Original Research

Effect of a Supervised Hip Flexor Stretching Program

on Gait in Frail Elderly Patients
Jaclyn R. Watt, MS, Keith Jackson, BS, Jason R. Franz, MS, Jay Dicharry, MPT,
Jonathan Evans, MD, D. Casey Kerrigan, MD

Objective: To determine whether a 10-week supervised hip flexor stretching program in

frail elderly subjects would increase peak hip extension, stride length, and gait speed and
reduce anterior pelvic tilt during comfortable and fast-paced walking.
Design: A double-blinded, randomized, controlled trial.
Setting: Pre- and post-treatment assessments were performed in a gait laboratory and
stretching exercises were performed outside of the laboratory, usually in the subjects’ place
of residence.
Participants: Seventy-four frail elderly individuals, with 41 subjects in the control group
and 33 subjects in the treatment group.
Intervention: The treatment group completed a 10-week twice-daily hip flexor stretching
program that was supervised twice weekly by a rehabilitation clinician. The control group
completed a 10-week shoulder abductor stretching program.
Main Outcome Measurements: Dynamic peak hip extension and peak anterior
pelvic tilt, stride length, and gait speed while walking at a comfortable pace and a fast pace,
as well as passive hip extension range of motion.
Results: The treatment group showed significant increases in walking speed and stride
length after the intervention but showed no significant changes in peak hip extension or
anterior pelvic tilt during comfortable and fast-paced walking. The treatment group also
showed significantly increased passive hip extension range of motion.
Conclusions: These results indicate that a simple stretching program is effective in
improving some measures of age-related decline in gait function in frail elderly patients. The
J.R.W. Department of Physical Medicine and
lack of consistent improvements in walking kinematics is attributed to the presence of Rehabilitation, University of Virginia, Charlot-
multiple disabilities and limitations present in the frail subjects. tesville, VA
PM R 2011;3:330-335 Disclosure: nothing to disclose

K.J. Department of Physical Medicine and

Rehabilitation, University of Virginia, Charlot-
tesville, VA
INTRODUCTION Disclosure: nothing to disclose
Frail elderly populations residing in assisted-living facilities have been shown to be generally J.R.F. Department of Integrative Physiology,
less active and to have greater mobility limitations than do healthy elderly populations [1,2]. University of Colorado, Boulder, CO
Disclosure: nothing to disclose
Reduced mobility in the frail population leads to an increased incidence of falls [3], which
are a major cause of injury, disability, further loss of functional independence, decline in J.D. Department of Physical Medicine and
Rehabilitation, University of Virginia, Charlot-
quality of life, and death [4-9]. Frail persons typically are excluded from gait intervention tesville, VA
studies even though they are often the very population in which the intervention is most Disclosure: nothing to disclose
needed [10]. J.E. Department of Physical Medicine and
In previous research we have shown that the gait of elderly subjects exhibits consistently Rehabilitation, University of Virginia, Charlot-
tesville, VA
reduced peak hip extension compared with that of young adults during both comfortable
Disclosure: nothing to disclose
and fast-paced walking [11,12]. In addition, we and others have noted that this consistent
D.C.K. JKM Technologies, Charlottesville,
reduction in peak hip extension is associated with compensatory increases in anterior pelvic VA. Address correspondence to D.C.K., 525
tilt [13-15], indicating a reduced hip flexion range of motion (ROM) in the elderly Rookwood Place, Charlottesville, VA 22903;
population. Reduced peak hip extension and increased anterior pelvic tilt can lead to e-mail: dckerrigan@oeshshoes.com
Disclosure: 1B, major ownership in athletic
smaller step lengths and thus decreased gait velocity in elderly adults compared with young shoe company, OESH; 8B, NIH, grant
adults [12,16,17]. RO1AG027192
Because limited hip extension ROM is generally acknowledged in rehabilitation practice Submitted for publication April 6, 2010; ac-
to be reversible with hip flexor stretching [13,18-20], we previously investigated the effects cepted January 9, 2011.

PM&R © 2011 by the American Academy of Physical Medicine and Rehabilitation

1934-1482/11/$36.00 Vol. 3, 330-335, April 2011
330
Printed in U.S.A. DOI: 10.1016/j.pmrj.2011.01.006
PM&R
of an unsupervised 10-week hip flexor stretching program on
gait in healthy elderly subjects [21]. Although significant
increases in peak passive hip extension ROM (2°) occurred,
the subsequent increases in dynamic peak hip extension
during walking (1.6°) observed in the treatment group did
not reach significance. However, because the magnitudes of
improvement in passive and dynamic hip extension were
similar, the results indicated that static hip flexor contracture
was likely responsible for the age-related decreases in peak
hip extension while walking.
The authors of other studies also have found that lower
limb stretches can significantly alter hip extension, anterior
pelvic tilt, and stride length during walking [22-25]. How-
ever, with the exception of the study by Rodacki et al [23],
most of the stretching exercises in these studies were aimed at
multiple muscle groups. Rodacki and colleagues discovered
that subjects who used a one-time hip flexor stretch exhibited
immediate improvements in stride length and gait speed, but
these investigators did not examine long-term effects or an
ongoing stretching program. Furthermore, these previous
studies involved analysis of only healthy elderly persons, and
thus little is known about how a stretching intervention
would affect a frail population presenting with multiple
conditions and limitations. In the current study we evaluated
the efficacy of a 10-week supervised, rigorous hip flexor
stretching program in counteracting age-related decrease in
gait function in a frail elderly population. It was hypothesized
that after the stretching program, subjects would show in-
creased peak hip extension, stride length, and gait speed and
reduced anterior pelvic tilt during both comfortable and fast
walking accompanied by increased passive hip extension
ROM.
METHODS
Participants
One hundred frail elderly subjects who were older than 65
years and were living either independently or in assisted-
living facilities were recruited from the local population.
Before testing, each subject completed a face-to-face history
and physical examination screening performed by a clinician.
Subjects were screened for inclusion in the study on the basis
of any of the following factors: (1) a low Instrumental Activ-
ities of Daily Living score (⬍3/5); (2) a major orthopedic
diagnosis in the lower back, pelvis, or lower extremities since
the age of 50 years; or (3) a performance on a Mini Mental
Status Examination of less than 24/30. These factors, which
were used to classify elderly subjects as frail, showed either a
lack of daily functional independence or a measurable dete-
rioration in physical health, thus enabling us to include a
complex elderly population with a wide variety of conditions
in the study. Subjects were excluded from the study if they
were unable to walk independently, had hip- or knee-re-
Vol. 3, Iss. 4, 2011 331
placement surgery or a hip fracture in the past 6 months, had
dementia or severe cognitive impairment, or had an acute
medical illness that would make it unsafe for them to partic-
ipate.
The study was approved by the Institutional Review Board
for Health Science Research, and all subjects gave written
informed consent before participating in any of the study
sessions. Study sessions included a pre-intervention assess-
ment, a 10-week stretching program intervention, and a
post-intervention assessment.
Intervention
Subjects were randomly assigned to either a hip extension
stretching treatment group or a shoulder abductor stretching
control group (ncontrol ⫽ 41, ntreatment ⫽ 33). A rehabilitation
clinician instructed each subject in the treatment group to
perform 8 minutes of a hip extension stretching exercise daily
and each subject in the control group to perform a shoulder
abductor stretching exercise daily. The treatment group was
shown a hip-stretching exercise (Figure 1) that was consid-
ered feasible for elderly subjects to perform independently on
a daily basis. The control group was shown a shoulder deltoid
stretching exercise. Both subject groups were instructed to
perform 2 sets of their stretch, holding each stretch for 60
seconds, alternating the right and left limb (4 minutes in
total). The exercise session was performed once in the
morning and once in the afternoon for a total of 8 minutes
per day.
Subjects were instructed to precede and follow their as-
signed stretching exercise with a warm-up and cool-down
period as recommended by the American College of Sports
Medicine [26,27]. The warm-up period included (1) side
stepping to the right and left 4 times in each direction, (2) 3
sets of walking forward 3 steps and clapping and walking
backward 3 steps and clapping, and (3) 4 sets of high knee
marching while holding onto a chair for balance. The cool-
down period included (1) taking a deep breath while bring-
ing both arms over the head and letting the breath out while
bringing the arms back down, (2) shaking out the arms and
legs, and (3) rotating the wrists and ankles alternatively
clockwise and then counterclockwise.
Subjects were given a written description of their exercise
program illustrated with photos and were instructed to per-
form the 4-minute stretching exercise twice daily on their
own for a period of 10 weeks. Twice each week, a rehabilita-
tion clinician went to the subjects’ homes and supervised the
stretching exercise to ensure that the exercise was being
performed correctly and thoroughly. Subjects also completed
a daily calendar in which they logged whether they com-
pleted the 2 exercise sessions each day. This calendar was
returned and recorded after completion of the study.
332 Watt et al EFFECT OF SUPERVISED HIP FLEXOR STRETCHING PROGRAM ON GAIT IN FRAIL ELDERLY
Figure 1. Hip flexor stretching exercise performed by subjects
in the treatment group (n ⫽ 41).
Assessments
The pre-intervention assessment was performed after a sub-
ject was placed into 1 of the 2 study groups, and the post-
intervention assessment was performed within 1 week after
the subject completed the 10-week stretching program. Each
technician performing the assessments had no role in the
intervention and was blinded to each subject’s treatment or
control group designation. The pre- and post-intervention
assessments involved measurement of passive hip extension
ROM and dynamic gait evaluation during walking with use of
a 10-camera Vicon 624 motion analysis system (Vicon, Cen-
tennial, CO). For the measurement of passive hip extension,
the subject lay supine with the leg being tested hanging off
the end of the examination table and the contralateral leg
held flexed, similar to position of the subject in the Thomas
test. A pressure cuff (The Stabilizer; Chattanooga Industries,
Hixson, TN) was used under the low back to ensure that
subjects maintained a lumbar neutral position and a constant
magnitude of pelvic tilt during the examination. The relaxed
hip extension angle was then measured with use of a goni-
ometer and defined as the angle between the horizontal and a
line from the greater trochanter to the lateral femoral con-
dyle.
Sixteen retroreflective markers were placed over anatomic
landmarks of the pelvis and lower extremity for dynamic gait
assessment. Markers were placed on the lateral mid thighs,
lateral femoral condyles, lateral mid shanks, lateral malleoli,
second metatarsal heads, and heels. Because the subject’s
arms and/or clothing interfered with markers placed directly
on the left and right anterior and posterior superior iliac
processes, a rigid cluster of four markers was securely fas-
tened directly to the subject’s sacrum with Coban self-adher-
ent wrap (3M, St. Paul, MN).
A static calibration procedure included 4 pointing trials to
determine the virtual positions of the left and right anterior
and posterior superior iliac processes relative to a coordinate
system defined by the marker cluster. The 3-dimensional
(3-D) positions of each marker were captured at 250 Hz with
use of a 10-camera Vicon 624 motion analysis system (Vi-
con). The subject walked along a 10-meter raised platform
(35 cm high and 150 cm wide) at a both a self-selected
comfortable speed and a self-selected “fast” speed while
ground reaction force (GRF) and kinematic data were col-
lected synchronously. Four platform-imbedded AMTI force
plates (AMTI, Watertown, MA) were used to collect 3-D GRF
data during the walking trials. Data were collected until 3
successful trials were obtained for each limb at both comfort-
able and fast speed conditions. A successful trial was consid-
ered a clean strike of one force plate by a single foot and
complete marker data during the subsequent gait cycle.
Data Analysis
Motion capture and GRF data were processed with use of the
Vicon Plug-in Gait to calculate joint kinematics, joint kinet-
ics, and temporospatial parameters. GRFs and joint powers
were normalized to subject body mass, and joint moments
were normalized to subject body mass and height. Average
curves, which were normalized to 100% of the gait cycle,
were created for each kinematic and kinetic parameter. Re-
ported pelvic kinematics were movements of the pelvis seg-
ment in the laboratory coordinate system. Bilateral kinemat-
ics of the hip were reported as rotations of the thigh segments
in the pelvic coordinate system, and the remaining lower
limb joint angles were rotations of the distal segment in the
coordinate system of the proximal segment. Three-dimen-
sional joint moments at the hip, knee, and ankle were re-
ported as external moments and were resolved in the refer-
ence frame of the proximal segment.
PM&R Vol. 3, Iss. 4, 2011 333

Table 1. Comfortable walking primary parameters (mean ⫾ SD) pre- and postintervention

Control (n ⴝ 41) Treatment (n ⴝ 33)

Parameter Pre- Post- P Value Pre- Post- P Value

Cadence, steps/min 108.1 ⫾ 9.5 107.6 ⫾ 10.9 .70 106.5 ⫾ 9.4 108.9 ⫾ 9.0 .04
Walking speed, m/s 1.10 ⫾ 0.2 1.10 ⫾ 0.2 .83 1.15 ⫾ 0.2 1.20 ⫾ 0.2 .02
Stride length, m 1.22 ⫾ 0.2 1.22 ⫾ 0.2 .99 1.30 ⫾ 0.2 1.32 ⫾ 0.2 .05
Peak hip extension, degree 8.0 ⫾ 8.4 8.8 ⫾ 8.4 .24 10.9 ⫾ 7.3 10.5 ⫾ 6.9 .67
Peak anterior pelvic tilt, degree 11.6 ⫾ 5.7 10.8 ⫾ 5.8 .28 10.1 ⫾ 6.1 10.5 ⫾ 5.6 .63
Passive peak hip extension, degree 20.5 ⫾ 8.6 22.3 ⫾ 8.6 .10 19.9 ⫾ 8.6 25.2 ⫾ 7.7 ⬍.001

Maximum and minimum kinematic and kinetic values at
characteristic peaks were obtained from each right and left
cycle and then averaged for each subject for each condition.
Kinematic parameters over the entire gait cycle were consid-
ered, whereas GRF and kinetic parameters were considered
during stance only. Paired-sample t-tests were used to com-
pare pre- and post-intervention kinematic and kinetic peak
values. For the primary parameters, a P value of less than .05
indicated a significant change. For the remaining 49 explor-
atory kinematic and kinetic parameters, a Bonferroni adjust-
ment was made such that P ⬍ .001 was required for signifi-
cance (.05/49).
RESULTS
in self-selected walking speed were observed after treatment
while walking at a comfortable pace (Table 1).
No significant changes were noted in any of the primary
kinematic parameters. During fast-paced walking, no signif-
icant change occurred in any of the primary gait parameters
for the treatment group, but the control group showed sig-
nificantly reduced peak anterior pelvic tilt (P ⫽ .05) and a
trend toward increased peak hip extension (Table 2). After
the stretching program, the treatment group showed a
greater than 5° increase in passive hip extension ROM (P ⬍
.001) compared with an increase of less than 2° for the
control group (P ⫽ .1). None of the secondary parameters
showed significant changes during either comfortable or
fast-paced walking.

Of the 100 recruited participants, 74 subjects (40 women

and 34 men) ages 65-87 years (mean 77 years, SD 8 years)
were included in the analysis, with 33 in the treatment group
and 41 in the control group. A total of 26 subjects either
voluntarily dropped out of the study or were removed from
the data analysis because of poor data quality or low compli-
ance. Program compliance, as self-recorded by the log books,
was 91% for the treatment group; 3 subjects missed more
than 20 days of the program and were removed from the
analysis.
The control and treatment groups showed no significant
differences in pretreatment gait parameters. After treatment,
while walking at a comfortable pace, the treatment group
showed significantly increased cadence, walking speed, and
stride length, whereas no significant change was seen in the
control group. Specifically, a 2.7-cm increase in stride length,
a 2.3 steps/min increase in cadence, and a 0.05-m/s increase
DISCUSSION
This study confirmed our hypothesis that a supervised hip
flexor stretching program can significantly improve key gait
parameters in a frail elderly population. Specifically, stride
length, cadence, and self-selected comfortable walking speed
significantly increased in the treatment group. Contrary to
our hypothesis, however, no changes in peak hip extension
or peak anterior pelvic tilt were observed during either com-
fortable or fast-paced walking, and fast-paced walking did
not exaggerate the improvements observed during comfort-
able walking.
Although our findings of greater stride length and walking
speed correspond with the findings of some similar interven-
tion studies of healthy elderly persons, the absence of im-
provements in dynamic hip extension or pelvic tilt contrast
with the findings of other studies [21-25]. For example,

Table 2. Fast-paced walking primary parameters (mean ⫾ SD) pre- and postintervention

Control (n ⴝ 22) Treatment (n ⴝ 24)

Parameter Pre- Post- P Value Pre- Post- P Value

Cadence, steps/min 128.3 ⫾ 14.3 126.5 ⫾ 14.9 .17 126.8 ⫾ 12.8 125.6 ⫾ 15.0 .33
Walking speed, m/s 1.5 ⫾ 0.3 1.5 ⫾ 0.3 .34 1.55 ⫾ 0.3 1.53 ⫾ 0.3 .63
Stride length, m 1.4 ⫾ 0.2 1.4 ⫾ 0.2 .60 1.47 ⫾ 0.2 1.47 ⫾ 0.2 .85
Peak hip extension, degree 9.5 ⫾ 7.3 10.8 ⫾ 8.2 .10 11.4 ⫾ 8.9 10.5 ⫾ 5.9 .45
Peak anterior pelvic tilt, degree 13.8 ⫾ 4.6 12.2 ⫾ 5.4 .05 12.1 ⫾ 6.6 12.3 ⫾ 5.3 0.87
Passive peak hip extension, degree 20.5 ⫾ 8.6 22.3 ⫾ 8.6 .1 19.9 ⫾ 8.6 25.2 ⫾ 7.7 ⬍.001
334 Watt et al EFFECT OF SUPERVISED HIP FLEXOR STRETCHING PROGRAM ON GAIT IN FRAIL ELDERLY
Rodacki et al [23] demonstrated a similar 3-cm increase in
step length and 0.06-m/s improvement in walking speed
immediately after a single session of passive hip flexor
stretches, but changes in overall pelvic tilt were seen as the
mechanism for improvement. However, results from these
previous studies and our results may not be directly compa-
rable because the subjects studied previously did not present
with the multiple health problems and reduced abilities of
the frail subject population in our study.
Our previous hip-stretching study showed improvements
in hip extension and pelvic tilt during walking that were not
seen here [21]. It was expected that the increases in passive
hip extension resulting from the more rigorous 10-week
stretching program used in this study would result in even
greater improvements in hip extension during walking and
would be accompanied by a decrease in anterior pelvic tilt
along with greater stride length, cadence, and walking speed.
We had hypothesized that improved stride length would be
the result of increased hip extension in the subjects’ gait, but
that did not occur. The results suggest that the increased
stride length was achieved through a different but unknown
mechanism.
One possible explanation might be that the increased hip
extension flexibility made it easier and more comfortable for
hip extension to occur within the subjects’ original ROM. The
improved freedom of movement could have resulted in
quicker hip extension during walking, which potentially
could have resulted in a faster cadence, which we indeed did
observe. Another possible explanation could be that the
increased hip extension flexibility resulted in a sense of
security of having a greater reserve in peak hip extension,
which indirectly resulted in a greater stride length and ca-
dence. Clearly, further investigation into these potential
mechanisms is needed.
Although age-related decline in walking speed has been
seen in combination with reduced ankle peak plantar flexion
and dorsiflexion and reduced ankle power output, this study
found no significant changes in any of these variables
[12,17,21,28]. The lack of improvement at the fast walking
pace also indicates that the subjects’ mobility at greater
speeds was not changed by the stretching program. It is
apparent that although greater hip extension ROM was avail-
able to the subjects after treatment, they did not utilize it
while walking. The subjects’ differing physical limitations
may have prevented them from easily adopting new gait
biomechanics or may simply have resulted in different indi-
viduals altering different biomechanical parameters to
achieve the same goal.
We believe that the complex limitations of the group are
the reason for the lack of expected changes in hip and pelvic
mechanics. Gait training to cue greater use of hip extension
while walking could possibly elicit the desired changes in gait
mechanics and produce greater improvements in stride
length and gait speed while counteracting the greater anterior
pelvic tilt (lumbar lordosis) typically shown by this popula-
tion at higher gait speeds. It also is possible that focusing on
a single factor (dynamic hip extension) in the frail population
is not enough to result in desirable improvements in gait
mechanics at both slower and faster speeds.
Our previous unsupervised hip flexor stretching study of
healthy elderly adults showed only a nonsignificant smaller
increase in walking speed that was also present in the control
group [21]. The current stretching program was modified to
include weekly supervision and longer required stretching
sessions and has been shown to be more successful in signif-
icantly improving gait speed by 4% in the treatment group,
with no corresponding increase in the control group. Because
reduced gait speed has been linked with a risk of falls in
elderly adults [29-31], improvement in comfortable gait
speed should be an important intervention goal for elderly
persons. It has been suggested that 0.1 m/s is a meaningful
change in gait speed for older adults because a decrease of
this amount can lead to a 7% greater risk for falls [29].
Although the average improvement shown in this study is
less than that of the aforementioned benchmark value, more
than half of the persons in the treatment group showed a
0.1-m/s or greater improvement in walking speed; this find-
ing indicates that improvements were made that could re-
duce the risk of falls in these persons.
Because this study is unique in its use of a complex frail
elderly subject population, it is of interest to compare the gait
parameters of this population with those of previously inves-
tigated healthy elderly populations. In this study, the frail
elderly showed an average pre-intervention comfortable
walking speed of 1.13 m/s. Our previously studied healthy
elderly populations showed comfortable walking speeds of
1.21 m/s and 1.19 m/s [11,21]. The frail elderly population
showed a 1.25-m stride length and a cadence of 107 steps/
min compared with a previously recorded stride length of
1.22 m and cadence of 120 steps/min in a healthy elderly popula-
tion [11]. Kinematically, the frail population showed pre-interven-
tion dynamic hip extension of 9.5° and anterior pelvic tilt of
10.9°. In the healthy elderly population, we have previously
recorded dynamic peak hip extension of 5.1° and anterior pelvic
tilt of 13.1°.
Overall, it is apparent that although in some areas (eg,
walking speed and cadence) the frail elderly showed greater
gait limitations than did previously studied healthy popula-
tions, the stride length, hip extension, and anterior pelvic tilt
did not reflect these limitations. This study does not include
a rigorous comparison between frail and healthy popula-
tions, because such a comparison was not the purpose of the
investigation. However, because of these observations, we
suggest that in future studies, dynamic gait analysis could be
useful in screening elderly patients before classifying them as
frail.
PM&R
CONCLUSION
This study is the first investigation to address hip extension
limitations in the gait of frail elderly subjects. The results
show that a simple hip flexor stretching program can be
effective for improving the comfortable gait speed, cadence,
and stride length of frail elders. These improvements could
allow persons to more easily adapt to their walking environ-
ment by enabling them to rapidly change stride length or
walking speed as a result of obstacles or uneven ground, thus
resulting in a reduced risk of falls in this population. The
greater improvement in temporospatial parameters, when
compared with our previous study, can be attributed to
subject supervision and the doubled stretch time required by
this study [21]. The simplicity of the program also resulted in
high self-reported compliance in the frail elderly population.
However, the program did not produce the expected im-
provements in the key gait parameter—that is, dynamic peak
hip extension— even though passive hip extension ROM was
increased. The lack of improvement in hip mechanics sug-
gests that more than a single gait limitation (ie, tight hip
flexors) may need to be addressed in the frail population who
present with multiple diseases and limitations.
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