FA Davis Company, Philadelphia. Bartlett, MJ., Warren, PJ. (2002) Effect of warming up on knee proprioception before sporting activity. British Journal of Sports ...
The effects of static stretching on knee proprioception R Madden, S Barnett, J Bowden, J Mytton, M Theodoreson and G Titman, University of the West of England, Bristol
Study objectives
Results
• Determine whether static stretching has a direct effect on knee proprioception.
Three studies met the inclusion criteria (two randomised controlled trials and one cohort study). Two studies revealed an increase in knee JPS (Bartlett & Warren, 2002; Ghaffarinejad et al, 2007) with the third study producing equivocal results (Larsen et al, 2005).
Anderson, O. (2000) Can stretching really lower your risk of injury? Running Research News, 16:1-7
All the studies used static stretching as the sole stretching intervention. Two of the studies (Larsen et al, 2005; Ghaffarinejad et al, 2007) specify 30 seconds of static stretching on muscles surrounding the knee (such as hamstrings and quadriceps) with 30 seconds pause and three repetitions.
Björklund, M., Hamberg, J., Crenshaw, AG. (2001) Sensory adaptation after a 2-week stretching regimen of the rectus femoris muscle. Archive Physical Medicine and Rehabilitation, 82:1245-1250
• Implement recommendations for best practice. • Provide an educational tool.
Background
According to the current research, the role that static stretching has on knee proprioception as well as injury risk continues to remain unclear. Static stretching is used as a treatment intervention within many aspects of musculoskeletal healthcare and sports medicine (Björklund et al, 2001). There is a variety of contrasting literature surrounding the benefits of static stretching and the physiological effects it may have on various factors in sport such as injury risk and performance (Anderson, 2000; Weldon, et al, 2003; Shrier, 2004). Many SLRs have shown that static stretching is not significantly associated with injury prevention (Shier, 1999; Thacker et al 2004).
Methods and Measures
To develop a search strategy, key words were identified relevant to the title and truncated to include all endings. These included Propriocepti*; Joint Position Sense (JPS); Kinesthes*; Kinaesthes*; and Stretch* in an electronic database search of AMED; CINAHL; Compendex; Cochrane Library; EMBASE; HMIC; IEEE Xplore; Medline; PEDro; OVID; Science Direct; SPORTSDiscus; and Sports and Leisure Index as well as hand searching. 1102 articles underwent an inclusion criterion resulting in three studies being selected. These were assessed by combining the PEDro scale (1999) and the Cochrane Collaboration Tool (2008).
Table 1
Bailey, DM. (1997) Research for Health Professionals - A practical Guide. 2nd edition. FA Davis Company, Philadelphia Bartlett, MJ., Warren, PJ. (2002) Effect of warming up on knee proprioception before sporting activity. British Journal of Sports Medicine, 36:132-134
Photographs: Sam Cullum - Team GB Snowboard Athlete
• Assess the quality and gaps of the literature.
References
The PEDro scale was used to assess study quality, whilst the Cochrane Collaboration tool looked at the possibility of bias in each study (Table 1). The study by Ghaffarinejad et al (2007) stretched and tested one muscle group at a time. In 45° of knee flexion they found a significant decrease in Absolute Angular Error (AAE, the difference between target and actual angle) values after the stretching protocols for quadriceps (p0.05). Bartlett and Warren’s study (2002) concluded that a gentle warm up, including static stretches, demonstrated a mean decrease in error from 10.59° to 8.21° when reproducing an angle of knee flexion. This was confirmed through a Wilcoxon signed rank test, which reported a statistically significant difference in knee JPS (p = 0.005) after a warm up period. The third study by Larsen et al (2005) also used the AAE as their outcome measure and reported no significant difference in knee JPS before and after static stretching of the quadriceps and hamstrings in both sitting (p = 0.99) and prone (p = 0.89) positions.
Author assessment of studies PEDro scale (study quality/internal validity
Cochrane Collaboration tool (risk of bias)
Bartlett & Warren (2002)
4/10 (low-moderate quality)
3/6 (moderate risk of bias)
Ghaffarinejad et al (2007)
8/10 (high quality)
5/6 (low risk of bias)
Larsen et al (2005)
8/10 (high quality)
5/6 (low risk of bias)
Limitations
Conclusion
• Bartlett & Warren (2002) had jogging as another independent variable in the same period as static stretching which adds threat to the external validity of the study (Bailey, 1997). Stretching and jogging could have the potential to affect proprioception and the muscle spindles in different ways (Proske et al, 2000).
From the evidence presented in this review it is not possible to establish any firm conclusions regarding the effect static stretching has on knee proprioception. Findings of this review suggest there could be a link between static stretching and knee proprioception. However, due to a limited range of studies available no patterns or trends can be established in the evidence and therefore the results should be viewed with caution despite the apparent face validity.
• Proprioception is constructed of many different components such as joint position sense, movement detection, force and velocity (Olsson et al, 2004). Therefore, it could be suggested that it is difficult to measure proprioceptive acuity at the knee from a single submodality such as JPS and that clinicians should incorporate a variety of accurate and reliable measures to assess static and dynamic knee proprioception (Grob et al, 2002; Nasseri et al, 2007). • The length of time given after static stretching may have a significant impact on the results of JPS. To justify this scientifically, it is important to consider that the thixotropic behaviour believed to be gained after stretching and lengthening of the muscle spindles may only last for a short period (Proske et al, 1993; Proske, 2006).
Surrounding research around static stretching must also be taken into consideration due to the proposed effect it has on the muscle tendon unit, flexibility, muscle power, performance, and injury risk. By collating the available research and identifying gaps in the literature, this review presents valuable information for musculoskeletal practitioners and researchers. There is limited research evidence related to the effects of static stretching on knee proprioception and further methodologically sound studies need to be carried out to support the findings of this review if the results are going to be considered clinically applicable to sports medicine.
Cochrane Collaboration (2008) Cochrane Handbook for Systematic Reviews of Interventions, Version 5.0.0, Higgins, JPT., Altman, DG. (Eds). [online] Available from: http://www.cochrane-handbook.org [Accessed 27/11/07] Ghaffarinejad, F., Taghizadeh, S., Mohamadi, F. (2007) Effect of static stretching of muscles surrounding the knee on knee joint position sense. British Journal of Sports Medicine, 41:684-687 Grob, KR., Kuster, MS., Higgins, SA., Lloyd, DG., Yata, H. (2002) Lack of correlation between different measurements of proprioception in the knee. Journal of Bone and Joint Surgery, 84:614-618 Larsen, R., Lund, H., Christensen, R., Rogind, H., DanneskioldSamsoe, B., Bliddal, H. (2005) Effect of static stretching of quadriceps and hamstring muscles on knee joint position sense. British Journal of Sports Medicine, 39:43-46 Nasseri, N., Hadian, MR., Bagheri, H., Talebian, S., Olyaei, G. (2007) Reliability and accuracy of joint position sense measurement in the laboratory and clinic; utilizing a new system. Acta Medica Iranica, 45(5):395-404 Olsson, L., Lund, H., Henriksen, M., Rogind, H., Bliddal, H., Danneskioldsamsoe, B. (2004) Test-retest Reliability of a Knee Joint Position Sense Measurement Method in Sitting and Prone Position. Advances in Physiotherapy, 6(1):37-47 Proske, U., Morgan, DL., Gregory, JE. (1993) Thixotropy in skeletal muscle and in muscle spindles: a review. Progress in Neurobiology, 41:705-721 Proske, U., Wise, AK., Gregory, JE. (2000) The role of muscle receptors in the detection of movements. Progress in Neurobiology, 60:85-96 Proske, U. (2006) Kinesthesia: The role of muscle receptors. Muscle and Nerve, 34:545-558 Physiotherapy Evidence Database (PEDro) (1999) [online]. Available from: http://www.pedro.fhs.usyd.edu.au/scale_ item.html#scale_10 [Accessed 26/11/07] Shrier, I. (1999) Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clinical Journal of Sport Medicine, 9:221–227 Shrier, I. (2004) Does Stretching Improve Performance? A Systematic and Critical review of the Literature. Clinical Journal of Sport Medicine, 14(5):267–273 Thacker, SB. Gilchrist, J. Stroup, DF. Dexter Kimsey JRC. (2004) The Impact of stretching on Sports Injury Risk: A systematic Review of the Literature. Medicine and Science in Sports and Exercise, 36(3):371-378 University of the West of England (2007) Health and Social Care Databases, UWE library services [online]. Available from: http://www.uwe.ac.uk/library/resources/databases. html Weldon, SM. Hill, RH. (2003) The efficacy of stretching for prevention of exercise-related injury: a systematic review of the literature. Manual Therapy, 8(3):141-150
