Accepted Manuscript

Hold-relax and contract-relax stretching for hamstrings flexibility: a systematic

review with meta-analysis

Christopher S. Cayco, Alma V. Labro, Edward James R. Gorgon

PII: S1466-853X(18)30036-1

DOI: 10.1016/j.ptsp.2018.11.001

Reference: YPTSP 972

To appear in: Physical Therapy in Sport

Received Date: 31 January 2018

Accepted Date: 02 November 2018

Please cite this article as: Christopher S. Cayco, Alma V. Labro, Edward James R. Gorgon, Hold-
relax and contract-relax stretching for hamstrings flexibility: a systematic review with meta-analysis,
Physical Therapy in Sport (2018), doi: 10.1016/j.ptsp.2018.11.001

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 ACCEPTED MANUSCRIPT

Title

Hold-relax and contract-relax stretching for hamstrings flexibility: a systematic review with

meta-analysis

Authors

Christopher S. Cayco, PTRP, MPTa

Alma V. Labro, BSPTb

Edward James R. Gorgon, PTRP, MPhysioa

Institutional affiliations
aDepartment of Physical Therapy, University of the Philippines Manila, Manila, Philippines
bCollege of Allied Medical Professions, University of the Philippines Manila, Manila,

Philippines

Corresponding author

Christopher S. Cayco, PTRP, MPT

Department of Physical Therapy

College of Allied Medical Professions

University of the Philippines Manila

Pedro Gil Street, Malate

Manila 1004, Philippines

Telephone: +63 2 5267125

Email: cscayco1@up.edu.ph

Acknowledgements
 ACCEPTED MANUSCRIPT

We are grateful to Aila Nica Bandong, Maria Eliza Aguila, Maricar Maandal, and Lenin

Grajo for providing assistance in locating key literature used in this review, and Marina De

Barros Pinheiro for providing mentoring for the meta-analysis.

 ACCEPTED MANUSCRIPT

1 Title

2 Hold-relax and contract-relax stretching for hamstrings flexibility: a systematic

3 review with meta-analysis

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25 Abstract

26 Objective: To synthesize evidence on the effects of hold-relax and contract-relax

27 stretching (HR and CR) on hamstrings flexibility compared with no intervention and

28 other stretching techniques.

29 Design: Electronic databases (PubMed, PEDro, Cochrane CENTRAL, Scopus,

30 LILACS) were searched from inception until March 31, 2014 and updated until May

31 31, 2017. Randomized controlled trials involving HR and CR to improve hamstrings

32 flexibility in adults (aged ≥18 years old) with or without a pathological condition

33 were included. Two reviewers independently searched literature, assessed risk of bias,

34 and extracted data, while a third reviewer settled disagreements.

35 Results: Thirty-nine trials (n = 1,770 healthy adults; median PEDro score = 4/10)

36 were included. Meta-analysis showed large effects compared to control immediately

37 after 1 session (6 trials, SMD = 1.02, 95% CI = 0.69 to 1.35, I2 = 2%) and multiple

38 sessions (4 trials, SMD = 1.02, 95% CI = 0.64 to 1.40, I2 = 0%). Meta-analysis

39 showed conflicting results compared to static stretching, while individual trials

40 demonstrated conflicting results compared to other techniques.

41 Conclusions: The immediate effects of HR and CR on hamstrings flexibility in adults

42 are better against control. The long-term effects against other stretching types, and

43 optimal exercise prescription parameters require further research.

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49 Highlights

50  Both HR and CR are effective in immediately increasing hamstrings

51 flexibility when compared to a control group

52  Conflicting evidence exists on the superiority of HR and CR to other

53 techniques

54  Limited evidence supports long-term effects of HR and CR on hamstrings

55 flexibility

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57 Keywords

58 Hamstring muscles, Muscle stretching exercises, Physical therapy modalities, Range

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81 INTRODUCTION

82 Sufficient muscle flexibility is related to the muscle’s ability to partially absorb

83 lengthening and limit strain on the myofibrils (Croisier, 2004). Insufficient hamstrings

84 flexibility is associated with adverse alterations in lower limb kinematics (Gaudreault,

85 Fuentes, Mezghani, Gauthier, & Turcot, 2013). Various musculoskeletal injuries

86 such as lower back (Radwan et al., 2014), hip, and knee joint impairments

87 (Messier et al., 2008), and strains (Bahr & Holme, 2003; Hrysomallis, 2013) have

88 been associated with hamstrings tightness in both athletes and non-athletes (van

89 Beijsterveldt, van de Port, Vereijken, & Backx, 2013; van der Worp et al., 2015;

90 Watsford et al., 2010).

91

92 Stretching exercises have been used in sports medicine and physical therapy to

93 improve hamstrings flexibility and joint range of motion (ROM), and enhance

94 outcomes of rehabilitation (Decoster, Cleland, Altieri, & Russell, 2005;

95 Malliaropoulos et al., 2004; McHugh & Cosgrave, 2010). The rationale behind how

96 stretching increases flexibility remains unclear. Current explanations indicate

97 that stretching improves flexibility through mechanisms including decrease in

98 either muscle and tendon stiffness (Konrad, Stafilidis, & Tilp, 2017). Some

99 studies suggest that stretching decreases viscosity of tendons to increase tissue

100 elasticity (Kubo et al., 2002; Kubo et al., 2001). This decrease in tendon stiffness

101 however contradicts findings of other studies which found changes in muscle

102 stiffness instead (Kay, Husbands-Beasley, & Blazevich, 2015). Aside from soft

103 tissue changes, increased stretch tolerance after stretching showed a strong

104 correlation with ROM changes (Kay et al., 2015). Stretching is also hypothesized

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105 to result in changes through structural adaptations of muscles and other soft

106 tissues (Harvey, Herbert, & Crosbie, 2002). In practice, long-term changes translate

107 into greater functional carry-over compared to acute effects (Shrier, 2004), and are

108 therefore more important.

109

110 Several systematic reviews of randomized controlled trials (RCT) have previously

111 attempted to synthesize direct evidence on the effects of stretching on hamstrings

112 flexibility (Decoster et al., 2005; Harvey et al., 2002; Medeiros, Cini, Sbruzzi, &

113 Lima, 2016). In two systematic reviews, positive immediate and short-term effects

114 have been demonstrated (Harvey et al., 2002; Medeiros et al., 2016). However, the

115 evidence pooled in these reviews focused primarily (Harvey et al., 2002) or solely

116 (Medeiros et al., 2016) on static stretching. One systematic review examined the

117 effects of various stretching techniques to decrease hamstrings tightness (Decoster et

118 al., 2005). It covered only literature up to the year 2004 and concluded that data were

119 insufficient to establish the superiority of stretching types and treatment parameters

120 (Decoster et al., 2005). Therefore, the effects of stretching techniques other than static

121 stretching and the comparative effects of different stretching techniques for

122 hamstrings tightness are still not clear.

123

124 Hold-relax and contract-relax stretching (HR and CR, respectively), methods rooted

125 in the proprioceptive neuromuscular facilitation (PNF) approach, have been applied

126 with the intention of stimulating sensory receptors that provide information about

127 body position and movement to facilitate a desired motion (Adler, Beckers, & Buck,

128 2008). Theoretically, CR involves an isotonic contraction resisted by the therapist,

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129 while HR requires a resisted isometric contraction (Adler et al., 2008). For either, the

130 joint or body part is repositioned either actively or passively to the new limit of ROM

131 following the contraction (Adler et al., 2008). In a review by Sharman, Cresswell,

132 & Riek (2006), these techniques often have variations in their descriptions, and

133 at times have been named to mean the same technique. Improvement in ROM

134 attributed to HR and CR has been explained through autogenic or reciprocal

135 inhibition depending on the muscle being contracted (i.e. autogenic inhibition,

136 when the target muscle is contracted; reciprocal inhibition, when the opposing

137 muscle is contracted), or through altered stretch tolerance (Sharman et al., 2006). HR

138 and CR encourage active patient participation and do not require specialized

139 instrumentation (Adler et al., 2008).

140

141 One systematic review with meta-analysis examined the effectiveness of CR over

142 SS and found that both techniques were equally effective in producing

143 immediate, short-term and long-term hamstrings flexibility changes (Borges,

144 Medeiros, Minotto, & Lima, 2018). However, it included controlled clinical trials

145 and cross-over trials. The inclusion of non-randomized and cross-over over

146 groups increases risk for bias due to possible systematic differences of treatment

147 groups (Sibbald & Roland, 1998) and carry-over effects (Sedgwick, 2015),

148 respectively. These limitations can preclude attribution of effects to the assigned

149 interventions. Additionally, there is a need to assess HR and CR effectiveness

150 compared with stretching techniques aside from SS. This study aimed to answer

151 the following research questions: (1) Are HR and CR effective in developing

152 immediate (effects present < 24 hours after stretch), short-term (effects present

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153 24 hours – 1 week after stretch), or long-term (effects present > 1 week after

154 stretch) changes in hamstrings flexibility compared with control or no

155 intervention? (2) What is the comparative effect of HR and CR and other stretching

156 techniques on immediate, short-term, and long-term changes in hamstrings

157 flexibility? To provide a strong basis for making practice recommendations, high-

158 level evidence from clinical trials was required. The Preferred Reporting Items for

159 Systematic Reviews and Meta-Analyses (PRISMA) guided the design and reporting

160 of this review (Liberati et al., 2009).

161

162 MATERIALS AND METHODS

163

164 Search strategy

165 Reviewers conducted a comprehensive search on the following electronic databases

166 from inception until March 31, 2014: PubMed, Physiotherapy Evidence Database

167 (PEDro), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and

168 Latin American and Caribbean Health Sciences Literature (LILACS). The search

169 strategy comprised keywords and synonyms based on these key concepts: PNF,

170 stretching, hamstrings, flexibility, and clinical trial (see Appendix 1 for detailed

171 search strategy). Search terms were combined using Boolean terms as applicable. No

172 restrictions were placed on publication date and language. Reviewers performed an

173 updated search covering April 1, 2014 to May 31, 2017 in all the databases. Clinical

174 trials investigating the effects of HR and CR on hamstrings flexibility underwent hand

175 searching. Reviewers X and Y independently conducted the literature search and

176 screened articles for inclusion and exclusion. Reviewers resolved any disagreement

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177 by re-examining the article full text. Where a consensus was not achieved, Reviewer

178 Z assisted in resolving disagreements.

179

180 Eligibility criteria

181 Types of studies and participants

182 Studies were included if they were randomized controlled trials published as full

183 text articles. Studies should have included adults (aged ≥18 years) with hamstrings

184 tightness with or without a pathological condition. Hamstrings tightness was

185 defined as a limitation in full knee extension (hip in flexion) of at least 10-20°

186 (Depino, Webright, & Arnold, 2000) or hip flexion ROM of <70-80° during a straight

187 leg raise (Göeken & Hof, 1991). No restrictions were placed on the sex,

188 socioeconomic background, lifestyle, and health status.

189

190 Interventions

191 Studies must have used HR or CR to improve hamstrings flexibility compared to

192 either control conditions or another stretching intervention. No intervention was

193 excluded based on dose and duration. Studies were excluded if HR and CR were

194 combined with another intervention (e.g. heating agents) as such combination would

195 affect attribution of effects. Studies not involving direct application of HR and CR to

196 the knee muscles, or studies where participants received both experimental and

197 control conditions such as cross-over designs were excluded.

198

199 Outcomes

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200 The outcome of interest was change in hamstrings flexibility, defined operationally as

201 change in range of motion of the hip joint with the knee extended or of the knee joint

202 with the hip flexed. Any outcome measure that objectively assessed such change was

203 included. Torque-controlled measures of joint mobility (e.g. torque controlled

204 devices) were preferred as they have improved reliability (Harvey et al., 2003;

205 Katalinic, Harvey, & Herbert, 2011). If torque-controlled measures were not reported,

206 passive measures (e.g. passive knee extension test (PKE)) were prioritized

207 followed by active measures (e.g. active knee extension test (AKE)). Adverse

208 events were documented.

209

210 Methodological quality assessment

211 Risk of bias was estimated using the PEDro scale, a valid and reliable measure of

212 internal validity specific to clinical trials (de Morton, 2009; Maher, Sherrington,

213 Herbert, Moseley, & Elkins, 2003). The 11-item instrument contains one item on

214 external validity (reporting of eligibility criteria) and 10 scored items assessing

215 internal validity threats related to lack of randomization, allocation concealment,

216 baseline comparability, blinding, adequate follow-up, intention-to-treat analysis, and

217 statistical reporting. Two reviewers independently appraised risk of bias (Reviewers

218 X and Y). Disagreements were resolved through consultation with a third reviewer

219 (Reviewer Z) and re-examination of the article toward arriving at a consensus.

220

221 Data analysis

222 Reviewers X and Y independently extracted data using a tool developed based on the

223 Data Extraction Template for Cochrane Reviews (Cochrane, 2011). The following

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224 were extracted from each included study: (1) participant characteristics (sample size,

225 age, sex, and health condition); (2) details of interventions (specific HR and CR

226 techniques, control conditions, or comparison interventions, including dose,

227 frequency, and duration); (3) outcome measures used to assess hamstrings flexibility;

228 and (4) results (summary data for intervention groups, any participant attrition, and

229 any adverse event related to an intervention). Disagreements were settled with a third

230 reviewer (Reviewer Z) and the article full text was re-examined to arrive at a

231 consensus. For included studies in which data were presented only graphically or not

232 reported, authors were contacted through email.

233

234 Bias-corrected standardized mean differences (SMD) using Hedges g (Higgins &

235 Green, 2011) and 95% confidence intervals (95% CI) were computed to determine

236 effect sizes (ES). Existing convention for ES interpretation was applied: 0.2 to <0.5,

237 small effect; 0.5 to <0.8 = medium effect; and ≥0.8 = large effect (Rosenthal &

238 Rosnow, 1991). All reviewers assessed clinical heterogeneity of included studies

239 together and determined suitability for inclusion in the meta-analysis by consensus.

240 Results of clinically homogenous studies (ie, similar interventions and outcomes)

241 were pooled through meta-analysis using a random effects model. Statistical

242 heterogeneity was assessed using the I2 statistic, with a value of 50% and higher

243 representing substantial heterogeneity (Higgins & Green, 2011). If the I2 was greater

244 than 50%, a sensitivity analysis was conducted to determine the cause of

245 heterogeneity. Sensitivity analysis examined the effects of concealment of treatment

246 allocation, blinding of outcome assessment, and handling of withdrawals (Jüni,

247 Witschi, Bloch, & Egger, 1999). The reviewers analyzed effects of the comparability

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248 of groups at baseline. RevMan 5.3 software (The Cochrane Collaboration, 2014) was

249 used in all quantitative analyses. Reviewers pre-planned to analyze and report

250 separately for samples with physical injury or disability, and those without (i.e.

251 “healthy” adults). Data not eligible for meta-analysis were analyzed descriptively.

252

253 RESULTS

254 Flow of studies in the literature search is detailed in Figure 1. All included studies are

255 described in Table 1. Fifteen clinical trials published from 2004 through the early part

256 of 2014 were included from the original literature search. From the updated search, 10

257 relevant articles published in 2014 and 2015 were added. Hand searching yielded 14

258 additional relevant records. In total, 39 trials met the inclusion criteria. Authors were

259 contacted via email for additional data with two authors responding (Beltrão et al.,

260 2014; Mallmann et al., 2011). The final sample involved 1,770 adults with ages

261 ranging from 19 to 65 years (670 females and 1,012 males; sex not specified for 88

262 participants). Participants were reported as either healthy or active. No studies

263 involving adults with hamstrings tightness resulting from physical injury or

264 disability were located. All studies were RCT, with a median PEDro score of 4/10

265 and individual scores ranging from 2 – 7/10 (Table 1). Detailed PEDro ratings for

266 included trials are found in Appendix 2.

267

268 Interventions

269 Of the 39 included trials, 15 investigated the effects of HR and CR against no

270 intervention only, eight trials compared HR and CR against other stretching

271 techniques only, and 16 trials compared HR and CR with both no intervention and

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272 another stretching technique. Only ten trials studied short-term effects of HR and CR

273 against either control or another stretching intervention (Beltrão et al., 2014; Chebel

274 et al., 2010; Eston et al., 2007; Hardy, 1985; Hardy & Jones, 1986; Hartley-O’Brien,

275 1980; Junker & Stöggl, 2015; Poor et al., 2014; Rowlands et al., 2003; Sady,

276 Wortman, & Blanke, 1982), and only three trials studied its long-term effects at one

277 week (Tanigawa, 1972), 15 days (Silva, 2012), and eight weeks (Moesch et al., 2014).

278 Intervention durations ranged from one session to 10 weeks. Frequencies of sessions

279 ranged from one to seven times per week. Applications of HR and CR varied:

280 isometric contractions were held for 5 – 15 seconds; static stretch and relaxation

281 components lasted for 6 – 32 seconds and 3 – 15 seconds, respectively; and stretches

282 were repeated one to four times per session. No adverse events were reported in all

283 trials.

284

285 Effects of HR and CR compared with control

286 Meta-analysis of six trials (median PEDro score = 6.5/10, range = 3 – 8/10) with a

287 total of 168 participants was done. Studies using the AKE and PKE were

288 analyzed separately. Each analysis demonstrated that HR and CR were better

289 than control in immediately decreasing hamstrings tightness after one session

290 using either AKE (SMD = 0.96, 95% CI = 0.48 to 1.44, I2 = 33%) or PKE (SMD

291 = 1.19, 95% CI = 0.58 to 1.80, I2 = 0%) (Figure 2). One trial (Gama, Medeiros,

292 Dantas, & Souza, 2007) was excluded from the meta-analysis due to non-

293 comparability of groups at baseline (I2 = 57%). Meta-analysis of four trials (median

294 PEDro score = 5/10, range = 4 – 5/10) with a total of 101 participants demonstrated

295 that HR and CR were also better than control immediately after multiple sessions

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296 ranging from five days to six weeks of intervention using either AKE (SMD = 1.02,

297 95% CI = 0.44 to 1.59, I2 = 0%) or SLR (SMD = 1.03, 95% CI = 0.51 to 1.54, I2 =

298 1%) (Figure 3). Three trials were excluded from the meta-analysis due to non-

299 comparability of groups at baseline (Gama et al., 2007; Magalhães et al., 2015;

300 Rowlands et al., 2003) and large number of dropouts (Magalhães et al., 2015) (I2 =

301 67%). Two individual trials that measured short-term effects showed that changes

302 lasted 24 hours after cessation (SMD = 2.79, CI = 1.67 to 3.92; SMD = 1.04, CI =

303 0.23 to 1.86) (Junker & Stöggl, 2015; Rowlands et al., 2003) while one trial showed

304 that effects were lost 15 days after cessation (SMD = -0.44, CI = -1.33 to 0.45) (Silva,

305 2012).

306

307 Effects of HR and CR compared with other stretching techniques

308 Five trials (median PEDro score = 6/10; range = 4 – 7/10) with 176 participants

309 compared the immediate effects of HR and CR against SS after one session and found

310 a small significant effect in favor of HR and CR on the AKE (SMD = 0.39, 95% CI =

311 0.02 to 0.76, I2 = 0%) but no significant difference between the two techniques on the

312 PKE (SMD = 0.15, 95% CI = -0.37 to 0.66, I2 = 0%) (Figure 4). Individual trials on

313 the immediate effects of HR and CR against ballistic or dynamic stretching after

314 multiple sessions exhibited inconsistent findings, with one trial showing no

315 significant effects after six consecutive days (Hardy & Jones, 1986) (SMD = 0.08,

316 95% CI = -1.05 to 1.21) and another showing a large effect after eight weeks (Poor,

317 2014) (SMD = 1.58, 95% CI = 0.55 to 2.62). Other individual trials showed that

318 immediate effects of HR and CR were not superior to kinesiostretching (SMD = 0.55,

319 95% CI = -0.24 to 1.33), Mulligan stretching (SMD = -0.43, 95% CI = -1.50 to 0.65),

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320 and muscle energy technique (Moesch et al., 2014; Yildirim et al., 2016; Alcântara et

321 al., 2011). Individual studies measuring short-term effects of HR and CR against SS

322 showed conflicting results. One study showed a large effect in favor of HR and CR on

323 the PKE (SMD = 2.40, 95% CI = 1.31 to 3.49) (Chebel et al., 2010) and two studies

324 showed no significant differences on the PKE (SMD = -0.02, 95% CI = -0.76 to 0.72)

325 (Mallmann et al., 2011) and AKE (SMD = 0.43, 95% CI = -0.05 to 0.90) (Beltrão et

326 al., 2014). One trial found that the long-term effects of HR and CR after eight weeks

327 were not superior to kinesiostretching (SMD = 0.16, 95% CI = -0.61 to 0.93) (Moesch

328 et al., 2014).

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Records identified through database

search (n = 1,651)
Duplicate records excluded
(n = 107)
Records remaining after removal of
duplicates (n = 1,544)

Records excluded as clearly irrelevant

based on title and abstract (n = 1,524)

Full-text articles reviewed

(n = 20)
Records excluded after evaluation of
full-text (n = 5)
 Study design not RCT (n = 2)
 HR and CR combined with another
intervention (n = 3)

Full-text articles reviewed from

updated search (n = 14)

Full-text articles excluded from

updated search (n = 4)
 Study design not RCT (n = 2)
 HR and CR combined with another
intervention (n = 2)

Full-text articles included from hand

search (n = 14)

Studies included in qualitative

synthesis
(n = 39)

Studies included in quantitative

synthesis (meta-analysis)
(n = 12)
329

330 Figure 1. Flow of studies through selection process.

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331 Table 1

332 Characteristics of included trials on HR and CR for hamstrings flexibility (n = 39).

Study Participants Experimental Control condition Comparison Outcome Results PEDro

condition condition measures score

Alcântara, n = 90 CR with 10s No intervention Muscle energy SLR using CR > CG 6/10

Firmino, & active maximum technique using goniometer CR > muscle

Lage (2011) adults isometric 25% of maximum energy

Age (yr) = contraction of contraction held technique

24 (SD 7) agonist against for 10s followed

Gender = 60 resistance by 6s relaxation

M, 30 F followed by 30s 3 x 1 session

active contraction

of quadriceps

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 until point of

tissue resistance

1 x 1 session

Azevedo, n = 60 CR with 6s No intervention None AKE using CR > CG 7/10

Melo, Alves healthy isometric inclinometer

Corrêa, & students contraction at

Chalmers Age (yr) = point of

(2011) 23 (SD 2) hamstrings

Gender = 60 stretch followed

M, 0 F by relaxation and

10s stretch hold

2 x 1 session

Beltrão et al. n = 70 CR with 30s None SS using pulley AKE using CR = SS 6/10

(2014) young stretch hold at and rope system goniometer

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 healthy point of with 1min stretch

adults hamstrings hold using 7kg

Age (Exp) stretch followed load

(yr) = 23 by 6s maximal 1 x 7 sessions on

(SD 4) isometric consecutive d

Age (Com) contraction and

(yr) = 22 relaxation

(SD 3) 2 x 7 sessions on

Gender = 32 consecutive d

M, 38 F

Brasileiro, n = 40 CR with 15s No intervention None AKE using CR > CG 5/10

Faria, & healthy isometric goniometer

Queiroz students contraction at

(2007) point of

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 Age (yr) = hamstrings

22 (SD 3) stretch followed

Gender = 12 by 15s relaxation

M, 28 F 4 x 10 sessions

Chebel et al. n = 24 Exp = HR with None SS for 30s PKE using HR = SS 4/10

(2007) sedentary 6s isometric 5 x 2/wk x 5 wk goniometer

students contraction of

Age range hamstrings

(yr) = 18 – followed by 30s

26 stretch hold

Gender = 0 5 x 2/wk x 5 wk

M, 24 F

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Cornelius, n = 120 Exp 1 = passive None SS in agonist SLR using CR > SS 4/10

Ebrahim, healthy stretch of hip pattern (hip Leighton

Watson, & students extensors, active flexion) flexometer

Hill (1992) Age (yr) = stretch facilitated 3 x 1 session

22 (SD 3) by concentric

Gender = contraction of hip

120 M, 0 F flexors, and

passive stretch of

hip extensors

3 x 1 session

Exp 2 = passive

stretch of hip

extensors, 3s

maximal

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isometric

contraction of hip

extensors, active

stretch facilitated

by concentric

contraction of hip

flexors, and

passive stretch of

hip extensors

3 x 1 session

Exp 3 = passive

stretch of hip

extensors, 3s

maximal

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 isometric

contraction of hip

flexors, active

stretch facilitated

by concentric

contraction of hip

flexors, and

passive stretch of

hip extensors

3 x 1 session

Davis, n = 19 10s concentric No intervention Com 1 = active PKE using CR > CG 3/10

Ashby, young contraction of self-stretching for inclinometer CR < SS

McCale, healthy quadriceps 30s CR = active self-
adults against resistance 1 x 3/wk x 4 wk stretching

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McQuain, & Age range with hip Com 2 = manual

Wine (2005) (yr) = 21 – passively flexed SS for 30s

35 to 90° and knee 1 x 3/wk x 4 wk

Age (yr) = passively

23 (SD 2) extended,

Gender = 11 followed by 30s

stretch hold
M, 8 F
1 x 3/wk x 4 wk

Eston, n = 14 CR with 6s No intervention None Adapted sit- CR > CG 3/10

Rowlands, young maximal and-reach

Coulton, active isometric test using

Mckinney, & students contraction tape measure

Gleeson Age (yr) = followed by

(2007) 21 (SD 1) active movement

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 Gender = 14 to new range held

M, 0 F for 5s

3 x 2x/wk x 5 wk

Farquharson n = 30 CR with 10s None SS for 30s with AKE using CR = SS 5/10

& Greig active stretch hold at 10s rest goniometer

(2015) adults point of 3 x 1 session

Age (yr) = hamstrings

21 (SD 0.1) stretch, 10s

Gender = 30 contraction

M, 0 F against 75%

resistance, 3s

relaxation, and

10s stretch hold

3 x 1 session

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Fasen et al. n = 87 Agonist No intervention Com 1 = SS held PKE using CR > CG 3/10

(2009) healthy contraction of for 30s goniometer CR < SLR

adults quadriceps by 3 x 1 session CR = SS

Age range actively Com 2 = active-

(yr) = 21 – extending knees assisted SLR

57 with 30s stretch stretch held for

Age (yr) = hold 30s

33 (SD 8) 3 x 1 session 3 x 1 session

Age (Exp) Com 3 = passive

(yr) = 32 SLR stretch held

(SD 8) for 30s

Age (Com 3 x 1 session

1) (yr) = 31

(SD 6)

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 Age (Com

2) (yr) = 37

(SD 9)

Age (Com

3) (yr) = 31

(SD 6)

Age (Con)

(yr) = 36

(SD 10)

Gender = 47

M, 40 F

Feland & n = 72 Exp 1= CR with No intervention None PKE using CR > CG 4/10

Marin (2004) healthy 6s contraction at goniometer

students 20% of MVIC

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Age (yr) = followed by 10s

23 (SD 2) relaxation and

Age range further passive

(yr) = 18 – extension

27 3 x 5d

Gender = 72 Exp 2 = CR with

M, 0 F 6s contraction at

60% of MVIC

followed by 10s

relaxation and

further passive

extension

3 x 5d

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 Exp 3 = CR with

6s contraction at

100% of MVIC

followed by 10s

relaxation and

further passive

extension

3 x 5d

Feland, n = 97 CR with 6s No intervention SS for 32s PKE using CR > CG 4/10

Myrer, & older MVIC of hip 1 x 1 session goniometer CR > SS

Merrill athletes extensors

(2001) Age range = followed by 10s

55 – 79 relaxation and

stretch

Page 29 of 91
 Age (yr) = 2 x 1 session

65

Gender = 66

M, 31 F

Ford & n = 32 CR agonist No intervention Com 1 = SS using AKE using CR > CG 4/10

McChesney active contract with 6s modified inclinometer CR = SS

(2007) adults stretch hold at hurdler’s stretch CR = active

Age (yr) = point of for 30s followed control

21 (SD 3) hamstrings by 10s relaxation stretching

Gender = 18 stretch followed 5 x 1 session

M, 14 F by 6s isometric Com 2 = active

contraction and control stretching
6s relaxation with knee held in

Page 30 of 91
 4 x 1 session extended position

while seated for

10s followed by

10s relaxation

10 x 1 session

Gama et al., n = 28 Exp 1 = HR with No intervention None AKE using HR > CG 5/10

(2007) young 5s contraction at goniometer

healthy point of

adults hamstrings

Age (yr) = stretch followed

23 (SD 2) by 30s stretch

Age (Exp 1) hold and 10s rest

(yr) = 22 3 x 3/wk x 10

(SD 3) sessions

Page 31 of 91
 Age (Exp 2) Exp 2 = HR with

(yr) = 23 5s contraction at

(SD 2) point of

Age (Con) hamstrings

(yr) = 23 stretch followed

(SD 3) by 30s stretch

Gender = 0 hold and 10s rest

M, 28 F 3 x 5/wk x 10

sessions

Gama et al. n = 36 Exp 1 = HR with No intervention None AKE using HR > CG 5/10

(2009) young 5s contraction at photometric

healthy point of analysis

adults hamstrings

stretch followed

Page 32 of 91
Age (yr) = by relaxation and

22 (SD 2) 30s stretch hold

Age (Exp 1) 1 x 5/wk x 2

(yr) = 22 consecutive wk

(SD 1) Exp 2 = HR with

Age (Exp 2) 5s contraction at

(yr) = 20 point of

(SD 1) hamstrings

Age (Exp 3) stretch followed

(yr) = 22 by relaxation and

(SD 2) 30s stretch hold

Age (Con) 3 x 5/wk x 2

(yr) = 23 consecutive wk

(SD 2)

Page 33 of 91
 Gender = 0 Exp 3 = HR with

M, 36 F 5s contraction at

point of

hamstrings

stretch followed

by relaxation and

30s stretch hold

6 x 5/wk x 2

consecutive wk

Gribble, n = 42 HR with 8s No intervention SS for 30s AKE and HR > CG 5/10

Guskiewicz, college stretch hold at 4 x 4/wk x 6 wk SLR using HR = SS

Prentice, & students point of goniometer

Shields Age (yr) = hamstrings

(1999) 20 (SD 2) stretch followed

Page 34 of 91
 Gender = by 7s isometric

not specified contraction, 5s

rest, and 10s

stretch hold

4 x 4/wk x 6 wk

Hardy n = 42 Exp 1 = 3s No intervention Com 1 = SS for SLR using CR > CG 3/10

(1985) healthy maximal 30s Leighton CR > SS

students isometric 3 x 6 consecutive flexometer

Age range contraction of hip d

(yr) = 18 – extensors Com 2 = passive

22 followed by 10s lift, active hold

Gender = 0 stretch hold with leg taken to

M, 42 F 3 x 3 sets x 6 endpoint followed

consecutive d by concentric

Page 35 of 91
Exp 2 = 6s contraction of hip

maximal flexors for 10s

isometric 3 x 3 sets x 6

contraction of hip consecutive d

extensors

followed by 10s

stretch hold

3 x 3 sets x 6

consecutive d

Exp 3 = 3s

maximal

isometric

contraction of hip

extensor

Page 36 of 91
followed by 10s

concentric

contraction of hip

flexors

3 x 3 sets x 6

consecutive d

Exp 4 = 6s

maximal

isometric

contraction of hip

extensor

followed by 10s

concentric

Page 37 of 91
 contraction of hip

flexors

3 x 3 sets x 6

consecutive d

Hardy & n = 24 Passive leg raise No intervention Com 1 = ballistic Sproboscopic CR > CG 4/10

Jones healthy to endpoint, 6s stretching as photography CR = ballistic

(1986) students MVIC of many times as stretching

Age range antagonist, active possible in 30s

(yr) = 18 – concentric with emphasis on

22 contraction of speed

Gender = 0 agonist, followed 3 (30s rest

M, 24 F by another between rep) x 7

passive maneuver daily sessions

Page 38 of 91
 3 x 3 sets (30s Com 2 = ballistic

rest between sets) stretching as

x 7 daily sessions many times as

possible in 30s

with emphasis on

range

3 (30s rest

between rep) x 7

daily sessions

Hartley- n = 119 Exp 1 = active No intervention Com 1 = SS for SLR using CR > CG 4/10

O’Brien healthy hip flexion in 6s 6s followed by 6s Leighton CR = SS

(1980) students followed by 6s active contraction flexometer CR = dynamic

Age (yr) = maximum of hip flexors stretch

20 isometric 5 x 9 sessions

Page 39 of 91
Gender = 0 contraction Com 2 = dynamic

M, 119 F against resistance stretch and hold

5 x 9 sessions with 4 leg swings

Exp 2 = passive starting at 45°

movement to angle with 6s

end-point in 6s hold at endpoint

followed by 6s of fourth swing

maximum 6 x 9 sessions

isometric Com 3 =

contraction prolonged stretch

against resistance for 1min

5 x 9 sessions 1 x 9 sessions

Com 4 =

relaxation method

Page 40 of 91
 with prolonged

stretching at

endpoint for 1min

with addition of

mental relaxation

and mind-set

technique

1 x 9 sessions

Junker & n = 40 CR with 6s No intervention None Stand-and- CR > CG 5/10

Stöggl active contraction at reach test

(2015) adults 25% MVIC at

Age (yr) = point of

31 (SD 9) hamstrings

stretch followed

Page 41 of 91
 Age (Exp) by 10s stretch

(yr) = 33 3 x 3 sets x 3/wk

(SD 11) x 4 wk

Age (Con)

(yr) = 30

(SD 9)

Gender = 40

M, 0 F

Lim, Nam, & n = 48 HR with 6s No intervention SS for 30s AKE using HR > CG 6/10

Jung (2014) healthy contraction at 1 x 1 session goniometer HR = SS

adults point of

Age (Exp) hamstrings

(yr) = 24 stretch followed

(SD 2) by 5s relaxation,

Page 42 of 91
 Age (Com) 6s contraction, 5s

(yr) = 22 relaxation, and 6s

(SD 2) contraction

Age (Con) 1 x 1 session

(yr) = 22

(SD 2)

Gender = 48

M, 0 F

Magalhães et n = 32 CR with 5s No intervention None AKE using CR > CG 3/10

al. healthy submaximal goniometer

(2015) adults isometric

Age range = contraction

20 – 25 followed by

Page 43 of 91
 Age (yr) = relaxation and

22 30s stretch hold

Gender = 14

M, 18 F

Mallmann et n = 41 5s maximum None Com 1 = SS for PKE using CR = SS 6/10

al. healthy contraction at 32s goniometer CR =

(2011) adults point of 1 x 1 session kinesiostretching

Age (yr) = hamstrings Com 2 =

20 (SD 3) stretch followed kinesiostretching

Gender = 5 by 32s stretch for 8s

M, 36 F hold 3 x 1 session

Markos n = 30 Exp 1 = HR with 9s isometric None SLR using HR > CG 4/10

(1979) healthy 9s isometric contraction plumbline

adults contraction

Page 44 of 91
 Age range followed by 3s against gravity

(yr) = 19 – relaxation only

34 2 x 1 session

Age (yr) = Exp 2 = CR with

22 9s maximal

Gender = 0 contraction

M, 30 F followed by 3s

relaxation

2 x 1 session

Minshull, n = 18 CR agonist None SS with 10s SLR using CR = SS 4/10

Eston, active contraction with passive motion at Leighton

Bailey, Rees, adults 10s maximal endpoint followed flexometer

& Gleeson contraction of by 5s relaxation

(2014) knee flexors and 3 x 3/wk x 8 wk

Page 45 of 91
 Age (Exp) hip extensors

(yr) = 20 followed by 5s

(SD 2) relaxation and

Age (Com) 10s stretch hold

(yr) = 21 3 x 3/wk x 8 wk

(SD 2)

Gender = 18

M, 0 F

Moesch et al. n = 40 5s maximal None Com 1 = SS for PKE using CR = SS 6/10

(2014) healthy contraction at 32s goniometer CR =

adults point of 1 x 3/wk x 6 wk kinesiostretching

Age (yr) = hamstrings Com 2 =

20 (SD 3) stretch, followed kinesiostretching

in sittting, 8s

Page 46 of 91
Gender = 5 by relaxation and extension of

M, 35 F 32s stretch hold dominant lower

1 x 3/wk x 6 wk limb with flexion

and external

rotation of

contralateral

limb, followed by

moving torso

forward, and

performing ankle

dorsiflexion and

head flexion

3 x 3/wk x 6 wk

Page 47 of 91
O’Hora, n = 45 6s contraction of No intervention SS for 30s PKE using CR > CG 7/10

Cartwright, healthy hamstrings 1 x 1 session goniometer CR > SS

Wade, students against resistance

Hough, & Age (Exp) followed by

Shum (2011) (yr) = 27 passive

(SD 4) movement of

Age (Com) knee to full

(yr) = 24 extension

(SD 2) 1 x 1 session

Age (Con)

(yr) = 26

(SD 3)

Gender = 22

M, 23 F

Page 48 of 91
Poor et al. n = 30 Exp 1 = 10s None Dynamic AKE CR = dynamic 4/10

(2014) healthy stretch hold stretching (unspecified stretching

students followed by 5s 1 x 5/wk x 8 wk instrument)

Age range contraction, 10s

(yr) = 18 – relaxation, and

24 another 10s

Gender = 30 stretch hold

M, 0 F 2 x 5/wk x 8 wk

Exp 2 = 10s

stretch hold

followed by 10s

contraction, 10s

relaxation, and

Page 49 of 91
 another 10s

stretch hold

2 x 5/wk x 8 wk

Prentice n = 46 10s isometric None SS for 10s at SLR using CR > SS 2/10

(1983) healthy contraction of endpoint followed goniometer

students hamstrings at by 10s relaxation

Age range endpoint 3 x 3/wk x 10 wk

(yr) = 18 – followed by

34 relaxation and

Gender = contraction of

not specified quadriceps until

further stretch

was felt in

hamstrings

Page 50 of 91
 3 x 3/wk x 10 wk

Rezaeeshirazi n = 60 HR with 10s No intervention None SLR HR > CG 4/10

et al. healthy stretch hold (unspecified

(2012) students followed by 3s instrument)

Age (Exp) rest

(yr) = 22 3 x 3/wk x 4 wk

(SD 7)

Age (Con)

(yr) = 22

(SD 5)

Gender = 60

M, 0 F

Page 51 of 91
Rowlands et n = 37 Exp 1 = CR No intervention None SLR using CR > CG 3/10

al., (2003) healthy agonist contract Leighton

students with 5s maximal flexometer

Age (yr) = isometric

20 (SD 1) contraction of

Gender = 0 hamstrings

M, 37 F followed by 5s

relaxation and

10s stretch hold

3 x 2/wk x 6 wk

Exp 2 = CR

agonist contract

with 10s MVIC

followed by 5s

Page 52 of 91
 relaxation and

10s stretch hold

3 x 2/wk x 6 wk

Sady, n = 43 6s contraction No intervention Com 1 = ballistic SLR using CR > CG 3/10

Wortman, & healthy followed by stretching through Leighton CR > SS

Blanke students relaxation and full range of flexometer CR > ballistic
(1982) Age (yr) = further stretch motion stretching

23 (SD 3) 3 x 3/wk x 6 wk 20 x 3/wk x 6 wk

Gender = 43 Com 2 = SS for

M, 0 F 6s followed by

relaxation

3 x 3/wk x 6 wk

Page 53 of 91
Schuback et n = 40 Exp 1 = active No intervention None SLR using CR > CG 7/10

al. healthy SLR followed by goniometer

(2004) students 15s isometric

Age (Exp 1) contraction

(yr) = 34 against self-

(SD 10) induced

Age (Exp 2) resistance

(yr) = 35 through the hands

(SD 11) followed by 15s

relaxation; leg
Age (Con)

(yr) = 38 straightened after

each repetition
(SD 13)
4 x 1 session
Gender = 20

M, 20 F

Page 54 of 91
 Exp 2 = 15s

contraction

against therapist

resistance at

point of

hamstrings

tightness

followed by 15s

relaxation

4 x 1 session

Silva et al. n = 30 Exp 1 = HR in No intervention None SLR using HR > CG 4/10

(2012) healthy sagittal plane Flexis

students with 5s isometric fleximeter

contraction

Page 55 of 91
Age range followed by 15s

(yr) = 19 – relaxation

40 6 x 5d

Age (yr) = Exp 2 = HR in

24 diagonal plane

Gender = 30 with 5s isometric

M, 0 F contraction

followed by 15s

relaxation

6 (3 in medial

plane and 3 in

lateral plane) x

5d

Page 56 of 91
Spernoga, n = 30 Modified HR No intervention None AKE using HR > CG 3/10

Uhl, Arnold, military with no hip goniometer

& Gansneder cadets rotation with 7s

(2001) Age (yr) = stretch hold,

19 (SD 1) followed by 7s

Gender = 30 maximal

M, 0 F isometric

contraction of

hamstrings and

5s relaxation

5 x 1 session

Tanigawa n = 30 HR using 2 No intervention Passive SLR using HR > CG 4/10

(1972) healthy diagonal patterns mobilization plumb line HR > passive

adults with 7s isometric stretch (limb mobilization

Page 57 of 91
 Age range contraction elevated until

(yr) = 20 – followed by 5s pulling sensation

48 rest in posterior knee,

Age (Exp) 2 for each pattern with further

(yr) = 26 x 2/wk x 4 wk elevation at

Age (Com) moderate rate of

2s followed by 5s
(yr) = 24
hold and 5s rest)
Age (Con)
4 x 2/wk x 4 wk
(yr) = 27

Gender = 30

M, 0 F

Trampas, n = 30 Modified CR No intervention None PKE using CR > CG 7/10

Kitsios, healthy without hip goniometer

Sykaras, students rotation with 15s

Page 58 of 91
Symeonidis, Age (Exp) stretch hold at

& Lazarou (yr) = 21 point of

(2010) (SD 1) hamstrings

Age (Con) stretch, followed

(yr) = 21 by 6s maximal

(SD 1) isometric

Gender = 30 contraction,

M, 0 F relaxation, and

10s stretch hold

with 30s rest

period between

each repetition

3 x 1 session

Page 59 of 91
Yıldırım, n = 26 HR with No intervention Com 1 = SS for SLR using HR > CG 5/10

Ozyurek, young isometric 30s digital HR = Mulligan

Tosun, Uzer, healthy contraction for 10 x 3x/wk x 4 goniometer stretching
& Gelecek adults 10s, relaxation wk HR > SS
(2016) Age (yr) = for 10s, followed Com 2 = traction

22 (SD 1) by straightening applied to leg

Gender = 17 of leg while lifting limb

M, 9 F 1 x 3x/wk x 4 wk through pain-free

range of SLR

until onset of

discomfort

(Mulligan

stretching)

3 x 3x/wk x 4 wk

Page 60 of 91
 Yuktasir & n = 28 CR with 10s No intervention SS for 30s with PKE using CR > CG 5/10

Kaya (2009) healthy stretch followed 10s rest period goniometer CR = SS

students by 5s contraction, between

Age (yr) = 5s relaxation, and repetitions

22 (SD 2) 15s stretch hold 4 x 4/wk x 6 wk

Gender = 28 with 10s rest

M, 0 F period between

repetitions

4 x 4/wk x 6 wk

333 Abbreviations: AKE, active knee extension test; Com, comparator stretching group; CG, control group; CR, contract-relax; Exp,

334 experimental group; HR, hold-relax; MVIC, maximum voluntary isometric contraction; PKE, passive knee extension test; SLR, straight

335 leg raise.

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336

337

338 Figure 2. Pooled SMD (95% CI) of effect of HR and CR stretching compared with control on hamstrings flexibility: immediately after

339 one session, six trials (n = 168). Abbreviations: AKE, active knee extension test; IV, inverse variance analysis; PKE, passive knee

340 extension test; Std., standard.

341

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342

343

344 Figure 3. Pooled SMD (95% CI) of effect of HR and CR stretching compared with control on hamstrings flexibility immediately after

345 multiple sessions, four trials (n = 101). Abbreviations: AKE, active knee extension test; IV, inverse variance analysis; SLR, straight leg

346 raise; Std., standard.

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347

348 Figure 4. Pooled SMD (95% CI) of effect of HR and CR compared with SS on hamstrings flexibility immediately after one session, five

349 trials (n = 176). Abbreviations: AKE, active knee extension test; IV, inverse variance analysis; PKE, passive knee extension test; Std.,

350 standard.

351

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352 DISCUSSION

353 This systematic review of 39 RCT (n = 1,770 participants) demonstrated that: (1) HR

354 and CR were better than control in improving hamstrings flexibility immediately after

355 intervention; (2) the effects of HR and CR can last for at least 24 hours but may not

356 be sustained for longer periods of time based on limited evidence; and (3) the

357 superiority of HR and CR to other stretching techniques in terms of immediate, short-

358 term and long-term effects is unclear based on limited evidence. No adverse events

359 were reported. Findings should be interpreted in light of the methodological quality of

360 the available evidence. The median PEDro score of the included trials was relatively

361 low at 4/10, with only a small proportion having important methodological features

362 including assessor blinding (11/39, 28%), allocation concealment (8/39, 21%), and

363 intention-to-treat analysis (1/39, 3%). Clinicians must weigh the available evidence in

364 light of potential threats to internal validity. Consequently, high-quality research is

365 needed to generate definitive evidence for the effects of HR and CR against other

366 techniques.

367

368 The large positive effects of HR and CR against control are consistent with literature

369 that theoretically predicts HR and CR to be effective in enhancing immediate and

370 short-term flexibility (Hindle, Whitcomb, Briggs, & Hong, 2012; Smedes, Heidmann,

371 Schäfer, Fischer, & Stępień, 2016; Westwater-Wood, Adams, & Kerry, 2010). Exact

372 mechanisms underpinning such flexibility gains are not well established although

373 there appears to be both mechanical and neural factors involved (Guissard &

374 Duchateau, 2006). Adding muscle contractions, regardless of intensity and duration,

375 prior to stretching decreases muscle stiffness and transiently inhibits spinal reflexes

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376 long enough to be advantageous for subsequent stretching (Guissard & Duchateau,

377 2006). These changes in neural excitability need to be investigated further as

378 originally proposed mechanisms, such as reciprocal and autogenic inhibition, lack

379 convincing empirical evidence (Chalmers, 2004; Ferber, Osternig, & Gravelle, 2002;

380 Mitchell et al., 2009; Olivo & Magee, 2006; Sharman et al., 2006; Smedes et al.,

381 2016). The positive large effects that lasted for more than 24 hours in individual trials

382 (Junker et al., 2015; Rowlands et al., 2007) suggest that HR and CR may induce

383 structural adaptations in soft tissues but this hypothesis warrants further study.

384 Alteration in stretch tolerance is suggested as a more plausible explanation for HR-

385 and CR-related gains (Behm et al., 2016; Laessøe & Voigt, 2004; Sharman et al.,

386 2006; Smedes et al., 2016), with progressive increases in stretch tolerance observed

387 after repeated procedures (Mitchell et al., 2007). It is worth exploring the mechanisms

388 of HR and CR that can explain immediate and short-term effects. Regardless, this

389 systematic review informs clinicians that they can expect large effects on hamstrings

390 flexibility when applying the technique in practice.

391

392 Evidence from one trial suggests that gains from HR and CR may be lost days after

393 cessation (Silva et al., 2012). This finding is important to consider since transient

394 effects have little clinical usefulness (Katalinic et al., 2011). Systematic review

395 evidence indicates that acute bouts of stretching may not translate to functional gains,

396 while regular stretching does (Shrier, 2004). Wallin et al. (1985) found that

397 continuation of CR at least once a week was necessary to maintain gains. Therefore, if

398 the goal is to induce functional changes to minimize injury risk, stretching must be

399 administered routinely. A potential challenge is that HR and CR procedures require

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400 several steps, making it difficult for some clients to carry out unsupervised

401 (Schuback, Hooper, & Salisbury, 2004) or unassisted (Behm et al., 2016). Clinicians

402 need to consider this dimension when planning routine use among clients outside of

403 therapist-supervised sessions.

404

405 This study found small immediate effects in favor of HR and CR compared to SS

406 using the AKE, in contrast to the findings of a recent systematic review (Borges

407 et al., 2018). However, the finding of this study that CR was not superior to SS in

408 inducing long-term changes was in agreement with that of this earlier systematic

409 review. Nonetheless, this study parallels previous systematic reviews in that HR and

410 CR stretching is effective in immediately improving hamstrings flexibility (Borges et

411 al., 2018; Decoster et al., 2005; Harvey et al., 2002; Medeiros et al., 2016). Further,

412 the current study highlights the lack of available published studies that makes it

413 difficult to ascertain the superiority of HR and CR over other types of stretching

414 techniques apart from SS. Limited evidence from individual trials showed either

415 conflicting or no evidence of the superiority of HR and CR to other stretching

416 techniques. Musculotendinous unit changes attributed to HR and CR, and other

417 stretching techniques are underpinned by similar theories such as stress relaxation,

418 creep, post-stretch decreases in motor neuron excitability, and increased stretch

419 tolerance (Behm et al., 2016; Magnusson et al., 1996; Weppler & Magnusson, 2010).

420 A possible reason for the inability of trials to clarify any difference of HR and CR

421 against other stretching techniques may be the insufficiency of stretching exercise

422 prescription parameters applied in the interventions. HR and CR techniques are

423 recommended to be repeated until no more range is gained (Adler et al., 2008),

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424 although the included trials only used 1 – 4 repetitions. Although isometric

425 contractions used across trials concurred with recommended parameters (Adler et al.,

426 2008; Kwak & Ryu, 2015), the stretching component varied in duration from 6 – 32

427 seconds and was generally sub-optimal based on recommendations (Ryan et al.,

428 2008). Stretching intensity is an important consideration in potentially influencing

429 changes in joint flexibility (Apostolopoulos et al., 2015), however none of the

430 included trials examined its effects. Overall, this systematic review provides

431 additional knowledge on the comparative effects of HR and CR against various other

432 stretching techniques for improving hamstrings flexibility and builds on previous

433 systematic reviews. It highlights gaps in the knowledge on the comparative long-term

434 effects of stretching techniques and optimal exercise prescription parameters for

435 stretching.

436

437 Several methodological strengths underpin the present findings. Only trials that used

438 HR and CR without being combined with other treatments were included, allowing

439 the research questions to be answered directly. Comprehensiveness of the literature

440 search was enhanced by using multiple electronic databases, keyword searching

441 without restrictions on publication language and date, contacting authors for

442 additional data, hand searching included and relevant studies, and conducting an

443 updated search up to May 31, 2017. Risk of bias in included studies was assessed

444 using widely used criteria. All included studies were RCT and results were pooled

445 through meta-analysis, which represented highest-level evidence for treatment effects.

446 Finally, use of bias-corrected ES diminished the possibility of overestimating the

447 effects of HR and CR stretching.

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448

449 Study limitations

450 Findings need to be interpreted considering several limitations. Exclusion of

451 unpublished literature might have introduced publication bias. Differences in outcome

452 measures and incomplete data reporting in some included trials precluded further

453 quantitative synthesis. Limited conclusions could be made regarding comparative

454 effects of HR and CR versus other stretching techniques due to insufficient available

455 evidence. Conclusions were based on relatively low quality data (median PEDro score

456 = 4/10) and therefore high risk of bias. Key methodological issues such as lack of

457 allocation concealment, baseline participant group comparability, assessor blinding,

458 and intention-to-treat analysis limited the strength of conclusions of the included

459 trials. Most trials did not carry out power calculation in determining sample size,

460 which could negatively impact statistical conclusions.

461

462 CONCLUSION

463 Current best evidence from multiple RCT with generally low- to moderate-quality

464 trials in adults demonstrates that HR and CR are safe and effective in increasing

465 hamstrings flexibility immediately within-session and after repeated administration

466 (ie, it is better than control/nothing). Conflicting or limited evidence from generally

467 low- to moderate-quality trials demonstrates that HR and CR have long-term effects

468 and are superior to other stretching techniques. Long-term effects of HR and CR

469 and superiority to other stretching techniques require further examination.

470 Further research to test effects of HR and CR should use rigorous trial designs, and

471 apply optimal exercise prescription parameters. Although clinicians can expect

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472 large gains following administration of HR and CR, a regular stretching routine is

473 needed to maintain gains and for such gains to be clinically useful.

474

475 REFERENCES

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519 application and modified PNF stretching techniques on hip joint flexibility in

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525 effectiveness of 3 stretching techniques on hamstring flexibility using

526 consistent stretching parameters. Journal of Strength and Conditioning

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529 stretching on range of motion: a systematic literature review. The Journal of

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683 effects of PNF versus passive stretch conditioning on neuromuscular

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697 Efficacy of static stretching and proprioceptive neuromuscular facilitation

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699 Conditioning Research, 25(6), 1586–1591.

700 https://doi.org/10.1519/JSC.0b013e3181df7f98

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702 Comparing the effectiveness of an eight-week period stretching PNF, and

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719 Cramer, J. T. (2008). The time course of musculotendinous stiffness responses

720 following different durations of passive stretching. The Journal of

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722 https://doi.org/10.2519/jospt.2008.2843

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724 static or proprioceptive neuromuscular facilitation? Archives of Physical

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727 incorporating proprioceptive neuromuscular facilitation components and a

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744 Smedes, F., Heidmann, M., Schäfer, C., Fischer, N., & Stępień, A. (2016). The

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771 Watsford, M. L., Murphy, A. J., McLachlan, K. A., Bryant, A. L., Cameron, M. L.,

772 Crossley, K. M., & Makdissi, M. (2010). A prospective study of the

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787 of effects of static, proprioceptive neuromuscular facilitation and Mulligan

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793 https://doi.org/10.1016/j.jbmt.2007.10.001

794

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795 Appendix 1 PubMed search strategy

796 1. Muscle stretching exercises [MeSH]

797 2. Proprioceptive neuromuscular facilitation

798 3. Hamstrings

799 4. Stretch*

800 5. Flexib*

801 6. PNF

802 7. Neuromuscular facilitation

803 8. PNF stretch*

804 9. Proprioceptive

805 10. Proprioceptive neuromuscular facilitation patterns

806 11. Randomized controlled trial

807 12. RCT

808 13. Quasi-randomized study

809 14. Quasi-randomized controlled trial

810 15. Controlled clinical trial

811 16. Proprioceptive neuromuscular facilitation techniques

812 17. Knee flexors

813 18. Hip extensors

814 19. Connective tissue

815 20. Tissue manipulation

816 21. Soft tissue mobilization

817 22. Therapeutic exercise

818 23. Dynamic stretching

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819 24. Isometric stretching

820 25. Active stretching

821 26. Passive stretching

822 27. Muscle length

823 28. ROM

824 29. Range of motion

825 30. Joint range of motion

826 31. Joint flexibility

827 32. Extensib*

828 33. Flex*

829 34. Adapt*

830 35. Pliab*

831 36. Tight*

832 37. Contracture

833 38. Muscle tightness

834 39. Muscular tension

835 40. Muscle tone

836 41. Shorten*

837 42. Straight leg raise

838 43. SLR

839 44. Active knee extension test

840 45. Manual therapy

841 46. Neurofacilitation

842 47. (#1 OR #2 OR # 6 OR # 7 OR #8 OR #9 #10 OR #16 OR #45 OR #46)

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843 48. (#3 OR #17 OR #18 OR #19)

844 49. (#4 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26)

845 50. (#5 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35

846 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44)

847 51. (#11 OR #12 OR #13 OR #14 OR #15)

848 52. (#47 AND #48 AND #49 AND #50 AND #51)

849

850

851

852

853

854

855

856

857

858

859

860

861

862

863

864

865

866

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867 Appendix 2

868 Methodological quality assessment of included trials using PEDro scale (n = 39).

Study 1 2 3 4 5 6 7 8 9 10 11 Total

Alcântara et al. Y Y Y N N N Y Y N Y Y 6

(2011)

Azevedo et al. (2011) N Y Y Y N N Y Y N Y Y 7

Beltrão et al. (2014) Y Y N Y N N N Y Y Y Y 6

Brasileiro et al. Y Y Y N N N N Y N Y Y 5

(2007)

Chebel et al. (2007) Y Y N Y N N N N N Y Y 4

Cornelius et al. Y Y N N N N N Y N Y Y 4

(1992)

Davis et al. (2005) N Y N N N N Y N N Y N 3

Eston et al. (2007) N Y N N N N N N N Y Y 3

Page 87 of 91
Farquharson & Greig Y Y N Y N N N Y N Y Y 5

(2015)

Fasen et al. (2009) N Y N N N N N Y N Y N 3

Feland & Marin N Y N N N N N Y N Y Y 4

(2004)

Feland et al. (2001) Y Y N N N N N Y N Y Y 4

Ford & McChesney Y Y N Y N N N Y N Y Y 4

(2007)

Gama et al. (2007) N Y N N N N Y Y N Y Y 5

Gama et al. (2009) Y Y N Y N N N Y N Y Y 5

Gribble et al. (1999) Y Y N Y N N N Y N Y Y 5

Hardy (1985) Y Y N N N N N N N Y Y 3

Hardy et al. (1986) N Y N Y N N N N N Y Y 4

Page 88 of 91
Hartley-O’Brien Y Y N Y N N N N N Y N 4

(1980)

Junker & Stöggl Y Y N Y N N N Y N Y Y 5

(2015)

Lim et al. (2014) Y Y Y Y N N N Y N Y Y 6

Magalhães et al. N Y N N N N N N N Y Y 3

(2015)

Mallmann et al. N Y Y Y N N Y Y N Y Y 6

(2011)

Markos (1979) Y Y N N N N N Y N Y Y 4

Minshull et al. (2013) N Y N Y N N N N N Y Y 4

Moesch et al. (2014) Y Y Y Y N N Y N N Y Y 6

O'Hora et al. (2011) Y Y N Y N N Y Y N Y Y 7

Poor et al. (2014) Y Y N N N N N N N Y Y 4

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Prentice (1983) Y Y N N N N N N N Y N 2

Rezaeeshirazi et al. Y Y N Y N N N N N Y Y 4

(2012)

Rowlands et al. Y Y N N N N N N N Y Y 3

(2003)

Sady et al. (1982) N Y N Y N N N N N Y Y 3

Schuback et al. Y Y Y Y N N Y Y N Y Y 7

(2004)

Silva et al. (2012) Y Y N Y N N N N N Y Y 4

Spernoga et al. Y Y N N N N N N N Y Y 3

(2001)

Tanigawa (1972) Y Y N Y N N N Y N Y N 4

Trampas et al. (2010) Y Y Y Y N N Y Y N Y Y 7

Yildirim et al. (2016) N Y N Y N N Y N N Y Y 5

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 Yuktasir & Kaya Y Y N N N N Y Y N Y Y 5

(2009)

Studies that satisfied 27 39 8 22 0 0 11 22 1 39 34

each criterion (69%) (100%) (21%) (56%) (0%) (0%) (28%) (56%) (3%) (100%) (87%)

869

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Conflict of Interest
None

Ethical Statements
None declared

Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors

Acknowledgements

We are grateful to Aila Nica Bandong, Maria Eliza Aguila, Maricar Maandal, and Lenin

Grajo for providing assistance in locating key literature used in this review, and Marina De

Barros Pinheiro for providing mentoring for the meta-analysis.

 ACCEPTED MANUSCRIPT

Highlights

 HR and CR increase hamstrings flexibility immediately better than control

 Conflicting evidence exists on the superiority of HR and CR to other techniques

 Limited evidence supports long-term effects of HR and CR on hamstrings flexibility