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BRIEF REVIEW

EFFECTS OF ACUTE STRETCHING EXERCISE AND


TRAINING ON HEART RATE VARIABILITY: A REVIEW
ALEXEI WONG1 AND ARTURO FIGUEROA2
1
Department of Health and Human Performance, Marymount University, Arlington, Virginia; and 2Department of Kinesiology
and Sport Management, Texas Tech University, Lubbock, Texas

ABSTRACT
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intervention for the potential improvement of cardiovascular


health in a variety of individuals, including those unable to
Wong, A and Figueroa, A. Effects of acute stretching exercise and
perform traditional aerobic or resistance exercise.
training on heart rate variability: A review. J Strength Cond Res
One of many objective measures to determine the effective-
XX(X): 000–000, 2019—Stretching (ST), an exercise modality
ness of ST on cardiovascular health includes heart rate (HR)
widely used for flexibility improvement, has been recently pro-
variability (HRV). Heart rate variability, the oscillation in the
posed as an effective adjunct therapy for declines in cardiovas- interval between consecutive R waves on the electrocardiogram
cular health, warranting research into the effects of ST exercise on (ECG) (R-R intervals), has been established as a reliable and
cardiac autonomic function (CAF). Heart rate (HR) variability noninvasive tool for the assessment of cardiac autonomic
(HRV) is a reliable measure of CAF, mainly the sympathetic and function (CAF) (40). Heart rate variability parameters can be
parasympathetic modulations of HR. A low HRV has been asso- used to derive the cardiac sympathovagal balance (SVbal), the
ciated to increased risk of cardiovascular events and mortality. magnitude of sympathetic to parasympathetic nerve activity
Exercise interventions that enhance HRV are therefore seen as (24). Therefore, different cardiac autonomic conditions can be
beneficial to cardiovascular health and are sought after. In this identified by HRV (15). An enhanced SVbal resulting from an
review, we discuss the effect of ST both acute and training on increase in sympathetic activity and reduction in parasympa-
thetic (vagal) activity leads to depressed HRV (40). From a clin-
HRV. Stretching training seems to be a useful therapeutic inter-
ical standpoint, an augmented SVbal and a reduction in HRV are
vention to improve CAF in different populations. Although the
associated with increased risks of cardiovascular events and mor-
mechanisms by which ST training improves CAF are not yet well
tality (9,35). Consequently, any strategy that reduces SVbal and
understood; increases in baroreflex sensitivity, relaxation, and ni- enhances HRV is, therefore, considered beneficial to cardiovas-
tric oxide bioavailability seem to play an important role. cular health and may have potential clinical implications.
Despite the known strong relationship between autonomic
KEY WORDS stretching training, autonomic function, stretch
function and HRV and despite different reports of changes in
exercise
HRV with ST practice, the literature on ST and HRV has not
yet been subjected to a comprehensive review. It is important
to understand HRV responses to ST, as it is a low-intensity
modality that has been shown to elicit a lower cardiovascular
INTRODUCTION

S
and metabolic demand than traditional aerobic or resistance
tretching (ST) is a form of exercise that is recom- exercise (20). These characteristics depict ST as feasible alter-
mended as a part of a general fitness program, native for individuals with cardiovascular conditions, such as
which is widely used for flexibility improvement
cardiac autonomic dysfunction, that may not have the capac-
and injury prevention (41). Recently, ST has been
ity to perform traditional exercise. Therefore, the present
proposed as an effective adjunct therapy for declines in car-
review aims to discuss the effects of ST on CAF. Published
diovascular function associated with aging and sedentary
studies that have investigated the effects of acute ST and ST
lifestyle (23). Other attractive characteristics of ST include
its low-intensity nature as well as the lack of monetary cost training are summarized. In addition, we discuss the potential
and additional equipment/facilities needed for its regular prac- mechanisms by which ST may improve HRV. Marymount
tice. Consequently, ST may be a viable nonpharmacological University approved this brief review.

METHODS
Address correspondence to Dr. Alexei Wong, awong@marymount.edu. Literature Search
00(00)/1–8 A systematic review of literature from January 1950 to April
Journal of Strength and Conditioning Research 2018 using MEDLINE, Google Scholar, PubMed, Web of
Ó 2019 National Strength and Conditioning Association Science, Scopus, and SPORTDiscus databases was used to

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ST and CAF

identify important studies. The following keywords, alone or in power (TP), an approximation of the global activity of the
conjunction, were used to find relevant publications: cardiac autonomic nervous system. The HF power is a marker of
autonomic function, heart rate variability, vagal modulation, cardiovagal activity (34). It is recognized that the LF com-
stretching, flexibility, stretch exercise, and stretching training. ponent of HRV expressed in absolute units is mediated by
All the eligible articles were in English. The inclusion criteria both sympathetic and parasympathetic activities (40). Abso-
focused on the utilization of acute ST exercise (ASTE) and ST lute units (ms2) for HF and LF in direct proportion to the TP
training on cardiac autonomic modulation. All articles were are expressed in normalized units (nu). The normalized LF is
required to have a detailed explanation of their ST exercise considered a marker of sympathetic activity. In addition, the
protocol, be it acute or chronic, including number of exercises, ratio of LF to HF power (LF/HF) is also often reported,
duration, sets per exercise, and rest periods. The articles quantifying the relationship between sympathetic and para-
included women and men. sympathetic nerve activities, the SVbal (34). Increased SVbal,
showed by a higher LF/HF, is considered a reflection of
Cardiac Autonomic Control
sympathetic predominance and is associated with increased
The cardiovascular center in the medulla oblongata is
cardiovascular risk (35) and a reduced longevity (37).
responsible for HR regulation through reciprocal
Both time- and frequency-domain HRV measures are often
changes in the activity of the sympathetic and para-
not normally distributed. For this reason, data transformation
sympathetic neurons innervating the sinoatrial node (16).
(typically, natural logarithm, Ln) is sometimes applied to yield
The postganglionic sympathetic neurons secrete cate-
an approximately normal distribution and permit parametric
cholamines (epinephrine and norepinephrine) to the
statistical analysis. For clinicians and exercise scientists, the
sinoatrial node, leading to increases in HR (16). On the
primary interest in HRV relates to its prognostic value in
other hand, postganglionic parasympathetic neurons in
cardiovascular events and morbidities (21,42). In addition, it is
the vagus nerve secrete acetylcholine, leading to de-
often used to evaluate cardiac autonomic control during and
creases in HR.
after (recovery phase) acute exercise (14).
Heart Rate Variability
Heart rate variability quantifies the variations in R-R intervals RESULTS
on an ECG. Heart rate variability is analyzed in the time Acute Effects of Stretching on Heart Rate Variability
domain and frequency domain. Time-domain measures have Reports investigating autonomic recovery from ASTE only
been proposed as the simplest method for deriving HRV, as include interventions using static ST (Table 1). It has been
they plot changes in normal R-R intervals over time (40). This reported that vagal activity increases after this type of ST in
is accomplished by analyzing relatively short ECG time seg- different populations. Logan and Yeo (27) assessed the effects of
ments (5–30 minutes). The 2 most common derived measures a 20-minute whole-body active ST session during the third
are the SD of normal R-R intervals (SDNN), a measure of trimester of pregnancy in 15 young women. Heart rate variabil-
overall variability, and the root mean square of successive ity was quantified for 10 minutes in the semi-Fowler position
differences of R-R intervals (RMSSD), a measure of beat-to- before and after ASTE. All ST movements were completed
beat variability and a marker of vagal activity. A decreased either in the sitting or hands-and-knees position on the floor.
SDNN is clinically relevant given that it is independently They reported increases in RMSSD 10 minutes after
associated to left ventricular hypertrophy and aortic stiffness ASTE. Although not significant, HR (23 b$min21, p =
(3), while a reduced RMSSD may be indicative of impaired 0.053) showed a trend to decrease at this time point. A study
cardiac autonomic modulation and cardiovascular disease by Hotta et al. (18) investigated the effects of ASTE on HRV
(24,25). Another measure of vagal activity that is also widely in patients with ischemic heart disease. Heart rate variability
derived is the percent of differences of adjacent R-R intervals was evaluated at baseline and for 15 minutes after ASTE. The
over 50 ms (PNN50). The PNN50 has proved very useful in participants performed 5 active static ST exercises (with 30-
providing diagnostic and prognostic information in a variety second intervals) for the forearm, trunk, and hamstrings. The
of conditions (40,42). results of this study showed a significant increase in HF power
Frequency-domain measures express HRV as a function of 15 minutes after ASTE. This evidence indicates that ASTE
frequency, rather than time. This method involves plotting may be a favorable intervention for improving cardiovagal
the frequency at which the length of the normal R-R interval modulation in patients with increased cardiovascular risk. Far-
changes (40). Cyclic fluctuations of the normal R-R intervals inatti et al. (11) assigned young men with low flexibility levels
are analyzed by autoregressive modeling or fast Fourier to ASTE that consisted of 3 active static stretches (3 sets per
transformation techniques using short ECG sampling times exercise with 30-second ST length) for the trunk and ham-
(2–5 minutes) (40). Measures derived include the very-low- strings. Significant increases in SDNN and RMSSD were
frequency (VLF, ,0.04 Hz) spectra, low-frequency (LF, noted after ST at 30 minutes after intervention. Farinatti
often 0.04–0.15 Hz), and high-frequency (HF, often 0.15– et al. (11) also reported that HR decreased after ST, which
0.40 Hz) spectral power. However, VLF is not often reported led these investigators to the conclusion that an increase vagal
on HRV-related literature. Together, these constitute total tone may have been responsible for the reduction in HR in
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the postintervention period. Decreases in HR 15–


60 minutes after acute active static ST have been pre-

[HF at 15 min after stretching


viously reported in normotensive young women (29).

[HF at 5 min after stretching


30 s between sets, YHR and [SDNN [RMSSD

[SDNN and [RMSSD at 1


at 30 min after stretching

No significant changes at
10 min after stretching

0 min after stretching


Previous work has demonstrated that active static ST
activates type III fiber mechanoreceptors, which leads to
the inhibition of parasympathetic discharges and
Findings

increase in sympathetic activity (10,32), thereby con-


tributing to an increase in HR during active static ST and
the early recovery period after ASTE (8,11,29). Thus, it
seems that 15 minutes is enough time for sympathetic
recovery and vagal reactivation after ASTE, leading to
decreases in HR.
1 min between

Contrary to the previously mentioned findings, Silva

*HF = high frequency; SDNN = SD of normal R-R intervals; RMSSD = root mean square of successive differences; NR = not reported.
Rest period

exercises

et al. (38) reported no significant changes in HR or HRV


30 s

60 s

40 s

NR
indices 10 minutes after ASTE in young trained men. A
possible explanation for the discrepancy is that the vol-
ume of work completed during this ST intervention was
not sufficient to produce significant changes in auto-
exercises exercise Duration

nomic function at 10 minutes after intervention. This


30 s

30 s

60 s

30 s

NR

notion is supported by the difference in ST exercises


and sets per exercise (1 ST exercise, 2 sets of 30 seconds
TABLE 1. Studies that have evaluated the effects of acute stretching on heart rate variability (HRV).*

No. of Sets per

in length) in the study by Silva et al. (38) compared with


NR

other studies (Table 1) (11,18). Thus, higher volume


3

active ST protocols might elicit greater cardiovagal in-


creases after intervention. Another potential reason for
NR

the contrasting findings by Silva et al. (38) may be the


3

study population, as young trained individuals may


require a significant higher volume of ST to elicit signif-
Static passive
Static active

Static active

Static active

Static active
stretching

icant autonomic changes when compared with other


Type of

untrained populations used on previous ST studies


(11,18). Nevertheless, this notion is somewhat specula-
tory because HRV responses to a higher volume ASTE in
trained individuals have not been evaluated to date.
of rest

of rest
protocol
Control

30 min

20 min
10 Resistance trained None

32 Untrained men and None

None

To the best of our knowledge, only one study has


examined the acute effects of passive ST on HRV. Inami
et al. (19) evaluated HRV at rest, during and within 5 mi-
acute myocardial

pregnant women
flexibility levels
men with low
Characteristics

20 Untrained men
women with

trained men

nutes after passive ST in healthy young men. Participants


infarction

Resistance

Untrained

performed five 1-minute sets of static passive ST to the


calf muscles in healthy young men. The results of this
investigation showed increases in HF power during and
5 minutes after passive ST. Therefore, it seems that unlike
active static ST, the response during passive ST is char-
8

15
Age (y) n

acterized by a shift to a parasympathetic activity-


dominant state. This result indicates the possibility that
23

66

19

22

29

the process differs between active and passive stretches,


although the response after the completion of ASTE is
Logan and Yeo (27)

similar for both. It is difficult to identify the mechanisms


Farinatti et al. (11)

Hotta et al. (18)

Inami et al. (19)

responsible for the difference between autonomic re-


Silva et al. (38)

sponses during active and passive ST from the current


literature. However, nontarget muscle contraction might
be considered as a possibility for the increase sympa-
Study

thetic activity during active ST (1), which is not seen


during passive ST (Figure 1). Future studies should aim
at evaluating these mechanisms.

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ST and CAF

were reported after ST training.


Of note, LF power or other
markers of sympathetic modu-
lation were not evaluated on
this previous study. Hence,
Mueck-Weymann et al. (31)
concluded that the reductions
in SVbal after daily ST in this
cohort may be partially ex-
plained by an increase in cardio-
vagal modulation. Contrary to
these findings, a study by Gerage
et al. (13) found no changes in
resting HRV parameters in
elderly women after 12 weeks
of ST training 2 times a week.
These investigators compared
elderly women performing 2 dif-
ferent exercise modalities, ST and
resistance. The training sessions
lasted 25–30 minutes and
included active ST exercises for
Figure 1. Schematic representation of heart rate responses to an acute session of active static stretching (A) and both upper- and lower-body
passive static stretching (B). Nontarget muscle contraction during active static stretching may cause increases in
sympathetic activity ([SA) and decreases in parasympathetic activity (YPA), leading to significant (*) increases in muscle groups. For each ST exer-
heart rate, which recovers and decreases below baseline during the recovery period. A passive stretching session cise, the muscle was held at the
is characterized by a progressive [PA, leading to significant decreases in heart rate in the early recovery period. maximal stretched position for 20
However, heart rate and the cardiac autonomic responses to passive static stretching beyond 5 minutes of the
recovery period remain uncertain (?). seconds. The discrepancy
between the studies might be
related to the role of aging on
the reduction of HRV or a lower
Effects of Stretching Training on Heart Rate Variability frequency of ST training. Compared with adults aged between
The effects of ST training on HRV have been assessed after 40 and 60 years, older adults have lower cardiovagal baroreflex
4- to 12-week interventions in healthy individuals and in sensitivity (30) due to increased central arterial stiffness (28). Pre-
populations that exhibit heightened risk of developing vious studies have demonstrated improvements in HRV after 6
cardiovascular diseases (Table 2). Some studies have re- months (26) but not after 8 weeks of aerobic training for older
ported improvements in both time- and frequency-domain adults (36), suggesting that longer training periods are required to
parameters. In obese postmenopausal women, our group improve HRV in older adults. Another possible reason for the
(44) used 8 weeks of static ST 3 times a week that consisted controversial findings could be related to the length of the ST
of a combination of 18 active and 20 passive stretches for the exercises, as 20 seconds per exercise was used by Gerage et al.
whole body. The ST was held for 30 seconds at the point of (13), which is below the 30 seconds in length recommended by
maximal exertion, or range of motion, without the partici- the American College of Sports Medicine (41) and the time used
pant experiencing major discomfort or pain. In this study, by previous studies (Table 2). This shorter ST exercise length
certified trainers pushed or pulled a specific body part until may have contributed to a decrease training volume in the study
they received verbal acknowledgment that the stretch was by Gerage et al. (13) compared with other studies (31,44) and
felt at maximal exertion for 30 seconds. Each stretch was hence the lack of changes in HRV parameters.
followed by a 15-second relaxation period. After ST training, To the best of our knowledge, only 2 studies have
there were significant improvements in frequency-domain evaluated the changes in R-R intervals after ST training.
parameters such as increases in HF nu power and decreases Gerage et al. (13) found no significant changes in R-R inter-
in LF nu power and LF nu/HF nu. There were also im- vals after 12 weeks of ST training in elderly women. This
provements in time domain reflected by increases in Ln observation is similar to that previously reported after 8
RMSSD. Similar improvements were demonstrated by weeks of ST training in obese postmenopausal women by
Mueck-Weymann et al. (31) after ST training in young male our group (44). Although the R-R interval was not reported
bodybuilders. In this particular study, participants performed in the previous study, there were no significant changes in
15 minutes of static ST exercises daily for a period of 4 weeks. resting HR. By contrast, the previous work by Mueck-
Significant decreases in LF/HF and increases in RMSSD Weymann et al. (31) found decreases in resting HR after 4
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TABLE 2. Studies that evaluated the effects of ST training on heart rate variability (HRV).*

Study Age (y) n Characteristics Duration (wk) Frequency Control protocol Type of ST ST protocol Findings

Mueck-Weymann 28 15 Healthy male 4 Daily None Static 15 min of ST after YHR, YLF/HF,
et al. (31) bodybuilders bodybuilding routine. [RMSSD,
No other protocol and [PNN50
details were reported.
Gerage et al. (13) 66 14 Untrained elderly 12 2 3 week None Static 25–30 min of active ST. No significant
women 2 sets per exercise. changes
20-s length per exercise. were reported.
15-s rest period between
sets and 30 s between
exercises. Number of
exercises was not reported.
Wong et al. (44) 57 12 Untrained obese 8 3 3 week No changes in Static 50 min of ST. YLFnu, [HFnu,

Journal of Strength and Conditioning Research


the
postmenopausal lifestyle during the 18 active and 20 YLFnu/HFnu,
women study period passive exercises. YLnLF/LnHF. and
1 set per exercise. [LnRMSSD
30-s length per exercise
15-s rest period.

*ST = stretching; RMSSD = root mean square of successive differences; PNN50 = the percent of differences of adjacent R-R intervals over 50 ms; LF = low frequency; HF = high
frequency; LF/HF = LF to HF ratio; nu = normalized units; Ln = natural logarithm.
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5
ST and CAF

response, a hypometabolic
state that is caused by an inte-
grated hypothalamic response
characterized by a decrease in
sympathetic activity (2). The
physiological effects of that
response include a reduction in
oxygen consumption, HR,
blood pressure, and respiratory
rate. Stretching has been shown
to cause the physiological ef-
fects of the relaxation response
(4,31,43). Furthermore, previous
literature has indicated ST as
a relaxation procedure (4,5).
Therefore, we can speculate
that relaxation could be one of
the mechanisms involved in the
decreased SVbal after ST.
Another potential mechanism
could be a rise in nitric oxide
Figure 2. Schematic representation of the potential mechanisms for the improvement in heart rate variability by (NO) levels. Findings from pre-
stretching training. vious investigations suggest that
NO may play a role in CAF by
increasing parasympathetic and
reducing sympathetic activity (7,17,45). Stretching exercises
weeks of ST training in young male athletes. Decreases in
have been shown to increase NO-dependent vasodilation
the resting HR with training in postmenopausal women
acutely, while improving cardiovagal control in patients with
seem to be influenced by exercise intensity because
acute myocardial infarction (18). Hence, it is possible that the
light-intensity interventions, either aerobic or resistance
connection between ST training and the increases in cardio-
(12,39), have had no effect on resting HR in postmenopausal
vagal activity is mediated, at least in part, by NO.
women. Therefore, the lack of changes in HR after ST train-
ing in postmenopausal women (13,44) reinforces the idea DISCUSSION
that light-intensity interventions do not change resting HR
Overall, the findings to date imply that ST training exerts
or R-R intervals in older populations.
a positive influence on resting HRV through increasing
Potential Mechanisms for the Improvement in Heart Rate vagal modulation and decreasing sympathetic tone. Yet, the
Variability by Stretching Training mechanisms mediating the improvement of HRV by ST
The potential mechanisms underlying the effect of ST training are currently unknown. Some evidence suggests
training on HRV are not completely understood (Figure 2). that baroreflex sensitivity, psychic-physical relaxation
One possibility is an improved baroreflex sensitivity (6,22). response, and NO may play mediating roles. Further
Certainly, evidence suggests that acute passive ST augments research is needed to evaluate the effects of extended
baroreflex control of HR (10). Although aortic stiffness is an periods (.12 weeks) of ST training on resting HRV to
important determinant of the reduced cardiovagal baroreflex warrant its clinical usefulness. Research findings suggest
sensitivity in older adults (28), the effects of ST on arterial that during passive ST, there is an increase in parasympa-
stiffness are controversial. A previous study demonstrated thetic activity, while active ST is characterized by increase
a decrease in arterial stiffness after ST in middle-aged in sympathetic activation. However, the cardiac autonomic
healthy men (33). On the contrary, we previously reported response after the completion of ST is similar for both
decreases in aortic mean blood pressure and vascular sym- active and passive exercises, which is characterized by
pathetic activity—LF of blood pressure variability—but not acute increase in vagal reactivation during the early recov-
arterial stiffness after 8 weeks of ST in obese postmenopausal ery period, resulting in lower postexercise HR compared
women (43). Those findings suggested that ST may improve with levels observed during inactive recovery. Finally, cur-
autonomic activity by reducing mean blood pressure, the rent literature has only focused on static ST. Studies evalu-
distending pressure on the arterial wall that influences arte- ating CAF to other types of ST, such as dynamic and
rial stiffness. Another potential mechanism for a shift toward proprioceptive neuromuscular facilitation ST, are lacking;
cardiovagal dominance is the psychic-physical relaxation thus, further research is warranted.
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PRACTICAL APPLICATIONS 14. Goldberger, JJ, Le, FK, Lahiri, M, Kannankeril, PJ, Ng, J, and Kadish,
AH. Assessment of parasympathetic reactivation after exercise. Am
This research supports the improvement of resting CAF in J Physiol Heart Circ Physiol 290: H2446–H2452, 2006.
different populations with static ST training programs, 15. Greiser, KH, Kluttig, A, Schumann, B, Swenne, CA, Kors, JA, Kuss,
$33 week with $30 seconds of length per ST exercise. This O, et al. Cardiovascular diseases, risk factors and short-term heart
review also illustrates how different ST modalities acutely rate variability in an elderly general population: The CARLA study
2002–2006. Eur J Epidemiol 24: 123–142, 2009.
result in diverse cardiac autonomic responses during ST.
16. Hall, JE and Guyton, AC. Textbook of Medical Physiology, 2006.
Taking into consideration that there is a progressive increase Available at: http://www.us.elsevierhealth.com/Medicine/
in parasympathetic activity during passive ST and its early Physiology/book/9781416045748/Guyton-and-Hall-Textbook-of-
recovery period, exercise professionals should emphasize the Medical-Physiology/. Accessed April 1, 2018.
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