Miller, J.P., Mulrow, C.D., Ory, M.G., Sattin, R.W., Tinetti, M.E., & Wolf, S.E. (1995). T he effects of exercise on falls in elderly patients: A preplanned M eta­ analysis of th e FICSIT trials. Journal of the American Medical AsSO.çj.atLQD, 212(17), 1341-1347. Rheault, W., Miller, M., Nothnagel, P., S traessle, J., & Urban, D. (1988). Intratester reliability and concurrent validity of fluid-based and universal goniom eters for active knee flexion. Phvsical T herapv. 68. 1676- 1678. R oach K.E., & Miles, T.P. (1991). Normal hip and knee active range of motion: T he relationship to ag e. Phvsical T herapy. 71. 656-664. Sholz, J.P ., & Cam pbell, S.K. (1980). Muscle spindles and the regulation of m ovem ent. Physical Therapy. SÛ, 1416-1425. Starring, D.T., G ossm an, M R., Nicholson, G.G., & Lem ons, J. (1988). C om parison of cylic and sustained passive stretching using a m echanical device to in crease resting length of ham string m uscles. Physical TJiecapy., SS. 314-320. Sullivan, M.K., DeJulia, J.J., & Worrell, T.W. (1992). Effect of pelvic position and stretching m ethod on hamstring m uscle flexibility. Medicine and Science in S ports and E xercise. 24(12). 1383-1389. Taylor, D.C., Dalton, J.D., S eab er, A.V., & Garrett, W.E. (1990). Viscoelastic properties of m u sd e-ten d o n units: T he biom echanical effects of stretching. T he American Journal of Sports M edicine. 1S(3), 300-309. Tinetti, M.E., Speechley, M., & G inter, S.F. (1988). Risk factors for falls am ong elderly p erso n s living in the community. New E nqand Journal of M edicine. 31 9 (26). 1701-1707. Vaiias, A C., Pedrini, V.A., Pedrini-Mille, A.P., & Holioszy, J.D. (1985). Patellar ten d o n matrix c h a n g e s associated with aging and voluntary exercise. Journal of Applied Physiology. 58(5), 1572-1576.

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Walker, B.M., S ue, D., Miles-Elkousy, N., Ford, G. & Trevelyan, H. (1984). Active mobility of the extrem eties in older subjects. Physical T herapy. M (6). 919-923. Watkins, M.A., Riddle, D .L, Lamb, R.L. & Personius, W.J. (1991). Reliability of goniom etric m easu rem ents and visual estim ates of knee range of motion obtained in a clinical setting. Phvsical Therapy. Zl(2), 90-97. W essling, K.C., DeVane, D A. & Hylton, C.R. (1987). Effects of static stretch v ersus static stretch and ultrasound combined on triceps su ra e m uscle extensibility in healthy women. Physical Therapy. 6Z(5), 674-679. W eston, I.E. (1993). Physiological and Psychological benefits of exercise. In C.B.Lewis, K.A. Knortz (Eds.) Orthopedic a sse ssm e n t and treatm ent of the geriatric patient (pp 17-23). St. Louis: Mosby. Woo, S.L-Y., G om ez, M.A., Amiel, D., Ritter, M.A., G elbennan, R.H. & Akeson, W.H. (1981). T he effects of exercise on the biomechanical and biochemical properties of swine digital flexor tendons. Journal of Biomechanical Engineering. 103.51 -58.

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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