Journal of Cardiovascular Nursing

Vol. 33, No. 4, pp 322Y328 x Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.

Effects of Static Stretching Exercise on Lumbar

Flexibility and Central Arterial Stiffness
Jeongok G. Logan, PhD, MSN, RN; Suk-Sun Kim, PhD, MSN, RN; Mijung Lee, PhD(c), MSN, RN;
Ha Do Byon, PhD, MS, MPH, RN; SeonAe Yeo, PhD, WHNP-BC, FAAN

Background: Previous studies have demonstrated that arterial stiffness is associated with lumbar flexibility (LF).
Stretching exercise targeted to improve LF may have a beneficial effect on reducing arterial stiffness.
Objectives: We examined the effects of a single bout of a structured, static stretching exercise on arterial
stiffness, LF, peripheral and central blood pressure (BP), and heart rate (HR) and tested the association between LF
Downloaded from http://journals.lww.com/jcnjournal by BhDMf5ePHKbH4TTImqenVBTqaQBI4TdoDK81RTdckBLqXhBduGSWvIhn3+I0RTDm8c/fOMab00M= on 06/25/2018

and central arterial stiffness. Method: The study had a pretest-posttest design without a control group. Thirty
healthy women followed a video demonstration of a 30-minute whole-body stretching exercise. Carotid-femoral
pulse wave velocity (cf-PWV), augmentation index, LF, peripheral and central BP, and HR were measured
before and after the stretching exercise. Results: One bout of a static stretching exercise significantly reduced
cf-PWV (t29 = 2.708, P = .011) and HR (t29 = 7.160, P = .000) and increased LF (t29 = 12.248, P G .000).
Augmentation index and peripheral and central BP also decreased but did not reach statistical significance.
Despite no association found between cf-PWV and LF, the larger increase in LF the subjects had, the larger
decrease in cf-PWV they had after exercise (r = 0.500, P = .005). Conclusions: Study findings highlight the
potential benefit of a static stretching exercise on central arterial stiffness, an independent predictor of
cardiovascular morbidity. Static stretching exercise conducted in the sitting position may be used as an effective
intervention to reduce cardiovascular risk after a cardiac event or for patients whose sympathetic function
should not be overly activated or whose gaits are not stable.
KEY WORDS: blood pressure, heart rate, pulse wave velocity, stretching exercise, vascular stiffness

E pidemiological studies have established arterial stiff-

ness as an independent predictor of cardiovascular
morbidity and mortality.1Y6 Diminished elasticity of
arterial walls results in earlier arrival of wave reflection,
and reflected waves that arrive during left ventricular
ejection increase left ventricle afterload and the am-
plification of systolic blood pressure (BP).3 Indeed, several
population-based longitudinal studies have shown that
Jeongok G. Logan, PhD, MSN, RN
Assistant Professor, University of Virginia School of Nursing, Charlottesville.
Suk-Sun Kim, PhD, MSN, RN
Assistant Professor, Ewha Womans University College of Nursing,
Seoul, Korea.
Mijung Lee, PhD(c), MSN, RN
Doctoral Student, University of Virginia School of Nursing, Charlottesville.
Ha Do Byon, PhD, MS, MPH, RN
Assistant Professor, University of Virginia School of Nursing, Charlottesville.
SeonAe Yeo, PhD, WHNP-BC, FAAN
Professor, University of North Carolina at Chapel Hill School of Nursing.
This study is funded by the Oscar and Ruth Lanford Research Award,
University of Virginia School of Nursing.
The authors have no conflicts of interest to disclose.
Correspondence
Suk-Sun Kim, PhD, MSN, RN, College of Nursing, Ewha Womans
University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
(suksunkim@ewha.ac.kr).
DOI: 10.1097/JCN.0000000000000460
arterial stiffness independently predicts hypertension in
nonhypertensive subjects,1,2 left ventricular hypertrophy,4
myocardial infarction,5 and stroke.6
Scientific evidence has accumulated demonstrating
the role of exercise in the prevention and treatment of
coronary vascular disease.7Y9 Randomized controlled
trials have shown different effects of various types of
exercises on arterial stiffness measured by pulse wave
velocity (PWV) and augmentation index (AI). For ex-
ample, a recent meta-analysis showed that aerobic exer-
cise reduced PWV and AI in a dose-dependent manner.10
However, both resistance exercise and combined exer-
cise of aerobic and resistance had no effect on PWV and
AI.10 Stretching exercise has been shown to reduce sore-
ness in overworked muscles and improves flexibility.11
Previous studies have demonstrated that arterial stiffness
is associated with lumbar or trunk flexibility as mea-
sured by a sit-and-reach test12 and by an inclinometer.13
Stretching exercise targeted to improve flexibility may
also exert a beneficial effect on reducing arterial stiff-
ness. Previously, 2 studies reported that static stretch-
ing reduces stiffness of peripheral arteries14,15; however,
the studies that revealed whether stretching can change
stiffness of central arteries, which reflects true cardio-
vascular risk, are rare. Therefore, this study aimed to
examine the effects of stretching exercise on central

322

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


arterial stiffness, lumbar flexibility (LF), peripheral and
central BP, and heart rate (HR) in community-residing
healthy women. The authors also tested whether LF is
associated with central arterial stiffness. We hypothe-
sized that 1 bout of static stretching exercise would
decrease aortic stiffness, peripheral and central BP, and
HR and increase LF and that LF would be negatively
associated with central arterial stiffness.
Method
Participants
After approval was obtained from the institutional re-
view board, a convenience sample of 32 healthy adult
volunteers was recruited from multiple community loca-
tions of Charlottesville, Virginia, by word of mouth.
To minimize gender effects, only women were included.
Because adults have a greater cardiovascular risk than
children, only adults were recruited. To exclude any con-
founding effect of other exercises, the study excluded
people who were engaging in any types of regular exer-
cise, defined as more than 3 times a week and more than
30 minutes per exercise. Because the device measuring
arterial stiffness requires a regularly occurring pulse
waveforms, participants with irregular cardiac rhythm
were excluded. The study excluded people with known
cardiovascular conditions (correx against style, hyper-
tension, heart failure, diabetes, or peripheral vascular
diseases) that may affect arterial stiffness. The people
with use of medications (eg, antihypertensives, "-blockers,
thyroid hormones, or steroids) that may affect BP and
HR were also excluded. After excluding 2 women
who presented irregular heart rhythm and hyperten-
sion, data from a total of 30 women (mean [SD] age,
44.37 [10.87] years) were used for data analysis. The
sample consisted of 1 black, 5 Chineses, 2 Indians,
14 Koreans, 1 Taiwanese, and 7 whites. The partici-
pants received an incentive after their participation.
Measures
Central arterial stiffness was noninvasively measured
by carotid-femoral PWV (cf-PWV) and Augmentation
Index using the SphygmoCor system (AtCor Medical,
New South Wales, Australia). To measure cf-PWV, an
electrocardiogram monitor was connected, and carotid
and femoral waveforms were captured by a pressure-
sensitive transducer applied on participants" carotid and
femoral sites. The system software calculates the transit
time of the pulse from the left ventricle to the carotid
arterial site (t1) and the transit time of the pulse from
the left ventricle to the femoral arterial site (t2), using
the foot-to-foot method. The distance from the supra-
sternal notch to the carotid artery site (d-carotid) and
the distance from the suprasternal notch to the femoral
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Stretching Exercise and Arterial Stiffness 323
artery site (d-femoral) were measured on the body
surface using a tape measure. Carotid-femoral PWV
was calculated as the difference in the distances from
suprasternal notch to 2 arterial sites (dpwv) divided by
the mean time difference (%t) in t1 from t2 (Figure 1).16
Higher cf-PWV indicates increased arterial stiffness.
Augmentation index is a commonly used measure
of arterial stiffness obtained from pulse wave analysis
(PWA).17 Pulse wave analysis was obtained by apply-
ing a tonometer on the radial arterial site. It generates
the ascending aorta pressure wave from the arterial
pulse waveform by mathematical transformation, using
the method based on Fourier analysis.18 Augmentation
index indicates the size of the increase or decrease in
the pulse height as a result of the reflected wave. If the
reflected peak is greater than the primary peak, AI is
positive; if the reflected peak is less than the primary
peak, AI is negative.19 A higher positive AI indicates
increased arterial stiffness. Figure 2 shows how AI is
derived from pulse waveforms on the radial artery
site. Augmentation index is known to be affected by
multiple factors including left ventricular ejection, PWV,
timing of reflection, BP, and HR.20 Therefore, the AI
was adjusted to an HR of 75 beats per minutes and
was used only to complement PWV data.
Central BP was also derived by PWA. The shape of
aortic pressure waves derived from arterial pulse waves
provides central systolic and diastolic BP, as well as AI.
Blood pressure and HR were determined by measur-
ing brachial BP using WelchAllyn Vital Signs Monitor
300 Series (WelchAllyn, New York). The upper arm
circumference was measured with a tape to select the
properly sized cuff.21 The cuff was placed over the bare
arm to maximize validity and reliability of the measures,
with the artery marker on the cuff placed over the
FIGURE 1. Carotid-femoral pulse wave velocity (PWV) using
SphygmoCor. (AtCor Medical, New South Wales, Australia).
t1, indicates the transit time of the pulse from the left
ventricle to the carotid arterial site; t2, the transit time of the
pulse from the left ventricle to the femoral arterial site.
324 Journal of Cardiovascular Nursing x July/August 2018

motions lasting 30 minutes. This video was originally

developed to promote stretching exercise for pregnant
women.25 Each stretching was designed to enhance
flexibility in 10 body areas including the neck, shoul-
der, upper arm, upper back, lower back, hip, back of
the leg, thigh, calf, and ankle. Each stretching was
repeated 3 to 5 times with 10 seconds of rest between
stretching motions.

FIGURE 2. Representation of central arterial waveform from
pulse wave analysis.19 delta P, indicates difference between
systolic blood pressure and pressure at inflection point; PP,
pulse pressure; AI, augmentation index.
brachial artery. The arm was positioned at the level of
the heart without movement.22 Blood pressure was
measured in the dominant arm twice with 1-minute
rest between measures, and the average of the 2 mea-
sures was used for data analysis.23
Lumbar flexibility (LF) was calculated by the sit-and-
reach method with a tape measure (ACE Protocol).24
The sit-and-reach test was first described by Wells and
Dillon (1952) to measure lower back and hamstring
flexibility. Subjects sat on a yoga mattress with feet 12-in
apart and heels aligned with the tape measure at the 15-in
mark. While keeping legs and arms straight with palms
down and 1 hand placed on top of the other, they were
asked to bend forward slowly and reach forward as far as
possible. When subjects held the position of maximum
reach for 2 seconds, flexion distance was recorded in
inches.
Intervention
In the clinical research unit at the university, partic-
ipants were instructed to follow the video demonstra-
tion, which consists of whole-body static stretching
Study Procedure
The authors used a pretest-posttest design without a
comparison group. According to the recommendations
for standardization of subject conditions,26 subjects were
instructed to refrain from physical exercise and caf-
feinated beverage on the day of research participation
until data collection was completed. After obtaining
informed consent, participants changed into a gown
keeping underwear on, and their height and weight
were measured. After resting in the supine position for
10 minutes, baseline arterial stiffness, BP, and HR were
measured. Lumbar flexibility was measured before the
intervention. Subjects were then asked to follow the
30-minute static stretching exercise video. After the stret-
ching, the LF measure was repeated. After a 5-minute
rest period in the supine position, measures of arterial
stiffness, BP, and HR were repeated. For the accurate
measures of the physiological data, there was no verbal
exchange between the subjects and the research staff.
Statistical Analysis
Statistical analyses were performed using SPSS for
Windows (version 20.0; Chicago, Illinois). Descriptive
statistics were calculated for all variables of interest.
Paired t tests were conducted to compare LF, arterial
stiffness, BP, and HR before and after the stretching
exercise. Pearson correlation coefficients were com-
puted to explore the associations between LF and cen-
tral arterial stiffness assessed by cf-PWV. All reported

TABLE 1 Differences of Cardiovascular Variables Between Before and After Stretching (N = 30)
Pre Post Paired Difference (Pre - Post)
Measures Mean (SD) Mean (SD) Mean (SD) t df Sig. (2-tailed)
cf-PWV, m/s 6.93 (1.54) 6.29 (1.17) .64 (1.28) 2.708 29 .011
AI at HR 75, % 18.67 (11.33) 17.70 (11.02) 0.97 (5.06) 1.046 29 .304
SBP, mm Hg 107.87 (10.75) 106.82 (12.48) 1.05 (4.89) 1.174 29 .250
DBP, mm Hg 63.37 (6.71) 61.88 (6.47) 1.48 (4.41) 1.841 29 .076
MAP, mm Hg 79.63 (8.34) 75.32 (16.45) 4.32 (17.81) 1.328 29 .195
C-SBP, mm Hg 98.30 (12.07) 97.50 (15.06) 0.80 (5.80) 0.862 29 .396
C-DBP, mm Hg 64.07 (6.83) 62.77 (7.08) 1.30 (4.71) 1.513 29 .141
C-MAP, mm Hg 79.30 (8.10) 78.13 (9.10) 1.17 (4.35) 1.470 29 .152
HR, beats per minute 64.88 (6.29) 61.77 (6.29) 3.12 (2.38) 7.160 29 G.001
Sit-and-reach, in 13.37 (4.63) 16.45 (4.79) j3.08 (1.38) j12.248 29 G.001

Abbreviations: AI at HR 75, augmentation index adjusted at a heart rate of 75 beats per minute; C-DBP, central diastolic blood pressure; cf-PWV,
carotid-femoral pulse wave velocity; C-MAP, central mean arterial pressure; C-SBP, central systolic blood pressure; DBP, diastolic blood pressure;
HR, heart rate; MAP, mean arterial pressure; SBP, systolic blood pressure.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


P values are calculated using a 2-tailed test with statis-
tical significance set at P G .05.
Results
The age of the subjects ranged from 30 to 64 years,
with a mean (SD) of 44.37 (10.87) years. Body mass
index ranged from 17.30 to 32.56 kg/m2, with a mean
(SD) of 24 (4.09) kg/m2. The means and standard devi-
ations of all the cardiovascular variables before and
after stretching are displayed in Table 1. The table also
shows the effects of stretching exercise on all the car-
diovascular variables and lumber flexibility. There was
a significant difference in the scores from preYcf-PWV
(mean [SD], 6.93 [1.54]) to postYcf-PWV (mean [SD],
6.29 [1.17]; t29 = 2.708, P = .011). In addition, HR
significantly reduced from 64.88 (SD, 6.29) to 61.77
(SD, 6.29) beats per minute after stretching exercise
(t29 = 7.160, P G .001). Furthermore, a significant
increase in sit-and-reach was detected from 13.37
(SD, 4.63) to 16.45 (SD, 4.79) after stretching exercise
(t29 = -12.248, P G .001). All other cardiovascular
variables including AI and peripheral and central BP
also decreased after stretching exercise, but the differ-
ence did not reach statistical significance. As shown in
Table 2, there were no significant associations between
pre-cf-PWV and pre-LF (r = j0.073, P = .703) and
between post-cf-PWV and post-LF (r = 0.082, P =
.666). However, subjects who had a greater increase
in LF after the exercise showed a larger decrease in
PWV (r = 0.500, P = .005). In addition, subjects who
had higher PWV before stretching had a greater
decrease in PWV after stretching (r = 0.670, P G .001)
and were likely to have a greater increase in LF (r =
0.348, P = .060).
Discussion
The current study demonstrates that 1 bout of a struc-
tured, static stretching exercise significantly reduced
central arterial stiffness and resting HR. Peripheral BP,
as well as AI and central BP, also decreased after stret-
ching, but the difference between prestretching and
poststretching did not reach statistical significance.
Despite numerous studies examining the benefi-
cial effects of aerobic exercise on cardiovascular health,
a very few studies have explored the effects of stretching
TABLE 2 Correlation Between Lumbar Flexibility and Carotid-Femoral Pulse Wave Velocity (N = 30)
Difference in
cf-PWV
PreYcf-PWV 0.670a
PostYcf-PWV j0.210
Difference in cf-PWV V j0.189
Abbreviation: cf-PWV, carotid-femoral pulse wave velocity.
a
P G .001.
b
P G .01.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Stretching Exercise and Arterial Stiffness 325
exercise on arterial stiffness. Two studies have demon-
strated that static stretching decreased peripheral
PWV.14,15 However, 3 studies that included the mea-
sure of cf-PWV reported no change in cf-PWV after
stretching.15,27,28 Yamato"s15 (2016) recent study
demonstrated that cf-PWV did not change after
stretching, whereas peripheral arterial stiffness mea-
sured by femoral-ankle PWV and brachial-ankle
PWV significantly reduced after stretching. Measur-
ing peripheral arterial stiffness is easier and simpler
because it does not require access to carotid and
femoral arterial sites. However, a few studies reported
limitation of peripheral arterial stiffness in predicting
cardiovascular outcomes.29 On the other hand, the
measure of cf-PWV, despite its inconvenience, mea-
sures arterial stiffness along the aortic-iliac pathway,
which makes the largest contribution to BP buffering.
Therefore, cf-PWV more accurately reflects patho-
physiological effects of arterial stiffness on cardio-
vascular conditions and is considered the criterion
standard measure of arterial stiffness.6 The results of
the current study highlight the potential beneficial
effect of stretching exercise on the central arterial
system.
Pulse wave velocity measures are directly affected
by BP; thus, studies must discern whether the change
in PWV is secondary to BP change.26 The current
results demonstrate that the observed decrease in
cf-PWV after stretching is independent of BP.
Stretching is an important element of yoga and tai
chi, and some studies have shown an effect of
yoga30Y32 and tai chi33 on reducing arterial stiffness;
however, it is worth noting that certain yoga postures,
particularly standing posture and tai chi motions
combined with dynamic tension, may evoke increases
in BP and HR,13 as often observed during isometric
exercises.34 Although cardiovascular activity was not
monitored concurrently during the stretching exercise
in this study, the gentle stretching motions that were
conducted in the sitting position are unlikely to cause
a substantial increase of BP, because the results
demonstrated reduced HR and peripheral and central
BP after stretching exercise. Consequently, a structured,
static stretching exercise may be a particularly useful
intervention for people who have risks of cardiac events
or who are recovering from cardiac events. Moreover,
PreYLumbar PostYLumbar Difference in Lumbar
Flexibility Flexibility Flexibility
j0.073 0.030 0.348
0.111 0.082 j0.089
j0.039 0.500b
326 Journal of Cardiovascular Nursing x July/August 2018
What’s New and Important
h One bout of a static stretching exercise significantly
reduced central arterial stiffness, which is an important
subclinical cardiovascular condition.
h A stretching exercise also significantly increased lumbar
flexibility; the greater increase in lumbar flexibility was
associated with a greater decrease in central arterial
stiffness.
h Given the beneficial effects of a stretching exercise on
reducing central arterial stiffness without increasing BP,
static stretching may be used as a preventative or
rehabilitation regimen for people who have a high risk
of cardiovascular events.
static stretching exercise may be more feasible for
people with disabilities or stroke patients, postsurgery
patients, and people who have unsteady walking or are
homebound. Whereas yoga generally requires various
postures that involve twists, inversions, backbends,
and balancing poses and sometimes incorporates
physically rigorous postures, a static stretching exer-
cise that consists of gentle movements can be easily
followed by most people with minimal risk of injuries.
The potential mechanism by which stretching may
decrease arterial stiffness can be explained by changes
in nitric oxide (NO) and arterial smooth muscle tone.
Arterial walls have 3 layers: tunica intima, tunica
media, and tunica adventitia. Whereas atherosclero-
sis is a condition where plaques accumulate on the
innermost layer, intima, arterial stiffness (ie, arterio-
sclerosis) is characterized by degeneration of the
medial layer.35 Nevertheless, the noninvasive measure
of arterial stiffness reflects characteristics of the endo-
thelium of both the intima and medial layers (which
include smooth muscle and elastic tissue). Therefore,
arterial stiffness is determined by functional and
structural changes in all layers of the arterial wall.36
Given the short time of vessel response to stretching, it
is unlikely that structural changes have occurred
during this study. However, endothelial-derived NO
may play an important role in the decrease of arterial
stiffness. Lansman et al37 demonstrated that, when the
aortic endothelial cell-attached membrane patch is
stretched, there is increased Ca2+ influx, which medi-
ates the synthesis and release of endothelium-derived
relaxing factor, NO. A recent in vitro study also
reported that production of NO was significantly
increased when muscle tissues were elongated to 30%
beyond their initial length.38 Hotta et al39 also reported
that 1 round of stretching exercises increased NO
bioavailability from vascular endothelial cells and
decreased arterial stiffness in acute myocardial infarc-
tion patients. It should be noted that arterial stiffness
was measured by cardio-ankle vascular index and
ankle brachial index in their study. Considered that
elastic central arteries are known to produce more
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
basal NO production than peripheral arteries,40 the
reduction in stiffness of central arteries, although it
was not measured, can be greater than what has been
reported in their study. In addition to the increase of
NO, stretching may create a reduction in passive ten-
sion of arterial smooth muscles when they are elon-
gated beyond their resting length.41 The slower the
stretch, the less stiffness may be present in the muscle.41
Thus, the slow motions of stretching conducted in this
study might further contribute to significant reduction
in stiffness of the arterial smooth muscle.
In this study, LF increased significantly after the
stretching exercise. Although no significant associa-
tion was observed between LF and central arterial
stiffness, the significant association between changes
of LF and central arterial stiffness vaguely supports
previous studies reporting that poor LF is associated
with peripheral arterial stiffness,12 as well as central
arterial stiffness.42 Possible explanations for our non-
significant finding on the association between LF and
central arterial stiffness may be inconsistency of subject
conditions including data collection time during a day,
levels of physical activity, and difference in foods con-
sumed before the data collection, each of which may
affect arterial stiffness.
The major limitations of this study are related to study
design. First, although participants took a 10-minute
rest before data collection and we are encouraged to
consider that the observed differences are due to the
intervention, without a proper control group and ran-
domization, conclusive evidence of the effects of stretch-
ing on cf-PWV remain tentative. Second, the authors
measured cf-PWV only once after stretching; thus, it is
unknown how long this effect might last. Third, the
study failed to include demographic and lifestyle factors
that may affect arterial stiffness. The results can be
further supported by future studies with more rigorous
control of potential confounding factors. Last, the small
sample size recruited by word of mouth may generate
sampling bias and limit the generalizability of the study.
Conclusion
In conclusion, this study highlights the effects of 1
bout of static stretching exercise on central arterial
stiffness, an independent predictor of cardiovascular
disease. The results also demonstrate that HR
significantly decreased after the stretching exercise.
Given no sign of overactivity of sympathetic func-
tion, this type of a stretching exercise can be used for
people with a high risk of cardiac events, which can
be triggered by sympathetic overactivity. In addition,
stretching motions that were conducted in the sitting
position may be an effective intervention to reduce
arterial stiffness in poststroke patients and people with
disability whose gaits are not stable. These findings are

encouraging that mild, self-directed, inexpensive stretch-
ing exercises can produce significant improvement in
physiological states that are precursors of cardiac disease.
For this simple intervention to be used to decrease both
cardiovascular morbidity/mortality and healthcare
costs, further studies are warranted to confirm the
results in a larger population.
REFERENCES
1. Dernellis J, Panaretou M. Aortic stiffness is an independent
predictor of progression to hypertension in nonhypertensive
subjects. Hypertension. 2005;45(3):426Y431.
2. Liao D, Arnett DK, Tyroler HA, et al. Arterial stiffness and
the development of hypertension. the ARIC study. Hyper-
tension. 1999;34(2):201Y206.
3. Safar ME, Levy BI, Struijker-Boudier H. Current perspec-
tives on arterial stiffness and pulse pressure in hypertension
and cardiovascular diseases. Circulation. 2003;107(22):
2864Y2869. http://www.ncbi.nlm.nih.gov/pubmed/12796414;
http://www.ncbi.nlm.nih.gov/pubmed/12796414.
4. Chung CM, Lin YS, Chu CM, et al. Arterial stiffness is the
independent factor of left ventricular hypertrophy deter-
mined by electrocardiogram. Am J Med Sci. 2012;344(3):
190Y193.
5. Mitchell GF, Hwang SJ, Vasan RS, et al. Arterial stiffness
and cardiovascular events: the Framingham heart study.
Circulation. 2010;121(4):505Y511.
6. Laurent S, Katsahian S, Fassot C, et al. Aortic stiffness is
an independent predictor of fatal stroke in essential hyper-
tension. 2003;34(5):1203Y1206. http://www.ncbi.nlm.nih.gov/
pubmed/12677025; http://www.ncbi.nlm.nih.gov/pubmed/
12677025.
7. Nocon M, Hiemann T, Muller-Riemenschneider F, Thalau
F, Roll S, Willich SN. Association of physical activity with
all-cause and cardiovascular mortality: a systematic review
and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2008;
15(3):239Y246.
8. Schuler G, Adams V, Goto Y. Role of exercise in the pre-
vention of cardiovascular disease: results, mechanisms, and
new perspectives. Eur Heart J. 2013;34(24):1790Y1799.
9. Mora S, Cook N, Buring JE, Ridker PM, Lee IM. Physical
activity and reduced risk of cardiovascular events: potential
mediating mechanisms. Circulation. 2007;116(19):2110Y2118.
10. Ashor AW, Lara J, Siervo M, Celis-Morales C, Mathers JC.
Effects of exercise modalities on arterial stiffness and wave
reflection: a systematic review and meta-analysis of random-
ized controlled trials. PLoS One. 2014;9(10):e110034.
11. Sihawong R, Janwantanakul P, Jiamjarasrangsi W. A pro-
spective, cluster-randomized controlled trial of exercise pro-
gram to prevent low back pain in office workers. Eur Spine J.
2014;23(4):786Y793.
12. Yamamoto K, Kawano H, Gando Y, et al. Poor trunk flex-
ibility is associated with arterial stiffening. Am J Physiol Heart
Circ Physiol. 2009;297(4):H1314YH1318.
13. Miles SC, Chun-Chung C, Hsin-Fu L, et al. Arterial blood
pressure and cardiovascular responses to yoga practice. Altern
Ther Health Med. 2013;19(1):38Y45.
14. Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N.
Four weeks of regular static stretching reduces arterial stiff-
ness in middle-aged men. Springerplus. 2015;(4):555.
15. Yamato Y, Hasegawa N, Sato K, Hamaoka T, Ogoh S,
Iemitsu M. Acute effect of static stretching exercise on arterial
stiffness in healthy young adults. Am J Phys Med Rehabil.
2016;95(10):764Y770.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Stretching Exercise and Arterial Stiffness 327
16. Millasseau SC, Stewart AD, Patel SJ, Redwood SR,
Chowienczyk PJ. Evaluation of carotid-femoral pulse wave
velocity: influence of timing algorithm and heart rate. Hyper-
tension. 2005;45(2):222Y226. http://www.ncbi.nlm.nih.gov/
pubmed/15642772; http://www.ncbi.nlm.nih.gov/pubmed/
15642772.
17. Crilly M, Coch C, Clark H, Bruce M, Williams D. Repeat-
ability of the measurement of augmentation index in the
clinical assessment of arterial stiffness using radial applanation
tonometry. Scand J Clin Lab Invest. 2007;67(4):413Y422. http://
www.ncbi.nlm.nih.gov/pubmed/17558896; http://www.
ncbi.nlm.nih.gov/pubmed/17558896.
18. O"Rourke MF, Pauca AL. Augmentation of the aortic and
central arterial pressure waveform. Blood Press Monit. 2004;
9(4):179Y185. http://www.ncbi.nlm.nih.gov/pubmed/15311144;
http://www.ncbi.nlm.nih.gov/pubmed/15311144.
19. Lane HA, Smith JC, Davies JS. Noninvasive assessment of
preclinical atherosclerosis. Vasc Health Risk Manag. 2006;
2(1):19Y30.
20. Hamilton PK, Lockhart CJ, Quinn CE, McVeigh GE. Arterial
stiffness: clinical relevance, measurement and treatment. Clin
Sci (Lond). 2007;113(4):157Y170.
21. Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfeld LP.
Error in blood-pressure measurement due to incorrect cuff
size in obese patients. Lancet. 1982;2(8288):33Y36. http://
www.ncbi.nlm.nih.gov/pubmed/6123760; http://www.ncbi.
nlm.nih.gov/pubmed/6123760.
22. Umana E, Ahmed W, Fraley MA, Alpert MA. Comparison
of oscillometric and intraarterial systolic and diastolic
blood pressures in lean, overweight, and obese patients.
Angiology. 2006;57(1):41Y45. http://www.ncbi.nlm.nih.
gov/pubmed/16444455; http://www.ncbi.nlm.nih.gov/
pubmed/16444455.
23. Pickering TG. Measurement of blood pressure in and out of
the office. 2005;7(2):123Y129. http://www.ncbi.nlm.nih.gov/
pubmed/15722659; http://www.ncbi.nlm.nih.gov/pubmed/
15722659.
24. Lemmink KA, Kemper HC, de Greef MH, Rispens P, Stevens M.
The validity of the sit-and-reach test and the modified sit-and-
reach test in middle-aged to older men and women. Res Q
Exerc Sport. 2003;74(3):331Y336.
25. Yeo S, Davidge S, Ronis DL, Antonakos CL, Hayashi R,
O"Leary S. A comparison of walking versus stretching
exercises to reduce the incidence of preeclampsia: a ran-
domized clinical trial. Hypertens Pregnancy. 2008;27(2):
113Y130.
26. Laurent S, Cockcroft J, Van Bortel L, et al. Expert consensus
document on arterial stiffness: methodological issues and
clinical applications. 2006;27(21):2588Y2605. http://www.
ncbi.nlm.nih.gov/pubmed/17000623; http://www.ncbi.nlm.
nih.gov/pubmed/17000623.
27. Wong A, Figueroa A. Eight weeks of stretching training
reduces aortic wave reflection magnitude and blood pressure
in obese postmenopausal women. J Hum Hypertens. 2014;
28(4):246Y250.
28. Cortez-Cooper MY, Anton MM, Devan AE, Neidre DB,
Cook JN, Tanaka H. The effects of strength training on
central arterial compliance in middle-aged and older adults.
Eur J Cardiovasc Prev Rehabil. 2008;15(2):149Y155.
29. Choi JC, Lee JS, Kang SY, Kang JH, Bae JM, Lee DH.
Limitation of brachial-ankle pulse wave velocity in assess-
ing the risk of stroke: importance of instantaneous blood
pressure. Cerebrovasc Dis. 2009;27(5):417Y425.
30. Hunter SD, Dhindsa MS, Cunningham E, et al. Impact of
hot yoga on arterial stiffness and quality of life in normal
and overweight/obese adults. J Phys Act Health. 2016;13(12):
1360Y1363.
328 Journal of Cardiovascular Nursing x July/August 2018
31. Patil SG, Aithala MR, Das KK. Effect of yoga on arterial
stiffness in elderly subjects with increased pulse pressure:
a randomized controlled study. Complement Ther Med.
2015;23(4):562Y569.
32. Parshad O, Richards A, Asnani M. Impact of yoga on
haemodynamic function in healthy medical students. West
Indian Med J. 2011;60(2):148Y152.
33. Shin JH, Lee Y, Kim SG, Choi BY, Lee HS, Bang SY. The
beneficial effects of tai chi exercise on endothelial function
and arterial stiffness in elderly women with rheumatoid
arthritis. Arthritis Res Ther. 2015;17:380.
34. Tanaka S, Sugiura T, Yamashita S, Dohi Y, Kimura G,
Ohte N. Differential response of central blood pressure to
isometric and isotonic exercises. Sci Rep. 2014;4:5439.
35. Orourke M. Mechanical principles in arterial-disease. Hyper-
tension. 1995;26(1):2Y9.
36. Logan JG, Engler MB, Kim H. Genetic determinants of
arterial stiffness. J Cardiovasc Transl Res. 2015;8(1):23Y43.
37. Lansman JB, Hallam TJ, Rink TJ. Single stretch-activated ion
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
channels in vascular endothelial cells as mechanotransducers?
Nature. 1987;325(6107):811Y813.
38. Zheng J, Zhai K, Chen Y, et al. Nitric oxide mediates stretch-
induced Ca2+ oscillation in smooth muscle. J Cell Sci. 2016;
129(12):2430Y2437.
39. Hotta K, Kamiya K, Shimizu R, et al. Stretching exercises
enhance vascular endothelial function and improve periph-
eral circulation in patients with acute myocardial infarction.
Int Heart J. 2013;54(2):59Y63.
40. Leloup AJ, Van Hove CE, Heykers A, Schrijvers DM, De
Meyer GR, Fransen P. Elastic and muscular arteries differ
in structure, basal NO production and voltage-gated ca(2+)-
channels. Front Physiol. 2015;6:375.
41. Knudson D. The biomechanics of stretching. J Exercise Sci
Physiother. 2006;2:3Y12.
42. Lee YH, Yoon ES, Park SH, Heffernan KS, Lee C, Jae SY.
Associations of arterial stiffness and cognitive function with
physical fitness in patients with chronic stroke. J Rehabil Med.
2014;46(5):413Y417.