Adding Weights to Stretching Exercise Increases Passive Range of Motion for Healthy Elderly

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Journal of Strength and Conditioning Research, 2003, 17(2), 374378 2003 National Strength & Conditioning Association

Adding Weights to Stretching Exercise IncreasesPassive Range of Motion for Healthy Elderly

ANN MARIE SWANK,1 DANIEL C. FUNK,2 MICHAEL P. DURHAM,1 AND

SHERRI ROBERTS3

1Exercise Physiology Lab, University of Louisville, Louisville, Kentucky 40292; 2Sport Management Program,University of Texas at Austin, Austin, Texas 78712; 3Baptist East Hospital, Cardiac Rehabilitation Department,Louisville, Kentucky 40292.

ABSTRACT

Stretching exercise is effective for increasing joint range ofmotion (ROM). However, the Surgeon Generals Report andthe American College of Sports Medicine cite a lack of stud-ies identifying strategies capable of increasing the effective-ness of stretching exercise. This investigation evaluated add-ing modest weight (0.451.35 kg) to a stretching exercise rou-tine (Body Recall [BR]) on joint ROM. Forty-three subjectsages 5583 years participated in 1 of 2 training groups, BR,BR with weights (BRW), or a control group (C). ROM wasevaluated at the neck, shoulder, hip, knee, and ankle beforeand after 10 weeks of exercise. Using ANCOVA, significantdifferences (p 0.01) were observed for right and left cer-vical rotation, hip extension, ankle dorsiflexion, ankle plantarflexion, and shoulder flexion. Post hoc analysis revealed thatcervical rotation (left and right), hip extension, and ankle

dorsiflexion for BR

W subjects differed significantly fromBR and C (p 0.01). Significant differences with shoulderflexion and ankle plantar flexion were found for both BR andBRW in comparison to C (p 0.01). Results indicate thataddition of weights enhanced the effectiveness of stretchingexercise for increasing joint ROM with 4 of the 6 selectedmeasurements. Thus, a modest intensity exercise programthat is within the reach of most elderly may significantlyaffect joint ROM and flexibility.

Key Words:aging, flexibility, independence, activitiesof daily living

Reference Data: Swank, A.M., D.C. Funk, M.P. Dur-ham, and S. Roberts. Adding weights to stretching ex-ercise increases passive range of motion for healthyelderly.J. Strength Cond. Res. 17(2):374378. 2003.

Introduction

Range of motion (ROM) decreases with increasingage, a decline related to the aging process itself,

trauma from mechanical stress, disuse, and diseasessuch as arthritis (7, 12, 18). Stretching exercise is aneffective means of increasing ROM for older adults (4,

6, 10, 13, 16). However, both the Surgeon GeneralsReport and the American College of Sports Medicineacknowledge a lack of studies evaluating exercise and

ROM (11, 19). Specifically, there is a need to identifystrategies capable of enhancing the effectiveness ofstretching exercise on ROM, especially for the elderly,for whom adequate ROM is important for performanceof activities of daily living and maintenance of an in-dependent lifestyle (11, 19).

Raab et al. (16) postulated that adding modesthand and ankle resistance may increase the effective-ness of stretching exercise on joint ROM. The authorscompared ROM responses for a weighted group to

both a nonexercising control group and an exercisegroup without weights. Both exercise groups increased

joint ROM relative to the control group; however, ad-dition of weights provided no additional benefit. Todecrease potential for injury, weighted stretching ex-ercises used by Raab et al. (16) were not performedthrough a full ROM. The authors concluded that thisexercise modification was a plausible reason for lackof a positive effect with weights on ROM (16).

The current investigation evaluated adding modesthand and ankle weights to stretching exercise onROM, with an emphasis that exercises were performedthrough full ROM. The exercise program used in thisinvestigation was Body Recall (BR), (5) a program de-veloped at Berea College, Owensboro, KY, by Dorothy

Chrisman, Ph.D. This low-intensity program empha-sizes pain-free, smooth, rhythmic movement for thepurpose of maintaining, enhancing, and restoringstrength and flexibility. In addition, BR classes provideknowledge and motivation for lifetime fitness in amanner that is within the reach of most elderly indi-viduals. The sequence of class activities begins withmaneuvers such as slow ankle circles and progressesto more complex activities involving larger musclegroups and more physical effort. Exercises are per-formed in sitting, standing, and lying positions (5).


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Weighted Exercise for Healthy Elderly 375

Statistics from 1993 indicate that the BR network hadspread into 43 states, trained and certified over 700teachers, and involved over 30,000 participants. Ourpurpose was to evaluate a simple strategy, addingmodest weights to routine body movements, that mayenhance compliance with an exercise program for theelderly. This enhanced compliance would likely be due

to the simplicity of the program, a byproduct of thedesign of BR, and the ability for the individual to per-form the movements without supervision, in contrastto most traditional and more aggressive resistancetraining regimens. We hypothesized that addingweights would enhance the effectiveness of stretchingexercise on joint ROM beyond that of the stretchingexercise alone.

MethodsSubjects

Subjects were recruited from ongoing classes of BR,and 43 healthy elderly individuals ages 5583 yearscompleted the requirements. A total of 11 subjectsfrom the original subject pool of 54 dropped out of thestudy because of personal illness (n 2), subject re-quest (n 1), or were excluded from analysis becauseof lack of compliance, defined as attendance less than50% (n 8). BR group comprised 18 subjects (8 men,10 women, average age 67.9 5.6 years and weight 74.1 14.2 kg). BR weights (BRW) group com-prised 14 subjects (4 males, 10 females, average age 68.4 3.1 years and weight 67.3 13.2 kg). Control(C) group comprised 11 subjects (1 man, 10 women,average age 68.6 6.5 years and weight 68.4

15.4 kg).Health status of subjects was determined with amedical history questionnaire and a risk factor profilefor cardiovascular disease to ensure safe participation.Participants were excluded if they were shown to haveovert disease or any severely limiting orthopedic prob-lems that may have prohibited performance of BR ex-ercise. Medical history questionnaires revealed thatseveral subjects were currently on medication for hy-pertension, tachycardia, depression, and arthritis. Sub-

jects reported numerous minor orthopedic problems,but none that prohibited them from participating fullyin the BR exercise with or without weights. After an

explanation of the study and potential risks of partic-ipation, all subjects signed an informed consent, whichhad been approved by the legal counsel of Baptist EastHospital, Louisville, KY, and the University of Louis-ville Human Studies Committee. All testing and ex-ercise training was conducted at Baptist East Hospital,Louisville, KY.

Experimental Design

Forty-three subjects, ages 5583 years, participated in1 of 2 training groups, BR and BRW or C. ROM wasevaluated at the neck, shoulder, hip, knee, and ankle

before and after 10 weeks of exercise. BR classes con-sisted of 60 minutes of group instruction 3 times week-ly for a period of 10 weeks. A Body Recall, Inc. certi-fied instructor led participants in performing an ana-tomically balanced selection of movements. The se-quence of activity began with maneuvers that usedisolated muscle groups such as slow, thorough ankle

circles on 1 side at a time, and progressed to activitiesthat were more complex involving more muscles andeffort. Good posture and appropriate breathing wereemphasized to reduce potential for a Valsalva maneu-ver. Table 1 lists sample arm and leg movements per-formed either sitting or standing during the BR classfor both BR and BRW groups.

HeavyHands, Inc. (Pittsburgh, PA) hand weightswere used with various arm movements of BR pro-gram for BRW group. HeavyHands are cushionedweights ranging from 0.43 to 1.36 kg with a handlethat fits snugly over the knuckles. Ankle wrap weights(0.91 kg) were utilized for nonweight-bearing (chair)

and weight-bearing (standing) exercises. Ankleweights were padded to provide comfort and a Velcrostrap facilitated ease in attaching and removingweights. The first 5 weeks of training for BRW groupconsisted of a gradual progression of number ofweighted exercises. At week 1, 1015 exercises utilizedweights. A weekly increase of 5 exercises allowed agoal number of 35 exercises to be attained by week 6.Weeks 6 through 10 served as maintenance phase oftraining, with total number of exercises remainingconstant at 35. All subjects began training with 0.43-kg HeavyHands and 0.91-kg ankle weights. Weeklysurveys were given to all participants to determine if

training was causing injuries and determine subjectcompliance. Injury reports were limited to generalmuscle soreness after weighted exercise during initial5 weeks of training. No training sessions were missed

because of soreness or injury.

ROM Evaluation

ROM was evaluated at the neck, shoulder, hip, knee,and ankle. All measurements were taken on the rightside, except for the neck, where both left and rightcervical rotation were measured. The same investiga-tor obtained before and after exercise training mea-surements (3). Measurement procedures followed therecommendations of Russe and Gerhardt (17). A full-circle and half-circle goniometer were used in deter-mining joint ROM.

Cervical rotation was measured to the left andright with subject seated. With both shoulders in con-tact with a chair and head upright, subject passivelyrotated head as far as possible to the appropriate side.Degree of rotation was measured as 90 minus angle

between shoulders and sagittal plane of head, asviewed from above subject.

Shoulder flexion was measured in the supine po-


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376 Swank, Funk, Durham, and Roberts

Table 1. Selected body recall exercises utilized for both BRW and BR.*

Arm exercises (chair)

Open/close handsElbow flex and extendWrist circlingSmall arm circlingLarge arm circling

Shoulder shrugsArm lift from kneesSingle arm flings

Leg exercises (chair)

Ankle circlingHeel toe rockToe rising/pedalingBent leg liftAlternate leg lift/extend

Lower leg extensionsStraight leg liftsLeg sweeps to sideSingle knee lift to chestSingle leg lift/extend/lowerDouble knee liftSingle leg sweepLeg circlingHeel lift with bent knee

Arm exercises (standing)

Bent arms backward pullJoggerDouble arm flings

Swing forward/side/forward/sideArm coordination

Leg exercises (standing)

Single straight leg liftToe risingForward stride

Leg lift backwardLeg lift sidewardLeg lift forwardKnee liftsKnee swing

* BR body recall; BRW body recall with weights.

sition with thumb pointing up and arm passively lift-ed over the head to full ROM. A goniometer wasplaced on lateral side of shoulder joint with right axisparallel to the trunk and left axis pointed toward themedial epicondyle. Shoulder abduction was measured

in the supine position with arm passively moved fromside of the body to beside the head, with points ofreference identical to shoulder flexion.

Hip flexion was measured in the supine position,left leg extended, right leg bent with foot on the table.Subject was assisted to pull knee as close to chest aspossible with hips stabilized. The goniometer wasplaced with center axis at greater trochanter with leftaxis parallel to side of the body and right axis pointingtoward head of the fibula. Hip extension was mea-sured with subject lying on stomach, hips stabilized,and leg passively lifted to full ROM. The goniometerwas placed at greater trochanter with left axis parallelto trunk and right axis pointed toward lateral malle-olus.

Knee extension was measured in the supine posi-tion, legs extended, and ankle supported by a towelroll to check for hyperextension. The goniometer cen-ter axis was placed at lateral aspect of knee with leftaxis toward greater trochanter and right axis towardlateral malleolus. Knee flexion was measured in thesupine position, left leg extended, right leg bent withfoot on the table. Subject was assisted by investigatorto pull foot as near buttocks as possible. The goni-

ometer was placed with center axis at lateral aspect ofknee with left axis pointing toward greater trochanterand right axis pointing toward lateral malleolus.

Ankle measurements were performed with subjectsupine on a table with knees extended and feet un-

supported. During measurement of plantar flexion,right ankle was passively extended with leg stabilized.During dorsiflexion measurement, subject was assisted

by investigator to attain maximum ROM. The goni-ometer was placed on medial side of foot with centeraxis on lateral malleolus. Left axis pointed towardhead of the fibula and right axis was parallel with fifthmetatarsal.

Statistical Analyses

ANCOVA was used with the pretest scores serving ascovariates in each analysis to statistically control for

preexercise training group differences (8, 9). Homo-geneity of regression assumption was tested and re-sults of a Levenes test of equality indicated that theassumption of homogeneity of variance was support-ed. A series of ANCOVAs were conducted on 11 ROMoutcomes using pretest scores as a covariate. Tests ofsimple effects were followed by a Tukey Honestly Sig-nificant Difference post hoc test to follow up the effectand test observed differences on the adjusted means.A p value of0.01 was chosen as the level of signifi-cance.


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Weighted Exercise for Healthy Elderly 377

Table 2. Posttest joint ROM (degrees) mean scores for 3 groups and baseline covariate (BCov).

Flexibility measures

Conditioning method

BCov BRW BR Control p

Cervical rotation rightCervical rotation leftHip extensionAnkle dorsiflexionShoulder flexion

56.6 12.059.9 14.721.3 7.7

6.0 7.6167.4 8.7

73.4 8.267.1 2.014.9 2.4

8.2 0.9171.5 1.2

52.2 9.156.2 1.632.9 1.5

4.4 0.8171.3 1.0

55.6 4.858.6 1.931.8 2.0

5.1 1.0166.6 1.3

0.01*0.01*0.01*0.01*0.01**

Ankle plantar flexionKnee extensionHip flexionKnee flexionShoulder abduction

42.9 13.72.5 2.6

118.5 11.5138.9 16.1166.9 14.9

51.8 1.40.69 0.40

125.0 2.2146.0 1.7164.2 2.1

49.4 1.21.5 0.40

121.8 1.8143.1 1.4168.5 1.8

46.7 1.51.4 0.5

126.1 2.2142.7 1.7170.6 2.3

0.01**0.300.260.040.12

ROM range of motion; BR body recall; BRW body recall with weights.* BRW significantly increased compared to both BR and C.** BRW and BR significantly increased compared to C.

ResultsANCOVA-adjusted means for before exercise, 2 exper-imental groups, and control, as well as standard de-viations, and p-values of ROM for subjects are listedin Table 2. Significant differences across experimentalconditions for 6 ROM measures were observed: leftand right cervical rotation, hip extension, ankle dor-siflexion, shoulder flexion, and ankle plantar flexion.No significant differences were observed (p 0.01) forthe other 5 ROM measures. Post hoc analysis revealedthat ROM of cervical rotation (left and right), hip ex-tension, and ankle dorsiflexion for BRW subjects wassignificantly greater than BR and C (p 0.01). BR andC for these measurements were not significantly dif-ferent (p 0.01). Significant differences with shoulderflexion and ankle plantar flexion were found for bothBR and BRW in comparison to C (p 0.01). Themain effect of BRW had moderate power with eta-square values ranging from 0.21 to 0.43. In general,these results suggest that participants increased ROMwhen assigned to a BRW program, and the additionof weights provided more benefit than BR.

Discussion

This investigation compared joint ROM between 2groups (BR and BRW) and a control group forhealthy elderly subjects. Results indicate that additionof weights enhanced effectiveness of stretching exer-cise by increasing ROM on 4 measurements above thatachieved with traditional stretching exercise associatedwith BR program.

Prior investigations (4, 6, 10, 13, 16) have demon-strated increases in ROM for elderly using a combi-nation of stretching and rhythmic movements throughfull ROM. Although it is difficult to compare resultsof various studies given different joints measured and

different techniques, a consistent finding is thatstretching exercise is effective for enhancing ROM.

Only 1 study added weights with a purpose of in-creasing effectiveness of stretching exercises on ROM.Raab et al. (16) reported increases in ROM for shoulderflexion, shoulder abduction, left cervical rotation, andankle plantar flexion in elderly women after a 25-weekexercise program for both weighted and nonweightedgroups. Addition of wrist and ankle weights providedno additional benefit and in the case of shoulder ab-duction the nonweighted groups joint ROM was great-er than that of the weighted group. To enhance safetyof exercises performed with weights, investigators

modified several of the leg and arm movements bymethods such as flexing knees or elbows, modifica-tions that shortened the lever arm (16). However, it islikely that for weights to be effective in increasing jointROM, the limb must move beyond a vertical plane tomaximize effect of gravity (16). Our current studyfound that addition of weights enhanced effectivenessof stretching exercise. It is likely a positive effect wasnoted for 2 reasons: increased resistance during exer-cise movement and exercises were performed throughfull ROM. Safety of exercise routine was enhanced bycarefully selected exercises, modest additional weight,and healthy and active subjects.

Limitations of the current investigation are twofold.The interpretation of beneficial effects of addingweights to stretching exercise on ROM is limited bynonrandom assignment of subjects; however, ANCO-VA may correct for initial group differences. In addi-tion, the ability to generalize responses is limited tohealthy, active, older adults who may not represent thenormal aging population. An indication of relative

joint fitness of subjects is that pre-ROM values for theBRW, BR, and C groups represent respectively 97%,94%, and 95% of American Academy of Orthopedic


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378 Swank, Funk, Durham, and Roberts

Surgeons standards (1). It seems plausible to hypoth-esize that greater effects would be shown by additionof weights to stretching routines for nursing home cli-ents or free-living, otherwise sedentary elderly.

Practical Applications

The significant improvements in joint ROM observedwith addition of weights may affect performance ofactivities of daily living, a factor critical in mainte-nance of an independent lifestyle (14, 18). For example,increased ROM at shoulder complex may be related toactivities such as reaching overhead to a shelf (2). Im-proved knee flexion and extension would be associatedwith increased ability to climb stairs or rise from achair. Improvements in hip extension, ankle plantarflexion, and ankle dorsiflexion may serve a crucial rolein the maintenance of normal gait patterns in the el-derly (14, 18), whereas increased cervical rotation has

been shown to improve driving skills for an older

driver (15).This study demonstrated that adding weights tostretching exercise represents an effective strategy forincreasing joint ROM. Future research should evaluatethis modification on other aspects of muscular fitnessincluding endurance and strength. In addition, the ef-fectiveness of this exercise modification should be eval-uated with different populations such as the nursinghome individual and less fit albeit free-living elderly.

References

1. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS. Joint Motion:Method of Measuring and Recording. Edinburgh: Churchill Liv-ingston, 1966. pp. 575.

2. BASSEY, E., J.K. MORGAN, H.M. DALLOSSO, ANDS.B.J. EBRAHIM.Flexibility of the shoulder joint as range of abduction in a largerepresentative sample of men and women over 65 years of age.

Eur. J. Appl. Physiol. 58:353360. 1989.3. BOONE, D.C., S.P. AZEN, C.M. LIN, C. SPENCE, C. BARON, AND

L. LEE. Reliability of goniometric measurements.Phys. Ther.58:13551360. 1978.

4. BROWN, M., ANDJ.O. HOLLOSZY. Effects of a low intensity ex-ercise program on selected physical performance characteris-tics of 60- to 71-year olds. Aging3:129139. 1991.

5. CHRISMAN, D.C.Body Recall, A Program of Physical Fitness for theAdult (5th ed.). Berea, KY: Berea College Press, 1990. pp. 198205.

6. FREKANY, G.A., ANDD.L. LESLIE. Effects of an exercise programon selected flexibility measurements of senior citizens. Geron-tologist 15:182183. 1975.

7. GRIMBY, G. Physical activity and muscle training in the elderly.Acta. Med. Scand.711(Suppl.):233237. 1986.

8. HAYS, W.L. Statistics (4th ed.). New York: Holt Rinehart and

Winston, 1992. pp. 810847.9. KEPPEL, G. Design and Analysis: A Researchers Handbook (3rd

ed.). Uppersaddle River, NJ: Prentice Hall, 1991. pp. 297328.10. LESSER, M. The effects of rhythmic exercise on the range of

motion in older adults. Amer. Corr. Ther. 32:48. 1978.11. MAZZEO, R.S., P. CAVANAGH, W.J. EVANS, M. FIATARONE, J.

HAGBERG, E. MCAULEY, AND J.K. STARTZELL. ACSM positionstand on exercise and physical activity for older adults. Med.Sci. Sports Exerc. 30:9921008. 1998.

12. MOREY, M.C., P.A. COWPER, J.R. FEUSSNER, C . DIPASQUALE,G.M. CROWLEY, G.P. SAMSA, AND R.T. SULLIVAN. Two-yeartrends in physical performance following supervised exerciseamong community-dwelling older veterans. J. Am. Geriatr. Soc.39:986992. 1991.

13. MUNNS, K. Effects of exercise on the range of joint motion in

elderly subjects. In: Exercise and Aging, the Scientific Basis. E.L.Smith and R.C. Seratas, eds. Hillside, NJ: Enslow Publishers,1980. pp. 167178.

14. MURRAY, M.P. Gait as a total pattern of movement: Includinga bibliography on gait. Am. J. Phys. Med. 46:290333. 1967.

15. OSTROW, A.C., P. SHAFFRON, ANDK. MCPHERSON. The effectsof a joint range-of-motion physical fitness training program onthe automobile driving skills of older adults. J. Safety Res. 23:207219. 1992.

16. RAAB, D.M., J.C. AGRE, M. MCADAM, AND E.L. SMITH. Lightweight and stretching exercise in elderly women. Effect uponflexibility.Arch. Phys. Med. Rehabil.69:268272. 1988.

17. RUSSE, O.A., AND J.J. GERHARDT. ISOM International StandardOrthopaedic Measurements. International SFTR Method of Measur-ing and Recording Joint Motion. Bern, Switzerland: Hans HuberPublishers, 1975. pp. 732.

18. STEINBERG, F. Gait disorders of the aged.J. Am. Geriatr. Soc. 20:537540. 1985.

19. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. PhysicalActivity and Health: A Report of the Surgeon General.Atlanta, GA:U.S. Department of Health and Human Services, Centers forDisease Control and Prevention, National Center for ChronicDisease Prevention and Health Promotion, 1996. S/N 017-023-00196-5.

Address correspondence to Dr. Ann Marie Swank,[email protected].

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Adding Weights to Stretching Exercise Increases Passive Range of Motion for Healthy Elderly