Hindawi Publishing Corporation

Journal of Aging Research
Volume 2012, Article ID 306818, 30 pages
doi:10.1155/2012/306818
Review Article
Flexibility Training and Functional Ability in Older Adults:
A Systematic Review
Liza Stathokostas,
1
Robert M. D. Little,
1
A. A. Vandervoort,
2
and Donald H. Paterson
1
1
Canadian Centre for Activity and Aging, School of Kinesiology, The University of Western Ontario, London, 3M Centre 2225,
ON, Canada N6A 3K7
2
School of Physical Therapy, Elborn College 1400, The University of Western Ontario, London, ON, Canada N6A 3K7
Correspondence should be addressed to Liza Stathokostas, lstatho2@uwo.ca
Received 9 July 2012; Accepted 11 September 2012
Academic Editor: Wojtek Chodzko-Zajko
Copyright © 2012 Liza Stathokostas et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Background. As indicated in a recent systematic review relating to Canada’s Physical Activity Guidelines for Older Adults,
exercise interventions in older adults can maintain or improve functional abilities. Less is known about the role of flexibility
in the maintenance or improvement of functional abilities, and there currently does not exist a synthesis of the literature
supporting a consensus on flexibility training prescription. Purpose. To systematically review the effects of flexibility-specific
training interventions on measures of functional outcomes in healthy older adults over the age of 65 years. Methods. Five electronic
databases were searched for intervention studies involving concepts related to aging, flexibility, functional outcomes, and training
interventions. After evaluating the articles for relevance, 22 studies were considered. Results. The results suggested that while
flexibility-specific interventions may have effects on range of motion (ROM) outcomes, there is conflicting information regarding
both the relationship between flexibility interventions and functional outcomes or daily functioning. Conclusions. Due to the
wide range of intervention protocols, body parts studied, and functional measurements, conclusive recommendations regarding
flexibility training for older adults or the validity of flexibility training interventions as supplements to other forms of exercise, or
as significant positive influences on functional ability, require further investigation.
1. Introduction
As indicated in a recent systematic review relating to
Canada’s Physical Activity Guidelines for Older Adults,
exercise interventions (comprised of aerobic and strength
training) in older adults can maintain or improve functional
abilities [1]. Less is known about the role of flexibility in
the maintenance or improvement of functional abilities.
While joint flexibility may decrease with age, with the
potential to affect normal daily function, older adults do
maintain the ability to improve flexibility through stretching
exercises [1]. The 2009 American College of Sports Medicine
(ACSM) position statement “Exercise and Physical Activity
for Older Adults” [2] noted there is a lack of studies
of the effects of range of motion exercises on flexibility
outcomes in older populations and a lack of consensus
regarding the prescription of stretching exercises for older
adults. Despite the lack of a synthesis of the literature to
support the recommendation of the inclusion of a flexibility
component to older adult exercise programs, many older
adult activity programs place a considerable emphasis on
flexibility. Stretching exercises are used extensively in the
rehabilitation context wherein injury or disease may have
resulted in a restricted range of motion specific to given
joints, and the goal is to regain “normal” range of motion
[3]. However, the present paper is focused not on stretching
exercise for rehabilitation purposes but for the role of
flexibility in general exercise prescription for older adults.
In light of the significant benefits of an exercise program
for an aging population, it is important to provide evidence-
based prescription for older adult exercise programs and
highlight areas of research requiring further investigation in
order to maximize these benefits. The goal of a flexibility
program is to improve range of motion in the major muscle-
tendon groups in accordance with individualized goals [4].
For the majority of the aging population, the goals may not
2 Journal of Aging Research
be related to athletic performance, but rather performance of
functional abilities in activities of daily living. Nevertheless,
there is relatively little research on the potential benefits of
flexibility-specific training interventions for this population
in that context. Despite the lack of research and no “known
health benefits” [5], again, there is still a tendency in the
literature to mention flexibility training as a presumed
“component of fitness” and beneficial adjunct to other forms
of exercise. Therefore, the purpose of this systematic review
is to investigate the functional outcomes of flexibility specific
training in older adults.
2. Methods
2.1. The Literature Search and Inclusion Criteria. A search
strategy was developed, where all reasonable expressions
of the concepts of aging, flexibility, functional outcomes,
and training interventions were considered (see Appendix
for a sample search strategy). A comprehensive electronic
literature search was conducted on five online databases:
PubMed (NCBI; 1950-), Embase (OVID; 1974-), CINAHL
(OVID & EBSCO; 1982-), Scopus (1823-), and SportDis-
cus (EBSCO; 1800-). The literature was searched up to
January 2011. The final inclusion criteria for this paper
were (1) an original research article, (2) human subjects,
(3) an intervention study, (4) flexibility training was an
independent intervention or was used as a control, (5) aged
population (mean age ≥ 65 years), and (6) the population
was healthy but allowing for arthritis, osteoarthritis, and
those residing in assisted living (based on age and risk,
not diseases or other medical conditions). For this paper,
healthy was operationally defined as community-dwelling
and assisted living with the health and function and cognitive
ability to participate in light physical activity interventions
and complete physical function measures. Interventions
targeting specific chronic conditions (aside from arthritis
and osteoarthritis) were excluded from review. Despite their
use in flexibility training, tai chi- and yoga-based studies
were excluded fromthis paper because by nature they include
strength components. The electronic search yielded 4037
citations. The citations and applicable electronic versions
of the article (where available) were downloaded to an
online research management system (RefWorks, Bethesda,
MD, USA).
2.2. Screening. Two reviewers independently (RL, LS) eval-
uated the articles for relevance using standard systematic
review methodology leading to further consideration of 22
articles.
Two reviewers independently completed standardized
data extraction forms for each level of screening. Three levels
of screening were utilized. Level 1 screening was based on
article titles, Level 2 was based on the title and abstract, and
Level 3 was a full text screening. The articles that progressed
through to Level 3 were retrieved electronically or manually
via the Canadian interlibrary system and were printed
from electronic copy. Any cross-referenced articles from the
reference section of Level 3 articles were hand-screened.
Disagreements regarding inclusion were resolved through
discussion with a third reviewer (DP).
2.3. Data Extraction. Data from the included studies were
extracted (Table 1) and organized by the target muscle
groups of the flexibility interventions. Two reviewers com-
pleted standardized data extraction forms. One reviewer
performed the data extraction for each paper assigned to
them and the extraction was verified by another reviewer.
The reviewers were not blinded to the journal or the author
names when extracting information from the articles.
2.4. Level of Evidence. The approach used to establish the
level and grade of evidence was consistent with Lau et al.
[6] which provide predefined and objective criteria. Thus,
the strength of the evidence was assessed for flexibility
interventions and functional outcomes in older adults with
respect to general recommendations and appropriate dose.
2.5. Quality Assessment. Quality assessment of the included
studies was also performed (Table 1). The Downs and Black
[7] scale was selected to assess the quality of each study as it is
appropriate to evaluate nonrandomized investigations, and it
contained the highest number of relevant items for the needs
of this paper. However, as not all items were relevant to the
various study types included in this paper, a modified version
of the checklist was employed for each of RCTs (randomized
control trials), and non-RCTs study types. Thus, the quality
of each study was also established similar to the method of
Gorber et al. [8] to include the most relevant components
of the scoring tool. Therefore, a modified version of the
Downs and Black checklist was used with the final checklist
consisting of 22 items with a maximum score of 24 points for
the studies of a RCT design; 22 items for non-RCT designs
with a maximum score of 23; experimental single group
interventions had a maximum score of 18 from 18 items;
experimental single-group and single-session studies were
based on 14 items for a maximum score of 14. Higher scores
reflected a superior quality of investigation.
2.6. Integration of Findings. Due to the heterogeneity across
study populations, methods used, and outcomes assessed, we
conducted a narrative synthesis of the results.
3. Results
3.1. Description of Studies. The initial search yielded 4037
articles. Twenty-two articles were ultimately included after
meeting Level 3 inclusion criteria (Figure 1). Of the final 22
articles, 18 were from electronic database searching, and 4
were found by hand searching. Quality assessment indicated
that the RCT studies (n = 13) were of good quality with an
average score of 18 out of 24. The non-RCT studies (n = 6)
had an average score of 14 out 23. An average score of 12
out of 18 was assessed for the experimental single-group
studies (n = 3). Fourteen articles were conducted in the
United States [10–12, 14, 15, 17, 18, 20, 22, 25–29], while
the remainder of the studies were from Japan [19], Brazil
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1
3
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1
8
Journal of Aging Research 5
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2
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2
4
Journal of Aging Research 7
T
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Journal of Aging Research 9
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4
Journal of Aging Research 11
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3
12 Journal of Aging Research
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14 Journal of Aging Research
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1
9
/
2
4
Journal of Aging Research 15
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Journal of Aging Research 19
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1
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4
Journal of Aging Research 23
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24 Journal of Aging Research
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Journal of Aging Research 25
Electronic database search
Level 1 screening: title
Level 2 screening: title
Level 3 screening: full text
Final full text articles
10: not original article
69: no intervention studied
280: no flexibility intervention
5: subjects not healthy
1: study not in english
32: flexibility not focus of
intervention or control protocol
6: no flexibility intervention
2: not original article
Hand searching of references
Relevant database articles
4: single-session studies
and abstract
n = 4037
n = 4037
n = 436
n = 62
n = 18
n = 22
n = 4
Excluded or duplicates (n = 3601)
Excluded (n = 374)
9: subjects not >65 yr
Excluded (n = 44)
+
Figure 1: Article Screening Flow Chart.
[23, 24], Turkey [21], Australia [9, 16], Taiwan [30], and
Canada [13].
3.2. Population. The mean sample age was 74.1 years,
ranging from 64 years [30] to 88.8 years [14]. Seven studies
included populations that were ≥80 years of age [10, 11, 13,
14, 18, 25, 27]. The number of participants in the articles
of this paper ranged from 7 [27] to 132 [30]. There were a
total of 1127 participants, 841 of whom were female (75%),
while 286 were male. Six studies were female only [15, 23–
26, 29]. Twenty studies were based on community-dwelling
populations, and two studies involved individuals residing in
assisted-living facilities [10, 13].
3.3. Outcome Measures. Outcomes were measured using
flexibility measurements, physical ability tests, and question-
naires. One study also used brain imaging for the purposes
of identifying changes in hippocampal volume with training
[20]. A common outcome measure was simply whether
there was a change in range of motion usually assessed by
goniometry [15, 17, 20, 24–28, 30]. The inclusion of these
studies in the review (although they reported no “functional
outcome”) was to provide the data for the purpose of
determining whether older adults would, in fact, improve
range of motion about different joints with various flexibility
exercise programs. Functional outcomes were operationally
defined as tests or measures designed to reflect abilities for
various levels of daily activities and potentially related to
maintenance of independence of older adults. In general,
these tests assessed ability in a function that involved more
than a single fitness component (e.g., not just a strength
measure of a weight that could be lifted, but rather a
performance that may involve strength and power as well
as balance and agility). The most commonly used tests of
functional outcome were gait and various walking speeds
[11, 13, 14, 19, 21, 22, 26], the sit-and-reach test [10, 12–14,
19, 29], the sit-to-stand test [9, 12, 14, 16, 18, 19], functional
reach test [9, 10, 21, 26], step test [9, 16], timed up-and-go
(TUG) [10, 13, 14, 16, 19, 24, 26], and Romberg test [11,
21]. Other functional outcome measures were Berg balance
scale [13], questionnaires [9, 12], peg board [11], red-light-
green-light [11], Lequesne’s index of disability [30], the
physical performance test (PPT) [11], and the gallon jug
shelf test [14]. Gait and walking speed proved to be more
positively affected by flexibility training than other outcome
measures [14, 19, 21, 22, 26], although this was not entirely
consistent [11, 13]. Several studies showed increases in
flexibility-related outcomes, but lacked significant changes in
other more applicable and generic measures of functionality.
Only one study followed up on outcome maintenance after
the postintervention measurements. This study found that
knee torque and timed up-and-go showed improvements
compared to the control group, which persisted for four
weeks after intervention [24].
In the sub-group containing eight studies of the very old
(≥80 years), frail, and assisted-living populations [10, 11, 13,
14, 18, 21, 25, 27], there were significant improvements seen
in functional reach [21], sit-to-stand [10, 14] and 30 m walk
times [21], but no changes in the PPT [11] and mixed results
for flexibility, strength, balance, and TUG tests. As compared
to studies on less aged independently-living populations,
the outcomes results of this sub-group were similar, except
that the more aged/dependent group had less consistent
flexibility outcomes; there were some neutral outcomes and
some negative changes following flexibility training.
Six out of the 22 studies included several functional
outcome measures and were considered most relevant to
this paper [11–14, 16, 19], and are individually reviewed
herein. Four of the six conducted randomized control trials
(RCT) [11–14], and only two studies reported sample sizes
less than 68 participants. Brown et al. [11] conducted a 12-
week RCT (n = 87), wherein the flexibility trained group
demonstrated only flexibility measure improvements and no
change in functional outcomes. The measures included were
very practical and included the chair stand, picking up a
penny, putting on and taking off a coat, and the Romberg
balance test. However, it should be noted that this study
also showed minor strength and balance losses. In a one
year RCT, King et al. [12], similarly, showed no change in
most functional outcomes in the flexibility trained group.
Functional measures included lift-and-reach, sit-to-stand,
sit-and-reach, self-rated physical performance, self-efficacy
for physical performance scale, and perceived functioning
and well-being. There were only significant increases for the
sit-and-reach test in men only (10.4 to 11.9 inches) and
decreases in self-rated daily bodily pain scores (by 7.3% for
women and 9.4% for men). Lazowski et al. [13] conducted
26 Journal of Aging Research
a 16-week RCT (n = 68). Timed up-and-go increased
(worsened) from 27 to 33 seconds, and no changes were
seen in any other functional measures or in the sit-and-
reach test. Additional functional measures included strength
tests, Berg balance scale, self-paced and fast-paced walk tests,
stair-climbing, and the functional independence measure
for functional capacity. Stanziano et al. [14] employed an
8-week RCT (n = 17), where the experimental flexibility
group significantly improved in every measure: chair stand
repetitions (11 to 13), modified ramp power (69 W to 86 W),
arm curl repetitions (12.9 to 18.8), gallon jug shelf test
(13.4 to 11.5 seconds), 8 foot timed up-and-go (8.7 to 7.6
seconds), and 50 foot gait speed (13.9 to 12.3 seconds). The
study by Bird et al. [16] was a 32-week randomized cross-
over design (n = 32) with 16 weeks spent in the flexibility
group. Four functional outcomes improved significantly for
the flexibility group: TUG (7.6 to 6.6 seconds), sit-to-stand
(22.6 to 18.0 seconds), step test (13.5 to 17.6 steps), and
mediolateral sway range (eyes open: 4.16 to 2.97 cm; eyes
closed: 6.87 to 5.64 cm). Strength was also tested, with no
improvement by the flexibility group. In a 12-week non-RCT
(n = 117), Takeshima et al. [19] reported no improvements
for the flexibility trained group in the 12-minute walk, arm
curls, chair stand, TUG, functional reach, back scratch, and
sit-and-reach. These six studies exemplify the mixed results
of the functional outcome measures in this paper. They
serve as a strong representation of the lack of consistency
of functional outcomes in the literature and therefore, any
specific recommendation regarding type or frequency of
stretching exercises is premature.
Overall, seven of 22 studies demonstrated mostly positive
functional outcomes [9, 10, 14, 16, 21, 23, 29], while
six reported mostly negative functional results, that is, no
improvement in variables [11–13, 18, 19, 22]. Ten studies
showed no functional outcome measures [15, 17, 20, 24–30]
and only reported changes in flexibility and ROM (although
they purported to relate flexibility to function, and were
included for their results related to the ability of older adults
to improve flexibility). There were no obvious differences
between the characteristics of the studies with positive,
negative, or no functional outcomes.
3.4. Intervention Characteristics. Twelve studies used flexibil-
ity training as the sole intervention [10, 11, 14, 17, 21–27,
29], four studies used flexibility training as a significant part
of an intervention protocol [15, 16, 19, 30], five studies used
flexibility as a control group to compare with various other
exercise interventions [9, 11–13, 18, 20], and four studies
utilized flexibility exercises along with strength or aerobic
exercise in the intervention protocol but in the control
group, the entire exercise protocol was flexibility exercises
[9, 11, 13, 20]. The types of flexibility training methods
varied from simple static stretches (19 studies) to different
proprioceptive neuromuscular facilitation (PNF) techniques
(1 study). Passive static stretching was the most common
method used [9, 11–13, 16, 18–29], while passive static
stretching with added weights was used once [17], active-
assisted (AA) was used twice [14, 30], active and passive
were used in conjunction once [15], contract-relax (CR)
PNF was used once [30], contract-relax-agonist contract
(CRAC) PNF was used once [30], and hold-relax-agonist
contract (HRAC) PNF was used once as well [30]. One study
compared multiple methods with each other [30]. Active-
assisted stretching had positive and sometimes significant
improvements in several outcome measures as compared
to the inactive control group, but less significant than the
improvements seen with the PNF techniques [30]. Weighted
flexibility exercises were similar to nonweighted exercises in
one study [15], but significantly better than nonweighted
exercises in another [17].
Thirteen studies involved whole body flexibility training
[9–21], two focused on hips and calves [22, 23], one focused
on hamstrings [24], three focused on calves [25–27], one
focused on hip flexors [28], one focused on the trunk
[29], and one study focused on the quadriceps muscles
[30]. Whole body flexibility training showed some minor to
significant increases in outcomes; however, most increases
were seen in ROM and flexibility measures, per se, and
not in other functional outcome measures. These results
were consistent with the overall effects of specific isolated
stretching interventions on outcome measures for the related
specific body parts.
The mean length of the included studies was 14.2 weeks,
ranging from 4 weeks to one year [12, 20]. Results did
not differ significantly throughout the range of intervention
durations. In the three studies of at least 25 weeks in duration
[12, 15, 20], no functional outcome measures were improved
other than flexibility and ROM. In the four studies with
durations of 6 weeks or less [23–25, 27] TUG improved
from 8.4 to 7.2 seconds [24], walking velocity increased 1.07
to 1.22 m/s [23], and flexibility and ROM were improved
overall.
The mean frequency was 4-exercise sessions per week,
ranging from the lowest frequency of twice per week [9, 10,
12, 22, 24] to 14x/week [27, 28]. Two studies did not report
exercise frequency [20, 22]. Some results from these studies
include a TUGtime decrease from8.4 to 7.2 seconds [24] and
a no-change [10], sit-to-stand time decreased from 10.2 to
9.2 seconds [9] and 9.3 to 7.9 seconds [10] and a no-change
[12], a step test increased in reps from 16.5 to 20.2 [9], and
an increase in freely chosen gait speed from 1.23 to 1.30 m/s
[22]. The 5x/week and 14x/week studies did not include
functional outcomes similar to the twice weekly studies. The
3x/week studies included results such as an improved TUG
time from 7.6 to 6.6 seconds [16] and a worsening time from
26.8 to 33.0 seconds [13], a functional reach improvement
of 16.0 to 19.6 cm [21] and two no-changes [19, 26], a sit-
to-stand improvement of 22.6 to 18.0 seconds [16], a step
test improvement of 13.5 to 17.6 repetitions [16], a 10 m
walk time improvement from 6.44 to 5.99 seconds [26], and
a 30 m walk time improvement from 28.1 to 20.0 seconds
[21]. Although limited in number, these results show that
the frequency of the flexibility training interventions had no
noticeable differences compare with 2 and 3 times per week.
The mean flexibility exercise session time was 32 minutes,
ranging from 30 seconds [29] to 85 minutes [19].
Journal of Aging Research 27
4. Discussion
There are currently scientific discussions regarding the utility
of stretching exercises which are regularly recommended and
conducted as a part of preexercise protocols to reduce injury
and increase performance. Earlier reviews of stretching and
flexibility have questioned their value in terms of injury pre-
vention, delayed onset of muscle soreness, and improvement
of performance [31, 32]. In fact, what occurs physiologically
with stretching remains unknown [32]. Due to equivocal
evidence thus far, the current American College of Sports
Medicine’s guidelines for exercise testing and prescription
[33] recommended the removal of static stretching as part
of a warm-up routine for strength and power activities.
Additionally, based on available evidence, the 2011 ACSM
position statement for guidance on prescribing exercise sug-
gests performing flexibility after cardiorespiratory endurance
or resistance exercise for general fitness programs. This
position stand highlighted the need for further research
to ascertain the effects of various flexibility prescriptions
for various activities and performance goals. From the
present review, there is not enough consistent evidence to
make recommendations for any specific prescriptions of
type, frequency, duration, or length of program related to
flexibility training; particularly no specific recommendations
can be made regarding the program or dose response of
flexibility training to the focus of the present study, the
transfer of flexibility gains to functions of daily life, or
ability to live independently. A recent systematic review of
106 articles relating the effects of pre-exercise acute-passive
static stretching on maximal muscle performance provided
74 methodologically sound studies providing 104 findings
[34]. This paper showed that 50% of the 104 findings
reported significant reductions in task performances, and
the authors concluded that static muscle stretches totaling
less than 45 s can be used in pre-exercise protocols without
significant decrement to strength, power or speed type tasks;
thus a conclusion was to recommend stretches held for at
maximum 45 s to avoid loss of strength. Shrier [35] had
also previously reported the potential negative acute effects
of stretching on performance, but additionally reviewed the
literature regarding regular stretching on performance which
indicates that regular stretching improves force, jump height,
and speed performance. Both reviews recommend further
synthesis of the literature with respect to the effects of other
forms of stretching on various performance measures.
The difficulties of the ability of this paper to provide
a consensus on flexibility training prescription for healthy
older adults include the lack of well-conducted studies
focused on flexibility in older adults and the lack of
consistency in the flexibility protocols employed, functional
outcomes measured, and functional results observed. As
such, according to the criteria used to assess level of evidence,
to recommend stretching/flexibility exercises as a routine
component of an exercise program for older adults to
enhance health or functional abilities is Level 4, Grade
C. The more influential studies in this paper (based on
focused flexibility protocols with clear functional outcomes
and relatively large sample sizes) [11–14, 16, 19] showed very
comparable effects to the overall outcomes of the 26 studies,
namely, an ambivalence in the value of flexibility training on
functional outcomes that may be related to maintenance of
independence in daily activities of older adults. Of these six
studies, 5 were RCTs with an average quality assessment score
of 18 out of 24. Only two of the six showed improvement in
flexibility and functional outcomes ([14] 16/24; [16] 19/24).
In the sub-group (≥80 years), frail, and assisted-living
populations there were significant improvements seen in
functional reach, sit-to-stand, and 30 m walk times, but
no changes in the PPT, and mixed results were observed
for flexibility, strength, balance, and TUG tests. This sub-
group was similarly ambivalent in the role of flexibility
training with functional outcomes to the rest of the study
populations, although this group had less consistency in
the flexibility-related outcome measures. Frequency and
duration differences between studies showed no noticeable
differences in outcomes. When different muscle groups
were targeted, the flexibility outcomes were expectedly fairly
body-part specific. Regarding the different flexibility training
methods, active-assisted (AA) stretching had positive and
sometimes significant improvements in several outcome
measures as compared to the inactive control group, but
less significant than the improvements seen with the PNF
techniques. Weighted flexibility exercises were similar to
nonweighted exercises in one study, but significantly better
than nonweighted exercises in another. One study showed
ACR-PNF to be much more effective than CR-PNF and static
stretching for both ROM and EMG activity. The overall
results point to PNF stretching being more effective than
non-PNF techniques for improving flexibility outcomes, but
not necessarily functional outcome measures.
While flexibility training interventions synthesized in
the present paper have been shown to increase flexibility
and joint ROM, no consistent increases in functional out-
comes have been observed. Therefore, future studies should
consider the relationship that increased flexibility and joint
ROM have with functional outcomes to determine if the
increased flexibility is beneficial and worthwhile in terms
of maintaining or increasing functional capacity for healthy
older adults. More research is also needed regarding the rela-
tionships between outcome variables (i.e., how one variable
such as functional reach would relate to another variable such
as the timed up-and-go) and on the relationships between
outcome measures and quality of life through self-reported
functioning/quality of life questionnaires to best determine
the applicability of the outcome measures.
Older adults are less concerned with high performance
benefits from increased flexibility and more focused on being
safely active and safely performing activities of daily living
[36]. Injury and fall prevention are also common motives
for recommending flexibility programs to older adults.
The 2011 ACSM position statement notes that flexibility
training may enhance postural stability and balance when
combined with resistance training; however, no consistent
link has been shown between regular flexibility exercise and
a reduction of musculoskeletal injuries or delayed onset of
muscle soreness [4]. However, despite the growing literature
describing the relationship of flexibility to injury risk in
28 Journal of Aging Research
younger populations [31], there is little research regarding
older adults.
5. Conclusions
This paper found that flexibility training interventions in
older adults are often effective at increasing joint range of
motion in various joints, and various functional outcomes
can be improved. However, due to the wide range of
intervention protocols, body parts studied, and functional
measurements, conclusive recommendations regarding flex-
ibility training and functional outcomes for older adults
remain ungrounded. As such, a specific prescription of how
long to hold a stretch, howmany repetitions of each stretch to
conduct, and the type of stretches to do, is not determinable
at this point. Because there is conflicting information
regarding both the relationship between flexibility training
interventions and functional outcomes, and the relationship
between improved flexibility and daily functioning and
health benefits have not been established, future research
studies should attempt to address these issues.
While there is a lack of evidence to recommend stretching
routines outside of a rehabilitative context, there is no
additional health or functional risk of including flexibility
exercises. As such, in light of increases in functional out-
comes achieved by other exercise modes (balance, aerobic
exercise, and strengthening exercises), stretching exercises
can be included as an adjunct to the above, but the current
literature would indicate it would add little to the functional
benefits of the other exercise modes. Of note, the evidence-
based and expert consensus statements of “Physical Activity
Guidelines for Older Adults” of the US, the UK, Canada,
and the World Health Organization (Global recommenda-
tions) have not included flexibility as a component in the
recommendations.
Appendix
See Table 2.
Abbreviations
ACSM: American College of Sports Medicine
RCT: Randomized control trial
TUG: Time-Up-and Go
ROM: Range of motion
PNF: Proprioceptive neuromuscular facilitation
CR-PNF: Contract-relax proprioceptive
neuromuscular facilitation
EMG: Electromyography
ACR-PNF: Active assisted contract-relax
proprioceptive neuromuscular facilitation.
Conflict of Interests
All the authors declare that they have no conflict of interests.
Table 2: Sample electronic database search strategy.
Sample search strategy-PubMed-January 2011
(1) Aged 331 611
(2) Aging 236 732
(3) Ageing 247 317
(4) “Older age” 15 622
(5) “Older adult

” 2 357
(6) Elderly 3352095
(7) Senior

22 086
(8) “Senior citizens” 734
(9) (1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8) 3505009
(10) “Muscle stretching exercises” [Mesh] 420
(11) “Pliability/physiology” [Mesh] 28
(12) “Range of motion, Articular/physiology” [Mesh] 8 786
(13) “Joint motion” 1 420
(14) “Joint movement” 722
(15) “Joint mobility” 888
(16) “Joint range” 491
(17) “Joint adhesion” 1 825
(18) “Joint articulation” 42
(19) “Muscle lengthening” 141
(20) “Muscle elongation” 35
(21) “Proprioceptive neuromuscular facilitation” 117
(22) “Isometric contraction” 12 414
(23) Yoga 1 483
(24) “Tai chi” 455
(25) Pilates 56
(26)
(10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR
17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR
24 OR 25)
28 177
(27) Ability 455 298
(28) Mobility 94 157
(29) Frailty 2 112
(30) Disability 80 338
(31) Dependen

1066172
(32) Independen

560 960
(33) Reliance 8 424
(34) Living 818 389
(35) Institutionaliz

12 329
(36) “Nursing home” 13 615
(37) “Activities of daily living” 45 277
(38) “Independent activities of daily living” 3 979
(39) ADL 4 683
(40) IADL 1 147
(41) “Assisted living” 1 197
(42) “Long-term care” 25 605
(43) “Long-term care” 25 605
(44)
(27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR
34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR
41 OR 42 OR 43)
2738402
Journal of Aging Research 29
Table 2: Continued.
Sample search strategy-PubMed-January 2011
(45) Control 2295628
(46) Treatment 6813000
(47) Modality 165 777
(48) Adjunct 25 544
(49) Component 289 484
(50) Group 1741947
(51) Subset 76 495
(52) Subset 446
(53) Subgroup 55 099
(54) Subgroup 2 358
(55) “Exercise” [Mesh] 52 144
(56) “Exercise prescription” 772
(57) “Exercise program

” 3 376
(58) “Exercise treatment” 240
(59) “Exercise therapy” 20 527
(60) Activity 1731305
(61) “Physical activity” 37 516
(62) “Physical therapy” 38 673
(63) “Fitness program

” 277
(64) Dance 2 274
(65) “Rhythmic exercise” 86
(66)
(45 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR
52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR
59 OR 60 OR 61 OR 62 OR 63 OR 64 OR 65)
9 702
261
(67) (9 AND 26 AND 44 AND 66) 2 401
(67 NOT child NOT children NOT cognit

NOT
“alzheimer disease”
434
NOT depression NOT anxiety NOT post-surg

NOT postsurg

NOT surgery NOT surgical NOT cardiac NOT
fracture

NOT arthroplasty
(68)
NOT diabetes NOT diabetic NOT cancer NOT
stroke NOT Parkinson

NOT “multiple sclerosis” NOT sclerosis NOT
stenosis NOT memory
NOT mental NOT coronary NOT cerebral NOT
dystrophy NOT polio
NOT fibromyalgia)
Authors’ Contributions
All authors have made substantial contributions to the
conception and design of the present systematic review.
L. Stathokostas coordinated the conduct of the systematic
review. L. Stathokostas and R. M. D. Little were involved
in the acquisition and analysis of data. All authors were
responsible for the interpretation of data. All authors have
been involved in drafting the paper. All authors read and
approved the final manuscript for publication.
Disclosure
D. H. P. Paterson is the research director of the Cana-
dian Centre for Activity and Aging and is responsible for
evidence-based development of exercise programs for older
adults. Recently, DH was a coauthor of a systematic review
which resulted in the modification and update of Canada’s
Physical Activity Guidelines for Older Adults submitted to
IJBNPA in 2010. This paper showed that exercise inter-
ventions in older adults are effective in maintaining or
improving functional abilities. However, it was identified that
less is known about the role of flexibility in the maintenance
or improvement of functional abilities. As such, the present
paper was undertaken.
Acknowledgment
The authors gratefully acknowledge the assistance of Marisa
Surmacz, Health Sciences librarian, University of Western
Ontario.
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