1 Strength training is as effective as stretching for improving range of motion: A systematic

2 review and meta-analysis.

4 José Afonso, Ph.D. 1*, Rodrigo Ramirez-Campillo, Ph.D. 2,3, João Moscão4, Tiago Rocha,

5 M.Sc. 5, Rodrigo Zacca, Ph.D. 1,6,7, Alexandre Martins, B.Sc. 1, André A. Milheiro, M.Sc.1,

6 João Ferreira, B.Sc. 8, Hugo Sarmento, Ph.D. 9, Filipe Manuel Clemente, Ph.D. 10,11

7
8 1
Centre for Research, Education, Innovation and Intervention in Sport, Faculty of Sport of the University of Porto.

9 Rua Dr. Plácido Costa, 91, 4200-450 Porto, Portugal.

10 2
Department of Physical Activity Sciences. Universidad de Los Lagos. Lord Cochrane 1046, Osorno, Chile.

11 3
Centro de Investigación en Fisiología del Ejercicio. Facultad de Ciencias. Universidad Mayor. San Pio X, 2422,

12 Providencia, Santiago, Chile.

13 4
REP Exercise Institute. Rua Manuel Francisco 75-A 2º C 2645-558 Alcabideche, Portugal.

14 5
Polytechnic of Leiria, Rua General Norton de Matos, Apartado 4133, 2411-901 Leiria, Portugal.

15 6
Porto Biomechanics Laboratory (LABIOMEP), University of Porto, Rua Dr. Plácido Costa, 91, 4200-450 Porto,

16 Portugal.

17 7
Coordination for the Improvement of Higher Educational Personnel Foundation (CAPES), Ministry of Education

18 of Brazil, Brasília, Brazil.

19 8
Superior Institute of Engineering of Porto, Polytechnic Institute of Porto. Rua Dr. António Bernardino de

20 Almeida, 431, 4249-015 Porto, Portugal.

21 9
Faculty of Sport Sciences and Physical Education, University of Coimbra, 3040-256, Coimbra, Portugal.

22 10
Escola Superior Desporto e Lazer, Instituto Politécnico de Viana do Castelo, Rua Escola Industrial e Comercial

23 de Nun’Álvares, 4900-347, Viana do Castelo, Portugal.

24 11
Instituto de Telecomunicações, Department of Covilhã, 1049-001, Lisboa, Portugal.

25

26 *Corresponding author: José Afonso | jneves@fade.up.pt.

27

28

1
29

30 Summary box

31 What is already known?

32 • Stretching is effective for improving in range of motion (ROM), but promising findings

33 have suggested that strength training also generates ROM gains.

34

35 What are the new findings?

36 • Strength training seems to be as effective as stretching in generating ROM gains.

37 • In contradiction with existing guidelines, stretching is not strictly necessary for improving

38 ROM, as strength may provide an equally valid alternative.

39 • These findings were consistent across studies, regardless of the characteristics of the

40 population and of the specificities of strength training and stretching programs.

41

42

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43

44 ABSTRACT

45 Background: Range of motion (ROM) is an important feature of sports performance and

46 health. Stretching is usually prescribed to improve promote ROM gains, but evidence has

47 suggested that strength training (ST) also improves ROM. However, it is unclear if its efficacy

48 is comparable to stretching. Objective: To perform a systematic review and meta-analysis of

49 randomized controlled trials (RCTs) assessing the effects of ST and stretching on ROM.

50 Protocol: INPLASY: 10.37766/inplasy2020.9.0098. Data sources: Cochrane Library,

51 EBSCO, PubMed, Scielo, Scopus, and Web of Science were consulted in early October 2020,

52 followed by search within reference lists and consultation of four experts. No constraints on

53 language or year. Eligibility criteria (PICOS): (P) humans of any sex, age, health or training

54 status; (I) ST interventions; (C) stretching interventions (O) ROM; (S) supervised RCTs. Data

55 extraction and synthesis: Independently conducted by multiple authors. Quality of evidence

56 assessed using GRADE; risk-of-bias assessed with RoB 2. Results: Eleven articles (n = 452

57 participants) were included. Pooled data showed no differences between ST and stretching on

58 ROM (ES = -0×22; 95% CI = -0×55 to 0×12; p = 0×206). Sub-group analyses based on RoB,

59 active vs. passive ROM, and specific movement-per-joint analyses for hip flexion and knee

60 extension showed no between-protocol differences in ROM gains. Conclusion: ST and

61 stretching were not different in improving ROM, regardless of the diversity of protocols and

62 populations. Barring specific contra-indications, people who do not respond well or do not

63 adhere to stretching protocols can change to ST programs, and vice-versa.

64

65 KEYWORDS: systematic review; meta-analysis; strength training; flexibility; stretching;

66 range of motion.

67

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68

4
69

70 Introduction

71 Improving range of motion (ROM) is a core goal for the general population,[1] as well

72 as in clinical contexts,[2] such as when treating acute respiratory failure,[3] plexiform

73 neurofibromas,[4] and total hip replacement.[5] Unsurprisingly, ROM gains are also relevant

74 in different sports,[6] such as basketball, baseball and rowing,[7-9] among others. ROM is

75 improved through increased stretch tolerance, augmented fascicle length and changes in

76 pennation angle,[10] as well as reduced tonic reflex activity.[11] Stretching is usually

77 prescribed to increase ROM in sports,[12, 13] clinical settings such as chronic low back

78 pain,[14] rheumatoid arthritis,[15] and exercise performance in general.[16] Stretching

79 techniques include static (active or passive), dynamic, or proprioceptive neuromuscular

80 facilitation (PNF), all of which can improve ROM.[1, 17-20]

81 However, reduced ROM and muscle weakness are deeply associated.[21-23] Therefore,

82 although strength training (ST) primarily addresses muscle weakness through methods such as

83 resistance training or similar protocols, it has been shown to increase ROM in athletic

84 populations,[24, 25] as well as in healthy elderly people[26] and women with chronic

85 nonspecific neck pain.[27] ST focused on concentric and eccentric contractions has been

86 shown to increase fascicle length. [28-30] Better agonist-antagonist co-activation[31],

87 reciprocal inhibition,[32] and adjusted stretch-shortening cycles[33] may also explain why ST

88 is a suitable method for improving ROM.

89 Nevertheless, studies comparing the effects of ST and stretching in ROM have

90 presented conflicting evidence,[34, 35] and many have small sample sizes.[36, 37] Developing

91 a systematic review and meta-analysis (SRMA) may help summarize this conflicting evidence

92 and increase statistical power, thus providing clearer guidance for interventions.[38] Therefore,

5
93 the aim of this SRMA was to compare the effects of supervised and randomized ST versus

94 stretching protocols on ROM in participants of any health and training status.

95

96

97 METHODS

98 Protocol and registration

99 The methods and protocol registration were preregistered prior to conducting the

100 review: INPLASY, no.202090098, DOI: 10.37766/inplasy2020.9.0098.

101

102 Eligibility criteria

103 Articles were eligible for inclusion if published in peer-reviewed journals, with no

104 restrictions in language or publication date. The Preferred Reporting Items for Systematic

105 Reviews and Meta-Analyses (PRISMA) guidelines were adopted.[39] Participants,

106 interventions, comparators, outcomes, and study design (P.I.C.O.S.) were established as

107 follows: (i) participants with no restriction regarding health, sex, age, or training status; (ii) ST

108 interventions supervised by a certified professional, using resistance training or similar

109 protocols; (iii) comparators were supervised groups performing any form of stretching (iv)

110 outcomes were ROM assessed in any joint; (v) randomized controlled trials (RCTs). RCTs

111 reduce bias and better balance participant features between the groups,[38] and are important

112 for the advancement of sports science.[40] There were no limitations regarding intervention

113 length.

114 Reviews, letters to editors, trial registrations, proposals for protocols, editorials, book

115 chapters, and conference abstracts were excluded. Exclusion criteria based on P.I.C.O.S.: (i)

116 research with non-human animals; (ii) non-ST protocols or ST interventions combined with

117 other methods (e.g., endurance); unsupervised interventions; (iii) stretching or ST + stretching

6
118 interventions combined with other training methods (e.g., endurance); protocols without

119 stretching; unsupervised interventions; (iv) studies not reporting ROM; (v) non-randomized

120 interventions.

121

122 Information sources and search

123 Six databases were used to search and retrieve the articles in early October 2020:

124 Cochrane Library, EBSCO, PubMed (including MEDLINE), Scielo, Scopus, and Web of

125 Science (Core Collection). Boolean operators were applied to search the article title, abstract

126 and/or keywords: (“strength training” OR “resistance training” OR “weight training” OR

127 “plyometric*” OR “calisthenics”) AND (“flexibility” OR “stretching”) AND “range of

128 motion” AND “random*”. Specificities of each search engine: (i) in Cochrane Library, items

129 were limited to trials, including articles but excluding protocols, reviews, editorials and similar

130 publications; (ii) in EBSCO, the search was limited to articles in scientific, peer-reviewed

131 journals (iii) in PubMed, the search was limited to title or abstract; publications were limited

132 to RCTs and clinical trials, excluding books and documents, meta-analyses, reviews and

133 systematic reviews; (iv) in Scielo, Scopus and Web of Science, the publication type was limited

134 to article; and (v) in Web of Science, “topic” is the term used to refer to title, abstract and

135 keywords.

136 An additional search within the reference lists of the included records was conducted.

137 The list of articles and inclusion criteria were then sent to four experts to suggest additional

138 references. The search strategy and consulted databases were not provided in this process to

139 avoid biasing the experts’ searches. More detailed information is available as supplementary

140 material.

141

142 Search strategy

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143 Here, we provide the specific example of search conducted in PubMed:

144 ((("strength training"[Title/Abstract] OR "resistance training"[Title/Abstract] OR

145 "weight training"[Title/Abstract] OR "plyometric*"[Title/Abstract] OR

146 "calisthenics"[Title/Abstract]) AND (“flexibility”[Title/Abstract] OR

147 “stretching”[Title/Abstract])) AND (“range of motion”[Title/Abstract])) AND

148 (“random*”[Title/Abstract]).

149 After this search, the filters RCT and Clinical Trial were applied.

150

151 Study selection

152 J.A. and F.M.C. each conducted the initial search and selection stages independently,

153 and then compared result to ensure accuracy. J.F. and T.R. independently reviewed the process

154 to detect potential errors. When necessary, re-analysis was conducted until a consensus was

155 achieved.

156

157 Data collection process

158 J.A., F.M.C., A.A.M. and J.F. extracted data, while J.M., T.R., R.Z. and A.M.

159 independently revised the process. Data for the meta-analysis was extracted by JA and

160 independently verified by A.A.M. and R.R.C. Data is available for sharing.

161

162 Data items

163 Data items: (i) Population: subjects, health status, sex/gender, age, training status,

164 selection of subjects; (ii) Intervention and comparators: study length in weeks, weekly

165 frequency of the sessions, weekly training volume in minutes, session duration in minutes,

166 number of exercises per session, number of sets and repetitions per exercise, load (e.g., %

167 1RM), full vs. partial ROM, supervision ratio; in the comparators, modality of stretching

168 applied was also considered; adherence rates were considered a posteriori; (iii) ROM testing:

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169 joints and actions, body positions (e.g., standing, supine), mode of testing (i.e., active, passive,

170 both), pre-testing warm-up, timing (e.g., pre- and post-intervention, intermediate assessments),

171 results considered for a given test (e.g., average of three measures), data reliability, number of

172 testers and instructions provided during testing; (iv) Outcomes: changes in ROM for

173 intervention and comparator groups; (vi) funding and conflicts of interest.

174

175 Risk of bias in individual studies

176 Risk of bias (RoB) in individual studies was assessed using the Cochrane risk-of-bias

177 tool for randomized trials (RoB 2).[41] J.A. and A.M. independently completed RoB analysis,

178 which was reviewed by F.M.C. Where inconsistencies emerged, the original articles were re-

179 analyzed until a consensus was achieved.

180

181 Summary measures

182 Meta-analysis was conducted when ≥3 studies were available.[42] Pre- and post-

183 intervention means and standard deviations (SDs) for dependent variables were used after

184 being converted to Hedges’s g effect size (ES).[42] When means and SDs were not available,

185 they were calculated from 95% confidence intervals (CIs) or standard error of mean (SEM),

186 using Cochrane’s RevMan Calculator for Microsoft Excel.[43] When ROM data from different

187 groups (e.g. men and women) or different joints (e.g. knee and ankle) was pooled, weighted

188 formulas were applied.[38]

189

190 Synthesis of results

191 The inverse variance random-effects model for meta-analyses was used to allocate a

192 proportionate weight to trials based on the size of their individual standard errors,[44] and

193 accounting for heterogeneity across studies.[45] The ESs were presented alongside 95% CIs

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194 and interpreted using the following thresholds:[46] <0×2, trivial; 0×2–0×6, small; >0×6–1×2,

195 moderate; >1×2–2×0, large; >2×0–4×0, very large; >4×0, extremely large. Heterogeneity was

196 assessed using the I2 statistic, with values of <25%, 25-75%, and >75% considered to represent

197 low, moderate, and high levels of heterogeneity, respectively.[47]

198

199 Risk of bias across studies

200 Publication bias was explored using the extended Egger’s test,[48] with p<0×05

201 implying bias. To adjust for publication bias, a sensitivity analysis was conducted using the

202 trim and fill method,[49] with L0 as the default estimator for the number of missing studies.[50]

203

204 Moderator analyses

205 Using a random-effects model and independent computed single factor analysis,

206 potential sources of heterogeneity likely to influence the effects of training interventions were

207 selected, including i) ROM type (i.e., passive vs active), ii) studies RoB in randomization and

208 iii) studies RoB in measurement of the outcome.[51] These analyses were decided post-

209 protocol registration.

210

211 All analyses were carried out using the Comprehensive Meta-Analysis program

212 (version 2; Biostat, Englewood, NJ, USA). Statistical significance was set at p≤0×05. Data for

213 the meta-analysis was extracted by JA and independently verified by A.A.M. and R.R.C.

214

215 Quality and confidence in findings

216 Although not planned in the registered protocol, we decided to abide by the Grading of

217 Recommendations Assessment, Development, and Evaluation (GRADE),[52] which addresses

218 five dimensions that can downgrade studies when assessing the quality of evidence in RCTs.

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219 RoB, inconsistency (through heterogeneity measures), and publication bias were addressed

220 above and were considered a priori. Directness was guaranteed by design, as no surrogates

221 were used for any of the pre-defined P.I.C.O. dimensions. Imprecision was assessed on the

222 basis of 95% CIs.

223

224

225 RESULTS

226 Study selection

227 Initial search returned 194 results (52 in Cochrane Library, 11 in EBSCO, 11 in

228 PubMed, 9 in Scielo, 88 in Scopus, and 23 in Web of Science). After removal of duplicates,

229 121 records remained. Screening the titles and abstracts for eligibility criteria resulted in the

230 exclusion of 106 articles: 26 were not original research articles (e.g., trial registrations,

231 reviews), 24 were out of scope, 48 did not have the required intervention or comparators, five

232 did not assess ROM, two were non-randomized and one was unsupervised. Fifteen articles

233 were eligible for full-text analysis. One article did not have the required intervention,[53] and

234 two did not have the needed comparators.[54, 55] In one article, the ST and stretching groups

235 performed a 20-30 minutes warm-up following an unspecified protocol.[56] In another, the

236 intervention and comparator were unsupervised[57], and in one the stretching group was

237 unsupervised[58]. Finally, in one article, 75% of the training sessions were unsupervised.[59]

238 Therefore, eight articles were included at this stage.[24, 34-37, 60-62]

239 A manual search within the reference lists of the included articles revealed five

240 additional potentially fitting articles. Two lacked the intervention group required[63, 64] and

241 two were non-randomized.[65, 66] One article met the inclusion criteria.[67] Four experts

242 revised the inclusion criteria and the list of articles and suggested eight articles based on their

243 titles and abstracts. Six were excluded: interventions were multicomponent;[68, 69]

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244 comparators performed no exercise;[70, 71] out of scope;[72] and unsupervised stretching

245 group.[73] Two articles were included,[74, 75] increasing the list to eleven articles,[24, 34-37,

246 60-62, 67, 74, 75] with 452 participants eligible for meta-analysis (Figure 1).

247

248

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249

Records identified through

database search
(n = 194)

Records after duplicates removed

(n = 121)

Records screened Records excluded

(n = 121) (n = 106)

Full-text articles excluded, with reasons

(n = 7)
• 3 articles did not have the required intervention
and/or comparators.
Full-text articles assessed for • 3 had at least one group of interest performing the
eligibility intervention unsupervised.
(n = 15) • 1 had an undisclosed warm-up protocol that was
longer than the intervention.

Additional records fitting inclusion criteria

identified after search within the reference
lists of the included articles
Studies included in qualitative synthesis (n = 1)
(n = 8+1+2 = 11)

Additional records fitting inclusion criteria

recommended by four external experts from
two countries and three different institutions
(n = 2)
Studies included in quantitative synthesis
(n = 11)

250

251 Figure 1. Flowchart describing the study selection process.

252

253

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255 Study characteristics and results

256 The data items can be found in Table 1. The study of Wyon, Smith [62] required

257 consultation of a previous paper[76] to provide essential information. Samples ranged from

258 27[37] to 124 subjects,[34] including: trained participants,[24, 36, 61, 62] healthy sedentary

259 participants,[35, 60, 67] sedentary and trained participants,[75] workers with chronic neck

260 pain,[37] participants with fibromyalgia,[74] and elderly participants with difficulties in at least

261 one of four tasks: transferring, bathing, toileting, and walking.[34] Seven articles included only

262 women[36, 62, 67, 74] or predominantly women,[34, 35, 37] three investigated only men[24,

263 75] or predominantly men,[60] and one article had a balanced mixture of men and women.[61]

264 Interventions lasted between five[60] and 16 weeks[67]. Minimum weekly training frequency

265 was two sessions[37, 74] and maximum was five.[62] Six articles provided insufficient

266 information concerning session duration.[35, 36, 61, 62, 67, 75] Ten articles vaguely defined

267 training load for the ST and stretching groups,[24, 34, 37, 60, 61, 74, 75] or for stretching

268 groups.[35, 36, 67] Six articles did not report on using partial or full ROM during ST

269 exercises.[24, 34, 36, 37, 61, 67] Different stretching modalities were implemented: static

270 active,[35, 37, 60, 67, 74, 75] dynamic,[34, 36] dynamic with a 10-second hold,[24] static

271 active in one group and static passive in another,[62] and a combination of dynamic, static

272 active, and PNF.[61]

273 Hip joint ROM was assessed in seven articles,[24, 34, 36, 60-62, 67] knee ROM in

274 five,[34-36, 60, 75] shoulder ROM in four,[34, 36, 60, 74] elbow and trunk ROM in two,[34,

275 36] and cervical spine[37] and the ankle joint ROM in one article.[34] In one article, active

276 ROM (AROM) was tested for the trunk, while passive ROM (PROM) was tested for the other

277 joints.[34] In one article, PROM was tested for goniometric assessments and AROM for hip

278 flexion.[36] In another, AROM was assessed for the shoulder and PROM for the hip and

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279 knee.[60] Three articles only assessed PROM[35, 61, 75] and four AROM,[24, 37, 67, 74]

280 while one assessed both for the same joint.[62]

281

282

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283 Table 1. Characteristics of included randomized trials.
Article Population and common
program features
Task-Specific Subjects: 161.
Resistance Health status: Elderly people Weekly volume (minutes):
Training to dependent on help for
Improve the performing at least one of four
Ability of tasks: transferring,
Activities of bathing, toileting and walking. No. exercises per session:
Daily Living– Gender: ST: 84% women;
Impaired Older STRE: 88% women.
Adults to Rise Age: ST: 82·0±6·4; STRE:
from a Bed and 82·4±6·3.
from a Chair.[34] Training status: Not
participating in regular
strenuous exercise.
Selection of subjects: Seven
congregate housing facilities.
Length (weeks): 12.
Weekly sessions: 3.
Adherence: average 81% of
the sessions.
Funding: National Institute on
Aging (NIA) Claude Pepper
Older Adults Independence
Center (Grant AG0 8808 and
NIA Grant AG10542), the
Department of Veterans
Affairs Rehabilitation
Research and Development,
and the AARP-Andrus
Foundation.
Conflicts of interest: N/A.
Stretching versus Subjects: 45 undergraduate
strength training students.
in lengthened Health status: 30º knee
position in extension deficit with the hip
subjects with at 90º when in supine
tight hamstring position. No injuries in the
Strength training group Comparator group(s)* ROM testing Qualitative
results for ROM
n = 81 (60 completed). STRE n = 80 (64 completed). Joints and actions: Elbow The ST group had
Weekly volume (minutes): 180. (extension), shoulder significant
180. Session duration in minutes: 60. (abduction), hip (flexion and improvements in
Session duration in No. exercises per session: N/A. abduction), knee (flexion and all ROM
minutes: 60. No. sets and repetitions: N/A. extension), ankle measures, except
Stretching modality: Dynamic. (dorsiflexion) and trunk hip flexion and
16. Load: Low-intensity, but without a (flexion, extension, lateral abduction.
No. sets and repetitions: specified criterion. flexion).
1*7-8 based on maximum Full or partial ROM: N/A. Positions: Supine (elbow, The STRE group
target of 9 (bed-rise Supervision ratio: One supervisor shoulder, hip, knee and had no significant
tasks). 1*5 based on per group, but group size was N/A. ankle); standing (lumbar change in any of
maximum target of 6 spine). the ROM values.
(chair-rise tasks). Mode: Active for trunk,
Load: Unclear. Loads passive for the other joints.
were incremented if Warm-up: N/A.
subjects were not feeling Timing: Baseline, 6 weeks,
challenged enough. 12 weeks.
Full or partial ROM: Results considered in the
N/A. tests: N/A.
Supervision ratio: 1:1. Data reliability: ICCs of 0·65
to 0·86 for trunk measures.
Unreported for other
measures.
No. testers: N/A.
Instructions during testing:
N/A.
n = 15. STRE n = 15. Joints and actions: Knee None of the
Weekly volume (minutes): Weekly volume (minutes): N/A. (extension). groups
N/A. Session duration in minutes: N/A. Positions: Sitting. experienced
Session duration in No. exercises per session: 1. Mode: Passive. significant
minutes: N/A. No. sets and repetitions: 4*30’’. Warm-up: Yes, but unclear improvements in
Stretching modality: Static. with regard to specifications. ROM.
16
 muscles: A lower limbs and no lower
randomized back pain.
controlled Gender: 39 women, 6 men.
trial.[35] Age: 21·33±1·76 years (ST);
22·60±1·84 years (STRE).
Training status: No
participation in ST or STRE
programs in the previous year.
Selection of subjects:
announcements posted at the
University.
Length (weeks): 8.
Weekly sessions: 3.
Adherence: N/A.
Funding: N/A.
Conflicts of interest: N/A.
Group-based Subjects: 35 video display
exercise at unit workers, 27 completed
workplace: short- the program.
term effects of Health status: chronic neck
neck and pain.
shoulder Gender: 27 women, 8 men.
resistance Age: 43 (41-45) in ST; 42
training in video (38·5-44) in STRE.
display unit Training status: N/A.
workers with Selection of subjects: intranet
work-related form.
chronic neck Length (weeks): 7.
pain – a pilot Weekly sessions: 2.
randomized Adherence: average 85% of
trial.[37] the sessions in ST and 86% in
STRE.
Funding: Under
“disclosures”, the authors
stated “none”.
Conflicts of interest: Under
“disclosures”, the authors
stated “none”.
No. exercises per session: Load: Unclear. Timing: Baseline, 1-week
1. Full or partial ROM: Full. post-protocol.
No. sets and repetitions: Supervision ratio: N/A. Results considered in the
3*12. tests: mean of three
Load: 60% of 1RM. measures.
Full or partial ROM: Data reliability: High.
Partial. No. testers: 1 (blinded).
Supervision ratio: N/A. Instructions during testing:
N/A.
n = 14. STRE n = 13. Joints and actions: Cervical Significant
Weekly volume (minutes): Weekly volume (minutes): 90. spine (flexion, extension, improvements in
90. Session duration in minutes: 45. lateral flexion, rotation). both groups for
Session duration in No. exercises per session: 11. Positions: Sitting (flexion, all ROM
minutes: 45. No. sets and repetitions: 10*10’’. extension, lateral flexion) and measurements.
No. exercises per session: Stretching modality: Static. supine position (rotation).
10. Load: N/A. Mode: Active. No differences
No. sets and repetitions: Full or partial ROM: N/A. Warm-up: N/A. between the two
2-3*8-20. Isometric Supervision ratio: ~1:8. Timing: Baseline, 1-week groups.
contractions up to 30’’. post-protocol.
Load: free-weights with a Results considered in the
maximum of 75% MVC tests: N/A.
and elastic bands of Data reliability: N/A.
unspecified load. No. testers: 1 (blinded).
Full or partial ROM: Instructions during testing:
N/A. N/A.
Supervision ratio: ~1:8.
17
 A randomized Subjects: 68; 56 completed
controlled trial of the program.
muscle Health status: Diagnosed with
strengthening fibromyalgia (FM).
versus flexibility Gender: Women.
training in Age: 49·2±6·36 years in ST,
fibromyalgia.[74] 46·4±8·56 in STRE.
Training status: 87% were
sedentary. Not engaged in
regular strength training
programs.
Selection of subjects: FM
patients referred to
rheumatology practice at a
teaching university.
Length (weeks): 12.
Weekly sessions: 2.
Adherence: 85% of the initial
participants attended ≥13 of
24 classes. N/A for the 46
women that completed the
interventions.
Funding: Individual National
Research Service Award
(#1F31NR07337-01A1) from
the National Institutes of
Health, a doctoral dissertation
grant (#2324938) from the
Arthritis Foundation, and
funds from the Oregon
Fibromyalgia Foundation.
Conflicts of interest: N/A.
Influence of Subjects:28 women.
Strength and Health status: Presumably
Flexibility healthy.
Training, Gender: Women.
Combined or Age: 46±6·5.
Isolated, on Training status: Trained in
Strength and strength and stretching.
n = 28. STRE n = 28. Joints and actions: Shoulder Both groups had
Weekly volume (minutes): Weekly volume (minutes): 120. (the authors report on internal significant
120. Session duration in minutes: 60. and external rotation, but the improvements in
Session duration in No. exercises per session: movements used actually ROM.
minutes: 60. Presumably 12. required a combination of No differences
No. exercises per session: No. sets and repetitions: N/A. motions). between groups.
Presumably 12. Stretching modality: Static. Positions: Presumably
No. sets and repetitions: Load: Low intensity. standing.
1*4-5, progressing to Full or partial ROM: N/A. Mode: Active.
1*12. Supervision ratio: Presumably Warm-up: N/A.
Load: Low intensity. 1:28. Timing: Baseline, 12 weeks.
Slower concentric Results considered in the
contractions with a 4’’ tests: N/A.
isometric hold in the end, Data reliability: referral to a
and a faster eccentric previous study, but no values
contraction. for these data.
Full or partial ROM: No. testers: 1.
Full. Instructions during testing:
Supervision ratio: Reach as far as possible.
Presumably 1:28.
n = 7. STRE n = 7. Joints and actions: Shoulder None of the
Weekly volume (minutes): Weekly volume (minutes): 240. (flexion, extension, abduction groups
N/A. Session duration in minutes: 60. and horizontal adduction) experienced
Session duration in No. exercises per session: N/A. elbow (flexion), hip (flexion significant
minutes: N/A. No. sets and repetitions: 3*30. and extension), knee improvements in
No. exercises per session: Stretching modality: Dynamic. (flexion), and trunk (flexion ROM.
8. Load: Stretch to mild discomfort. and extension).
18
 Flexibility Selection of subjects:
Gains.[36] Volunteers that would refrain
from exercise outside the
intervention.
Length (weeks):12.
Weekly sessions: 4. Not
explicit; 48 sessions over 12
weeks.
Adherence: Minimum was 44
of the 48 sessions.
Funding: N/A.
Conflicts of interest: N/A.
Effects of Subjects: 40 college students.
Flexibility and Health status: No history of
Strength lower extremity injury in the 2
Interventions on years prior to the study.
Optimal Lengths Gender: 20 men, 20
of Hamstring women.
Muscle-Tendon Age: 18–24 years.
Units.[61] Training status: participating
in exercise 2–3 times per
week.
Selection of subjects: college
students.
Length (weeks): 8.
Weekly sessions: 3.
Adherence: N/A.
No. sets and repetitions: Full or partial ROM: Full. Positions: Supine (shoulder
3*8-12 during the 1st Supervision ratio: N/A. flexion, abduction, horizontal
month; 3*6-10RM in the adduction, elbow and hip
2nd month; 3*10-15RM in STRE + ST n = 7. flexion), prone (shoulder and
the 3rd month. Completion of both protocols. hip extension, and knee
Load: 6-15RM, Unknown duration. flexion) and upright (trunk
depending on the month. flexion and extension) for
Full or partial ROM: ST + STRE n = 7. goniometric evaluations.
N/A. Completion of both protocols in Sitting for sit-and-reach.
Supervision ratio: N/A. reverse order. Unknown duration. Mode: Passive for
goniometry. Active for sit-
and-reach.
Warm-up: 5- minute walking
on treadmill at mild to
moderate intensity and four
stretching exercises.
Timing: Baseline, 12 weeks.
Results considered in the
tests: Best of 3 trials.
Data reliability: Very high.
No. testers: 1.
Instructions during testing:
N/A.
n = 20. STRE n = 20. Joints and actions: Hip Men and women
Weekly volume (minutes): Weekly volume (minutes): N/A. (flexion). in both groups
N/A. Session duration in minutes: N/A. Positions: Supine. significantly
Session duration in No. exercises per session: 4. Mode: Passive. improved ROM.
minutes: N/A No. sets and repetitions: 2*15 for Warm-up: Six-minute warm-
No. exercises per session: dynamic stretching, 2*40-60’’ for up including jogging and No differences
4. static stretching, 3*50’’ for PNF jumping. between groups.
No. sets and repetitions: and 3*40-50’’ for foam roll. Timing: Baseline, 8 weeks.
2-4*8-15. For one Stretching modality: active static, Results considered in the
exercise, 2*50-60’’. dynamic and PNF. tests: Mean of three trials.
Load: N/A. Load: N/A. Data reliability: Very high.
Full or partial ROM: Full or partial ROM: N/A. No. testers: N/A.
N/A. Supervision ratio: N/A. Instructions during testing:
Supervision ratio: N/A. N/A.
19
 Funding: Partially supported
by the National Natural
Science Foundation of China
(Grant No.: 81572212) and
the Fundamental Research
Fund for the Central
Universities, Beijing Sport
University (Grant No.:
2017XS017).
Conflicts of interest: N/A.
Resistance Subjects: 37 college students.
training vs. static Health status: Healthy.
stretching: Gender: 30 men, 12 women;
Effects on ratio is unclear in the final
flexibility and sample.
strength.[60] Age: 21·91±3·64 years.
Training status: Untrained.
Selection of subjects:
Recruited from Physical
Education or Exercise Science
Classes.
Length (weeks): 5.
Weekly sessions: 3.
Adherence: N/A.
Funding: N/A.
Conflicts of interest: N/A.
Eccentric Subjects: 69 high-schoolers.
training and Health status: Healthy, but
static stretching with a 30º loss of knee
improve extension.
hamstring Gender: Men.
flexibility of high Age: 16·45±0·96 years.
school men.[75] Training status: Some
sedentary, others involved in
exercise programs.
n = 12. STRE n = 12. Joints and actions: Hip Both groups had
Weekly volume (minutes): Weekly volume (minutes): 75-90. (flexion, extension), knee significant
135-180. Session duration in minutes: 25- (extension) and shoulder improvements in
Session duration in 35. (extension). knee extension,
minutes: 45-60. No. exercises per session: 13. Positions: Supine (knee and hip flexion and
No. exercises per session: No. sets and repetitions: 1*30’’ for hip). Prone (shoulder). hip extension, but
eight in days 1 and 2, four most stretches. 3*30’’ for one Mode: Passive for hip and not shoulder
in day 3. exercise and 3*20’’ for two. knee, active for shoulder. extension.
No. sets and repetitions: 4 Stretching modality: Static. Warm-up: 5 minutes of
sets of unspecified Load: N/A. stationary bicycle with No differences
repetitions. Full or partial ROM: Full. minimal resistance. between the
Load: N/A. Supervision ratio: 1:12. Timing: Baseline, 1-week interventions.
Full or partial ROM: post-protocol.
Full. Results considered in the
Supervision ratio: 1:12. tests: N/A.
Data reliability: N/A.
No. testers: 1.
Instructions during testing:
Technical instructions
specific to each test.
n= 24. STRE n= 21. Joints and actions: Knee Both groups
Weekly volume (minutes): Weekly volume (minutes): N/A. (extension). improved ROM.
N/A. Session duration in minutes: N/A. Positions: Supine.
Session duration in No. exercises per session: 1. Mode: Passive. No differences
minutes: N/A. No. sets and repetitions: Unknown Warm-up: No warm-up. between the
No. exercises per session: number of repetitions, each lasting Timing: Baseline, 6 weeks. interventions.
1. 30’’. Results considered in the
No. sets and repetitions: 6 Stretching modality: Static. tests: Two measures for
repetitions with 5’’ previous reliability
20
 Selection of subjects:
Volunteers with tight
hamstrings.
Length (weeks): 6.
Weekly sessions: 3 for STRE.
N/A for ST.
Adherence: N/A for ST.
STRE: subjects missing >4
sessions were excluded.
Funding: N/A.
Conflicts of interest: N/A.
Effects of Subjects: 34 trained hurdlers.
flexibility Health status: No lower
combined with extremity injury in the
plyometric previous 30 days.
exercises vs. Gender: Men.
isolated Age: 15±0·7 years.
plyometric or Training status: ≥3 years of
flexibility mode experience in hurdle racing.
in adolescent Selection of subjects:
men Recruited from three athletic
hurdlers.[24] teams.
Length (weeks): 12.
Weekly sessions: 4.
Adherence: N/A.
Funding: No funding.
Conflicts of interest: No
conflicts of interest.
isometric hold between Load: Stretch until a gentle stretch calculations, but unclear for
each. was felt on the posterior thigh. the groups’ evaluation.
Load: N/A. Full or partial ROM: Full. Data reliability: Very high.
Full or partial ROM: Supervision ratio: Description No. testers: 2 (1 blinded).
Full. suggests a 1:1 ratio. Instructions during testing:
Supervision ratio: N/A.
Description suggests a
1:1 ratio.
n= 9. STRE n = 8. Joints and actions: Hip All interventions
Weekly volume (minutes): Weekly volume (minutes): 320. (flexion and extension). had significant
320. Session duration in minutes: 80. Positions: Supine. improvements in
Session duration in No. exercises per session: 7. Mode: Active. ROM.
minutes: 80. No. sets and repetitions: 5*10’’. Warm-up: N/A.
No. exercises per session: Stretching modality: Dynamic with Timing: Baseline, 12 weeks. No differences
4. 10’’ static hold. Results considered in the between the
No. sets and repetitions: Load: Evolved from low to hard tests: Best of 3 attempts. interventions.
3*30’’. intensity, but no criteria were Data reliability: Referral to a
Load: Evolved from low provided. previous study, but no values
to hard intensity, but no Full or partial ROM: N/A. for these data.
criteria were provided. Supervision ratio: N/A. No. testers: 2.
Full or partial ROM: Instructions during testing:
N/A. Supervision ratio: STRE+ ST n = 9. N/A.
N/A. Weekly volume (minutes): 320.
Session duration in minutes: 80.
No. exercises per session: 11 (4
plyometric; 7 flexibility).
No. sets and repetitions: 3*30’’ for
plyometrics, 5*10’’ for stretching.
Stretching modality: Dynamic with
10’’ static hold.
Load: Evolved from low to hard
intensity, but no criteria were
provided.
Full or partial ROM: N/A.
Supervision ratio: N/A.
21
The influence of Subjects: 80 women.
strength, Health status: Healthy.
flexibility, and Gender: Women.
simultaneous Age: 35±2·0 (ST), 34±1·2
training on (STRE), 35±1·8 (ST +
flexibility and STRE), 34±2·1 (non-
strength exercise).
gains.[67] Training status: Sedentary.
Selection of subjects:
Volunteers that were
sedentary ≥12 months.
Length (weeks): 16.
Weekly sessions: 3.
Adherence: Minimum was 46
of the 48 sessions.
Funding: N/A.
Conflicts of interest: N/A.
A comparison of Subjects: 39 dance students,
strength and 35 completed.
stretch Health status: N/A.
interventions on Gender: Women (39).
active and Age: 17±0·49 years (ST
passive ranges of group); 17±0·56 years (low-
movement in intensity STRE); 17±0·56
dancers: a years (moderate to high
randomized intensity STRE).
control trial.[62] Training status: Moderately
trained dance students.
Selection of subjects:
Recruited from dance college.
Length (weeks): 6.
Weekly sessions: 5.
Adherence: N/A.
Funding: N/A.
Conflicts of interest: N/A.
n = 20. STRE n = 20. Joints and actions: Hip The interventions
Weekly volume (minutes): Weekly volume (minutes): N/A. (flexion) and knee significantly
N/A. Session duration in minutes: N/A. (extension) combined. improved ROM.
Session duration in No. exercises per session: N/A. Positions: Sitting.
minutes: N/A. No. sets and repetitions: 4*15- Mode: Active. No differences
No. exercises per session: 60’’. Duration of each set started at Warm-up: 4 stretching between the
8. 15’’ and progressed to 60’’ during exercises (2*10’’). interventions.
No. sets and repetitions: the intervention. Timing: Baseline, 16 weeks.
3*8-12 in the 1st and 4th Stretching modality: Static. Results considered in the
months; 3*6-10 in 2nd Load: Performed at the point of tests: Maximum of 3
month; 3*10-15 in 3rd mild discomfort. attempts.
month. Full or partial ROM: N/A. Data reliability: Very high.
Load: 8-12RM (1st and Supervision ratio: N/A. No. testers: 1.
4th months); 6-10RM (2nd Instructions during testing:
month); 10-15RM (3rd ST + STRE n = 20. N/A.
month). STRE protocol followed by the ST
Full or partial ROM: protocol.
N/A.
Supervision ratio: N/A.
n = 11. Low-intensity STRE n = 13. Joints and actions: Hip The three groups
Weekly volume (minutes): Weekly volume (minutes): N/A. (flexion). significantly
N/A. Session duration in minutes: N/A. Positions: Standing. improved passive
Session duration in No. exercises per session: 5. Mode: Active and passive. ROM, without
minutes: N/A. No. sets and repetitions: N/A, but Warm-up: 10 minutes of differences
No. exercises per session: 1’ for each stretch. cardiovascular exercise and between the
1. Stretching modality: Active static. lower limb stretches. groups.
No. sets and repetitions: Load: 3/10 perceived exertion. Timing: Baseline, 6 weeks.
3*5, increasing to 3*10 Full or partial ROM: N/A. Results considered in the The moderate-to-
during the program. Each Supervision ratio: N/A. tests: N/A. high intensity
repetition included a 3’’ Data reliability: N/A. STRE group did
isometric hold. Moderate-intensity or high- No. testers: N/A. not improve in
Load: Unclear, but using intensity STRE n = 11. Instructions during testing: active ROM. The
body weight. Weekly volume (minutes): N/A. Positioning cues for ensuring two other
Full or partial ROM: Session duration in minutes: N/A. proper posture. interventions did.
Partial (final 10º). No. exercises per session: 5.
Supervision ratio: N/A. No. sets and repetitions: N/A.
Stretching modality: Passive.
Load: 8/10 perceived exertion.
Full or partial ROM: N/A.
22
 Supervision ratio: N/A.
284 Legend: N/A – Information not available. ST – Strength training. STRE - Stretching. ROM – Range of motion. MVC – Maximum voluntary contraction. PNF –
285 Proprioceptive neuromuscular facilitation. * Non-exercise groups are not considered in this column.
286

287

23
288

289

290 In seven articles,[24, 37, 60, 61, 67, 74] ST and stretching groups significantly

291 improved ROM, and the differences between the groups were non-significant. In one article,

292 the ST group had significant improvements in 8 of 10 ROM measures, while dynamic

293 stretching did not lead to improvement in any of the groups.[34] In another article, the three

294 groups significantly improved PROM, without between-group differences; the ST and the

295 static active stretching groups also significantly improved AROM.[62] In two articles, none of

296 the groups improved ROM.[35, 36]

297

298 Risk of bias within studies

299 Table 2 presents assessments of RoB. Bias arising from the randomization process was

300 low in four articles,[34, 36, 62, 74] moderate in one,[37] and high in six.[24, 35, 60, 61, 67,

301 75] Bias due to deviations from intended interventions, missing outcome data, and selection of

302 the reported results was low. Bias in measurement of the outcome was low in six articles,[35-

303 37, 67, 74, 75] but high in five.[24, 34, 60-62]

304

305

24
306

307 Table 2. Assessments of risk of bias.

Leite, De
Alexander Aquino, Caputo, Jones, Morton, Wyon,
Cochrane’s Souza Li, Garrett Nelson and Racil, Jlid Simão,
, Galecki Fonseca Di Bari Burckhard Whitehead Smith
RoB 2 Teixeira [61] Bandy [75] [24] Lemos [67]
[34] [35] [37] t [74] [60] [62]
[36]
1.Bias arising from the randomization process
1.1.Was the
No No No No No No
allocation No
Yes. information Yes. Yes. information information information information information Yes.
sequence information.
. . . . . .
random?
1.2.Was the
allocation
sequence
concealed
until
Probably Probably Probably Probably Probably Probably
participants Yes. Yes. Yes. Yes. Yes.
no. no. no. no. no. no.
were enrolled
and assigned
to
interventions
?
1.3.Did
baseline
differences
between
No
groups Probably
No. information Yes. No. No. No. No. No. No. No.
suggest a no.
.
problem with
the
randomizatio
n process?
Some
1.4.RoB Low
Low risk. High risk. concerns Low risk. Low risk. High risk. High risk. High risk. High risk. High risk.
judgement risk.
.
2.Bias due to deviations from intended interventions

25
 (effect of assignment to intervention)
2.1.Were
participants
aware of their
assigned Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes.
intervention
during the
trial?
2.2.Were
carers and
people
delivering the
interventions
aware of Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes.
participants’
assigned
intervention
during the
trial?
2.3.If
Y/PY/NI to
2.1 or 2.2:
Were there
deviations
Probably Probably Probably Probably Probably Probably Probably Probably Probably Probably Probabl
from the
no. no. no. no. no. no. no. no. no. no. y no.
intended
intervention
because of
the trial
context?
2.4.If Y/PY
to 2.3: Were
these
deviations N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
likely to have
affected the
outcome?

26
 2.5.If
Y/PY/NI to
2.4: Were
these
deviations
from the N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
intended
intervention
balanced
between
groups?
2.6.Was an
appropriate
analysis used
Probably Probably Probably Probably Probably Probably Probably Probably Probably Probably Probabl
to estimate
yes. yes. yes. yes. yes. yes. yes. yes. yes. yes. y yes.
the effect of
assignment to
intervention?
2.7.If
N/PN/NI to
2.6: Was
there
potential for a
substantial
impact (on
the result) of N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
the failure to
analyze
participants
in the group
to which they
were
randomized)?
2.8.RoB Low
Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk.
judgement risk.
3.Bias due to missing outcome data
3.1.Were data
Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes.
for this

27
 outcome
available for
all, or nearly
all,
participants
randomized?
3.2.If
N/PN/NI to
3.1.: Is there
evidence that
the result was N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
not biased by
missing
outcome
data?
3.3.If N/PN
to 3.2: Could
missingness
in the N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
outcome
depend on its
true value?
3.4.If
Y/PY/NI to
3.3: Is it
likely that
missingness N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A. N/A.
in the
outcome
depended on
its true value?
3.5.RoB Low
Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk.
judgement risk.
4. Bias in measurement of the outcome
4.1.Was the
method of
No. No. No. No. No. No. No. No. No. No. No.
measuring the
outcome

28
inappropriate
?
4.2.Could
measurement
or
ascertainment
of the Probably Probably Probably Probably Probably Probably Probably Probably Probably Probably Probabl
outcome have no. no. no. no. no. no. no. no. no. no. y no.
differed
between
intervention
groups?
4.3.If
N/PN/NI to
4.1. and 4.2:
Were
outcome
Probably Probably Probably Probably Probably Probabl
assessors No. No. No. No. No.
yes. yes. yes. yes. yes. y yes.
aware of the
intervention
received by
study
participants?
4.4.If
Y/PY/NI to
4.3: Could
assessment of Probably no
the outcome Probably Probably Probably [blinded Probably Probabl
N/A. N/A. N/A. N/A. N/A.
have been yes. yes. yes. goniometer] yes. y yes.
influenced by .
knowledge of
intervention
received?
4.5.If
Y/PY/NI to
Probably Probably Probably Probably Probabl
4.4: Is it N/A. N/A. N/A. N/A. N/A. N/A.
yes. yes. yes. yes. y yes.
likely that
assessment of

29
 the outcome
was
influenced by
knowledge of
intervention
received?
4.6.RoB High
High risk. Low risk. Low risk. Low risk. Low risk. High risk. High risk. Low risk. High risk. Low risk.
judgement risk.
5.Bias in selection of the reported results
5.1.Were the
data that
produced this
result
analyzed in
accordance
with a pre-
specified
analysis plan Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes.
that was
finalized
before
unblinded
outcome data
were
available for
analysis?
5.2.Is the
numerical
result being
assessed
likely to have
been selected, Probably Probably Probably Probably Probably Probably Probably Probably Probably Probably Probabl
on the basis no. no. no. no. no. no. no. no. no. no. y no.
of the results,
from multiple
eligible
outcome
measurement

30
 s (e.g., scales,
definitions,
time points)
within the
outcome
domain?
5.3.Is the
numerical
result being
assessed
likely to have
been selected, Probably Probably Probably Probably Probably Probably Probably Probably Probably Probably Probabl
on the basis no. no. no. no. no. no. no. no. no. no. y no.
of the results,
from multiple
eligible
analyses of
the data?
RoB Low
Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk. Low risk.
judgement risk.
308

309

31
310

311

312 Synthesis of results

313 Comparisons were performed between ST and stretching groups, involving eleven

314 articles and 452 participants. Global effects on ROM were achieved pooling data from the

315 different joints. One article did not have the data required,[35] but the authors kindly supplied

316 it upon request. For another article,[36] we also requested data relative to the goniometric

317 evaluations, but obtained no response. Therefore, only data from the sit-and-reach test was

318 used. For one article,[37] means and SDs were obtained from 95% CIs, while in another SDs

319 were extracted from SEMs,[74] using Cochrane’s RevMan Calculator.

320 Of the five articles including both genders, four provided pooled data, with no

321 distinction between genders.[34, 35, 37, 60] One article presented data separated by gender,

322 without significant differences between men and women in response to interventions.[61]

323 Weighted formulas were applied sequentially for combining means and SDs of groups within

324 the same study.[38] Two studies presented the results separated by left and right lower limbs,

325 with both showing similar responses to the interventions;[24, 62] outcomes were combined

326 using the same weighted formulas for the means and SDs. Five articles only presented one

327 decimal place,[24, 34, 37, 61, 67] and so all values were rounded for uniformity.

328 Effects of ST versus stretching on ROM: no significant difference was noted between

329 ST and stretching (ES = -0×22; 95% CI = -0×55 to 0×12; p = 0×206; I2 = 65×4%; Egger’s test p =

330 0×563; Figure 2). The relative weight of each study in the analysis ranged from 6×4% to 12×7%

331 (the size of the plotted squares in Figure 2 reflects the statistical weight of each study).

332

333

32
334

Study name Hedges's g and 95% CI

Stretching Strength Hedges's
(n) (n) g

Alexander et al. (2001) 0.045

Aquino et al. (2010) 0.087
Caputo et al. (2017) 0.220
Jones et al. (2002) -0.282
Leite et al. (2015) -0.229
Li et al. (2020) -0.616
Morton et al. (2011) 0.123
Nelson & Bandy (2004) -0.101
Racil et al. (2020) -0.000
Simão et al. (2011) -1.922
Wyon et al. (2013) 0.247
-0.215
-3.00 -1.50 0.00 1.50 3.00
Favours stretching Favours strength
335
336 Figure 2. Forest plot of changes in ROM after participating in stretching-based compared to strength-based

337 training interventions. Values shown are effect sizes (Hedges’s g) with 95% confidence intervals (CI). The size

338 of the plotted squares reflects the statistical weight of the study.

339

340 Additional analysis

341 Effects of ST versus stretching on ROM, moderated by study RoB in randomization: No

342 significant sub-group differences in ROM changes (p = 0·256) was found when programs with

343 high RoB (6 studies; ES = -0·41; 95% CI = -1·02 to 0·20; within-group I2 = 77·5%) were

344 compared to programs with low RoB (4 studies; ES = -0·03; 95% CI = -0·29 to 0·23; within-

345 group I2 = 0·0%) (Supplementary figure 1).

346 Effects of ST versus stretching on ROM, moderated by study RoB in measurement of

347 the outcome: No significant sub-group difference in ROM changes (p = 0·320) was found

348 when programs with high RoB (5 studies; ES = -0·04; 95% CI = -0·31 to 0·24; within-group

349 I2 = 8·0%) were compared to programs with low RoB (6 studies; ES = -0·37; 95% CI = -0·95

350 to 0·22; within-group I2 = 77·3%) (Supplementary figure 2).

351 Effects of ST versus stretching on ROM, moderated by ROM type (active vs. passive):

352 No significant sub-group difference in ROM changes (p = 0·642) was found after training

33
353 programs that assessed active (8 groups; ES = -0·15; 95% CI = -0·65 to 0·36; within-group I2

354 = 78·7%) compared to passive ROM (6 groups; ES = -0·01; 95% CI = -0·27 to 0·24; within-

355 group I2 = 15·3%) (Supplementary figure 3).

356 Effects of ST versus stretching on hip flexion ROM: Seven studies provided data for hip

357 flexion ROM (pooled n = 294). There was no significant difference between ST and stretching

358 interventions (ES = -0·24; 95% CI = -0·82 to 0·34; p = 0·414; I2 = 80·5%; Egger’s test p =

359 0·626; Supplementary figure 4). The relative weight of each study in the analysis ranged from

360 12·0% to 17·4% (the size of the plotted squares in Figure 6 reflects the statistical weight of

361 each study).

362 Effects of ST versus stretching on hip flexion ROM, moderated by study RoB in

363 randomization: No significant sub-group difference in hip flexion ROM changes (p = 0·311)

364 was found when programs with high RoB in randomization (4 studies; ES = -0·46; 95% CI =

365 -1·51 to 0·58; within-group I2 = 86·9%) were compared to programs with low RoB in

366 randomization (3 studies; ES = 0·10; 95% CI = -0·20 to 0·40; within-group I2 = 0·0%)

367 (Supplementary figure 5).

368 Effects of ST versus stretching on hip flexion ROM, moderated by ROM type (active vs.

369 passive): No significant sub-group difference in hip flexion ROM changes (p = 0·466) was

370 found after the programs assessed active (4 groups; ES = -0·38; 95% CI = -1·53 to 0·76; within-

371 group I2 = 87·1%) compared to passive ROM (4 groups; ES = 0·08; 95% CI = -0·37 to 0·52;

372 within-group I2 = 56·5%) (Supplementary figure 6).

373 Effects of ST versus stretching on knee extension ROM: Four studies provided data for

374 knee extension ROM (pooled n = 223). There was no significant difference between ST and

375 stretching interventions (ES = 0·25; 95% CI = -0·02 to 0·51; p = 0·066; I2 = 0·0%; Egger’s test

376 p = 0·021; Supplementary figure 7). After the application of the trim and fill method, the

377 adjusted values changed to ES = 0·33 (95% CI = 0·10 to 0·57), favoring ST. The relative

34
378 weight of each study in the analysis ranged from 11·3% to 54·2% (the size of the plotted

379 squares in Supplementary figure 7 reflects the statistical weight of each study).

380 One article behaved as an outlier in all comparisons (favoring stretching),[67] but after

381 sensitivity analysis the results remained unchanged (p>0·05), with all ST vs. stretching

382 comparisons remaining non-significant.

383

384 Confidence in cumulative evidence

385 Table 3 presents GRADE assessments. ROM is a continuous variable, and so a high

386 degree of heterogeneity was expected.[77] Imprecision was moderate, likely reflecting the fact

387 that ROM is a continuous variable. Overall, both ST and stretching consistently promoted

388 ROM gains, but no recommendation could be made favoring one protocol.

389

390

35
391

392 Table 3. GRADE assessment for the certainty of evidence.

Outcome Study RoB1 Publication Inconsistency Indirectness Imprecision Quality Recommendation
design bias of
evidence
ROM 11 RCTs, Randomization – low in No 9 RCTs showed No serious Moderate.3 Moderate. Strong
452 four articles, moderate in publication improvements in ROM indirectness. ⨁⨁⨁ recommendation
participants one, and high in six. bias. in both groups. for either strength
in meta- Deviations from intended 2 RCTs showed no training or
analysis. interventions – Low. changes in ROM in stretching4.
Missing outcome data – either group.
Low. 11 RCTs No
Measurement of the showed effects of equal recommendation
outcome – low in six magnitude for ST and for choosing one
articles and high in five. stretching.2 of the protocols
Selection of the reported over the other, as
results – Low. their efficacy in
ROM gains was
statistically not
different.
1 - Meta-analyses moderated by RoB showed no differences between studies with low and high risk.
2 - Because ROM is a continuous variable, high heterogeneity was expected. However, this heterogeneity is mostly between small and large beneficial effects. No adverse
effects were reported.
3 - Expected because ROM is a continuous variable. Furthermore, imprecision referred to small to large beneficial effects.
4 – Both strength training and stretching presented benefits without reported adverse effects.
393 Legend: ROM – Range of motion. RCTs: randomized controlled trials. RoB: risk of bias.
394

395

36
396

397 DISCUSSION

398 Summary of evidence

399 The aim of this SRMA was to compare the effects of supervised and randomized ST

400 compared to stretching protocols on ROM, in participants of any health and training status.

401 Qualitative synthesis showed that ST and stretching interventions were not statistically

402 different in improving ROM, regardless of the nature of the interventions and moderator

403 variables such as gender, health, or training status. Meta-analysis including 11 articles and 452

404 participants showed that ST and stretching interventions were not statistically different in

405 active and passive ROM changes, regardless of RoB in the randomization process, or in

406 measurement of the outcome. RoB was low for deviations from intended interventions, missing

407 outcome data, and selection of the reported results. No publication bias was detected.

408 High heterogeneity is expected in continuous variables,[77] such as ROM. However,

409 more research should be conducted to afford sub-group analysis according to characteristics of

410 the analyzed population, as well as protocol features. For example, insufficient reporting of

411 training volume and intensity meant it was impossible to establish effective dose-response

412 relationships, although a minimum of 5 weeks of intervention,[60] and two weekly sessions

413 were sufficient to improve ROM.[37, 74] Studies were not always clear with regard to the

414 intensity used in ST and stretching protocols. Assessment of stretching intensity is complex,

415 but a practical solution may be to apply scales of perceived exertion,[62] or the Stretching

416 Intensity Scale.[78] ST intensity may also moderate effects on ROM,[79] and ST with full vs

417 partial ROM may have distinct neuromuscular effects[70] and changes in fascicle length.[28]

418 Again, information was insufficient to discuss these factors, which could potentially explain

419 part of the heterogeneity of results.

37
420 Most studies showed ROM gains in ST and stretching interventions, although in two

421 studies neither group showed improvements.[35, 36] Though adherence rates were unreported

422 by Aquino, Fonseca [35], they were above 91.7% in Leite, De Souza Teixeira [36], thus

423 providing an unlikely explanation for these results. In the study of Aquino, Fonseca [35], the

424 participants increased their stretch tolerance, and the ST group changed the peak torque angle,

425 despite no ROM gains. The authors acknowledged that there was high variability in

426 measurement conditions (e.g., room temperature), which could have interfered with

427 calculations. Leite, De Souza Teixeira [36] suggested that the use of dynamic instead of static

428 stretching could explain the lack of ROM gains in the stretching and stretching + ST groups.

429 However, other studies using dynamic stretching have shown ROM gains.[24, 34]

430 Furthermore, Leite, De Souza Teixeira [36] provided no interpretation for the lack of ROM

431 gains in the ST group.

432 Globally, however, both ST and stretching were effective to improve ROM. Why would

433 ST improve ROM in a manner that is not statistically distinguishable from stretching? ST with

434 an eccentric focus demands the muscles to produce force on elongated positions, and a meta-

435 analysis showed limited to moderate evidence that eccentric ST is associated with increases in

436 fascicle length.[80] Likewise, a recent study showed that 12 sessions of eccentric ST increased

437 fascicle length of the biceps femoris long head.[29] However, ST with an emphasis in

438 concentric training has been shown to increase fascicle length when full ROM was

439 required.[28] In a study with nine older adults, ST increased fascicle length in both the eccentric

440 and concentric groups, albeit more prominently in the former.[81] Conversely, changes in

441 pennation angle were superior in the concentric group (35% increase versus 5% increase).

442 Plyometric training can also increase plantar flexor tendon extensibility.[33]

443 One article showed significant reductions in pain associated with increases in

444 strength.[37] Thus, decreased pain sensitivity may be another mechanism through which ST

38
445 promotes ROM gains. An improved agonist-antagonist coactivation is another possible

446 mechanism promoting ROM gains, through better adjusted force ratios.[31, 62] Also, some

447 articles included in the meta-analysis assessed other outcomes in addition to ROM, and these

448 indicated that ST programs may have additional advantages when compared to stretching, such

449 as greater improvements in neck flexors endurance,[37] ten repetition maximum Bench Press

450 and Leg Press,[36, 67] and countermovement jump and 60-m sprint with hurdles,[24] which

451 may favor the choice of ST over stretching interventions.

452

453

454 Limitations

455 After protocol registration, we chose to improve upon the design, namely adding two

456 dimensions (directness and imprecision) that would provide a complete GRADE assessment.

457 Furthermore, subgroup analyses were not planned a priori. There is a risk of multiple subgroup

458 analyses generating a false statistical difference, merely to the number of analyses

459 conducted.[38] However, all analyses showed an absence of significant differences and

460 therefore provide a more complete understanding that the effects of ST or stretching on ROM

461 are consistent across conditions. Looking backwards, perhaps removing the filters used in the

462 initial searches could have provided a greater number of records. Notwithstanding, it would

463 also likely provide a huge number of non-relevant records, including opinion papers and

464 reviews. Moreover, consultation with four independent experts may hopefully have resolved

465 this shortcoming.

466 Due to the heterogeneity of populations analysed, sub-group analysis according to sex

467 or age group were not possible, and so it would be important to explore if these features interact

468 with the protocols in meaningful ways. And there was a predominance of studies with women,

469 meaning more research with men is advised. There was also a predominance of assessments of

39
470 hip joint ROM, followed by knee and shoulder, with the remaining joints receiving little to no

471 attention. In addition, dose-response relationships could not be addressed, mainly due to poor

472 reporting.

473

474 CONCLUSIONS

475 Overall, ST and stretching were not statistically different in ROM improvements, both

476 in short-term interventions[60] and in longer-term protocols,[67] suggesting that a combination

477 of neural and mechanical factors is at play. Therefore, if ROM gains are a desirable outcome,

478 both ST and stretching can be prescribed, in the absence of specific contraindications,

479 especially because studies did not report any adverse effects. People that do not respond well

480 or do not adhere to stretching protocols can change to ST programs, and vice-versa.

481 Furthermore, session duration may negatively impact adherence to an exercise program.[82]

482 Since ST generates ROM gains similar to those obtained with stretching, clinicians may

483 prescribe smaller, more time-effective programs when deemed convenient and appropriate,

484 thus eventually increasing patient adherence rates.

485

486

40
487

488

489 Declaration of interests: J.M. owns a company focused on Personal Trainer’s education but

490 made no attempt to bias the team in protocol design and search process and had no role in

491 extracting data for meta-analyses. The multiple cross-checks described in the methods

492 provided objectivity to data extraction and analysis. Additionally, J.M. had no financial

493 involvement in this manuscript. The other authors have no conflict of interest to declare.

494

495 Funding: No funding was used for conducting this meta-analysis.

496

497

41
498

499 Author’s contributions (following ICMJE recommendations)

Authors Substantial Drafting the Final Agreement to be

contributions to the manuscript; OR approval accountable for all
conceptualization revising the of the aspects of the work, and
or design of the manuscript version to to ensure that issues
study; OR the critically for be related to the accuracy or
acquisition, important published integrity of any part of
analysis, or intellectual the work are
interpretation of content appropriately
data investigated and resolved
José Afonso √ √ √ √
Rodrigo Ramirez- √ √ √ √
Campillo
João Moscão √ √ √ √
Tiago Rocha √ √ √ √
Rodrigo Zacca √ √ √ √
Alexandre Martins √ √ √ √
André A. Milheiro √ √ √ √
João Ferreira √ √ √ √
Hugo Sarmento √ √ √ √
Filipe Manuel √ √ √ √
Clemente
Acknowledgements Role
Richard Inman Language editing and proof reading.
Pedro Morouço Thorough pre-submission scientific review of the manuscript. Signed consent form
below.
Daniel Moreira- Review of inclusion criteria and included articles, and proposal of additional articles
Gonçalves, Fábio to be included in the systematic review and meta-analysis.
Yuzo Nakamura plus Signed consent forms below.
two experts who
wished to remain
anonymous.
500

501

42
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