Flexibility

Defining the Concept and Its Importance

Flexibility is a health-related physical fitness component defined as the range of motion (ROM) in a joint or in a group of joints and “can be limited by muscles, ligaments, tendons, and/or bone structures” (Akkurt et al., 2019, p. 42). Flexibility is determined by one’s genetics, physical body structure, age, and levels of physical activity and exercise (Micheo et al., 2012). Flexibility is critical as it affects an individual’s overall health, risk of injury, and performance of daily activities and physical activity (Micheo et al., 2012).

Research has demonstrated the importance of flexibility especially in terms of pain and injury prevention. Specifically, poor flexibility of the hamstrings is found to be associated with increased prevalence of low back pain, poor posture and postural disorders, increased risk of muscle injury, and physical health impairment in children (Akkurt et al., 2019). Castro-Piñero et al. (2009) revealed that lack of flexibility in young individuals is associated with increased susceptibility of experiencing low back pain in later years. Lucha-López et al. (2018) studied the relationship between knee alignment and flexibility. Their findings indicated the importance of maintaining flexibility in the quadriceps and iliopsoas muscles to preserve proper knee alignment and function which, in turn, can decrease risk of sport injuries and joint diseases (Lucha-López et al., 2018). Additionally, Kemmochi et al. (2018) studied the association of reduced trunk flexibility in children and lumbar stress fractures. Participants of this study ranged between 8 to 18 years of age. Findings reported that 92.3% of the patients with lumbar stress fractures displayed reduced trunk flexibility and almost all the patients had reduced hamstring flexibility (Kemmochi et al., 2018). Thus, they concluded that early recognition and acquisition of trunk flexibility is beneficial in minimizing repeated microtrauma and undue stress to the lumbar vertebra (Kemmochi et al., 2018). This may also be pertinent towards the treatment of stress fractures during the growth period.

With many of the conditions that may occur due to reduced flexibility being a predisposing factor, conservative treatment approaches often include flexibility training in the rehabilitation program (Johnson & Thomas, 2010). This alludes to the importance of incorporating exercises that target musculoskeletal flexibility starting from early childhood years to help mitigate potential future health complications.

From a developmental perspective, it is critical to acquire adequate levels of flexibility before young children reach adolescence. When youth are experiencing rapid height growth, it is accompanied by rapid growth in the lower limbs (Wild et al., 2013). During this time, girls generally exhibit decreased lower limb flexibility, which may increase their risk of lower limb injuries (Wild et al., 2013). The sensitive period for flexibility is from 6 to 10 years of age, in which children have the greatest capability for training flexibility (Sport for Life, 2019). Despite this, flexibility should not be overlooked during the adolescent growth spurt due to stress on muscles, ligaments, and tendons by the rapidly developing bones (Sport for Life, 2019). Although training flexibility during puberty can still provide good results, obtaining flexibility is the most optimal prior to children’s growth spurt (Sport for Life, 2019). By introducing flexibility into the system in the early stages of life, we are able to better maintain a sufficient ROM in our joints and experience less severe losses in flexibility due to age-related declines.

Role in Childhood Development and Contemporary Considerations

Children typically exhibit a greater ROM in their joints than adults, with ROM decreasing as we age (Schubert-Hjalmarsson et al., 2012). A hypermobile joint is a joint that displays a greater ROM than the average population considering one’s age, gender, and ethnic background (Bates & Alexander, 2015). Girls tend to be more hypermobile than boys, and children of Asian background also tend to be more hypermobile than Caucasian children (Tofts et al., 2008). Hypermobility may be advantageous for children who participate in gymnastics and ballet, where having an extensive ROM is ideal. However, children with symptomatic hypermobility requiring medical attention may be of concern (Scheper et al., 2013). Generalized joint hypermobility (GJH) is the term given for individuals with asymptomatic hypermobility (Bates & Alexander, 2015). GJH presented with symptoms is called Joint Hypermobility Syndrome (JHS) (Bates & Alexander, 2015). Flexibility is necessary for healthy physical functioning; however, an excessive level of flexibility should be given clinical attention as a prevalent problem affecting 7-36% of children (Scheper et al, 2013). GJH affects a child’s physical fitness, motor development, and proprioception and it may also affect different organ systems and cause psychological distress (Scheper et al., 2013). All these factors hinder the normal daily physical functioning and emotional well-being of a child. With children being more naturally hypermobile, it is beneficial if early childhood educators, teachers, and grassroots coaches are able to differentiate between normal and excessive levels of joint laxity, so children get the medical attention needed if they suspect pathology. Signs and symptoms to look out for are musculoskeletal complaints such as acute and chronic pain, reduced muscle strength, skin extensibility, poor coordination, and increased risk of injury (Scheper et al., 2013). From a developmental perspective, GJH and JHS are concerning as they lead to deficits in muscle toque, muscle strength, and proprioception which may impede motor proficiency (Scheper et al., 2013). However, with proper rehabilitation and treatment aimed towards “improving posture, joint stability, and specific motor skills, which include pain-free, cognitive exercise to enhance proprioception and muscle strength”, can assist with healthy motor development and increase motor competency of the child (Scheper et al., 2013, p. 5).

The body is a multi-segmental system, in that different limbs and parts of the body are made up of multiple interdependent segments, thus movement of each segment affects the entire kinetic chain (Sexton & Chambers, 2006). If one joint has lower than normal levels of mobility, the surrounding joints around it alter their function to compensate for the lack of mobility and to preserve overall function of the kinetic chain (Sexton & Chambers, 2006). By making these adjustments, they can lead to long term changes in the flexibility of surrounding muscles, tendons, and ligaments, and alter normal neuromuscular activation patterns (Sexton & Chambers, 2006). It is important for movement educators to consider development of flexibility for the entire body, to prevent individuals from having to resort to modifying movement patterns that are less efficient. A full body focus on flexibility will allow children to exhibit healthy movement behaviours and move more proficiently in the long term.

A contemporary issue to consider is the decrease in flexibility in elderly people due to the natural human aging process. With Canada’s population increasing in the number of seniors, age-related declines are a major concern. Falls are the leading cause of pain, disability, and death in elderly people; to prevent the risk of falling, balance control and flexibility are essential (Huang & Liu, 2015). Declines in flexibility and strength in the elderly also impair their ability to recover quickly from perturbation (Chiacchiero et al., 2010). Lack of flexibility and ROM in joints, especially at the hip and ankle, make it difficult for one to counteract a perturbation which may result in a fall (Chiacchiero et al., 2010). Exercise is the most beneficial and convenient method in improving flexibility and balance for the elderly. Despite the importance of physical activity, we see the lowest levels of physical activity among the elderly and this continues to decline with age. However, with sufficient levels of physical activity we can slow the loss of functional and motor abilities, maintain independence and improve the quality of life in the elderly (Milanovic et al., 2013). Yoga, pilates, hippotherapy, antagonist stretching, and Tai Chi are a few examples of physical activity that have been shown to improve flexibility in the elderly (Gonçalves et al., 2011; Francisco et al., 2015; Diniz et al., 2020; Saiki et al., 2015; Huang & Liu, 2015). Improvements in flexibility can still be made later in life, but it is recommended that individuals acquire it in the early childhood years. By developing and maintaining flexibility in the early childhood years, this will allow children to build a strong foundation for flexibility that will benefit them throughout the lifespan.

Practical Applications

Flexibility affects an individual’s overall health, risk of injury, and movement performance of physical activity. Therefore, it is important to develop and maintain flexibility in the early childhood years. There are various activities and games that an intermediary can implement and practice with their children or students to increase range of motion (ROM) in their joints to strengthen and improve fundamental movement skills.

Activity #1: Pizza Maker

Purpose

Children typically have a greater range of motion (ROM) in their joints (Schubert-Hjalmarsson et al., 2012). It is important for a child to maintain their flexibility throughout early childhood in order to facilitate fundamental movement skills to their greatest potential. The purpose of this game is to make stretching exercises fun while providing an opportunity for children to increase or maintain the ROM in their joints. Stretching exercises are important in order to develop sensory input from their joint capsules and ligaments, tendon receptors, muscle spindles, connective tissue, and vestibular receptors (Bredin, 2020). This means that the more frequently a child stretches, the easier the child can obtain greater flexibility, or a greater ROM in their joints. This game greatly targets the hamstrings, where as mentioned before, that flexibility of the hamstrings is important to develop and maintain in order to prevent low back pain, postural problems or muscle injuries such as a muscle strain (Akkurt et al., 2019). Although this game greatly targets the hamstrings, other muscle groups are also being targeted as well, such as the lower back, glutes, calves, groins, hip flexors and quadriceps. The take home message is that it is important to distribute flexibility evenly throughout the entire body by incorporating different muscle groups in a stretching exercise in order to exhibit proficient movement skills in the child’s active and healthy lifestyle.

Target Age

The target age is 2 to 6 years of age, because there is rapid growth in the legs during the early childhood years of physical growth changes (Gabbard, 2018). Therefore, it is important to ensure children are maintaining flexibility, especially throughout their lower body, in order to keep up with the rapid physical growth changes.

Apparatus/Equipment

Mats are optional, but strongly recommended if the surfaces available are not comfortable to sit on, such as a gym floor.

Environmental Space/Set-Up

The activity can be played in an open and quiet space, either outdoors or indoors. The stretching exercises are to be done on a comfortable surface such as a carpet, grass or artificial turf. If you only have access to less comfortable surfaces such as a gym floor, provide mats for the children. This game requires an intermediary to participate and/ or monitor the activity, in order to ensure the child or children are performing the stretching exercises properly.

Instructions

Sit with both legs out on your comfortable surface, straightened, and spread out legs at a 45 degree angle (shaped like a pizza).
Tell the children to “roll out the pizza dough”, by extending arms and reaching their upper body towards their toes. Hold this position for 3 to 5 seconds, come back up and “roll out pizza dough” again.
Tell children to “put their favourite pizza toppings on their pizza dough”, by “grabbing” their favourite topping and spreading it all over the pizza. Make sure they spread their favourite topping everywhere, by extending arms and propelling their upper body towards the right leg, moving arms and torso all the way down the right leg to the ends of the foot. Hold for 3-5 seconds. Do the same thing on the left side / leg.
Tell the children to “put their pizza in the oven” by extending both arms out with palms facing upwards to the ceiling like they are holding the pizza in their hands, and reach their torso all the way forwards and put their pizza in the oven for 5 seconds, and then take the pizza out by moving torso back to regular position.
Tell the children to “make a table for their pizza” by laying down on the floor with knees bent and feet flat. Raise their bottom up and off the floor by pressing the heels firmly into the ground. The head and shoulders should stay on the ground.

Modifications

This picture demonstrates a child performing a bridge pose. See step 6 under modifications.

To make the stretching slightly more difficult by targeting more muscles and joints, add more steps after step 5:

6.Tell the children to “make a table for their pizza” by doing a bridge pose depicted on the picture to the right. This will stretch out the hip flexors.

7. Tell the children to “cover up their pizza” by performing a downward dog position, stretching the lower back, glutes, hamstrings and calves.

Activity #2: The Wriggle Game

Purpose

Flexibility activities or games are typically seen as stretching exercises in the general population. But, developing flexibility should also be considered as activities or games that facilitate a greater range of motion (ROM) in fundamental movement skills. The purpose of this game is to facilitate the progression of leaping, a fundamental movement skill, by increasing a child’s ROM in their lower body joints (Walkley et al., 2009). If a child is experiencing difficulties extending the leg when leaping, then try the wriggle game. This game facilitates the movement of extending the leg while leaping, by having the child use more force to leap over the object to get to the other side, which implements the child to extend the legs further, providing a greater range of motion in their joints.

Target age:

The target age is 2 to 6 years of age. Children typically first start leaping around 2 years of age, but do not execute maximal height and distance until approximately 4 or 5 (Gabbard, 2018).

Apparatus/Equipment and Environmental Space/Set-up

The activity consists of five to ten children per group. Each group will be provided with one long skipping rope. The activity may be outdoors or indoors and must be in a large open space to provide enough room for each group of children to perform the activity.

This drawing is displaying how to set up and play the wriggles game

Instructions

Two children hold onto one end of the rope and wriggle it side to side. The rest of the group forms a line to leap over the rope. Each child in the group takes their turn leaping over the rope. If cleared, then the wriggle size is increased, where in the beginning the rope is wriggled slowly and narrower and as after each round, there is a gradually increase in the speed and width of the rope. If a child lands on the rope, they are out of the game. Make sure that the rope is on or close to the ground to prevent a child from getting tangled in the rope.

Modifications

For the children in the older age range, the game can be made more challenging by using a thinner rope for increasing speed, and wriggling the rope up and down, instead of side-to-side. As children around the ages of 4 to 6 are able to reach maximal height and distance, this modification will promote children to produce more force and leap higher. For younger children, a thicker rope could be used because the rope would move at a slower rate, due to friction from the ground surface, making it easier for the child to see the rope and to practice the fundamental movement skill properly.

Summary

Insert video vignette...as per Section 4 requirements

References

Akkurt, L., Gürbüz, I. A., Karaduman, A., & Yilmaz, Ö. T. (2019). Lower Limb Flexibility in Children With Duchenne Muscular Dystrophy: Effects on Functional Performance. Pediatric Exercise Science, 31(1), 42–46. https://doi.org/10.1123/pes.2018-0115

Bates, A. V., & Alexander, C. M. (2015). Kinematics and kinetics of people who are hypermobile. A systematic review. Gait & Posture, 41(2), 361–369. https://doi.org/10.1016/j.gaitpost.2015.01.009

Bredin, S (2020). Module 4: Developing Fundamental Movements. KIN 355 Movement Experiences for Young Children, School of Kinesiology, University of British Columbia

Castro-Piñero, J., Chillón, P., Ortega, F. B., Montesinos, J. L., Sjöström, M., & Ruiz, J. R. (2009). Criterion-Related Validity of Sit-and-Reach and Modified Sit-and-Reach Test for Estimating Hamstring Flexibility in Children and Adolescents Aged 6–17 Years. International Journal of Sports Medicine, 30(09), 658–662. https://doi.org/10.1055/s-0029-1224175

Chiacchiero, M., Dresely, B., Silva, U., Delosreyes, R., & Vorik, B. (2010). The Relationship Between Range of Movement, Flexibility, and Balance in the Elderly. Topics in Geriatric Rehabilitation, 26(2), 148–155. https://doi.org/10.1097/tgr.0b013e3181e854bc

Diniz, L. H., Mello, E. C. D., Ribeiro, M. F., Lage, J. B., Júnior, D. E. B., Ferreira, A. A., … Espindula, A. P. (2020). Impact of hippotherapy for balance improvement and flexibility in elderly people. Journal of Bodywork and Movement Therapies, 24(2), 92–97. https://doi.org/10.1016/j.jbmt.2019.10.002

Francisco, C. D. O., Fagundes, A. D. A., & Gorges, B. (2015). Effects of Pilates method in elderly people: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies, 19(3), 500–508. https://doi.org/10.1016/j.jbmt.2015.03.003

Gabbard C.P., (2018). Lifelong Motor Development (7th ed.) Philadelphia, PA. Wolter Kluwer

Gonçalves, L. C., Vale, R. G. D. S., Barata, N. J. F., Varejão, R. V., & Dantas, E. H. M. (2011). Flexibility, functional autonomy and quality of life (QoL) in elderly yoga practitioners. Archives of Gerontology and Geriatrics, 53(2), 158–162. https://doi.org/10.1016/j.archger.2010.10.028

Huang, Y., & Liu, X. (2015). Improvement of balance control ability and flexibility in the elderly Tai Chi Chuan (TCC) practitioners: A systematic review and meta-analysis. Archives of Gerontology and Geriatrics, 60(2), 233–238. https://doi.org/10.1016/j.archger.2014.10.016

Johnson, E. N., & Thomas, J. S. (2010). Effect of Hamstring Flexibility on Hip and Lumbar Spine Joint Excursions During Forward-Reaching Tasks in Participants With and Without Low Back Pain. Archives of Physical Medicine and Rehabilitation, 91(7), 1140–1142. https://doi.org/10.1016/j.apmr.2010.04.003

Kemmochi, M., Sasaki, S., & Ichimura, S. (2018). Association between reduced trunk flexibility in children and lumbar stress fractures. Journal of Orthopaedics, 15(1), 122–127. https://doi.org/10.1016/j.jor.2018.01.014

Lucha-López, M. O., Tricás-Moreno, J. M., Gaspar-Calvo, E., Lucha-López, A. C., Vidal-Peracho, C., Hidalgo-García, C., … Fanlo-Mazas, P. (2018). Relationship between knee alignment in asymptomatic subjects and flexibility of the main muscles that are functionally related to the knee. Journal of International Medical Research, 46(8), 3065–3077. https://doi.org/10.1177/0300060518771825

Micheo, W., Baerga, L., & Miranda, G. (2012). Basic Principles Regarding Strength, Flexibility, and Stability Exercises. Pm&r, 4(11), 805–811. https://doi.org/10.1016/j.pmrj.2012.09.583

Milanovic, Z., Sporis, James, Pantelic, S., Trajkovic, N., & Jorgic, B. (2014). Age-related decrease in physical activity and functional fitness among elderly men and women [Corrigendum]. Clinical Interventions in Aging, 979. https://doi.org/10.2147/cia.s67687

Saiki, T., Kurihara, T., Tsuji, K., Isaka, T., & Hamaoka, T. (2015). Examination of the acute effects of antagonist stretching on the flexibility and balance of elderly persons. Physiotherapy, 101. https://doi.org/10.1016/j.physio.2015.03.1235

Scheper, M. C., Engelbert, R. H. H., Rameckers, E. A. A., Verbunt, J., Remvig, L., & Juul-Kristensen, B. (2013). Children with Generalised Joint Hypermobility and Musculoskeletal Complaints: State of the Art on Diagnostics, Clinical Characteristics, and Treatment. BioMed Research International, 2013, 1–13. https://doi.org/10.1155/2013/121054

Schubert-Hjalmarsson, E., Öhman, A., Kyllerman, M., & Beckung, E. (2012). Pain, Balance, Activity, and Participation in Children With Hypermobility Syndrome. Pediatric Physical Therapy, 24(4), 339–344. https://doi.org/10.1097/pep.0b013e318268e0ef

Sexton, P., & Chambers, J. (2006). The Importance of Flexibility for Functional Range of Motion. Athletic Therapy Today, 11(3), 13–17. https://doi.org/10.1123/att.11.3.13

The Ten S's of Training and Performance. Sport for Life. (2019, September 19). https://sportforlife.ca/ten-ss-training-performance/.

Tofts, L., Elliott, E., Munns, C., Pacey, V., & Sillence, D. (2008). The differential diagnosis of children with joint hypermobility: a review of the literature. Pediatric Rheumatology, 6(S1). https://doi.org/10.1186/1546-0096-6-s1-p156

Walkley J., Armstrong D., Clohesy P., (2009). Fundamental Motor Skills: An Activities Resource For Classroom Teachers. Department of Education. Retrieved from https://www.education.vic.gov.au/Documents/school/teachers/teachingresources/social/physed/fmsactresource09.pdf

Wild, C. Y., Steele, J. R., & Munro, B. J. (2013). Musculoskeletal and Estrogen Changes during the Adolescent Growth Spurt in Girls. Medicine & Science in Sports & Exercise, 45(1), 138–145. https://doi.org/10.1249/mss.0b013e31826a507e