EFFICACY OF TWO DIFFERENT STRETCH TRAINING

PROGRAMS (PASSIVE VS. PROPRIOCEPTIVE

NEUROMUSCULAR FACILITATION) ON SHOULDER AND
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HIP RANGE OF MOTION IN OLDER PEOPLE

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JOSÉ M. GONZÁLEZ-RAVÉ, ANGELA SÁNCHEZ-GÓMEZ, AND DANIEL JUÁREZ SANTOS-GARCÍA

Sport Training Laboratory, Faculty of Sport Sciences, University of Castilla, La Mancha, Spain.

ABSTRACT variance showed significant differences in hip and shoulder

González-Ravé, JM, Sánchez-Gómez, A, and Santos-Garcı́a, ROM between passive and control groups and PNF and control
DJ. Efficacy of 2 different stretch training programs (passive vs. groups, but no significant differences were found between
proprioceptive neuromuscular facilitation) on shoulder and hip passive and PNF. The main finding was that the ability of
range of motion in older people. J Strength Cond Res 26(4): physically active older people to increase ROM in response to
1045–1051, 2012—The aim of this study was to determine the stretching techniques is similar for both passive and PNF
influence of 2 methods of stretch training (passive and techniques.
proprioceptive neuromuscular facilitation [PNF]) on range of KEY WORDS flexibility training, aging, ROM, stretch techniques
motion (ROM) in older people between the age of 60 and
70 years over a period of 13 weeks. Fifty-four participants
INTRODUCTION
(39 women and 15 men) were divided into 3 groups: passive

F
(n = 17; 66.5 6 6.5 years), PNF (n = 17; age, 64.7 6 4.0 years lexibility is an important functional capacity
old), and control (n = 17; age, 66.4 6 4.5 years). The subjects affecting the efficacy of daily living activities and
maintenance of an independent lifestyle in older
trained 2 times per week on nonconsecutive days for 13 weeks.
adults (1,10). The practice of stretching seems to
Each training session included 2 flexibility exercises focused
be a widely accepted means of trying to reduce injuries and
on the shoulder and hip joints. The PNF group performed
improve performance in athletes (5,7,11). Range of motion
6 seconds of passive stretching, 3 seconds of muscular (ROM) decreases with increasing age, a decline related to the
contractions, and 2 seconds of relaxation. The passive group aging process itself (24). In older people, it is an important
performed 10 seconds of stretching and 5 seconds of variable with respect to both health and athletic performance
relaxation. This sequence was repeated 3 times by each group. (1). Mobility problems in older people may lead to falls,
The control group did not perform any stretching. In the PNF which in turn may result in hip fractures. Coaches therefore
group, there was an increase in hip ROM (p , 0.001) between need to be aware of the most effective and efficient ways of
pretest and posttest in the passive group and an improvement achieving optimal increases in muscle length to improve the
(p , 0.001) was observed between pretest and posttest, health of older people. The Position Stand of the American
whereas in the control group, there was a significant decrease College of Sports Medicine states, ‘‘flexibility exercises should
be incorporated into the overall fitness program sufficient to
(p , 0.01) in hip ROM between pretest and posttest. In
develop and maintain range of movement. These exercises
shoulder ROM, there was an increase (p , 0.001) between
should stretch the major muscle groups and be performed
pretest and posttest in the passive group and an improvement
a minimum of 2–3 days a week. Stretching should include
(p , 0.001) was observed between pretest and posttest in the appropriate static and/or dynamic techniques.’’ Few studies
PNF group. There were no changes in shoulder ROM between have investigated the efficacy of passive vs. proprioceptive
pretest and posttest in the control group. The analysis of neuromuscular facilitation (PNF) training programs (3,8,14).
We found only 1 study comparing the effects of static, active,
and PNF stretching on flexibility in older people. Chow and
Address correspondence to Dr. José Maria González Ravé, JoseMaria. Ng (3) concluded that active stretching, passive stretching,
[email protected] and PNF stretching training were associated with an increase
26(4)/1045–1051 in knee flexion range, with no statistically significant
Journal of Strength and Conditioning Research differences between the stretching exercises observed for
Ó 2012 National Strength and Conditioning Association persons aged 60–70 years. With respect to increasing

VOLUME 26 | NUMBER 4 | APRIL 2012 | 1045

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 Stretch Training in Older People

hamstring flexibility, Funk et al. (8) studied the effects of both conditions were maintained constant during all the tests
static and PNF stretching on hamstring torque for persons (temperature, 22–24°C).
aged 18–23 years and concluded that either protocol was an
effective method for increasing both concentric and eccentric
Subjects
hamstring torque. Lucas and Koslow (14) investigated the
A population sample of 54 older participants (39 women and
effects of static, dynamic, and PNF stretching techniques on
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15 men) was recruited to the study and divided into 3 groups:

the flexibility of the hamstring-gastrocnemius muscle in
passive (n = 18; age, 66.5 6 6.5 years; height, 1.58 6 0.09 m;
college women. The findings indicated that all 3 methods of
body mass, 71.9 6 15.5 kg), PNF (n = 18; age, 64.7 6 4.0
flexibility training produced significant improvements.
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years; height, 1.62 6 0.08 m; body mass, 70.0 6 10.6 kg), and
Similar studies comparing the effects of passive vs. active
control (n = 18; age, 66.4 6 4.5 years; height, 1.61 6 0.07 m;
stretching techniques have concluded that active stretching
body mass, 68.5 6 7.8 kg). The male participants were
produces greater gain in knee extension for persons aged 20–
distributed evenly within each group (5 men per group).
28 years (16). To our knowledge, no studies have compared
Subjects were volunteers from the physical activity program
the efficacy of passive vs. PNF stretching techniques in older
for older people run by the University of Córdoba (Spain)
people.
and all were healthy and physically active but not specifically
The interventions designed to improve flexibility often
trained. Their previous physical activity background was
lacked sufficient numbers of subjects, randomization, and
limited to walking and other normal everyday activities.
control subjects and have failed to provide clear evidence for
Before participation, the experimental procedures were
dose-response effects of exercises.
explained to all the participants, who gave their voluntary
There is therefore a need for further research to determine
written informed consent and understood that they were free
the effects of different modes of stretching on shoulder and
to withdraw from the study at any time. The study was
hip flexion in older people. The purpose of this study was to
conducted in accordance with the Declaration of Helsinki,
compare the efficacy of passive and PNF stretching training
and all procedures were approved by the Research Ethics
during a 13-week period on shoulder and hip flexion in older
Committee at the Córdoba University relative to human or
people.
animal research. None of the subjects had previously
It was based on the hypothesis that passive stretching and
performed any flexibility training. All were given a medical
PNF are both associated with an increase in hip and shoulder
examination before participation to assess their state of
flexion and that there are no differences between the
health and detect any medical condition that might result in
stretching methods.
injury during the study. Participants were excluded from the
study if they fell into any of the following categories: (a) they
METHODS were younger than 60 years or older than 70 years; (b) they
recently had a shoulder or hip injury with no evidence of
Experimental Approach to the Problem
osteoporosis or arthritis or both; (c) their screening forms
A pretraining-posttraining intervention design was used with
indicated previous cardiovascular, respiratory, or other major
3 equivalent groups: 2 experimental groups (PNF vs. passive)
chronic diseases; (d) they had joint replacements or previous
and 1 control group. The experimental groups performed 2
surgery that might have altered ROM ability/potential; or (e)
different flexibility training programs for 26 weeks, one using
they had undergone any type of surgery or sustained an
the PNF method and the other using the passive method.
injury that might constitute a risk during exercise.
During the first 13 weeks, participants performed a shoulder
joint flexibility training program (PNF vs. passive), and during
the last 13 weeks, they performed a hip joint flexibility training Procedures
program (PNF vs. passive). Participants carried out 2 Training Programs. During the first 13 weeks, the subjects
nonconsecutive training sessions per week. Shoulder joint trained 2 times per week on nonconsecutive days. Each
flexion was measured in all participants in the study at weeks 1 training session included 2 flexibility exercises focused on the
and 13, whereas hip joint flexion was tested at weeks 13 and shoulder joint (Figures 1 and 2).
26. The control group did not perform stretching exercises  Exercise 1. The subject lies in a supine position on a mat
during the intervention period. Our dependent variables were with the knees flexed. The legs are allowed to fall toward
ROM in flexion (in degrees) measured in the shoulder and hip the side opposite the arm that is stretched out (Figure 1).
joints. Obtaining measures of ROM in flexion at 2 time points With the help of an assistant, the shoulder is flexed to the
(pretest and posttest) during the training cycle enabled us to maximum possible until stretch is felt.
determine how these participants responded to a specific  Exercise 2. The subject sits on a mat with his or her back
flexibility training program. resting against the assistant’s knees, hands behind the neck,
Each subject performed the tests at the same time of the and elbows open (Figure 2). The assistant takes hold of
day throughout the period of the study. Because the subjects each elbow and pulls it back until stretch is felt; the back
were evaluated at a different time of the year, the ambient should not be leaning and no pain should be felt.
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Figure 1. Exercise 1.

 Over the next 13 weeks, 2 flexibility exercises focusing on

the hip joint were performed (Figures 3 and 4).
 Exercise 3. The subject sits with one leg stretched out and
Figure 3. Exercise 3.
the other flexed. The trunk is bent forward (Figure 3). The
assistant places both hands on the lumbar region and pulls
forward until the stretch is noticed.
 Exercise 4. The subject lies in a supine position with hands The procedure used by the PNF group to perform the
under one thigh, which the assistant helps to flex while the exercises was as follows: 6 seconds of passive stretching, 3
other leg remains stretched out on the mat (Figure 4). seconds of muscular contractions, and 2 seconds of relaxation.
This sequence was repeated 3 times. Exercises performed by
the passive group consisted of 10 seconds of stretching and 5
seconds of relaxation, also repeated 3 times.
Participants in all the training sessions were closely
supervised by a qualified exercise leader (drawn from
graduates in physical activity and sports sciences and physical

Figure 2. Exercise 2. Figure 4. Exercise 4.

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 Stretch Training in Older People

therapy) to ensure that the proper technique was being used Statistical Analyses
and to minimize the risk of injury. The leader demonstrated Mean 6 SD of the data was calculated. Normal distribution
the exercises before the classes and supervised correct and homogeneity of the parameters were checked with
execution by participants and assistants. The leader also Shapiro-Wilk, and Levene’s test. A 2 -way (group 3 time)
controlled the time of execution of each stretch sequence. analysis of variance was performed to identify differences in
flexion angle between groups over time (pre/post). The null
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Testing Procedure hypothesis of no difference between groups was rejected if

We followed the recommendations of Wilson et al. (25) the probability that the measured difference was due to
regarding dietary control (food and beverages). We asked chance was less than 5% (p , 0.05). Reliability of the
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subjects to sleep at least 7 hours a day. The tests were carried dependent measures was assessed using single-measure
out at the same time of day, always in the afternoon. We intraclass correlations. In the current study, the measure-
focused on the 2 joints that are most important for the ments showed high reliability (intraclass correlation coef-
activities of daily life in older people. Only flexion was ficients, r = 0.90–0.95). SPSS for Windows version 17.0 (SPSS,
measured as a result of time limitations for the number of Inc., Chicago, IL, USA) was used for the statistical analysis.
subjects involved and because flexion movement was
considered by the principal investigator to be the most RESULTS
common in everyday life. Measurement was carried out on All the variables were normally distributed. Levene’s test
the joint least affected by age and following the test showed no violation of homogeneity of variance. The mean
recommendations. flexion for shoulder and hip are displayed in Tables 1 and 2.
The shoulder joint ROM test (9) was carried out before The results show that flexion in the hip decreased 0.68% for
starting the shoulder joint training program and on the control group, increased 2.61% for the passive group, and
completion (13th week). For this test, the subject lies in increased 4.17% for the PNF group. In the shoulder, flexion
a prone position facing the side opposite the shoulder to be decreased 2.83% for the control group, increased 7.27% for
measured, which lies over the edge of the training table. The the passive group, and increased 7.62% for the PNF group.
examiner was positioned at the side in such a way that their A repeated-measures analysis of variance between groups
line of sight was at the height of the subject’s shoulder. The was then conducted to examine the interaction between
subject’s arm was taken at the elbow and the shoulder flexed. treatments and changes in ROM between pretest and
An electronic goniometer (Muscle Lab Ergotest Technology, posttest. For both the hip and shoulder, the interaction was
Porsgrunn, Norway) was used to measure the range of significant (F = 26.08 and F = 12.44: p , 0.001 for the hip and
movement in flexion of each joint. This was held in place at shoulder, respectively). There were significant differences in
each end, and the subject’s arm was raised passively until posttest shoulder measurements between the control and
maximum flexion was reached. The hip joint flexion test (4) passive groups (10.86°; p , 0.01) and the control and PNF
was performed before the start of the hip joint training groups (9.43°; p , 0.01) (Table 1).
program (13th week) and upon its completion (26th week). In addition, significant differences were found between the
With the subject in the supine position, the primary examiner control and passive groups (14.95°; p , 0.001) and control
passively flexed the hip to 90° and zeroed the goniometer at and PNF groups (14.20°; p , 0.001) in posttest hip
the apex of the knee. The hip was then flexed until the measurements (Table 2). No significant differences were
opposite thigh began to rise off the table. The mean of the 3 observed between groups in the pretest.
measurements performed in each test was used for further There was a significant increase in hip flexion (3.29°;
analysis. p , 0.001) between pretest and posttest in the passive group.

TABLE 1. Results of range of motion for the shoulder joint.*

Group

n Pretest (mean 6 SD) Postest (mean 6 SD)

Range of motion (degrees) Control 16 68.11 6 9.17 66.06 6 9.37†

Passive 17 71.84 6 9.23 76.88 6 8.53
PNF 17 70.96 6 7.59 76.01 6 7.63
*PNF, proprioceptive neuromuscular facilitation.
†Significant differences (p , 0.01) between control group and passive and PNF groups.

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TABLE 2. Results of range of motion for the hip joint.*

Group

n Pretest (mean 6 SD) Postest (mean 6 SD)

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Range of motion (degrees) Control 16 125.11 6 11.87 124.26 6 9.66†

Passive 17 131.21 6 8.87 134.50 6 6.97
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PNF 17 127.83 6 9.06 133.68 6 8.32

*PNF, proprioceptive neuromuscular facilitation.

†Significant differences (p , 0.001) between control group and passive and PNF groups.

A considerable improvement (5.91°; p , 0.001) was observed The results showed that addition of weights to stretching
between pretest and posttest in the PNF group. However, hip routines for elderly people resulted in higher ROM.
flexion in the control group showed a significant decrease Lucas and Koslow (14) found significant improvements in
(–2.57°; p , 0.01) between pretest and posttest (Table 1). the flexibility of the hamstring-gastrocnemius muscle in
In the passive group, there was a significant increase in college women using different stretching techniques (static,
shoulder flexion (5.08°; p , 0.001) between pretest and post- dynamic, and PNF) over a 7-week period. However, Chow
test, and considerable improvement was also observed between and Ng (3) found no significant differences in a sample of 117
pretest and posttest in the PNF group (4.52°; p , 0.001). In the older people receiving total knee replacement due to knee
control group, no significant changes were observed between osteoarthritis among active stretching, passive stretching, and
pretest and posttest in shoulder flexion (Table 2). PNF stretch training in the knee flexion range. These results
agree with those of our study.
DISCUSSION Several scientific studies have shown that PNF stretching
This investigation compared hip and shoulder flexion over 13 techniques are more effective than simple passive-stretching
weeks between 2 groups (passive and PNF stretch training) techniques (13), which is in contrast to our findings. This
and a control group of healthy older subjects. It was based on could be because of the differences in the type of sample
the hypothesis that passive stretching and PNF are associated (physically older people vs. college students or athletes) used
with an increase in hip and shoulder flexion and that there is in other studies. Also, the ability to generalize responses is
no difference between the stretching methods used. limited to healthy, active, older adults who may not represent
Our results show significant gains in hip and shoulder the normal aging population (24). In this respect, Ninos (18)
flexion in older people using PNF and passive stretching recommended that older people use long slow static
techniques during a 13-week flexibility training program. stretches to achieve plastic changes in muscular and
No significant differences between programs were found, connective tissues and to make sure they stretched only to
thus confirming our hypotheses. Perhaps, a possible expla- a point of stretch without pain.
nation to these results is the fact that this investigation Improvements in flexibility using the passive technique may
used a similar dose of total daily stretch duration (30 seconds be the result of an increase in ROM as a result of enhanced
in passive vs. 27 seconds in PNF) and their participants stretch tolerance (22). Passive stretching does not activate the
had poor initial flexibility scores as a result of aging. These stretch reflex; if this is activated, it causes the stretched
findings are important because flexibility training is widely muscle to contract instead of lengthening (17). During
used in general fitness programs to improve the health of a passive stretch, reciprocal inhibition is accomplished by
older people (1,10). Gurjao et al. (10) investigated the acute simultaneously contracting the muscle opposing the muscle
effect of static stretching on both muscle activation and force being stretched. The tension in the contracting muscle
output in 23 older women. The results showed that older stimulates the Golgi tendon organ and causes a simultaneous
women’s capacity to produce muscular force decreased after reflex relaxation in the opposite muscle (13). For the passive
their performance of static stretching exercises. Although it is stretching group, it has been reported that the biomechanical
difficult to compare the results with other studies, given the effects of sustained stretching were because of the changes in
different joints measured and the different techniques used, the viscoelastic characteristics and stretch tolerance (15).
one consistent finding is that stretching exercises are effective The results of our investigation are consistent with most
for enhancing ROM (24). Swank et al. (24) evaluated adding studies affirming that passive stretching is an effective and
modest weight (0.45–1.35 kg) to a stretching exercise routine time-efficient method for enhancing flexibility in most
on joint ROM in 43 subjects aged between 55 and 83 years. populations (8,23).

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 Stretch Training in Older People

Funk et al. (8) compared 5 minutes of static stretching and consideration that in this study, the training frequency was
PNF on hamstring flexibility performed with and without 3 days per week, whereas in our study, it was 2 days per week.
exercise in a sample of 40 undergraduate student athletes. In relation to the PNF technique, in the study by Funk et al.
Results demonstrated that PNF performed after exercise (8), subjects maximally contracted the hamstring against
enhanced acute hamstring flexibility, and implementing resistance for 30 seconds and repeated this until completion
a PNF stretching routine after exercise may augment current of the 5-minute time. In our study, the PNF technique
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stretching practices among athletes. consisted of 6 seconds of passive stretching, 3 seconds of

Spernoga et al. (23) concluded that a sequence of 5 muscular contractions, and 2 seconds of relaxation, and this
modified hold-relax stretches produced significantly in- sequence being repeated 3 times. Several studies indicate that
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creased hamstring flexibility that lasted 6 minutes after the one repetition of PNF is sufficient to increase ROM with an
stretching protocol ended in 30 subjects (aged 18–23 years). expected change in ROM from anywhere between 3° and 9°,
However, it is necessary to take into account that the depending on the joint (6,14). In our study, the change in
participants in this study had limited hamstring flexibility in ROM in flexion was 5° in the shoulder and 6° in the hip,
the right lower extremity. results that confirm the efficacy shown in the studies cited.
Improvements in flexibility using the PNF technique could In conclusion, no significant differences were found
also be the result of the inhibitory effect of the Golgi tendon between PNF and passive stretching techniques after a
organs after resisted isometric contraction (13,19). Although 13-week flexibility training program in older people, but
several mechanisms have been reported to explain acute significant improvements were found in hip and shoulder
flexibility gains using PNF stretching (2,18), the mechanisms flexion with both training programs.
explaining the more long-term improvements when this
technique is performed have not been elucidated (12). Funk PRACTICAL APPLICATIONS
et al. (8) demonstrated the efficacy of performing PNF
stretching after exercise to optimize flexibility outcomes for The information of this research would be useful to coaches
college-aged athletes. However, in this study, no significant and athletes as recommendations regarding the optimal
differences were observed with static stretching. The findings stretching methods to improve hip and shoulder flexion in
of Funk et al. (8) coincide with our results in that no older people. The main finding was that the ability of
significant differences were found between stretching physically active older people to increase hip and shoulder
techniques, although the populations and treatments used flexion in response to a passive technique (3 sets of 10 seconds
were different from those of our study. of stretching and 5 seconds of relaxation) and a PNF
It is interesting that a practically and statistically significant stretching technique (3 sets of 6 seconds of passive stretching,
improvement in joint ROM is achievable using both passive 3 seconds of muscular contractions, and 2 seconds of
and PNF methods but that when differences observed relaxation) was similar in both groups, at least within the
between the 2 treatment groups were compared, there were 13-week training period (2 times per week) used here.
no significant differences in improvements between passive However, any practical application requires careful imple-
and PNF methods. Static (or passive) stretches have some mentation and individual experimentation in older people. An
benefits but may not work as good as PNF stretches. older individual could therefore choose either the passive or
The daily and weekly flexibility volume performed in our PNF technique to maintain the same gains in flexibility.
study was consistent with the recommendations of Riewald Improvements in flexibility in the older adult may enhance
(20), the American College of Sports Medicine (1), and the ability to perform daily living and recreational activities.
Roberts and Wilson (21). In our study, subjects maintained For example, increased ROM at the shoulder complex may be
the stretch for 10 seconds, then relaxed for 5 seconds for 2 related to activities such as reaching overhead to a shelf, and
minutes in passive stretching. Riewald (20) affirms that improved knee flexion and extension would be associated
a passive stretch held for 15-30 seconds is all that is needed to with an increased ability to climb stairs or rise from a chair
improve flexibility and that a single bout of stretching can (23). Strength and conditioning specialists are encouraged to
increase flexibility for up to 90 minutes. Roberts and Wilson use passive stretching techniques with older people because it
(21) found significant improvements in both active and is easy to administer and it is comfortably performed.
passive ROM (5 or 15 seconds) in the lower extremity during
a 5-week flexibility training program. In our study, the change REFERENCES
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