By Alex Germano, PT, DPT, GCS, AIB-VR
Physical Therapist

Older adults and stiffness. It feels like the two just go hand-in-hand. Healthy older adults experience changes to their joint capsules, ligaments, muscle-tendon complexes, and articular structures as a result of the aging process. Add on comorbidities, like Parkinson’s Disease or osteoarthritis, and you now have an even more restricted joint. Plus, think about decades of sedentary behavior layered on top of these conditions and you are definitely going to hear about stiffness and likely see it during functional mobility. 

It is going to feel natural as a clinician to see these range of motion deficits and decide that stretching should be a part of your treatment intervention. But before you jump to that conclusion, this article will help you conceptualize stretching differently.

The Evidence for Stretching

The American College of Sports Medicine recommends older adults engage in flexibility training (statically) at least two days a week at a moderate intensity, preferably after aerobic or resistance exercises. It should be noted that the evidence surrounding stretching for older adults continues to remain mixed, with evidence ratings at the C level. While there may be slight improvements in range of motion with a dedicated stretching protocol, these range of motion improvements are typically due to an increase in stretch tolerance rather than muscle extensibility. 

It is also important to consider that due to the sedentary lifestyle of many older adults, these gains may not last. This improvement in stretch tolerance will decline once the stretching stops and the older adult resumes a static activity, such as watching TV for many hours. 

Finally, stretching may not be the appropriate intervention to improve functional ability in older adults. A systematic review reports conflicting information on the relationship between flexibility interventions and functional outcomes. 

If our flexibility training isn’t making a direct impact on the patient’s function, we can explore other interventions that have more concrete evidence in improving functional capacity such as resistance, aerobic, and balance training.

Questions to Ask Before Prescribing Stretching

It can be helpful to ask yourself some clinical questions before prescribing stretching. Stretching is something many older adults like and want to participate in, and as clinicians, we need to respect their wants with our clinical goals. 

But in order to ensure stretching is appropriate for your patient, ask yourself these questions: 

1. Is Stretching the Best Use of Time with Your Patient?

Our patients often come to us with multiple problems that need to be addressed, and our sessions can feel jam-packed with things to do! We often need to triage what is most effective and important for our patients when deciding how to organize interventions. 

For example, for a patient with a high risk of falling, it may be more important to work on dynamic balance activities versus performing seated hamstring stretching. In cases like this, it may be easier or make more sense to add stretching to a rest interval in order to keep up session efficiency.

2. Are There More Effective Exercises than Stretching?

If increasing a patient’s flexibility through certain joints is a priority, but time is also a factor, we can utilize exercises that give us multiple benefits at once. Instead of a seated ankle dorsiflexion stretch, we can utilize heel raises off the edge of the step. With this exercise, we can elicit a stretch into ankle dorsiflexion, then perform a strengthening activity for ankle plantar flexors. 

Through activities like this, we get both a stretch and strengthening. Squatting or performing sit-to-stands from lower surfaces is also another way to influence joint mobility in the hips, knees, and ankles more effectively than just a regular sit-to-stand alone. There are also many stretches that can be performed in a more dynamic fashion to help improve coordination and balance. 

3. Are There Ways to Compensate for This Range of Motion Loss?

For many older adults, we will see a return in joint stiffness between sessions and no real improvements in range of motion. If the flexibility problem is truly limiting the functional performance of activities, we may need to lean into compensation techniques.

Occupational therapists are incredible providers to help make environmental suggestions to compensate for the loss of range of motion across different joints. We may notice gait deviations from a lack of ankle dorsiflexion, which could lead to things like tripping. Clinicians may want to dig into appropriate shoe wear to help determine if walking mechanics could be improved with a simple switch to a minimalist shoe that requires ankle range of motion to safely clear their heel.

4. Is Stretching Time Actually Skilled?

As with all of our interventions, we need to ensure we are the sole provider who performs this activity. Many seated and static stretches are something we can easily teach our patients or their family or caregivers to perform. 

When we begin to realize that our patient could have independence in this task, it is most appropriate to discharge the exercise to HEP. We can ask our patients to perform these stretches prior to our arrival in order to maximize our session efficiency.

5. How Can I Make Stretching Effective Long-Term?

Stretching and flexibility training needs to last to have any meaning to the patient. If stretching is going to make its way into our programs, we need to consider how to make it last between sessions. Consider positioning or activity recommendations after sessions and in between visits in order to maximize the range of motion improvements. Try not to leave the home with the patient in the exact position that made them stiff and tight in the first place!

Make Sure Stretching is Done Right

Range of motion is important for daily life, but stretching during therapy can tend to become an unskilled and overprescribed exercise intervention. We need to review the clinical effectiveness of stretching, the efficiency of performing stretching in session, and the ability of stretching to make long-term improvements to range of motion.

What we often see is that other exercises or compensatory interventions may provide range of motion improvements or improvements in the functional capacity that far exceed static stretching. It is important to check in clinically to make sure stretching is performed with high levels of clinical skill and meaning to the patient before applying this intervention strategy.