Stretching to prevent or reduce muscle soreness after exercise...The pooled estimate showed that...

Stretching to prevent or reduce muscle soreness afterexercise (Review)

Herbert RD, de Noronha M

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2008, Issue 4

http://www.thecochranelibrary.com

Stretching to prevent or reduce muscle soreness after exercise (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Pre-exercise stretching, Outcome 1 Soreness on day 0.5 (assessed 6-17 hours post-exercise). 20Analysis 1.2. Comparison 1 Pre-exercise stretching, Outcome 2 Soreness on day 1 (assessed 18-29 hours post-exercise). 21Analysis 1.3. Comparison 1 Pre-exercise stretching, Outcome 3 Soreness on day 1.5 (assessed 30-41 hours post-exercise). 21Analysis 1.4. Comparison 1 Pre-exercise stretching, Outcome 4 Soreness on day 2 (assessed 42-53 hours post-exercise). 22Analysis 1.5. Comparison 1 Pre-exercise stretching, Outcome 5 Soreness on day 2.5 (assessed 54-65 hours post-exercise). 22Analysis 1.6. Comparison 1 Pre-exercise stretching, Outcome 6 Soreness on day 3 (assessed 66-77 hours post-exercise). 23Analysis 2.1. Comparison 2 Post-exercise stretching, Outcome 1 Soreness on day 0.5 (assessed 6-17 hours post-exercise). 23Analysis 2.2. Comparison 2 Post-exercise stretching, Outcome 2 Soreness on day 1 (assessed 18-29 hours post-exercise). 24Analysis 2.3. Comparison 2 Post-exercise stretching, Outcome 3 Soreness on day 1.5 (assessed 30-41 hours post-exercise). 24Analysis 2.4. Comparison 2 Post-exercise stretching, Outcome 4 Soreness on day 2 (assessed 42-53 hours post-exercise). 25Analysis 2.5. Comparison 2 Post-exercise stretching, Outcome 5 Soreness on day 2.5 (assessed 54-65 hours post-exercise). 25Analysis 2.6. Comparison 2 Post-exercise stretching, Outcome 6 Soreness on day 3 (assessed 66-77 hours post-exercise). 26Analysis 3.1. Comparison 3 Either pre- or post-exercise stretching, Outcome 1 Soreness on day 0.5 (assessed 6-17 hours

post-exercise). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Analysis 3.2. Comparison 3 Either pre- or post-exercise stretching, Outcome 2 Soreness on day 1 (assessed 18-29 hours

post-exercise). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Analysis 3.3. Comparison 3 Either pre- or post-exercise stretching, Outcome 3 Soreness on day 1.5 (assessed 30-41 hours


post-exercise). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Analysis 3.5. Comparison 3 Either pre- or post-exercise stretching, Outcome 5 Soreness on day 2.5 (assessed 54-65 hours


post-exercise). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2929APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iStretching to prevent or reduce muscle soreness after exercise (Review)


[Intervention Review]

Stretching to prevent or reduce muscle soreness afterexercise

Robert D Herbert1, Marcos de Noronha2

1The George Institute for International Health, Camperdown, Australia. 2School of Physiotherapy, University of Sydney, Lidcombe,Australia

Contact address: Robert D Herbert, The George Institute for International Health, PO Box M201, Missendown Road, Camperdown,New South Wales, 2050, Australia. [email protected].

Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.Review content assessed as up-to-date: 15 August 2006.

Citation: Herbert RD, de Noronha M. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database of SystematicReviews 2007, Issue 4. Art. No.: CD004577. DOI: 10.1002/14651858.CD004577.pub2.


A B S T R A C T

Background

Many people stretch before or after (or both) engaging in athletic activity. Usually the purpose is to reduce risk of injury, reduce sorenessafter exercise, or enhance athletic performance.

Objectives

The aim of this review was to determine effects of stretching before or after exercise on the development of post-exercise muscle soreness.

Search strategy

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to April 2006), the Cochrane Central Registerof Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to May 2006), EMBASE (1988 to May 2006), CINAHL(1982 to May 2006), SPORTDiscus (1949 to May 2006), PEDro (to May 2006) and reference lists of articles.

Selection criteria

Eligible studies were randomised or quasi-randomised studies of any pre-or post-exercise stretching technique designed to prevent ortreat delayed-onset muscle soreness (DOMS), provided the stretching was conducted soon before or soon after exercise. To be eligiblestudies must have assessed muscle soreness or tenderness.

Data collection and analysis

Methodological quality of the studies was assessed using the Cochrane Bone, Joint and Muscle Trauma Group’s methodological qualityassessment tool. Estimates of effects of stretching were converted to a common 100-point scale. Outcomes were pooled in a fixed-effectmeta-analysis.

Main results

Of the 10 included studies, nine were carried out in laboratory settings using standardised exercise protocols and one involved post-exercise stretching in footballers. All participants were young healthy adults. Three studies examined the effects of stretching beforeexercise and seven studies investigated the effects of stretching after exercise. Two studies, both of stretching after exercise, involved

1Stretching to prevent or reduce muscle soreness after exercise (Review)


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repeated stretching sessions at intervals of greater than two hours. The duration of stretching applied in a single session ranged from40 to 600 seconds.

All studies were small (between 10 and 30 participants received the stretch condition) and of questionable quality.

The effects of stretching reported in individual studies were very small and there was a high degree of consistency of results acrossstudies. The pooled estimate showed that pre-exercise stretching reduced soreness one day after exercise by, on average, 0.5 points on a100-point scale (95% CI -11.3 to 10.3; 3 studies). Post-exercise stretching reduced soreness one day after exercise by, on average, 1.0points on a 100-point scale (95% CI -6.9 to 4.8; 4 studies). Similar effects were evident between half a day and three days after exercise.

Authors’ conclusions

The evidence derived from mainly laboratory-based studies of stretching indicate that muscle stretching does not reduce delayed-onsetmuscle soreness in young healthy adults.

P L A I N L A N G U A G E S U M M A R Y

Stretching to prevent or reduce muscle soreness after exercise

Many people stretch prior to or after engaging in physical activities such as sport. Usually the purpose is to reduce the risk of injury,reduce soreness after exercise, or enhance athletic performance.

The review located 10 relevant randomised trials looking at the effect of stretching before or after physical activity on muscle soreness.The trials were mostly small and of questionable quality. Nine were conducted in laboratories using standardised exercises. Only onestudy examined the effect of stretching on muscle soreness after sport. Three of the studies examined the effects of stretching beforephysical activity and seven examined effects of stretching after physical activity.

The 10 studies produced very consistent findings. They showed there was minimal or no effect on the muscle soreness experiencedbetween half a day and three days after the physical activity. Effects of stretching on effect on other outcomes such as injury andperformance were not examined in this review.

B A C K G R O U N D

Many people stretch before or after (or before and after) engagingin athletic activity. Usually the purpose is to reduce the risk ofinjury, reduce soreness after exercise, or enhance athletic perfor-mance (Cross 1999; de Vries 1961; Gleim 1990; Gleim 1997).This review focuses on the effects of muscle stretching on musclesoreness. Another Cochrane review (Yeung 2003) has examinedwhether stretching prevents injury, and several non-Cochrane sys-tematic reviews have examined whether stretching prevents mus-cle soreness or injury, or enhances performance (Herbert 2002;Shrier 2004; Thacker 2004; Weldon 2003).

The muscle soreness that is the focus of this review is sometimescalled delayed-onset muscle soreness to differentiate it from sore-ness that occurs as muscle fatigue, or immediately after muscleshave been fatigued. Delayed-onset muscle soreness (hereafter re-

ferred to simply as muscle soreness) is usually caused by unaccus-tomed exercise, particularly exercise that requires primarily eccen-tric muscle contraction. Eccentric contractions occur when themuscle lengthens as it contracts. Typically the soreness arises withinthe first day after exercise and peaks in intensity at around 48hours (Balnave 1993; Bobbert 1986; Wessel 1994). The sorenessis usually associated with tenderness and may be associated withswelling (Bobbert 1986; Wessel 1994).

The series of events that ultimately cause muscle soreness are onlypartly understood. The initial event is probably mechanical disrup-tion of sarcomeres (contractile units within muscle fibres; Proske2001). This causes swelling of damaged muscle fibres and initiatesan inflammatory response, which could excite nociceptors (recep-tors capable of transmitting information about pain; Lieber 2002).



Muscle soreness is usually only experienced when the muscle con-tracts or is stretched. This indicates that, while swelling of musclefibres and inflammation may be necessary for muscle soreness tooccur, swelling and inflammation are not sufficient to cause sore-ness on their own. Muscle soreness is exacerbated by vibration overthe belly of the muscle, and pressure thresholds increase when largediameter afferents are blocked (large diameter afferents are nervecells that conduct information about touch and limb position),indicating that excitation of large diameter muscle afferents, prob-ably primary spindle afferents from stretch receptors in muscles,is involved in generating the sensation of soreness (Weerakkody2001).

The practice of stretching to prevent muscle soreness was encour-aged by early investigators of muscle soreness who thought thatunaccustomed exercise caused muscle spasm (de Vries 1961). Mus-cle spasm was believed to impede blood flow to the muscle, caus-ing ischaemic pain and further spasm. Stretching the muscle wasthought to restore blood flow to the muscle and interrupt the pain-spasm-pain cycle. The muscle spasm theory of muscle soreness hassince been discredited (Bobbert 1986), but the practice of stretch-ing persists.

Typically people who stretch to prevent muscle soreness do so priorto exercise, but some people stretch after exercise. Usually each at-risk muscle is stretched for between 15 seconds and 2 minutes,once or several times. Some proponents of stretching recommendapplying a sustained stretch to the relaxed muscle (de Vries 1961;this is called static stretching), but others recommend more elabo-rate techniques such as the ’contract-relax-agonist contract’ tech-nique (Feland 2001). This technique and related techniques (col-lectively called proprioceptive neuromuscular facilitation (PNF)techniques) involve contracting the muscle strongly before apply-ing a stretch.

O B J E C T I V E S

This review aims to determine the effect of stretching before orafter exercise on the development of post-exercise muscle soreness.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We considered any randomised or quasi-randomised (method ofallocating participants to a treatment that is not strictly randome.g. by date of birth, hospital record number and alternation)

clinical trials of pre-or post-exercise stretching techniques designedto prevent or treat delayed-onset muscle soreness.

Types of participants

Trials involving participants of any age group, and of either sex.

Types of interventions

Any pre-or post-exercise stretching technique designed to preventor treat delayed-onset muscle soreness, provided the stretching wasconducted soon before or soon after exercise of any type.

Types of outcome measures

Measures of muscle soreness (pain) or tenderness (pain on palpa-tion of the muscle).

Search methods for identification of studies

We searched the Cochrane Bone, Joint and Muscle Trauma GroupSpecialised Register (12 April 2006), the Cochrane Central Reg-ister of Controlled Trials (The Cochrane Library 2006, Issue 2)(see Appendix 1), MEDLINE (OVID WEB; 1966 to 16 May2006), EMBASE (OVID WEB; 1988 to 16 May 2006), CINAHL(OVID WEB; 1982 to 16 May 2006), SPORTDiscus (OVIDWEB; 1949 to 16 May 2006), PEDro - Physiotherapy EvidenceDatabase (www.pedro.fhs.usyd.edu.au/accessed 16 May 2006)and reference lists of articles.In MEDLINE (OVID WEB) the subject-specific search inAppendix 2 was used. As it was anticipated that only a smallnumber of references would be identified, the results were notcombined with a trial search strategy. This strategy was modifiedslightly for use in the other OVID databases.In PEDro, two searches were conducted (see Appendix 3).

Data collection and analysis

Selection of trialsThe two authors screened search results for potentially eligiblestudies. When titles and abstracts suggested a study was potentiallyeligible for inclusion a paper copy of the report was obtained. Dis-agreements between the two people regarding a study’s eligibilitywere resolved by discussion or, where necessary, by a third person.Assessment of methodological qualityThe methodological quality of the studies was assessed using theCochrane Bone, Joint and Muscle Trauma Group quality assess-ment tool (Table 1). Two people independently assessed studyquality in this way. Disagreements were resolved by discussion.Where necessary, a third person was consulted. It was anticipatedthat several of the included studies would be laboratory-based stud-ies which were unlikely to describe elements thought important



in clinical trials. These studies may appear methodologically weakwhen assessed with a tool designed for clinical trials. Nonethelessit was thought useful to document the degree to which they con-form with best practice clinical trial design.

Table 1. Bone, Joint and Muscle Trauma Group methodological quality assessment tool

Item Criterion

A Was the assigned treatment adequately concealed prior to allocation?2 = clearly yes (method did not allow disclosure of assignment).1 = not sure (small but possible chance of disclosure of assignment or unclear).0 = clearly no (quasi-randomised or open list/tables).

B Were the outcomes of patients/participants who withdrew described and included in the analysis (intention to treat)?2 = withdrawals well described and accounted for in analysis.1 = withdrawals described and analysis not possible.0 = no mention, inadequate mention, or obvious differences and no adjustment.

C Were the outcome assessors blinded to treatment status?2 = effective action taken to blind assessors.1 = small or moderate chance of unblinding of assessors.0 = not mentioned or not possible.

D Were the treatment and control group comparable at entry?2 = good comparability of groups, or confounding adjusted for in analysis.1 = confounding small; mentioned but not adjusted for.0 = large potential for confounding, or not discussed.

E Were the participants blind to assignment status after allocation?2 = effective action taken to blind participants.1 = small or moderate chance of unblinding of participants.0 = not possible, or not mentioned (unless double-blind), or possible but not done.

F Were the treatment providers blind to assignment status?2 = effective action taken to blind treatment providers.1 = small or moderate chance of unblinding of treatment providers.0 = not possible, or not mentioned (unless double-blind), or possible but not done.

G Were care programmes, other than the trial options, identical?2 = care programmes clearly identical.1 = clear but trivial differences.0 = not mentioned or clear and important differences in care programmes.

H Were the inclusion and exclusion criteria clearly defined?2 = clearly defined.1 = inadequately defined.0 = not defined.



Table 1. Bone, Joint and Muscle Trauma Group methodological quality assessment tool (Continued)

I Were the interventions clearly defined? (This item was optional)2 = clearly defined interventions are applied with a standardised protocol.1 = clearly defined interventions are applied but the application protocol is not standardised.0 = intervention and/or application protocol are poorly or not defined.

J Were the outcome measures used clearly defined? (by outcome)2 = clearly defined.1 = inadequately defined.0 = not defined.

K Were diagnostic tests used in outcome assessment clinically useful? (by outcome)2 = optimal.1 = adequate.0 = not defined, not adequate.

L Was the surveillance active, and of clinically appropriate duration?2 = active surveillance and appropriate duration.1 = active surveillance, but inadequate duration.0 = surveillance not active or not defined.

Data extraction

Soreness or tenderness data from stretch and comparison groupswere extracted from study reports using a pro forma. This wasdone by the authors; again, disagreements were resolved by dis-cussion or a third person. It was expected that some studies wouldreport soreness data and some would report tenderness data. Somestudies reported raw scores, whereas others report change scoresor covariance-adjusted scores. It was also expected that outcomeswould usually be measured at a series of times following exercise.Where available, data were extracted for each of a series of 12-hourintervals following exercise (6-17 hours, 18-29 hours, 30-41 hours,etc). Only one outcome was recorded from each study for eachtime. Where multiple outcomes were available, soreness data waspreferred to tenderness data. Covariate-adjusted data were mostpreferred, then change scores, then raw scores. Where within-sub-ject studies (studies in which participants’ limbs were allocated tostretch and control conditions) or cross-over studies (studies inwhich each participant was sequentially exposed to both stretchand control conditions) did not provide estimates of the varianceof differences between conditions or of the correlations betweenoutcomes under the two conditions being compared (Elbourne2002) the variance of the difference between conditions was esti-mated by assuming the data were independent.

Analysis

Pain and tenderness data were typically reported on 100 mm visualanalogue scales or 10 point scales. To facilitate pooling, data wereconverted to a common 100-point scale. The effect of stretch-ing was estimated from each study using the difference betweenmean pain levels in stretch and comparison groups. Where therewas apparent qualitative homogeneity in participants, interven-tions and outcome measures, meta-analysis was considered. Meta-analysis was conducted using the RevMan Analysis program inReview Manager (RevMan 2003). The effects of stretching wasdescribed as a weighted mean difference. Data were inspected forstatistical heterogeneity. As there was no evidence of heterogeneityof effect (Cochran Q, P < 0.1; Fleiss 1993), a fixed-effect modelwas used to pool findings across studies. Effects of pre- and post-exercise stretching were initially estimated separately but, as therewas no evidence of heterogeneity, they were combined in a sec-ondary analysis. A post-hoc analysis was conducted to obtain sepa-rate estimates from laboratory-based studies and the one commu-nity-based study. An additional post-hoc analysis was conductedto obtain separate estimates from studies of static stretch and theone study that used another method of stretching.

R E S U L T S



Description of studies

See: Characteristics of included studies; Characteristics of excludedstudies.The search retrieved 25 potentially eligible studies of which 10were included (Buroker 1989; Dawson 2005; Gulick 1996; High1989; Johansson 1999; Maxwell 1988; McGlynn 1979; Terry1985; Wessel 1994a; Wessel 1994b). The titles or abstracts of afurther four papers appeared potentially eligible but could not beretrieved (Costa 1997; Buckenmeyer 1998; Lin 1999; Lu 1992)and still await assessment.

Included studies

Participants of all included studies were young healthy adults (ageless than 40 years or mean age less than 26 years); no studies in-vestigated effects of stretching on muscle soreness in children ormiddle-aged or older adults. All but one of the studies were car-ried out in laboratory settings and involved standardised exercise.The exception (Dawson 2005) investigated the effect of post-gamestretching on muscle soreness in Australian rules football players.

Three studies examined the effect of stretching before exercise (High 1989; Johansson 1999; Wessel 1994a); the remaining sevenstudies investigated the effects of stretching after exercise. Thestretch was of the knee extensor muscles (Buroker 1989; High1989; Maxwell 1988; Terry 1985), hamstring muscles (Johansson1999; Wessel 1994a; Wessel 1994b), ankle plantarflexor muscles (Buroker 1989), wrist extensor muscles (Gulick 1996), elbow flexormuscles (McGlynn 1979), or “legs and back” muscles (Dawson2005). All but one of the studies examined the effects of staticstretching; one study examined the effects of a PNF technique(“hold-relax”; Terry 1985). Two studies, both of stretching afterexercise, involved repeated stretching sessions (Buroker 1989: 12sessions; McGlynn 1979: 5 sessions). The duration of stretchingapplied in a single session ranged from 40 seconds (Terry 1985)to 600 seconds (Gulick 1996), with a median of 390 seconds.In six studies (Buroker 1989; Dawson 2005; Gulick 1996; High1989; Maxwell 1988; McGlynn 1979) participants were randomlyallocated to stretch and control conditions. One of these (Dawson2005) was a cross-over study in which each subject experiencedboth the stretch and control conditions. The remaining four stud-ies (Johansson 1999; Terry 1985; Wessel 1994a; Wessel 1994b)stratified by participant and randomised legs to stretch and con-trol conditions. Thus five studies (the single cross-over study and

the four studies that compared right and left legs) provided pairedcomparisons. In all but two of these sufficient data were suppliedto take account of the paired nature of the data. In the studiesby Wessell and Wan (Wessel 1994a; Wessel 1994b) the estimatesfrom an analysis which accounted for the paired nature of the datawere less precise (Wessel 1994a) or had similar precision (Wessel1994b) to estimates obtained by ignoring the paired nature of thedata, so the data were treated as if they were independent. Datafrom the other two studies (Dawson 2005; Johansson 1999) weretreated as independent. See ’Characteristics of included studies’for further details.One study (Gulick 1996) reported only pooled data from allgroups and another (Maxwell 1988) did not provide any datathat could be used to calculate precison. (Both studies concludedstretching had no effect.) Consequently these studies did not con-tribute to the meta-analysis.

Excluded studies

Eleven studies were excluded (see ’Characteristics of excluded stud-ies’).

Risk of bias in included studies

Table 2 summarises the methodological quality assessments. Thereviewers were not always able to agree on how particular itemswere rated; these items are marked as “No consensus” in Table2. All included studies were apparently randomised. None of thestudies described if the allocation schedule was concealed. Therewas no blinding in any studies: this is because it is difficult orimpossible in studies of stretching to blind the person supervisingthe stretching exercises and the person doing the stretches and, asthe outcome (soreness) must be self-reported, the assessor cannotbe blinded. None of the studies clearly indicated that analysis wasby intention to treat and in one study (Dawson 2005) analysiswas explicitly not by intention to treat. Only one study explicitlyreported completeness of follow up (Dawson 2005 reported datawere available for 31 of 34 player-conditions), although two fur-ther studies (High 1989; Terry 1985) provided data that impliedfollow up was complete. It is likely that follow up was completeor nearly complete in most or all studies because the follow-upperiod was very short (three days or less) and outcome measureswere not onerous.

Table 2. Quality of trials. Rows correspond to those in Table 01

Buroker1989

Dawson2005

Gulick1996

High1989

Johansson1999

Maxwell1988

McGlynn1979

Terry1985

Wessel1994a

Wessel1994b

1 0 1 1 1 1 1 1 1 1



Table 2. Quality of trials. Rows correspond to those in Table 01 (Continued)

0 0 0 0 Noconsensus

0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 2 0 0 0 0 0 0 2 2

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

2 2 2 2 2 2 2 2 2 2

2 0 Noconsensus

1 2 0 2 2 0 0

2 1 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2

Effects of interventions

One study (Gulick 1996) reported only pooled data from allgroups and another (Maxwell 1988) did not provide any data thatcould be used to calculate precision. Consequently these studiesdid not contribute to the meta-analysis. (Both studies concludedstretching had no effect.) The following results are based on datafrom the remaining studies.The mean effects of stretching reported in individual studies weretoo small to be of clinical relevance. There was a remarkable de-gree of consistency (homogeneity) of results across studies (I2 forall pooled estimates was 0%). The pooled estimate was that pre-exercise stretching reduced soreness one day after exercise by, onaverage, 0.5 points on a 100-point scale (95% CI -11.3 to 10.3; 3studies; Analysis 01.02). Post-exercise stretching reduced sorenessone day after exercise by, on average, 1.0 points on a 100-pointscale (95% CI -6.9 to 4.8; 4 studies; Analysis 02.02). Similar ef-fects were evident between half a day and three days after exercise.As there was no sign of statistical heterogeneity we pooled the pre-exercise and post-exercise studies. The pooled estimates are thatpre- and post-exercise stretching reduces soreness, on average, by0.9 points on a 100-point scale at one day (95% CI -6.1 to 4.2; 7

studies; Analysis 03.02), increases soreness by 1.0 points on a 100-point scale at two days (95% CI -4.1 to 6.2; 7 studies; Analysis03.04) and decreases soreness by 0.3 points on a 100-point scaleat three days (95% CI -6.8 to 6.2; 5 studies; Analysis 03.06).Similar estimates of effects were obtained in the only study thattested PNF stretching. Terry 1985 showed the effect of PNFstretching was to reduce soreness by 1.1 points on a 100-pointscale at both one and two days after exercise (95% CIs of -13.0to 10.8; and -13.3 to 11.1 respectively). Also similar effects wereobtained in the one study of stretching after sport. Dawson 2005showed that stretching increased muscle soreness by 3.0 points ona 100-point scale (95% CI -7.1 to 13.1) at 15 hours and by 4.0points (95% CI -5.2 to 13.2) at 48 hours after an Australian rulefootball match.

D I S C U S S I O N

The evidence from randomised studies indicates that stretchingsoon before or soon after exercise does not lessen muscle sorenesson subsequent days.



This conclusion is based on studies that rate poorly on conven-tional scales of study quality. None of the reviewed studies explic-itly concealed allocation, none were blinded, and none explicitlyanalysed by intention to treat. Nonetheless there are some reasonsto believe that the findings may not be seriously biased: First, thereis a high degree of consistency across studies in estimates of theeffect of stretching. Also, biases due to non-concealment, lack ofblinding and failure to analyse by intention to treat typically pro-duce exaggerated effects (Chalmers 1983; Colditz 1989; Moher1998; Schulz 1995), yet this review found consistent evidence ofnear-zero effects. The high degree of consistency of estimates acrossstudies suggests that alternative weightings (based, for example,on different approaches to estimating precision from studies thatused within-subject designs) would produce very similar pooledestimates of effects.

All but one of the eligible studies were laboratory-based stud-ies. These studies assessed whether supervised stretching reducedthe soreness produced by standardised exercise involving eccen-tric contractions of a particular muscle group. Such studies can beconsidered to have an “explanatory” orientation because they tellus about what the effects of stretching could be when adminis-tered under ideal conditions. It might have been expected that theeffects of stretching would be smaller in community settings. Incommunity settings, unlike the laboratory settings of these stud-ies, stretching is not usually supervised, so it may be carried outsub-optimally. Also, the everyday experience of muscle sorenessmay be of soreness in many muscle groups, and it may be diffi-cult to effectively stretch all of the muscle groups that might be-come sore. These considerations suggest the effects of stretchingmight be smaller in community settings than in laboratory set-tings. However the estimates from nine laboratory-based studiesand one community-based study suggest there are similar (near-zero) effects in both settings.

The practice of stretching before or after exercise may have beenarisen because of the mistaken belief, prevalent in the 1960s and1970s, that muscle soreness was due to muscle spasm (de Vries1961). This view has since been discredited (Bobbert 1986). Con-temporary beliefs about the mechanisms of muscle soreness donot suggest any means by which stretching before or after exercisecould reduce the soreness that follows that exercise session. How-ever if, as has been proposed, muscle soreness is due to excessiveelongation of some sarcomeres within muscle fibres (Proske 2001),it is conceivable that any intervention which increased the num-ber of sarcomeres in series in muscle fibres, or which increased thelength or compliance of tendons, could reduce sarcomere strainsand lessen muscle damage associated with unaccustomed eccentric

muscle contractions. This suggests the possibility that stretchingmay be more effective for people who have very short muscles, orif the stretching is repeated for weeks or months or years. To date,however, randomised trials have only examined the short-term ef-fects of one or a few sessions of stretching, and no randomisedtrials have specifically investigated interactions between effects ofstretching and flexibility.

The best available evidence indicates stretching does not reducemuscle soreness. However there are other justifications for stretch-ing. Some evidence suggests that once muscle soreness has devel-oped stretching may provide a transient relief of soreness (Reisman2005): some people stretch to reduce risk of injury, others stretchto enhance athletic or sporting performance, and yet others stretchbecause it gives them a sense of well-being. The current reviewdoes not provide any evidence of an effect or otherwise of stretch-ing on risk of injury, performance or well-being.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The available evidence from randomised trials carried out mainlyin laboratory settings consistently suggests that stretching beforeor after exercise does not prevent muscle soreness in young healthyadults.

Implications for research

Arguably the findings of this review are clear enough that furtherresearch into the effects of stretching on muscle soreness is notnecessary. We see some merit in this view. However, in our opinionit would be useful to conduct further trials of the effects of longer-term stretching programs, in community-based populations andfor people with reduced flexibility.

A C K N O W L E D G E M E N T S

This review is based on an earlier “non-Cochrane” review con-ducted by Rob Herbert and Michael Gabriel and published in2002 (Herbert RD, Gabriel M. BMJ 2002;325(7362):468-72).Through that earlier work Michael Gabriel indirectly contributedto the current review. His contribution is gratefully acknowledged.The authors thank Helen Handoll, Vicki Livingstone, Janet Wale,Gisela Sole and Lindsey Shaw for helpful comments on the review,and Lisa Harvey for assistance with data extraction.



R E F E R E N C E S

References to studies included in this review

Buroker 1989 {published data only}Buroker KC, Schwane JA. Does postexercise static stretchingalleviate delayed muscle soreness?. Physician and Sportsmedicine1989;17(6):65–83.

Dawson 2005 {published data only}

Dawson B, Gow S, Modra S, Bishop D, Stewart G. Effects ofimmediate post-game recovery procedures on muscle soreness,power and flexibility levels over the next 48 hours. Journal ofScience and Medicine in Sport 2005;8(2):210–21.

Gulick 1996 {published data only}Gulick DT, Kimura IF, Sitler M, Paolone A, Kelly JD. Varioustreatment techniques on signs and symptoms of delayed onsetmuscle soreness. Journal of Athletic Training 1996;31(2):145–52.

High 1989 {published data only}

High DM, Howley ET, Franks BD. The effects of static stretchingand warm-up on prevention of delayed-onset muscle soreness.Research Quarterly for Exercise and Sport 1989;60(4):357–61.

Johansson 1999 {published data only}

Johansson PH, Lindström L, Sundelin G, Lindström B. The effectsof preexercise stretching on muscular soreness, tenderness and forceloss following heavy eccentric exercise. Scandinavian Journal ofMedicine and Science in Sports 1999;9(4):219–25.

Maxwell 1988 {published data only}Maxwell S, Kohn S, Watson A, Balnave RJ. Is stretching effective inthe prevention of or amelioration of delayed-onset muscle soreness?.In: Torode M editor(s). The athlete maximising participation andminimising risk. Sydney: Cumberland College of Health Sciences,1988:109–18.

McGlynn 1979 {published data only}McGlynn GH, Laughlin NT, Rowe V. Effect of electromyographicfeedback and static stretching on artificially induced musclesoreness. American Journal of Physical Medicine 1979;58(3):139–48.

Terry 1985 {published data only}! Terry L. Stretching and muscle soreness. An investigation into theeffects of hold-relax stretch on delayed post-exercise soreness in thequadriceps muscle - a pilot study [thesis]. Adelaide (Australia): SouthAustralian Institute of Technology, 1985.Terry L. Stretching and muscle soreness: an investigation into theeffects of a hold-relax stretch on delayed post-exercise soreness inthe quadriceps muscle: a pilot study [abstract]. Australian Journal ofPhysiotherapy Australian Journal of Physiotherapy 1987;33(1):69.

Wessel 1994a {published data only}Wessel J, Wan A. Effect of stretching on the intensity of delayed-onset muscle soreness. Clinical Journal of Sport Medicine 1994;4(2):83–7.

Wessel 1994b {published data only}

Wessel J, Wan A. Effect of stretching on the intensity of delayed-onset muscle soreness. Clinical Journal of Sport Medicine 1994;4(2):83–7.

References to studies excluded from this review

Abraham 1977 {published data only}Abraham WM. Factors in delayed muscle soreness. Medicine andScience in Sports 1997;9(1):11–20.

Bale 1991 {published data only}Bale P, James H. Massage, warmdown and rest as recuperativemeasures after short term intense exercise. Physiotherapy in Sport1991;13(2):4–7.

de Vries 1966 {published data only}de Vries HA. Quantitative electromyographic investigation of thespasm theory of muscle pain. American Journal of Physical Medicine1966;45(3):119–34.

Jayaraman 2004 {published data only}Jayaraman RC, Reid RW, Foley JM, Prior BM, Dudley GA,Weingand KW, et al.MRI evaluation of topical heat and staticstretching as therapeutic modalities for the treatment of eccentricexercise-induced muscle damage. European Journal of AppliedPhysiology 2004;93(1-2):30–8.

Lightfoot 1997 {published data only}Lightfoot JT, Char D, McDermott J, Goya C. Immediatepostexercise massage does not attenuate delayed onset musclesoreness. Journal of Strength and Conditioning Research 1997;11:119–24.

Lund 1998 {published data only}Lund H, Vestergaard-Poulsen, Kanstrup I-L, Sejrsen P. The effect ofpassive stretching on delayed onset muscle soreness, and otherdetrimental effects following exercise. Scandinavian Journal ofMedicine and Science in Sports 1998;8:216–21.

Prentice 1982 {published data only}

Prentice WE. Electromyographic analysis of the effectiveness ofheat or cold and stretching for inducing relaxation in injuredmuscle. Journal of Orthopaedic and Sports Physical Therapy 1982;3(3):133–40.

Rahnama 2005 {published data only}Rahnama N. Rahmani-Nia F. Ebrahim K. The isolated andcombined effects of selected physical activity and ibuprofen ondelayed-onset muscle soreness. Journal of Sports Sciences 2005;23

(8):843–850.

Reilly 2002 {published data only}

Reilly T, Rigby M. Effect of an active warm-down followingcompetitive soccer. In: Spinks W, Reilly T, Murphy A editor(s).Science and Football IV. Proceedings of the 4th World Congress ofScience and Football; 1999 Feb 22-26; Sydney, NSW. London:Routledge, 2002:226–9.

Rodenburg 1994 {published data only}Rodenburg JB, Steenbeek, Schiereck P, Bar PR. Warm-up,stretching and massage diminish harmful effects of eccentricexercise. International Journal of Sports Medicine 1994;15(7):414–9.

Smith 1993 {published data only}Smith LL, Brunetz MH, Chenier TC, McCammon MR, HoumardJA, Franklin ME, et al.The effects of static and ballistic stretchingon delayed onset muscle soreness. Research Quarterly for Exerciseand Sport 1993;1:103–7.



References to studies awaiting assessment

Buckenmeyer 1998 {published data only}

Buckenmeyer P, Kokkinidis E. Machairidou M, Tsamourtas A. Theeffect of static stretching and cryotherapy on the recovery ofdelayed muscle soreness [Greek]. Exercise & Society Journal of SportScience (Komotini) 1998;(19):45–53.

Costa 1997 {published data only}Costa MC, Cabral JG, Muniz GMA, Silva EF, Silva MG, DuarteJAR, et al.Effects of stretching after exercise on some indirectmarkers muscle damage. 9th European Congress on SportsMedicine; 1997 Sept 23-26; Porto, Portugal. 1997:1.

Lin 1999 {published data only}Lin WH. The effects of massage, stretch and meloxicam on delayedonset muscle soreness [Masters thesis]. Taiwan: National College ofPhysical Education and Sports Taoyuan, 1999.

Lu 1992 {published data only}! Lu D, Fan JY, Qu Z. An immuno-electron microscopic study ofthe effect of acupuncture and static stretch on contractile structuralalteration of skeletal muscle after strenuous exercise. Sport Science(Beijing) 1992;12(6):47–51.Lu D, Fan JY, Qu Z. An immuno-electron microscopic study of theeffect of acupuncture and static stretch on ultrastructural alterationof M-line of skeletal muscle after strenuous exercise. Sports Science(Beijing) 1992;12(6):52–9.Lu D, Fan JY, Qu Z. An immuno-electron microscopic study of theeffect of acupuncture and static stretch on ultrastructural alterationof Z-band in human skeletal muscle after strenuous exercise. SportsScience (Beijing) 1992;12(6):60–5.

Additional references

Balnave 1993

Balnave CD, Thomson MW. Effect of training on eccentricexercise-induced muscle damage. Journal of Applied Physiology1993;75(4):1545–51.

Bobbert 1986Bobbert MF, Hollander AP, Huijing PA. Factors in delayed onsetmuscle sorenesss of man. Medicine and Science in Sports and Exercise1986;18(1):75–81.

Chalmers 1983Chalmers TC, Celano P, Sacks HS, Smith H. Bias in treatmentassignment in controlled clinical trials. New England Journal ofMedicine 1983;309(22):1358–61.

Colditz 1989

Colditz GA, Miller JN, Mosteller F. How study design affectsoutcomes in comparisons of therapy. I: Medical. Statistics inMedicine 1989;8(4):441–54.

Cross 1999Cross KM, Worrell TW. Effects of a static stretching program onthe incidence of lower extremity musculotendinous strains. Journalof Athletic Training 1999;34:11–4.

de Vries 1961

de Vries HA. Prevention of muscular distress after exercise. ResearchQuarterly 1961;32:177–85.

Elbourne 2002

Elbourne DR, Altman DG, Higgins JPT, Curtin F, WorthingtonHV, Vail A. Meta-analyses involving cross-over trials:methodological issues. International Journal of Epidemiology 2002;31(1):140–9.

Feland 2001Feland JB, Myrer JW, Merrill RM. Acute changes in hamstringflexibility: PNF versus static stretch in senior athletes. PhysicalTherapy in Sport 2001;2(4):186–93.

Fleiss 1993

Fleiss JL. The statistical basis of meta-analysis. Statistical Methods inMedical Research 1993;2:121–45.

Gleim 1990Gleim GW, Stachenfeld NS, Nicholas JA. The influence offlexibility on the economy of walking and jogging. Journal ofOrthopedic Research 1990;8:814–23.

Gleim 1997

Gleim GW, McHugh MP. Flexibility and its effects on sports injuryand performance. Sports Medicine 1997;24:289–99.

Lieber 2002Lieber RL, Friden J. Morphologic and mechanical basis of delayed-onset muscle soreness. Journal of the American Academy ofOrthopaedic Surgeons 2002;10(1):67–73.

Moher 1998

Moher D, Pham B, Jones A, Cook DJ, Jadad AR, Moher M, etal.Does quality of reports of randomised trials affect estimates ofintervention efficacy reported in meta-analyses?. Lancet 1995;352(9128):609–13.

Proske 2001Proske U, Morgan DL. Muscle damage from eccentric exercise:mechanism, mechanical signs, adaptation and clinical applications.Journal of Physiology 2001;537(2):333–45.

Reisman 2005Reisman S, Walsh LD, Proske U. Warm-up stretches reducesensations of stiffness and soreness after eccentric exercise. Medicineand Science in Sports and Exercise 2005;37(6):929–36.

RevMan 2003

The Nordic Cochrane Centre, The Cochrane Collaboration.Review Manager (RevMan). 4.2 for Windows. Copenhagen: TheNordic Cochrane Centre, The Cochrane Collaboration, 2003.

Schulz 1995Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidenceof bias. Dimensions of methodological quality associated withestimates of treatment effects in controlled trials. JAMA 1995;273

(5):408–12.

Shrier 2004Shrier I. Does stretching improve performance?A systematic andcritical review of the literature. Clinical Journal of Sport Medicine2004;14(5):267–73.

Thacker 2004Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. The impact ofstretching on sports injury risk: a systematic review of the literature.Medicine and Science in Sports and Exercise 2004;36(3):371–8.



Weerakkody 2001

Weerakkody NS, Whitehead NP, Canny BJ, Gregory JE, Proske U.Large-fibre mechanoreceptors contribute to muscle soreness aftereccentric exercise. Journal of Pain 2001;2(4):209–19.

Weldon 2003

Weldon SM, Hill RH. The efficacy of stretching for prevention ofexercise-related injury: a systematic review of the literature. ManualTherapy 2003;8(3):141–50.

Wessel 1994Wessel J, Wan A. Effect of stretching on the intensity of delayed-onset muscle soreness. Clinical Journal of Sport Medicine 1994;4(2):82–7.

Yeung 2003Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners. Cochrane Database of Systematic Reviews2003, Issue 4. [DOI: 10.1002/14651858.CD001256]

References to other published versions of this review

Herbert 2002

Herbert RD, Gabriel M. Effects of pre- and post-exercise stretchingon muscle soreness, risk of injury and athletic performance: asystematic review. BMJ 2002;325(7362):468–72.

! Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Buroker 1989

Methods Randomised (between subjects) design

Participants 23 participants (16 men and 7 women) aged 18-33 years with no known contraindications to exercise.None was highly physically trained and none were extremely active in the six weeks preceding the study.

Interventions Control group (N = 8): no stretching.One stretch group 1 (N = 7): stretched left knee extensors after exercise.A second stretch group (N = 8): stretched left knee extensors and right plantarflexors after exercise.Stretches (10 30-second static stretches, each separated by 10 seconds rest, to noticeable tension or slightdiscomfort)were performed at 2-hour intervals for the first 24 hours and 4-hour intervals for the following48 hours except that participants were allowed to sleep for 8 hours each night.

Outcomes The following measures were taken on days 1, 2 and 3:1. Soreness on a 0-6 scale (0 = no pain, light pain only on palpation, 4 = moderate pain, stiffness and/orweakness, especially on movement, 6 = severe pain limiting range of movement)2. Force required to invoke tenderness (sum of measures at 9 sites)3. Force required to invoke tenderness (highest value from 9 or 10 sites)

Notes Data from the two stretch groups were pooled.Stretched after exercise.Soreness induced with 20 minutes of step-down exercise.

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Dawson 2005

Methods Randomised (within subjects, cross-over)design

Participants 17 semi-professional Australian rules football players.

Interventions Stretch condition: 15 minutes of supervised gentle stretching of the legs and back. This involved “2-3repeats of 30 s held stretches across several muscle groups and joints”.Control condition: no recovery procedures.

Outcomes The following measures were taken at 15 and 48 hours:1. Soreness (“how do you feel today?”) measured on a 1-7 scale anchored at “very, very good” and “very,very sore”.



Dawson 2005 (Continued)

Notes Part of a larger study in which each subject was exposed on 12 occasions, each separated by one week, toone of four interventions (control, stretch, pool walking, hot-cold regimen).Initial condition was allocated randomly and subsequent conditions by alternation. Stretch was beforeexercise.Soreness was induced by playing football.All participants underwent a “pool recovery program” on the two days following exercise.

Risk of bias



Gulick 1996


Participants ~22 untrained participants randomly drawn from a larger sample of 35 men and 38 women aged 21 to40 years.

Interventions Stretch group (N ~ 11): static stretches of the wrist extensor muscles to “end range” for 10 minutes soonafter exercise.Control group (N ~ 11): two placebo tablets after exercise and one further placebo tablet 24 hours later.

Outcomes The following measures were taken 24, 48 and 72 hours after exercise:1. On a 10 cm visual analogue scale anchored at “no soreness at all” and “soreness as bad as it could be”2. Force required to invoke tenderness (sum of measures at 9 sites).

Notes Part of a larger study in which subjects were randomised to seven interventions (control, stretch, anti-inflammatory drug, intense exercise, ice massage, herbal ointment).Stretch was after exercise.Soreness was induced by 15 sets of 15 isokinetic eccentric wrist extensor contractions.

Risk of bias



High 1989


Participants 30 untrained participants (stretch group, 7 men and 7 women, mean age 19.4 years; control group, 8men and 8 women, mean age 20.4 years)



High 1989 (Continued)

Interventions Stretch group: stretched the quadriceps muscles (5 stretches, twice each on each leg for 50 seconds) ofboth legs prior to exercise. Control group: did not stretch.

Outcomes The following measures were taken at 24 hour intervals for 5 days:1. Soreness on a 0-6 scale (0 = “absence of soreness”, 6 = “most severe pain possible from soreness”.

Notes Part of a larger study in which subjects were randomised to four interventions (control, stretch, warm-up,warm-up and stretch).Stretch was before exercise.Soreness was induced by 80 up to minutes of step-down exercise.

Risk of bias



Johansson 1999

Methods Randomised (between legs) design

Participants 10 health female physiotherapy students (24 (SD 3) years, 62 (SD 3) kg, 169 (SD 5) cm), not taking anti-inflammatory medication, with no lower limb musculoskeletal symptoms, had not participated in weighttraining for more than 3 hours per week, and were not experiencing DOMS at the time of testing.

Interventions Stretch leg: four 20-second “hamstring hurdle” stretches, with 20 second rests between stretches. Stretchintensity was sufficient to induce a strong feeling of stretch but not pain.Control leg: the hamstring muscles on the other side of the body were not stretched.

Outcomes The following measures were taken 24, 48 and 96 hours after exercise:1. Hamstring muscle soreness on a 100 mm visual analogue scale (0 = “no soreness”, 100 = “worst possiblesoreness”).2. Tenderness measured with an algometer at 5 locations.

Notes Stretch was before exercise.Soreness was induced with 10 sets of 10 isokinetic knee flexor contractions.

Risk of bias





Maxwell 1988


Participants ~14 female first-year college students randomly drawn from a larger sample of 20 participants aged 18-25 years (mean 19.4) and with varying histories of physical activity

Interventions Stretch group (N ~ 6): participants lay in prone with the hips in a neutral position. A static stretch wasapplied to the quadriceps to the point of discomfort and held for 15 seconds.Control group (N ~ 6): participants did not stretch.

Outcomes The following measures were taken 24, 48 and 72 hours after exercise:1. Pain experienced in the quadriceps muscle whilst descending a flight of stairs rated on a 10 cm visualanalogue scale anchored at 0 (“no pain”) and 10 (“severe pain”).

Notes Stretch was after exercise.Soreness was induced with 15 minutes of step-down exercise.

Risk of bias



McGlynn 1979


Participants 24 men aged 18-26 years who had not engaged in any systematic activity with their non-dominant armsin the past 30 days

Interventions Stretch group (N ~ 12): participants “hyperextended” the “forearm” for two minutes before releasing thestretch for one minute. This sequence was repeated four times each at 6, 25, 30, 49 and 54 hours afterexercise.Control group (N ~12): participants did not stretch.

Outcomes The following measures were taken 24, 48 and 72 hours after exercise:1. Pain rated on a 30-point scale, where 0-10 was “mild” pain, 11-20 was “moderate” pain, and 21-30was “severe” pain.

Notes Part of a larger study in which subjects were randomised to three interventions (control, stretch, biofeed-back).Strech was after exercise.Soreness was induced with eccentric elbow flexor exercises perfomed to failure.

Risk of bias




McGlynn 1979 (Continued)


Terry 1985


Participants 30 healthy participants, 15 men and 15 women, aged between 18 and 35 years. The modal level of exercisewas three times per week.

Interventions Stretch (hold-relax)leg: participants lay prone with a wedge under the thigh and the knee was activelyflexed as far as possible. Then the participant performed an isometric contraction against manual resistancefor 4-6 seconds. This was followed by two seconds of relaxation and then an 8 second passive stretch. Thiswas repeated 5 times.Control leg: the other leg was not stretched.

Outcomes The following measures were taken on days 2 and 3:1. “Pain” (or, variably, “pain, soreness or stiffness” or “soreness”)experienced that day during functionalmovements rated on a scale of 0 (“no pain”) to 7 (“unbearably painful”).

Notes Stretching was after exercise.Soreness was induced with 20 minutes of step-up and step-down exercise.

Risk of bias



Wessel 1994a


Participants 10 sedentary adults (5 women and 5 men) with no history of back or lower limb injury or disease, meanage 24.2 (SD 5.37), mean height 175.5 cm (SD 7.6) and mean mass 66.3 kg (8.9)

Interventions Stretch leg: ten 60-second stretches of the hamstring muscles prior to exercise.Control leg: not stretched.

Outcomes The following measures were taken at 12 hour intervals to 72 hours after exercise:1. Pain on a 10 cm visual analogue scale while walking on an “even” surface.

Notes Randomisation was by toss of a coin.Stretching was before exercise.Soreness was induced by 3 sets of 20 isokinetic eccentric knee flexor contractions.

Risk of bias



Wessel 1994a (Continued)



Wessel 1994b


Participants 10 sedentary adults (2 women and 8 men) with no history of back or lower limb injury or disease, meanage 25.2 (SD 3.36), mean height 171.2 cm (SD 7.29) and mean mass 61.3 kg (7.12)

Interventions Stretch leg: ten 60-second stretches of the hamstring muscles after exercise.Control leg: not stretched.

Outcomes The following measures were taken at 12 hour intervals to 72 hours after exercise:1. Pain on a 10 cm visual analogue scale while walking on an “even” surface.

Notes Randomisation was by toss of a coin.Stretching was after exercise.Soreness was induced by 3 sets of 20 isokinetic eccentric knee flexor contractions.

Risk of bias



DOMS: delayed onset muscle sorenesss: secondSD: standard deviation~: approximatelyThe numbers of participants given in the Participants and Interventions columns are the number of participants who received thestretch or control intervention. Thus, in studies with three or more arms the number of participants given is less than the total numberof participants in the study. In Gulick 1996, 73 participants were randomised to 7 groups but the size of each group is not given, sosample sizes are given as “~11”. In Maxwell 1988, 20 participants were randomised to 3 groups but the size of each group is not given,so sample sizes are given as “~6”. In McGlynn 1979, 36 participants were randomised to 3 groups but the size of each group is notgiven, so sample sizes are given as “~12”.



Characteristics of excluded studies [ordered by study ID]

Abraham 1977 Stretching occurred 24 hours after exercise; not clear if conditions (stretch/flex) were randomised.

Bale 1991 No stretch condition.

de Vries 1966 Not randomised (compared before and after stretch).

Jayaraman 2004 Stretching did not begin until 36 hours after exercise.

Lightfoot 1997 Plantarflexors were sore, but quadriceps and hamstring muscles were stretched (fails criterion of “stretchingtechnique designed to prevent or treat delayed-onset muscle soreness”).

Lund 1998 Not randomised (used historical controls).

Prentice 1982 Stretch combined with heat or cold; interventions 24 hours after exercise; did not measure soreness.

Rahnama 2005 Stretching combined with jogging and walking and submaximal concentric contractions.

Reilly 2002 Not clearly randomised; stretch combined with jogging and “shake-down”.

Rodenburg 1994 Intervention was a combination of warm-up, stretch and massage.

Smith 1993 Compares effects of static and ballistic stretching.



D A T A A N D A N A L Y S E S

Comparison 1. Pre-exercise stretching

Outcome or subgroup titleNo. ofstudies

No. ofparticipants Statistical method Effect size

1 Soreness on day 0.5 (assessed 6-17 hours post-exercise)

1 Mean Difference (IV, Fixed, 95% CI) Totals not selected

2 Soreness on day 1 (assessed 18-29 hours post-exercise)

3 70 Mean Difference (IV, Fixed, 95% CI) -0.52 [-11.30,10.26]




2 40 Mean Difference (IV, Fixed, 95% CI) 0.72 [-11.20, 12.64]





Comparison 2. Post-exercise stretching




2 51 Mean Difference (IV, Fixed, 95% CI) -0.47 [-6.05, 5.12]













Comparison 3. Either pre- or post-exercise stretching















Analysis 1.1. Comparison 1 Pre-exercise stretching, Outcome 1 Soreness on day 0.5 (assessed 6-17 hourspost-exercise).

Review: Stretching to prevent or reduce muscle soreness after exercise

Comparison: 1 Pre-exercise stretching

Outcome: 1 Soreness on day 0.5 (assessed 6-17 hours post-exercise)

Study or subgroup Stretch Control Mean Difference Mean Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Wessel 1994a 10 4 (5) 10 9 (25) -5.00 [ -20.80, 10.80 ]

-100 -50 0 50 100

Favours stretch Favours control



Analysis 1.2. Comparison 1 Pre-exercise stretching, Outcome 2 Soreness on day 1 (assessed 18-29 hourspost-exercise).



Outcome: 2 Soreness on day 1 (assessed 18-29 hours post-exercise)

Study or subgroup Stretch Control Mean Difference Weight Mean Difference


High 1989 14 63.2 (37.5) 16 66.9 (37.5) 16.1 % -3.70 [ -30.60, 23.20 ]

Johansson 1999 10 52.2 (15.5) 10 51 (15.8) 61.7 % 1.20 [ -12.52, 14.92 ]

Wessel 1994a 10 14 (24) 10 17 (28) 22.2 % -3.00 [ -25.86, 19.86 ]

Total (95% CI) 34 36 100.0 % -0.52 [ -11.30, 10.26 ]Heterogeneity: Chi2 = 0.16, df = 2 (P = 0.92); I2 =0.0%

Test for overall effect: Z = 0.09 (P = 0.92)

-100 -50 0 50 100


Analysis 1.3. Comparison 1 Pre-exercise stretching, Outcome 3 Soreness on day 1.5 (assessed 30-41 hourspost-exercise).






Wessel 1994a 10 27 (30) 10 26 (28) 1.00 [ -24.43, 26.43 ]

-100 -50 0 50 100










Johansson 1999 10 70.5 (16.6) 10 69.4 (17.1) 65.1 % 1.10 [ -13.67, 15.87 ]

Wessel 1994a 10 32 (24) 10 32 (22) 34.9 % 0.0 [ -20.18, 20.18 ]

Total (95% CI) 20 20 100.0 % 0.72 [ -11.20, 12.64 ]Heterogeneity: Chi2 = 0.01, df = 1 (P = 0.93); I2 =0.0%


-100 -50 0 50 100


Analysis 1.5. Comparison 1 Pre-exercise stretching, Outcome 5 Soreness on day 2.5 (assessed 54-65 hours

post-exercise).






Wessel 1994a 10 27 (19) 10 29 (27) -2.00 [ -22.46, 18.46 ]

-100 -50 0 50 100










Johansson 1999 10 39.4 (23.8) 10 38.2 (24.1) 40.3 % 1.20 [ -19.79, 22.19 ]

Wessel 1994a 10 13 (17) 10 18 (22) 59.7 % -5.00 [ -22.23, 12.23 ]



-100 -50 0 50 100


Analysis 2.1. Comparison 2 Post-exercise stretching, Outcome 1 Soreness on day 0.5 (assessed 6-17 hours

post-exercise).


Comparison: 2 Post-exercise stretching




Dawson 2005 14 60 (17) 17 57 (10) 30.6 % 3.00 [ -7.09, 13.09 ]

Wessel 1994b 10 4 (6) 10 6 (9) 69.4 % -2.00 [ -8.70, 4.70 ]



-100 -50 0 50 100




Analysis 2.2. Comparison 2 Post-exercise stretching, Outcome 2 Soreness on day 1 (assessed 18-29 hourspost-exercise).






Buroker 1989 15 61.7 (15.1) 8 64 (5.9) 45.3 % -2.30 [ -10.97, 6.37 ]

McGlynn 1979 12 29.4 (20) 12 27.5 (19.5) 13.6 % 1.90 [ -13.90, 17.70 ]

Terry 1985 30 23.6 (23.6) 30 24.7 (23.6) 23.8 % -1.10 [ -13.04, 10.84 ]

Wessel 1994b 10 13 (16) 10 13 (16) 17.3 % 0.0 [ -14.02, 14.02 ]



-100 -50 0 50 100


Analysis 2.3. Comparison 2 Post-exercise stretching, Outcome 3 Soreness on day 1.5 (assessed 30-41 hours

post-exercise).






Wessel 1994b 10 22 (22) 10 21 (22) 1.00 [ -18.28, 20.28 ]

-100 -50 0 50 100










Buroker 1989 15 65.2 (23.1) 8 68.5 (13.7) 14.6 % -3.30 [ -18.36, 11.76 ]

Dawson 2005 14 52 (15) 17 48 (10) 39.2 % 4.00 [ -5.18, 13.18 ]

McGlynn 1979 12 29.4 (20) 12 27.2 (20.4) 12.7 % 2.20 [ -13.96, 18.36 ]

Terry 1985 30 23.3 (24) 30 24.4 (24) 22.4 % -1.10 [ -13.25, 11.05 ]

Wessel 1994b 10 26 (22) 10 26 (17) 11.1 % 0.0 [ -17.23, 17.23 ]



-100 -50 0 50 100


Analysis 2.5. Comparison 2 Post-exercise stretching, Outcome 5 Soreness on day 2.5 (assessed 54-65 hourspost-exercise).






Wessel 1994b 10 24 (19) 10 24 (17) 0.0 [ -15.80, 15.80 ]

-100 -50 0 50 100










Buroker 1989 15 51.8 (20.2) 8 50.3 (26.5) 12.6 % 1.50 [ -19.52, 22.52 ]

McGlynn 1979 12 11.4 (9.9) 12 11.4 (13) 65.1 % 0.0 [ -9.25, 9.25 ]

Wessel 1994b 10 17 (17) 10 18 (19) 22.3 % -1.00 [ -16.80, 14.80 ]



-100 -50 0 50 100


Analysis 3.1. Comparison 3 Either pre- or post-exercise stretching, Outcome 1 Soreness on day 0.5(assessed 6-17 hours post-exercise).


Comparison: 3 Either pre- or post-exercise stretching




Wessel 1994a 10 4 (5) 10 9 (25) 11.1 % -5.00 [ -20.80, 10.80 ]

Dawson 2005 14 60 (17) 17 57 (10) 27.2 % 3.00 [ -7.09, 13.09 ]

Wessel 1994b 10 4 (6) 10 6 (9) 61.7 % -2.00 [ -8.70, 4.70 ]



-100 -50 0 50 100




Analysis 3.2. Comparison 3 Either pre- or post-exercise stretching, Outcome 2 Soreness on day 1 (assessed18-29 hours post-exercise).






Buroker 1989 15 61.7 (15.1) 8 64 (5.9) 35.0 % -2.30 [ -10.97, 6.37 ]

High 1989 14 63.2 (37.5) 16 66.9 (37.5) 3.6 % -3.70 [ -30.60, 23.20 ]

Johansson 1999 10 52.2 (15.5) 10 51 (15.8) 14.0 % 1.20 [ -12.52, 14.92 ]

McGlynn 1979 12 29.4 (20) 12 27.5 (19.5) 10.5 % 1.90 [ -13.90, 17.70 ]

Terry 1985 30 23.6 (23.6) 30 24.7 (23.6) 18.4 % -1.10 [ -13.04, 10.84 ]

Wessel 1994a 10 14 (24) 10 17 (28) 5.0 % -3.00 [ -25.86, 19.86 ]

Wessel 1994b 10 13 (16) 10 13 (16) 13.4 % 0.0 [ -14.02, 14.02 ]



-100 -50 0 50 100








Wessel 1994a 10 27 (30) 10 26 (28) 36.5 % 1.00 [ -24.43, 26.43 ]

Wessel 1994b 10 22 (22) 10 21 (22) 63.5 % 1.00 [ -18.28, 20.28 ]



-100 -50 0 50 100




Analysis 3.4. Comparison 3 Either pre- or post-exercise stretching, Outcome 4 Soreness on day 2 (assessed42-53 hours post-exercise).






Buroker 1989 15 65.2 (23.1) 8 68.5 (13.7) 11.8 % -3.30 [ -18.36, 11.76 ]

Johansson 1999 10 70.5 (16.6) 10 69.4 (17.1) 12.3 % 1.10 [ -13.67, 15.87 ]

Dawson 2005 14 52 (15) 17 48 (10) 31.8 % 4.00 [ -5.18, 13.18 ]

McGlynn 1979 12 29.4 (20) 12 27.2 (20.4) 10.3 % 2.20 [ -13.96, 18.36 ]

Terry 1985 30 23.3 (24) 30 24.4 (24) 18.2 % -1.10 [ -13.25, 11.05 ]

Wessel 1994a 10 32 (24) 10 32 (22) 6.6 % 0.0 [ -20.18, 20.18 ]

Wessel 1994b 10 26 (22) 10 26 (17) 9.0 % 0.0 [ -17.23, 17.23 ]



-100 -50 0 50 100










Wessel 1994a 10 27 (19) 10 29 (27) 37.4 % -2.00 [ -22.46, 18.46 ]

Wessel 1994b 10 24 (19) 10 24 (17) 62.6 % 0.0 [ -15.80, 15.80 ]



-100 -50 0 50 100


Analysis 3.6. Comparison 3 Either pre- or post-exercise stretching, Outcome 6 Soreness on day 3 (assessed

66-77 hours post-exercise).






Buroker 1989 15 51.8 (20.2) 8 50.3 (26.5) 9.6 % 1.50 [ -19.52, 22.52 ]

Johansson 1999 10 39.4 (23.8) 10 38.2 (24.1) 9.6 % 1.20 [ -19.79, 22.19 ]

McGlynn 1979 12 11.4 (9.9) 12 11.4 (13) 49.6 % 0.0 [ -9.25, 9.25 ]

Wessel 1994a 10 13 (17) 10 18 (22) 14.3 % -5.00 [ -22.23, 12.23 ]

Wessel 1994b 10 18 (19) 10 17 (17) 17.0 % 1.00 [ -14.80, 16.80 ]



-100 -50 0 50 100




A P P E N D I C E S

Appendix 1. Search strategy for The Cochrane Library

#1. stretch*#2. flexib*#3. PLIABILITY single term (MeSH)#4. (range near motion)#5. (((((warmup or warm-up) or (warm next down)) or cooldown) or cool-down) or (cool next down))#6. ((((#1 or #2) or #3) or #4) or #5)#7. (sore* near musc*)#8. doms#9. MUSCLE CONTRACTION explode all trees (MeSH)#10. MUSCLE SKELETAL single term (MeSH)#11. (#9 or #10)#12. PAIN single term (MeSH)#13. (#11 and #12)#14. (#7 or #8 or #13)#15. (#6 and #14)

Appendix 2. Search strategy for MEDLINE (OVID WEB)

1. stretch$.tw.2. flexib$.tw.3. Pliability/4. (range adj3 motion).tw.5. Range of Motion, Articular/6. (warmup or warm-up or warm up or cooldown or cool-down or cool down).tw.7. or/1-68. (sore$ adj3 musc$).tw.9. DOMS.tw.10. exp Muscle Contraction/11. Muscle, Skeletal/12. or/10-1113. Pain/14. and/12-1315. or/8-9,1416. and/7,15

Appendix 3. Search strategy for PEDro

The first search combined the following terms with “OR”:[in the Title/abstract field] stretch*, sore*, DOMSThe second search combined the following terms with “AND”:[in the Therapy field] stretching, mobilisation, manipulation, massage[in the Subdiscipline field] sports[in the Problem field] pain



W H A T ’ S N E W

Last assessed as up-to-date: 15 August 2006.

4 July 2008 Amended Converted to new review format.

H I S T O R Y

Protocol first published: Issue 1, 2004

Review first published: Issue 4, 2007

C O N T R I B U T I O N S O F A U T H O R S

The protocol for the current review was written by Rob Herbert. Data collection, data extraction, quality assessment, data analysisand interpretation were carried out by Marcos de Noronha and Rob Herbert. Rob Herbert wrote the review. Marcos de Noronhacommented on drafts and approved the final version. Rob Herbert is guarantor for the review.

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

• University of Sydney, Australia.

External sources

• No sources of support supplied

I N D E X T E R M S



Medical Subject Headings (MeSH)

!Exercise; Muscle Stretching Exercises; Muscular Diseases [!prevention & control]; Pain [!prevention & control]; Randomized Con-trolled Trials as Topic

MeSH check words

Humans



Stretching to prevent or reduce muscle soreness after exercise...The pooled estimate showed that...

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