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6-3-2014

The Effects of Morning Versus Evening Stretching Exercises in Hamstrings Flexibility Gains Camron Einerman Graduate Center, City University of New York

Emily Eleff Graduate Center, City University of New York

Ana Ilijeska Graduate Center, City University of New York

Aliza Zinberg Graduate Center, City University of New York

How does access to this work benefit you? Let us know! Follow this and additional works at: http://academicworks.cuny.edu/gc_etds Part of the Physical Therapy Commons Recommended Citation Einerman, Camron; Eleff, Emily; Ilijeska, Ana; and Zinberg, Aliza, "The Effects of Morning Versus Evening Stretching Exercises in Hamstrings Flexibility Gains" (2014). CUNY Academic Works. http://academicworks.cuny.edu/gc_etds/654

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THE EFFECTS OF MORNING VERSUS EVENING STRETCHING EXERCISES IN HAMSTRINGS FLEXIBILITY GAINS

by Camron Einerman Emily Eleff Ana Ilijeska Aliza Zinberg

A capstone project submitted to the Graduate Faculty in Physical Therapy in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy

2014

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This manuscript has been read and accepted for the Graduate Faculty in Physical Therapy in satisfaction of the capstone project requirement for the degree of the DPT

Dr. Milo Lipovac

Date

Chair of Examining Committee/Mentor (required signature)

Jeffrey Rothman

Date

Executive Officer (required signature)

THE CITY UNIVERSITY OF NEW YORK

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Abstract THE EFFECTS OF MORNING VERSUS EVENING STRETCHING EXERCISES IN HAMSTRINGS FLEXIBILITY GAINS by Camron Einerman Emily Eleff Ana Ilijeska Aliza Zinberg

Advisor: Professor Milo Lipovac Many human physiological functions, including muscle flexibility, exhibit a pattern over a 24-hour period, known as circadian rhythm. Muscle flexibility and its circadian rhythm have been researched, though much more information is needed, especially regarding the hamstring muscle group. The object of this study was to determine if stretching at different times of the day results in differences in hamstring flexibility. Since muscles and joints are most flexible at night, greater ranges of motion should be available, allowing for a greater degree of stretching to take place. We hypothesize that when utilizing the optimal type, duration, and frequency of stretch, subjects who stretch later in the day will have more significant increases in hip range of motion post intervention, as compared to subjects who stretch in the morning. The study was a randomized trial parallel-group research design; with hamstring flexibility being the outcome measure. Ten subjects between the ages of 21 to 40 years old were randomized into two intervention groups, one stretched between 0600 to 0900 the other between 1800 to 2100. Both intervention groups participated in active and passive knee extension stretches, performed for 5 days a week for 6 weeks. Pre and post intervention hamstring flexibility measurements were recorded, via manual goniometry of the hip angle while undergoing a passive straight leg raise. Data Desk Software was used to analyze the data, utilizing a 2-sample T test and one way

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ANOVA, the results of this study were found to be insignificant for all variables. There is no significant difference in gains in hamstring flexibility with relation to Circadian Rhythm. Those who stretched in the evening did not have greater gains in ROM following a six week stretching protocol than those who stretched in the morning group.

ACKNOWLEDGEMENTS

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We would like to thank our research advisor and professor Dr. Milo Lipovac, as well as other faculty at Hunter College Physical Therapy Department for all the assistance during our research study process. We also thank our fellow physical therapy students for their continuous support. Most of all, we thank our families and loved ones for their love and encouragement throughout our journey in pursuing a degree in physical therapy.

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Table of Contents List of Tables…………………………………………………………………………………….vii List of Figures…………………………………………………………………..………………viii The Effects of Morning versus Evening Stretching Exercises in Hamstrings Flexibility Gains Introduction…………………………………………………………………..……1 Method...…………………………………………………………………………10 Results……………………………………………………………………………15 Discussion…..……………………………………………………………………16 Conclusion….……………………………………………………………………25 References………………………………………………………………………..33

Appendix A: Stretching Protocol Handout

Appendix B: List of Tables List of Figures .

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List of Tables Table 1. Description of sample……………………………………………………………14 2. Means+/- Standard Deviations Baseline to Final Measurements………………..16 3. List of variables for which statistical analysis was performed…………………..27 4. 2-Sample T-test and ANOVA comparisons……………………………………..30

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List of Figures Figure 1. Morning and Evening Groups Change (Baseline to Final)………………………28 2. Morning Group Change (Baseline to Final)……………………………………..28 3. Morning Group Change AROM (Baseline to Final)…………………………….28 4. Morning Group Change PROM (Baseline to Final)……………………………..29 5. Evening Group Change (Baseline to Final)……………………………………...29 6. Evening Group Change AROM (Baseline to Final)……………………………..29 7. Evening Group Change PROM (Baseline to Final)……………………………...30 8. Morning versus Evening Group Change (Baseline to Final)…………………….31 9. AROM Morning versus AROM Evening (Baseline to Final)…………………...31 10. PROM Morning versus PROM Evening (Baseline to Final)……………………31 11. Change in AROM versus change in PROM (Baseline to Final)………………...32 12. Athletes versus Non-Athletes AROM (Baseline to Final)………………………32 13. Athletes versus Non-Athletes PROM (Baseline to Final)……………………….32 14. Males versus Females AROM (Baseline to Final)………………………………33 15. Males versus Females PROM (Baseline to Final)……………………………….33 16. Asian versus White AROM (Baseline to Final)…………………………………33 17. Asian versus White PROM (Baseline to Final)…………………………………34 18. Right LE versus Left LE (Baseline to Final)……………………………………34 19. Age Regression Line……………………………………………………………34 20. Pie Chart Explaining Variables for Age Regression Line………………………30

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INTRODUCTION Flexibility- What is it? Flexibility is an intrinsic property of the body’s tissues that determines the amount of motion available at a joint or group of joints without causing injury (Thacker, Gilchrist, Stroup, & Kimsey, 2004). It describes a joints ability to complete a full range of motion smoothly and easily (Kisner & Colby, 2007). Flexibility is important for the performance of both simple activities of daily living and difficult athletic and professional feats. Multiple factors affect flexibility, including the viscoelasticity of muscles, ligaments, connective tissues, and joint mobility or hypomobility. Limitations in these structures can be caused by prolonged immobilization, trauma, muscle, tendon or fascial disorders, sedentary lifestyle, and postural malalignment. When these restrictions limit function, cause pain, or increase the risk of injury, stretching becomes a crucial component of the individual’s health regimen. Stretching can be defined as “any therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility by elongating structures that have adaptively shortened and have become hypomobile over time” (Kisner & Colby, 2007, p. 66). In a clinical setting, stretching is indicated when range of motion (ROM) is limited functionally, due to adhesions, contractures, and/or scar tissue formation; when structural deformities arise due to restricted motion, and in its more common usage, before and after intense exercise to minimize soreness and to prevent musculoskeletal injuries (Kisner & Colby, 2007). Thacker et al. (2004) reported in a literature review on stretching, that since 1962, 27 articles have reported that stretching exercises improve the flexibility in the knee, hip, trunk, shoulder, and ankle joints. Circadian Rhythm

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Many human physiological functions, including muscle flexibility, exhibit a pattern over a 24-hour period. This cycle, known as a circadian rhythm, has high and low points of performance occurring at specific points throughout the day (Alter, 2004). In the human body, the circadian rhythm is regulated by the suprachiasmic nucleus, which is located in the anterior portion of hypothalamus, superior to the optic chiasm. This center receives information about the time of day from the retina and then coordinates daily biological rhythms (Weipeng, Newton, & McGuigan, 2011). Circadian rhythm has been well researched in multiple areas of physiology, including the circadian rhythm of muscle strength and performance. In 1983, Baxter and Reilly studied the time of day effects of eight females cycling at maximal exertion. The results of this study indicated that exercise tolerance time, total work done, and peak lactate production were highest at 2200 h when compared to 0630 h. Deschenes et al, (1998) tested ten healthy males to determine whether muscle performance and the body’s response to exercise were influenced by the time of day. Muscle performance using an isokinetic dynamometer with maximal effort was recorded at 0800 h, 1200 h, 1600 h, and 2000 h. The results of the study indicated significant time-of-day effects in measures of peak torque, power, total work per set, and maximal work in a single repetition. The study also found significant time-of-day effects of plasma levels of testosterone and cortisol, with testosterone to cortisol ratios highest at 2000 h.

Wyse, Mercer, and Gleeson (1994), looked at circadian rhythm with regard to isokinetic muscle strength in order to determine when peak lower extremity muscle performance takes place. Nine adult male sportsmen’s isokinetic leg strength was tested for extension peak torque, flexion peak torque and peak torque ratio using a dynamometer between 0800-0900 h, 13001400 h and 1800-1930 h for three days. The results of the study using a one-way repeated

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measures ANOVA revealed that significantly higher scores were achieved between 1800-1930 h, showing that strength reaches its peak in the evening. In 2007, Reilly et al. performed a study looking at the effect of circadian rhythm on different aspects of the body. The researchers looked at 8 male soccer players, focusing on body temperature, grip strength, reactions times, flexibility, juggling and dribbling, and wall-volley test. Measurements were taken on different days at 0800 h, 1200 h, 1600 h, and 2000 h. When ANOVA statistics were performed, the results showed significant influence of circadian rhythm on body temperature, reaction time, self-rated alertness, fatigue, forward (sit and reach) flexibility, and right hand grip strength, all peaking between 1600 h and 2000 h. However, they found that Circadian rhythm was insignificant for left-hand grip strength and whole body flexibility, measured by the stand and reach test (Reilly et al., 2007). The circadian rhythm of muscle flexibility has been researched as well, though much more information is needed. Gifford (1987) took 25 subjects between the ages of 25 and 32 and tested lumbar flexion and extension, fingertip-to-floor distance, glenohumeral lateral rotation, and passive straight leg raising. Measurements were taken every two hours over a 24-hour period. Fingertip to floor values indicated maximum stiffness at 0600 h, increasing to maximum flexibility at midday to midnight. Similarly, lumbar flexion measurements showed the most stiffness in the morning with flexibility increasing to a peak in late afternoon and early evening followed by increased stiffness. Straight leg raising and glenohumeral lateral rotation values were less dramatic, however, both showed an overall rise in flexibility throughout the day, with straight leg raise values reaching their maximum between 0800 and 2200 h. Guariglia et al. (2011) looked at hamstring length of 26 males who did not regularly exercise, taking measurements at 0800 h, 1300 h, and 1800 h, using the Sit and Reach Test

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(SRT), as well as the the Angle of the Hip Joint (AHJ). An ANOVA analysis showed that flexibility increased significantly throughout the day and was greatest at 1800 h. Similarly, Dhariwal and Malik (2011) investigated flexibility in 25 males studying physical education using SRT, taking measurements at 0700, 1300, and 1900 h. Using an ANOVA analysis and Scheffe’s post-hoc test, researchers found decreased flexibility at 0700 h rising through 1300 h and finally peaking at 1900 h. Pearson and Onambele (2005) measured the time-of-day variability of internal muscle structure, measuring knee extension torque, fiber pennation and infrapatellar tendon characteristics, with results showing that tendons are more compliant at night. The results of all of these studies strongly indicate the presence of increased muscle compliance at night, and greater flexibility as a result. There are many explanations for the circadian changes seen in muscle flexibility. Weipeng, Newton, and McGuigan, (2011) explain that body temperature peaks in the early evening facilitating increased energy metabolism and muscle compliance. Deschenes et al. (1998) attribute changes in tendon stiffness to the pulsatile production of testosterone which peaks in the morning and declines in early evening. This study also points out that there is significant circadian impact on nerve conduction velocity, sensitivity, and neuromuscular efficiency that follow fluctuation of core temperature. Others attribute time-of-day changes in flexibility to anabolic steroid levels (Miles et al. 1992 cited by Pearson and Onambele, 2005). The Hamstrings The hamstring muscle group is one of the most commonly tight muscles, and as such, will be the muscle focused on in this study to further examine the effects of circadian rhythm. The hamstrings are responsible for extension at the hip and flexion at the knee (Moore, Dalley, & Agur, 2006), and eccentrically controlling the forward swing of the leg during the

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terminal swing phase of gait. The hamstrings also provide posterior support to the knee capsule during knee extension in stance phase, and will thus limit posterior translation of the femur on the tibia. If the hamstrings are not functioning properly, the knee may snap into hyperextension and/or genu recurvatum may occur as well, which could potentially lead to ligamentous, tendinous, muscular, or joint deformity and damage (Kisner & Colby, 2007). In addition, the hamstrings also affect pelvic tilt and rotation, sacral rotation, and rotation of the hip (Carlson, 2008). When the hamstring muscles are tight, there is less stretch and force absorption, putting the muscle at risk when it needs to lengthen (Prior, Guerin, & Grimmer, 2009). Athletes with an increased tightness of the hamstring and/or quadriceps muscles have been found to have a statistically higher risk for a subsequent musculoskeletal lesion secondary to having a muscular/ biomechanical disadvantage (Witvrouw, Dannels, Asselman, D’Have, & Cambier, 2003). The hamstrings muscle group is commonly tight in individuals who do not perform a stretching routine on a regular basis; furthermore, Carlson (2008) showed that those individuals with shortened or tight hamstrings who run with a longer stride length can have a predisposition to a potential hamstring injury. Hamstring injury is most common in sports that involve sudden bursts of acceleration and deceleration, such as soccer, football, and track/field. Unfortunately for athletes and nonathletes alike, hamstring strains or injuries tend to have a relatively high recurrence rate. In a study performed by Witvrouw et al. (2003), researchers correlated a high percentage of football players who suffered a hamstring injury with significantly less hamstring flexibility. Tight hamstrings may also lead to restricted talocrural dorsiflexion, which in turn leads to a biomechanical disadvantage, and the potential promotion of subtalar pronation, as well as excessive knee flexion. This can lead to increased compression of the patella on the femur,

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which will cause patellofemoral pain syndrome (Green, 2005). Reduced hamstring flexibility is often a cause of lower extremity injuries and low back pain as it can cause a posterior pelvic tilt, leading to lumbar spine dysfunction. (Decoster, Scanlon, Horn, & Cleland, 2004). It is therefore important to include hamstring stretching in a prevention, as well as a rehabilitation, protocol in order to prevent initial hamstring injury, recurrence of hamstring injury, and other musculoskeletal complications (DePino, Webright, & Arnold, 2005). Type, Frequency and Duration of Stretch Due its widespread usage both clinically and athletically, much investigation has been conducted to determine the most effective type of stretch, as well as the appropriate frequency and duration. The research is not definitive on the ideal parameters for hamstrings stretches. Duration of stretch ranges from 5-60 seconds, with frequency ranging from 1 to 3 times per day and up to 5 days per week. The length of the stretching program ranges from 1 day to 8 weeks, however 6 weeks has consistently shown to be most effective. Bandy and Irion (1994) compared four different combinations of duration and frequency of hamstring stretching in their study. They found that both a 30 and 60 second stretch of the hamstrings once per day, was more effective than a 15 second stretch at increasing range of motion. As a corollary to these findings, Bandy and Irion (1994) noted that the 60 second stretch was no more effective than the 30 second stretch. In a later study, Bandy, Irion, and Briggler (1997) further found that increasing the frequency of the stretch by either more repetitions, or more times per day, did not show increases in flexibility. Bandy, Irion, and Briggler (1998) whom fellow researchers have used as the gold standard, found that the most commonly used type of stretch is the static stretch. Static stretching is a common technique used by specialists within the sports medicine

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world in order to increase muscle length without potentially over-traumatizing tissue. Static stretching takes a muscle to its end range, and then maintains this position for a specified duration until a “release” or decreased tissue tension is felt (Meroni et al, 2010; Band and Irion, 1997; O'Sullivan, K., Murray, E., & Sainsbury, D., 2009). The mechanism of action for static stretching is based on the facilitation of the Golgi Tendon Organ, which is a proprioceptive sensory receptor found at both the origins and insertions of muscle, and responsible for sensing changes in muscle tension. Multiple studies have shown that static tension that is placed on the musculotendinous unit leads to activation of the watch GTO, which in response to increased tension leads to autogenic inhibition of the muscle being placed on stretch, thus decreasing tissue resistance and improving ROM (Meroni et al. 2010; Deyne, 2001). Active stretching, over the last 15 years, has been researched extensively in order to determine its efficacy and use within the rehabilitation world, as well as the world of sports medicine. Active stretching, unlike passive stretching, consists of performing an active contraction of the agonist muscle group through the full ROM in order to increase or improve the range of motion of the antagonist muscle group. The primary physiological response within the body related to active stretching is related to the use of the principle of reciprocal inhibition; essentially meaning that as one muscle is actively contracting (agonist), the body has a natural stretch reflex that is initiated, leading to the relaxation of the antagonist or opposing muscle group. Sahrmann and White have advocated for the use of an active stretching protocol to not only improve muscular flexibility, but concurrently improving function of the antagonist muscle group. For the purpose of this research study, it is imperative to understand how hamstring flexibility can be objectively measured with reliability and validity. The most common, as well

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as oldest method of measuring hamstring flexibility is the sit-and-reach test (SRT); first described by Wells and Dillion in 1952. As years have passed, additional research and knowledge about flexibility and muscular tightness has led to multiple variations of the SRT. One of the newest variations of the SRT, known as the Toe-Touch Test (TT), is the second most commonly selected tests used in order to determine hamstring flexibility. The major difference between the SRT and TT tests is patient positioning; long sitting versus standing, respectively (D Mayorga-Vega, 2014; Ayala et al, 2012). The current study utilizes the passive straight leg raise test (pSLR) and active straight leg raise (aSLR) as a means of measuring hamstring flexibility. Lee and Munn (2000) determined that the pSLR has an overall reliability of .97 which is significantly higher than the reliability of both the SRT and the TT test. Similarly, a 1982 study by Ekstrand et. al determined there was a high reliability (>than .85) when performing objective measurements of hamstring flexibility with a Myrin goniometer. The researchers felt that this was due to pSLR test’s ability to isolate the hip joint, as opposed to the multiple joints involved in measuring during an SRT, thus providing a more valid and reliable measure of hamstring flexibility. In support of this theory, Kendall et al. (1971) determined that the SRT does not isolate the joint at the time of the measurement, thus influencing the validity of this objective measure. Kendall et al. (1971) states that “the final result measurement of using a SRT test can be strongly influenced by the overall physiology of the person, neural tension, or by both contractile and non-contractile tissues in the posterior aspect of the knee, triceps surae complex, and back.” In contrast to the potential limitations using the SRT test, a manual goniometric measurement of the hip flexion angle while performing a passive straight leg raise provide direct isolation of the hamstring muscle group (Kendall et al., 1971; Davis, Ashby, McCale, McQuain, & Wine, 2005).

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In a more recent study from 2010, Bakirtzoglou et al. compared outcomes of hamstring flexibility using the SRT and the pSLR on athletes and nonathletes. The results of the study showed a statistically significant difference when using the pSLR; however no significant difference between the two populations was found with the SRT. The authors concluded that the two test are in fact not comparable, and recommended the use of the pSLR, as it is better at isolating the hip joint, thus providing a more valid measurement of hamstring flexibility. Static stretching is a common technique used by specialists within the sports medicine world in order to increase muscle length without potentially over-traumatizing tissue. Static stretching takes a muscle to its end range, and then maintains this position for a specified duration until a “release” or decreased tissue tension is felt. The mechanism of action for static stretching is based on the facilitation of the Golgi Tendon Organ, which is a proprioceptive sensory receptor found at both the origins and insertions of muscle, and responsible for sensing changes in muscle tension. Multiple studies have shown that static tension that is placed on the musculotendinous unit leads to activation of the watch GTO, which in response to increased tension leads to autogenic inhibition of the muscle being placed on stretch, thus decreasing tissue resistance and improving ROM. Active stretching, over the last 15 years, has been researched extensively in order to determine its efficacy and use within the rehabilitation world, as well as the world of sports medicine. Active stretching, unlike passive stretching, consists of performing an active contraction of the agonist muscle group through the full ROM in order to increase or improve the range of motion of the antagonist muscle group. The primary physiological response within the body related to active stretching is related to the use of the principle of reciprocal inhibition; essentially meaning that as one muscle is actively contracting (agonist), the body has a natural

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stretch reflex that is initiated, leading to the relaxation of the antagonist or opposing muscle group. Sahrmann and White have advocated for the use of an active stretching protocol to not only improve muscular flexibility, but concurrently improving function of the antagonist muscle group. With the knowledge that muscles exhibit the most flexibility at specific times of the day, the object of this study is to determine if variability exists in gains in flexibility, depending on the time of day that a stretching protocol is conducted. If muscles and joints have the most flexibility at specific times, then assumedly, greater ranges of motion will be available, allowing for a greater degree of stretching to take place. We therefore hypothesize that utilizing the optimal type, duration and frequency of stretch as noted above, subjects who stretch later in the day will have greater gains in flexibility than those who stretch in the morning. METHODS Trial Design This was non-controlled, two group, randomized prospective study. Within this study there were two experimental groups with participants randomly assigned to one of two groups: stretching in the morning or at night. Both groups participated in the same hamstring stretching protocol, and thus there was no comparative control group. Subjects The participants in the study were recruited from the Hunter College Department of Physical Therapy, Brookdale Campus. Recruitment flyers were posted in the classrooms and hallways beginning a month prior to commencement of the study. As an adjunct to the flyers, information sessions were conducted in the student classrooms for each respective class. These meetings, as well as the aforementioned flyer, briefly discussed the purpose and length of the

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study, as well as the protocol to be used. Approximately 80 people, both male and female, were given the opportunity to participate in this study. Although there were specific inclusion and exclusion criteria for participation of this study, initial recruiting was non-specific. After the initial recruiting, a total of 18 subjects provided verbal consent to participate in the eligibility screening for the study. Prospective participants were then provided with an eligibility questionnaire consisting of six questions to further ensure that they met inclusion criteria, and that it was medically safe for them to participate in the study. Finally, if the prior questions implicated that the potential participant was eligible for the study, bilateral hamstring measurements were taken in order to determine a flexibility limitation; both passive and active SLR measurement were assessed by the researchers using the protocol described below. If participants displayed