BRIEF REVIEW
EFFECTS OF ACUTE STRETCHING EXERCISE AND
TRAINING ON HEART RATE VARIABILITY: A REVIEW
ALEXEI WONG1 AND ARTURO FIGUEROA2
1
Department of Health and Human Performance, Marymount University, Arlington, Virginia; and 2Department of Kinesiology
and Sport Management, Texas Tech University, Lubbock, Texas
ABSTRACT
Downloaded from https://journals.lww.com/nsca-jscr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3qIsdRDyoedGLrbvKbCVBt8GBoz5l8hvA32EfAP4sBfQ= on 03/21/2019
Wong, A and Figueroa, A. Effects of acute stretching exercise and
training on heart rate variability: A review. J Strength Cond Res
XX(X): 000–000, 2019—Stretching (ST), an exercise modality
widely used for flexibility improvement, has been recently pro-
posed as an effective adjunct therapy for declines in cardiovas-
cular health, warranting research into the effects of ST exercise on
cardiac autonomic function (CAF). Heart rate (HR) variability
(HRV) is a reliable measure of CAF, mainly the sympathetic and
parasympathetic modulations of HR. A low HRV has been asso-
ciated to increased risk of cardiovascular events and mortality.
Exercise interventions that enhance HRV are therefore seen as
beneficial to cardiovascular health and are sought after. In this
review, we discuss the effect of ST both acute and training on
HRV. Stretching training seems to be a useful therapeutic inter-
vention to improve CAF in different populations. Although the
mechanisms by which ST training improves CAF are not yet well
understood; increases in baroreflex sensitivity, relaxation, and ni-
tric oxide bioavailability seem to play an important role.
KEY WORDS stretching training, autonomic function, stretch
exercise
INTRODUCTION
S
tretching (ST) is a form of exercise that is recom-
mended as a part of a general fitness program,
which is widely used for flexibility improvement
and injury prevention (41). Recently, ST has been
proposed as an effective adjunct therapy for declines in car-
diovascular function associated with aging and sedentary
lifestyle (23). Other attractive characteristics of ST include
its low-intensity nature as well as the lack of monetary cost
and additional equipment/facilities needed for its regular prac-
tice. Consequently, ST may be a viable nonpharmacological
Address correspondence to Dr. Alexei Wong, awong@marymount.edu.
00(00)/1–8
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intervention for the potential improvement of cardiovascular
health in a variety of individuals, including those unable to
perform traditional aerobic or resistance exercise.
One of many objective measures to determine the effective-
ness of ST on cardiovascular health includes heart rate (HR)
variability (HRV). Heart rate variability, the oscillation in the
interval between consecutive R waves on the electrocardiogram
(ECG) (R-R intervals), has been established as a reliable and
noninvasive tool for the assessment of cardiac autonomic
function (CAF) (40). Heart rate variability parameters can be
used to derive the cardiac sympathovagal balance (SVbal), the
magnitude of sympathetic to parasympathetic nerve activity
(24). Therefore, different cardiac autonomic conditions can be
identified by HRV (15). An enhanced SVbal resulting from an
increase in sympathetic activity and reduction in parasympa-
thetic (vagal) activity leads to depressed HRV (40). From a clin-
ical standpoint, an augmented SVbal and a reduction in HRV are
associated with increased risks of cardiovascular events and mor-
tality (9,35). Consequently, any strategy that reduces SVbal and
enhances HRV is, therefore, considered beneficial to cardiovas-
cular health and may have potential clinical implications.
Despite the known strong relationship between autonomic
function and HRV and despite different reports of changes in
HRV with ST practice, the literature on ST and HRV has not
yet been subjected to a comprehensive review. It is important
to understand HRV responses to ST, as it is a low-intensity
modality that has been shown to elicit a lower cardiovascular
and metabolic demand than traditional aerobic or resistance
exercise (20). These characteristics depict ST as feasible alter-
native for individuals with cardiovascular conditions, such as
cardiac autonomic dysfunction, that may not have the capac-
ity to perform traditional exercise. Therefore, the present
review aims to discuss the effects of ST on CAF. Published
studies that have investigated the effects of acute ST and ST
training are summarized. In addition, we discuss the potential
mechanisms by which ST may improve HRV. Marymount
University approved this brief review.
METHODS
Literature Search
A systematic review of literature from January 1950 to April
2018 using MEDLINE, Google Scholar, PubMed, Web of
Science, Scopus, and SPORTDiscus databases was used to
VOLUME 00 | NUMBER 00 | MONTH 2019 | 1
 ST and CAF
identify important studies. The following keywords, alone or in
conjunction, were used to find relevant publications: cardiac
autonomic function, heart rate variability, vagal modulation,
stretching, flexibility, stretch exercise, and stretching training.
All the eligible articles were in English. The inclusion criteria
focused on the utilization of acute ST exercise (ASTE) and ST
training on cardiac autonomic modulation. All articles were
required to have a detailed explanation of their ST exercise
protocol, be it acute or chronic, including number of exercises,
duration, sets per exercise, and rest periods. The articles
included women and men.
Cardiac Autonomic Control
The cardiovascular center in the medulla oblongata is
responsible for HR regulation through reciprocal
changes in the activity of the sympathetic and para-
sympathetic neurons innervating the sinoatrial node (16).
The postganglionic sympathetic neurons secrete cate-
cholamines (epinephrine and norepinephrine) to the
sinoatrial node, leading to increases in HR (16). On the
other hand, postganglionic parasympathetic neurons in
the vagus nerve secrete acetylcholine, leading to de-
creases in HR.
Heart Rate Variability
Heart rate variability quantifies the variations in R-R intervals
on an ECG. Heart rate variability is analyzed in the time
domain and frequency domain. Time-domain measures have
been proposed as the simplest method for deriving HRV, as
they plot changes in normal R-R intervals over time (40). This
is accomplished by analyzing relatively short ECG time seg-
ments (5–30 minutes). The 2 most common derived measures
are the SD of normal R-R intervals (SDNN), a measure of
overall variability, and the root mean square of successive
differences of R-R intervals (RMSSD), a measure of beat-to-
beat variability and a marker of vagal activity. A decreased
SDNN is clinically relevant given that it is independently
associated to left ventricular hypertrophy and aortic stiffness
(3), while a reduced RMSSD may be indicative of impaired
cardiac autonomic modulation and cardiovascular disease
(24,25). Another measure of vagal activity that is also widely
derived is the percent of differences of adjacent R-R intervals
over 50 ms (PNN50). The PNN50 has proved very useful in
providing diagnostic and prognostic information in a variety
of conditions (40,42).
Frequency-domain measures express HRV as a function of
frequency, rather than time. This method involves plotting
the frequency at which the length of the normal R-R interval
changes (40). Cyclic fluctuations of the normal R-R intervals
are analyzed by autoregressive modeling or fast Fourier
transformation techniques using short ECG sampling times
(2–5 minutes) (40). Measures derived include the very-low-
frequency (VLF, ,0.04 Hz) spectra, low-frequency (LF,
often 0.04–0.15 Hz), and high-frequency (HF, often 0.15–
0.40 Hz) spectral power. However, VLF is not often reported
on HRV-related literature. Together, these constitute total
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2 Journal of Strength and Conditioning Research
Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
power (TP), an approximation of the global activity of the
autonomic nervous system. The HF power is a marker of
cardiovagal activity (34). It is recognized that the LF com-
ponent of HRV expressed in absolute units is mediated by
both sympathetic and parasympathetic activities (40). Abso-
lute units (ms2) for HF and LF in direct proportion to the TP
are expressed in normalized units (nu). The normalized LF is
considered a marker of sympathetic activity. In addition, the
ratio of LF to HF power (LF/HF) is also often reported,
quantifying the relationship between sympathetic and para-
sympathetic nerve activities, the SVbal (34). Increased SVbal,
showed by a higher LF/HF, is considered a reflection of
sympathetic predominance and is associated with increased
cardiovascular risk (35) and a reduced longevity (37).
Both time- and frequency-domain HRV measures are often
not normally distributed. For this reason, data transformation
(typically, natural logarithm, Ln) is sometimes applied to yield
an approximately normal distribution and permit parametric
statistical analysis. For clinicians and exercise scientists, the
primary interest in HRV relates to its prognostic value in
cardiovascular events and morbidities (21,42). In addition, it is
often used to evaluate cardiac autonomic control during and
after (recovery phase) acute exercise (14).
RESULTS
Acute Effects of Stretching on Heart Rate Variability
Reports investigating autonomic recovery from ASTE only
include interventions using static ST (Table 1). It has been
reported that vagal activity increases after this type of ST in
different populations. Logan and Yeo (27) assessed the effects of
a 20-minute whole-body active ST session during the third
trimester of pregnancy in 15 young women. Heart rate variabil-
ity was quantified for 10 minutes in the semi-Fowler position
before and after ASTE. All ST movements were completed
either in the sitting or hands-and-knees position on the floor.
They reported increases in RMSSD 10 minutes after
ASTE. Although not significant, HR (23 b$min21, p =
0.053) showed a trend to decrease at this time point. A study
by Hotta et al. (18) investigated the effects of ASTE on HRV
in patients with ischemic heart disease. Heart rate variability
was evaluated at baseline and for 15 minutes after ASTE. The
participants performed 5 active static ST exercises (with 30-
second intervals) for the forearm, trunk, and hamstrings. The
results of this study showed a significant increase in HF power
15 minutes after ASTE. This evidence indicates that ASTE
may be a favorable intervention for improving cardiovagal
modulation in patients with increased cardiovascular risk. Far-
inatti et al. (11) assigned young men with low flexibility levels
to ASTE that consisted of 3 active static stretches (3 sets per
exercise with 30-second ST length) for the trunk and ham-
strings. Significant increases in SDNN and RMSSD were
noted after ST at 30 minutes after intervention. Farinatti
et al. (11) also reported that HR decreased after ST, which
led these investigators to the conclusion that an increase vagal
tone may have been responsible for the reduction in HR in
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Journal of Strength and Conditioning Research | www.nsca.com

the postintervention period. Decreases in HR 15–

60 minutes after acute active static ST have been pre-

[HF at 15 min after stretching

viously reported in normotensive young women (29).

[HF at 5 min after stretching

30 s between sets, YHR and [SDNN [RMSSD

[SDNN and [RMSSD at 1

at 30 min after stretching

No significant changes at
10 min after stretching

0 min after stretching

Previous work has demonstrated that active static ST
activates type III fiber mechanoreceptors, which leads to
the inhibition of parasympathetic discharges and
Findings

increase in sympathetic activity (10,32), thereby con-

tributing to an increase in HR during active static ST and
the early recovery period after ASTE (8,11,29). Thus, it
seems that 15 minutes is enough time for sympathetic
recovery and vagal reactivation after ASTE, leading to
decreases in HR.
1 min between

Contrary to the previously mentioned findings, Silva

*HF = high frequency; SDNN = SD of normal R-R intervals; RMSSD = root mean square of successive differences; NR = not reported.
Rest period

exercises

et al. (38) reported no significant changes in HR or HRV

30 s

60 s

40 s

NR
indices 10 minutes after ASTE in young trained men. A
possible explanation for the discrepancy is that the vol-
ume of work completed during this ST intervention was
not sufficient to produce significant changes in auto-
exercises exercise Duration

nomic function at 10 minutes after intervention. This

30 s

30 s

60 s

30 s

NR

notion is supported by the difference in ST exercises

and sets per exercise (1 ST exercise, 2 sets of 30 seconds
TABLE 1. Studies that have evaluated the effects of acute stretching on heart rate variability (HRV).*

No. of Sets per

in length) in the study by Silva et al. (38) compared with

NR

other studies (Table 1) (11,18). Thus, higher volume

3

active ST protocols might elicit greater cardiovagal in-

creases after intervention. Another potential reason for
NR

the contrasting findings by Silva et al. (38) may be the

3

study population, as young trained individuals may

require a significant higher volume of ST to elicit signif-
Static passive
Static active

Static active

Static active

Static active
stretching

icant autonomic changes when compared with other

Type of

untrained populations used on previous ST studies

(11,18). Nevertheless, this notion is somewhat specula-
tory because HRV responses to a higher volume ASTE in
trained individuals have not been evaluated to date.
of rest

of rest
protocol
Control

30 min

20 min
10 Resistance trained None

32 Untrained men and None

None

To the best of our knowledge, only one study has

examined the acute effects of passive ST on HRV. Inami
et al. (19) evaluated HRV at rest, during and within 5 mi-
acute myocardial

pregnant women
flexibility levels
men with low
Characteristics

20 Untrained men
women with

trained men

nutes after passive ST in healthy young men. Participants

infarction

Resistance

Untrained

performed five 1-minute sets of static passive ST to the

calf muscles in healthy young men. The results of this
investigation showed increases in HF power during and
5 minutes after passive ST. Therefore, it seems that unlike
active static ST, the response during passive ST is char-
8

15
Age (y) n

acterized by a shift to a parasympathetic activity-

dominant state. This result indicates the possibility that
23

66

19

22

29

the process differs between active and passive stretches,

although the response after the completion of ASTE is
Logan and Yeo (27)

similar for both. It is difficult to identify the mechanisms

Farinatti et al. (11)

Hotta et al. (18)

Inami et al. (19)

responsible for the difference between autonomic re-

Silva et al. (38)

sponses during active and passive ST from the current

literature. However, nontarget muscle contraction might
be considered as a possibility for the increase sympa-
Study

thetic activity during active ST (1), which is not seen

during passive ST (Figure 1). Future studies should aim
at evaluating these mechanisms.

VOLUME 00 | NUMBER 00 | MONTH 2019 | 3

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 ST and CAF

were reported after ST training.

Of note, LF power or other
markers of sympathetic modu-
lation were not evaluated on
this previous study. Hence,
Mueck-Weymann et al. (31)
concluded that the reductions
in SVbal after daily ST in this
cohort may be partially ex-
plained by an increase in cardio-
vagal modulation. Contrary to
these findings, a study by Gerage
et al. (13) found no changes in
resting HRV parameters in
elderly women after 12 weeks
of ST training 2 times a week.
These investigators compared
elderly women performing 2 dif-
ferent exercise modalities, ST and
resistance. The training sessions
lasted 25–30 minutes and
included active ST exercises for
Figure 1. Schematic representation of heart rate responses to an acute session of active static stretching (A) and both upper- and lower-body
passive static stretching (B). Nontarget muscle contraction during active static stretching may cause increases in
sympathetic activity ([SA) and decreases in parasympathetic activity (YPA), leading to significant (*) increases in muscle groups. For each ST exer-
heart rate, which recovers and decreases below baseline during the recovery period. A passive stretching session cise, the muscle was held at the
is characterized by a progressive [PA, leading to significant decreases in heart rate in the early recovery period. maximal stretched position for 20
However, heart rate and the cardiac autonomic responses to passive static stretching beyond 5 minutes of the
recovery period remain uncertain (?). seconds. The discrepancy
between the studies might be
related to the role of aging on
the reduction of HRV or a lower
Effects of Stretching Training on Heart Rate Variability frequency of ST training. Compared with adults aged between
The effects of ST training on HRV have been assessed after 40 and 60 years, older adults have lower cardiovagal baroreflex
4- to 12-week interventions in healthy individuals and in sensitivity (30) due to increased central arterial stiffness (28). Pre-
populations that exhibit heightened risk of developing vious studies have demonstrated improvements in HRV after 6
cardiovascular diseases (Table 2). Some studies have re- months (26) but not after 8 weeks of aerobic training for older
ported improvements in both time- and frequency-domain adults (36), suggesting that longer training periods are required to
parameters. In obese postmenopausal women, our group improve HRV in older adults. Another possible reason for the
(44) used 8 weeks of static ST 3 times a week that consisted controversial findings could be related to the length of the ST
of a combination of 18 active and 20 passive stretches for the exercises, as 20 seconds per exercise was used by Gerage et al.
whole body. The ST was held for 30 seconds at the point of (13), which is below the 30 seconds in length recommended by
maximal exertion, or range of motion, without the partici- the American College of Sports Medicine (41) and the time used
pant experiencing major discomfort or pain. In this study, by previous studies (Table 2). This shorter ST exercise length
certified trainers pushed or pulled a specific body part until may have contributed to a decrease training volume in the study
they received verbal acknowledgment that the stretch was by Gerage et al. (13) compared with other studies (31,44) and
felt at maximal exertion for 30 seconds. Each stretch was hence the lack of changes in HRV parameters.
followed by a 15-second relaxation period. After ST training, To the best of our knowledge, only 2 studies have
there were significant improvements in frequency-domain evaluated the changes in R-R intervals after ST training.
parameters such as increases in HF nu power and decreases Gerage et al. (13) found no significant changes in R-R inter-
in LF nu power and LF nu/HF nu. There were also im- vals after 12 weeks of ST training in elderly women. This
provements in time domain reflected by increases in Ln observation is similar to that previously reported after 8
RMSSD. Similar improvements were demonstrated by weeks of ST training in obese postmenopausal women by
Mueck-Weymann et al. (31) after ST training in young male our group (44). Although the R-R interval was not reported
bodybuilders. In this particular study, participants performed in the previous study, there were no significant changes in
15 minutes of static ST exercises daily for a period of 4 weeks. resting HR. By contrast, the previous work by Mueck-
Significant decreases in LF/HF and increases in RMSSD Weymann et al. (31) found decreases in resting HR after 4
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Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.

TABLE 2. Studies that evaluated the effects of ST training on heart rate variability (HRV).*

Study Age (y) n Characteristics Duration (wk) Frequency Control protocol Type of ST ST protocol Findings

Mueck-Weymann 28 15 Healthy male 4 Daily None Static 15 min of ST after YHR, YLF/HF,
et al. (31) bodybuilders bodybuilding routine. [RMSSD,
No other protocol and [PNN50
details were reported.
Gerage et al. (13) 66 14 Untrained elderly 12 2 3 week None Static 25–30 min of active ST. No significant
women 2 sets per exercise. changes
20-s length per exercise. were reported.
15-s rest period between
sets and 30 s between
exercises. Number of
exercises was not reported.
Wong et al. (44) 57 12 Untrained obese 8 3 3 week No changes in Static 50 min of ST. YLFnu, [HFnu,

Journal of Strength and Conditioning Research

the
postmenopausal lifestyle during the 18 active and 20 YLFnu/HFnu,
women study period passive exercises. YLnLF/LnHF. and
1 set per exercise. [LnRMSSD
30-s length per exercise
15-s rest period.

*ST = stretching; RMSSD = root mean square of successive differences; PNN50 = the percent of differences of adjacent R-R intervals over 50 ms; LF = low frequency; HF = high
frequency; LF/HF = LF to HF ratio; nu = normalized units; Ln = natural logarithm.
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5
 ST and CAF
Figure 2. Schematic representation of the potential mechanisms for the improvement in heart rate variability by (NO) levels. Findings from pre-
stretching training.
weeks of ST training in young male athletes. Decreases in
the resting HR with training in postmenopausal women
seem to be influenced by exercise intensity because
light-intensity interventions, either aerobic or resistance
(12,39), have had no effect on resting HR in postmenopausal
women. Therefore, the lack of changes in HR after ST train-
ing in postmenopausal women (13,44) reinforces the idea
that light-intensity interventions do not change resting HR
or R-R intervals in older populations.
Potential Mechanisms for the Improvement in Heart Rate
Variability by Stretching Training
The potential mechanisms underlying the effect of ST
training on HRV are not completely understood (Figure 2).
One possibility is an improved baroreflex sensitivity (6,22).
Certainly, evidence suggests that acute passive ST augments
baroreflex control of HR (10). Although aortic stiffness is an
important determinant of the reduced cardiovagal baroreflex
sensitivity in older adults (28), the effects of ST on arterial
stiffness are controversial. A previous study demonstrated
a decrease in arterial stiffness after ST in middle-aged
healthy men (33). On the contrary, we previously reported
decreases in aortic mean blood pressure and vascular sym-
pathetic activity—LF of blood pressure variability—but not
arterial stiffness after 8 weeks of ST in obese postmenopausal
women (43). Those findings suggested that ST may improve
autonomic activity by reducing mean blood pressure, the
distending pressure on the arterial wall that influences arte-
rial stiffness. Another potential mechanism for a shift toward
cardiovagal dominance is the psychic-physical relaxation
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response, a hypometabolic
state that is caused by an inte-
grated hypothalamic response
characterized by a decrease in
sympathetic activity (2). The
physiological effects of that
response include a reduction in
oxygen consumption, HR,
blood pressure, and respiratory
rate. Stretching has been shown
to cause the physiological ef-
fects of the relaxation response
(4,31,43). Furthermore, previous
literature has indicated ST as
a relaxation procedure (4,5).
Therefore, we can speculate
that relaxation could be one of
the mechanisms involved in the
decreased SVbal after ST.
Another potential mechanism
could be a rise in nitric oxide
vious investigations suggest that
NO may play a role in CAF by
increasing parasympathetic and
reducing sympathetic activity (7,17,45). Stretching exercises
have been shown to increase NO-dependent vasodilation
acutely, while improving cardiovagal control in patients with
acute myocardial infarction (18). Hence, it is possible that the
connection between ST training and the increases in cardio-
vagal activity is mediated, at least in part, by NO.
DISCUSSION
Overall, the findings to date imply that ST training exerts
a positive influence on resting HRV through increasing
vagal modulation and decreasing sympathetic tone. Yet, the
mechanisms mediating the improvement of HRV by ST
training are currently unknown. Some evidence suggests
that baroreflex sensitivity, psychic-physical relaxation
response, and NO may play mediating roles. Further
research is needed to evaluate the effects of extended
periods (.12 weeks) of ST training on resting HRV to
warrant its clinical usefulness. Research findings suggest
that during passive ST, there is an increase in parasympa-
thetic activity, while active ST is characterized by increase
in sympathetic activation. However, the cardiac autonomic
response after the completion of ST is similar for both
active and passive exercises, which is characterized by
acute increase in vagal reactivation during the early recov-
ery period, resulting in lower postexercise HR compared
with levels observed during inactive recovery. Finally, cur-
rent literature has only focused on static ST. Studies evalu-
ating CAF to other types of ST, such as dynamic and
proprioceptive neuromuscular facilitation ST, are lacking;
thus, further research is warranted.

PRACTICAL APPLICATIONS
This research supports the improvement of resting CAF in
different populations with static ST training programs,
$33 week with $30 seconds of length per ST exercise. This
review also illustrates how different ST modalities acutely
result in diverse cardiac autonomic responses during ST.
Taking into consideration that there is a progressive increase
in parasympathetic activity during passive ST and its early
recovery period, exercise professionals should emphasize the
use of passive ST exercises on regimens in individuals with
augmented SVbal who may have cardiovascular and meta-
bolic risk factors. On the other hand, active static ST exer-
cises should predominate on regimens tailored toward those
individuals with normal SVbal. The positive benefits of
ASTE and training on CAF cannot be overlooked. However,
it is evident that there is a need for further research using
a variety of populations and longer periods of ST training.
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