Journal of Bodywork & Movement Therapies 24 (2020) 15e20

Contents lists available at ScienceDirect

Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Prevention and Rehabilitation

A randomized clinical trial for the effect of static stretching and

strengthening exercise on pelvic tilt angle in LBP patients
MohammadBagher Shamsi, Ph.D. a, Soodeh Shahsavari b, Ameneh Safari c,
Maryam Mirzaei d, *
a
Rehabilitation and Sport Medicine Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
b
Health Information Management Department, Faculty of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
c
Research Management Office, Faculty of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
d
Faculty of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran

a b s t r a c t
Keywords: Background: Stretching and strengthening exercises are commonly used to improve muscle shortness of
Low back pain the hamstring as any tension in this muscle can have an effect on the pelvic posture. Thus, the aim of this
Pelvic tilt
study was to evaluate the effects of two methods of improving short hamstring on the angle of pelvic tilt
Hamstring
in LBP sufferers.
Methods: Forty-five low back pain patients aged 19e59 years with hamstring tightness participated in
this clinical trial. The patients were categorized randomly into three groups: 1- static stretching, 2-
strengthening exercise and 3-control group. The two intervention groups received physical therapy
and special exercise program thrice a week in a total of 12 sessions, while the control group received only
conventional physical therapy. Before and after the treatment implementation, the pelvic tilt and straight
leg raising (SLR) degree were assessed for each group.
Result: After 12 sessions of treatment, the ANCOVA models indicated non-significant differences in pelvic
tilt angle and SLR score changes (p > 0.05), among the three groups. In addition, no statistically signif-
icant correlation was observed between the pelvic tilt and SLR test [except for the strengthening exercise
group (Pearson correlation coefficient ¼ 0.54, P < 0.05)].
Conclusions: In LBP sufferers, both static stretching and strengthening of hamstring muscle in its
lengthened position caused elongation and extensibility in the hamstring muscle and increased SLR test
score, but did not change pelvic tilt angle.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction The angle between the horizontal plane and line which passes
through the midpoint of the posterior superior iliac spine and
Four muscle groups including erector spinae, hamstrings, ab- midpoint of the anterior superior iliac spine is the pelvic tilt angle
dominals and hip flexors, support and hold the pelvis in its natural (Marques et al., 2018; Walker et al., 1987). Excessive anterior pelvic
alignment. Their forces on the pelvis are balanced (Kendall et al., tilt has been regarded as undesirable because this change in
2005; Narouei et al., 2018; Rockey, 2008). Any imbalance in these movement pattern may cause excessive loading on back tissues and
muscles or change in posture can make the pelvis tilt anteriorly or lead to low back pain (LBP) (Norris and Matthews, 2006).Therefore,
posteriorly, and the anterior tilting is mostly due to weakened and it is thought that either bad static posture (change in body align-
lengthened hamstring muscles (Ghare et al., 2018; Kendall et al., ment) or impaired dynamic posture (alteration of back motor
2005; Nguyen and Shultz, 2007). control) is a common risk factor for LBP (Norris and Matthews,
2006). The origin of hamstring is ischial tuberosity of the pelvis;
thus, any tension in this muscle can have an effect on the pelvic
posture (Congdon et al., 2005). The pelvis is regarded as the base for
* Corresponding author. the vertebral column, and any deviation in it can cause a change in
E-mail addresses: [email protected] (M. Shamsi), soodeh_shahsavari@
pelvis alignment (Delisle et al., 1997; Iyer et al., 2018).
yahoo.com (S. Shahsavari), [email protected] (A. Safari), maryam.
[email protected] (M. Mirzaei). In forward trunk bending, there is coordination between back

https://doi.org/10.1016/j.jbmt.2020.02.001
1360-8592/© 2020 Elsevier Ltd. All rights reserved.
16 M. Shamsi et al. / Journal of Bodywork & Movement Therapies 24 (2020) 15e20

extensor muscles (erector spinae) and the hip extensor muscles eligible patients who had chronic non-specific LBP (LBP without
(glutei and hamstrings). This coordination causes a combined definite cause for more than three months), were enrolled in this
movement of lumbar flexion and pelvic rotation which is called the trial from April 2016 to August 2017. The eligibility criteria were as
lumbopelvic rhythm (Norris and Matthews, 2006). Because follows: 1. Subjects with LBP for more than 3 months; 2. pain
hamstring originates from the ischial tuberosity of the pelvis, poor intensity from 3 to 6 according to the visual analogue scale (VAS);
flexibility of this muscle can restrict anterior pelvic tilt and, 3. Subjects with hamstring muscle shortness in SLR test; 4. Age
therefore, restrict forward bending, too. In this case, hamstring between 18 and 60 years. History, imaging and clinical tests (pain
restriction may be compensated for by an increase in lumbar provocation tests) were used to define participants as chronic LBP.
flexion and consequently predispose LBP (Deguzman et al., 2018; Subjects were excluded if they had any pathology or anomaly in
Esola et al., 1996; Norris and Matthews, 2006). Based on these the lower limbs such as neuropathic pain, malignancy, inflam-
biomechanical concepts, there is a relevance between hamstring matory diseases, severe osteoporosis, arthritis and/or bone
muscle length and pelvic tilt range (Kendall et al., 2005; Mohamed diseases.
et al., 2002). At the beginning of the study, participants signed a written
Stretching is commonly used to improve muscle shortness. informed consent. Additionally, both participants and the ther-
Static stretching, which is based on a slight stretch in the muscles apist were not aware of the group assignment during the
while maintaining the joint in its end-range of position is well experimental period. The therapists were different from the main
accepted for treatment (Deguzman et al., 2018; Walker et al., researcher.
1987).
In response to strengthening exercise, the length in which the 2.3. Outcome measures
muscle is contracted is important. Some authors also believe that
stimulating a muscle to be contracted in such a joint position, At the baseline and end of the study, pelvic tilt angle and passive
while, the muscle is in its lengthened position can be effective in SLR degree were measured.
making structural changes in the muscle, and unlike stretching,
changes developed by this method are long lasting (Norris and 2.4. Pelvic tilt angle
Matthews, 2006). Thus, the aim of this study is to define how
these two methods of improving short hamstring (static Pelvic tilt angle was measured using an inclinometer (INSI-
stretching (SS) and strengthening of hamstring muscle in its ZE.CO.LTD) that was placed over the patient's sacrum. While the
lengthened position (SLP)) in chronic non-specific LBP sufferers patients were in the relaxed standing position, the upper edge of
can affect the pelvic tilt, and assess the relationship between the inclinometer was aligned with the line joining the patient's
hamstring length (assessed by straight leg raising test) and the posterior superior iliac spines (Fig. 2). To make and maintain the
angle of pelvic tilt. These two interventions (SS and SLP) were junction, an inclinometer was pressed tightly against the body.
selected because static stretching is a common treatment used by
strength and conditioning specialists and athletes to increase 2.5. Passive SLR score
muscle length (Lopez-Minarro et al., 2012), wherase SLP is a new
proposed method that should be evalutaed (Aquino et al., 2010). Participants were positioned in a supine position with the hip
Pelvic tilt and straight leg raising test (SLR) changes were eval- joint in 0 of flexion. The thigh was secured to the table by a Velcro
uated at baseline and at the end of the trial as the primary strap. An inclinometer (INSIZE.CO.LTD) was placed over the distal
outcomes. tibia and the subject's leg was elevated passively, making the hip
more flexed. While the leg was being raised, the knee was kept
2. Materials and methods straight. The pelvis was fixed using a Velcro strap. At the point of
maximum hip flexion, the maximum angle (degree) read from the
2.1. Design inclinometer was defined as the SLR score (Fig. 3).
All testing procedures for both Pelvic tilt and SLR were repeated
The sample size was computed based on the data from the three times and the mean of the three repetitions was used for data
previous study. With a 95% confidence level, 80% statistical power analysis. The intra-rater reliability of the recorded data was
and angle of pelvic tilt as a key factor, at least 15 patients per group assessed using the Intra-class Correlation Coefficient (ICC) for each
were chosen and recruited into this randomized clinical trial test.
(Borman et al., 2011). The ICC (95% CI) was 0.78 (0.65e0.86) and 0.91 (0.90e0.97) for
As a following step, after receiving the ethical approval of the pelvic tilt and SLR test, respectively.
study protocol (code: kums.rec.1394.26) from the ethics committee
of Kermanshah University of Medical Sciences and registering it in 2.6. Intervention
the Iranian Registry of Clinical Trials (IRCT)
(ID:IRCT201507258035N2), the selected patients were randomly Forty-five subjects (31 men and 14 women; mean age
allocated to either the control or intervention groups, including: (1) 38.80 ± 11.14) in all the groups received common interventions
SS: n ¼ 15 patients, (2) SLP: n ¼ 15 patients and (3) Control with no including 15 min of heat therapy (hot pack), 15 min application of
specific intervention: n ¼ 15 patients, through random blocks transcutaneous electrical nerve stimulation (TENS) to low back
strategy (Fig. 1). Moreover, to conceal treatment assignment, the area, and the common use of exercises for back pain for 12 sessions,
randomized allocation and assignment of patients to the groups three times per week; however, the intervention groups (SS and
was conducted by an expert statistician not involved in the trail SLP) received extra specific treatments.
(blinding). In the SS group, while the participants were in a lying position
with the knee fully extended, a passive stretch was applied on the
2.2. Participants hamstring by a spring (Fig. 4).
In the SLP group, participants were seated on a chair with their
Through a convenience sampling schedule at a physiotherapy thighs being supported on a surface which kept the hip joint in 120
clinic of Kermanshah University of Medical Sciences, Iran, 45 of flexion as well as the knee joint in full extension. They tried to
 M. Shamsi et al. / Journal of Bodywork & Movement Therapies 24 (2020) 15e20 17

Fig. 1. Flow diagram of the study.

Fig. 3. Passive straight leg raise score measurement.

Fig. 2. Pelvic tilt angle measurement.

analysis of variance (ANOVA) for categorical and continuous vari-

extend their hip against a spring and contract the hamstring ables, respectively.
muscle. The other hip and knee joint was kept flexed at 90 (Fig. 5). Analysis of covariance (ANCOVA) was used to compare the three
groups for the measures at the end of the study, adjusting for the
2.7. Data analysis baseline measures.
Moreover, a paired t-test was performed to evaluate within-
Statistical analyses were performed using SPSS software, group changes in baseline and end of measurements.
version 21.0 (SPSS Inc., Chicago, IL, USA), and all of the p-values In order to investigate the correlation between pelvic tilt and SLR
smaller than 0.05 were considered statistically significant. score, the Pearson correlation test was performed (after checking
Possible differences in baseline measurements among the three normality of data distribution by Kolmogorov-Simrnov test).
groups were assessed using the Chi-square test and one-way
18 M. Shamsi et al. / Journal of Bodywork & Movement Therapies 24 (2020) 15e20

presented in Table 2. Mean differences (95% CI) of the SLR test

scores for SS, SLP, and control group were 7.79 (2.90e12.67),
7.45(3.19e11.70) and 11.33 (4.10e18.56), respectively.
Within group analysis using paired t-test revealed that in the
three groups, changes in the mean values of the SLR scores after the
intervention were statistically significant (P < 0.001 for all groups).
In contrast, the within group comparison showed no significant
change in pelvic tilt at the end of the study (p > 0.05- paired t-test).
The results showed a weak negative correlation between SLR
score and pelvic tilt angle in the three groups (Table 3), and this
correlation is significant only for SLP group in the post-intervention
step (Pearson correlation coefficient ¼ 0.54, P < 0.05).

4. Discussion

Fig. 4. Static stretching exercise.

The main aim of the present study was to evaluate the effects of
two types of intervention for elongating short hamstring muscle on
pelvic tilt angle and SLR test score (both using an inclinometer) in
patients with LBP, and to investigate the correlation between these
two measures.
After 12 sessions of treatment, only SLR test score improved in
all three groups. The changes made in pelvic tilt angle and SLR score
after the intervention were not different among the three groups.
There was a correlation between SLR score and pelvic tilt angle in
the post-intervention step only for SLP group.
According to the literature, reliability of the SLR test is higher
than 0.9, and this test is commonly used to evaluate hamstring
flexibility (Boyd, 2012).
The results obtained from several studies on the effects of static
stretching and strengthening exercise on improvement in short-
ness of hamstring muscle are consistent with the current study.
Czaprowski observed that after 6 weeks of exercise program, the
two different physiotherapy techniques (post-isometric relaxation
and static stretching combined with stabilizing exercises) both led
Fig. 5. Hamstring strengthening exercises in lengthened position. to improvement in the SLR result (Czaprowski et al., 2013). Ramesh
showed that muscle energy technique (post-isometric relaxation
technique- PIR) made hamstring muscle more significantly flexible
3. Results than ultrasound therapy with active static stretching and passive
static stretching in patients with hamstring tightness (Ramesh and
Characteristics of the patients are shown in Table 1. As observed, Sivasankar, 2014). The intervention of PIR in this study is somehow
there were no significant differences between the characteristics of like SLP in our study, but PIR caused more improvement than static
the groups with regards to age, body mass index, weight, height stretch unlike our results showing no difference which may be due
and gender (all p > 0.05). The mean values of the SLR test and pelvic to more effects of PIR (passive muscle lengthening after submaxi-
tilt score in the pre and post-interventions for each group are mal contraction).
shown in Table 2. In this study, baseline measurement of the study Many studies have investigated the relationship between
variables (pelvic tilt and SLR scores) was adjusted, and the results of hamstring extensibility and pelvic tilt. Bellew showed a strong
the ANCOVA showed that changes in these variables were accom- correlation between hamstring extensibility and pelvic rotation
panied by no statistically significant difference among the three during trunk flexion with knees extended (Bellew et al., 2010).
groups (p > 0.05 for all of them). However, Norris and Matthews in their study on a student popu-
Moreover, the mean difference in the study variables between lation, reported no association between hamstring muscles
the baseline and end of the intervention for each group, is extensibility and pelvic tilt, but in this study the angle of pelvic tilt

Table 1
Baseline characteristics of the LBP patients in each group.

Groups Static Stretch (n ¼ 15) Strengthening Exercise (n ¼ 15) Control (n ¼ 15) p-value

Age(year) 37.67 (8.96) 37.07 (13.39) 39.12 (11.61) 0.823a

Height (cm) 171.93 (13.21) 172.64 (10.14) 172.31 (10.14) 0.995a
Weight (kg) 76.57 (13.05) 81.54 (16.59) 80.91 (14.1) 0.883a
BMI (kg/m2) 25.90 (3.15) 26.82 (4.21) 27.47 (3.17) 0.535a
Sex
Female 5 (33.3) 4 (26.7) 5 (33.3) 0.726b
Male 10 (66.7) 11 (73.3) 10 (66.7)

BMI: Body Mass Index/Data are means (SD) except sex that presented as number (percent)/.
a
Based on on-way ANOVA test/.
b
Based on chi-square test.
 M. Shamsi et al. / Journal of Bodywork & Movement Therapies 24 (2020) 15e20 19

Table 2
Results of variables measurements (pelvic tilt and SLR test) of low back pain patient before and after intervention and between three groups.
a
Variables Measurement period Static Stretch (n ¼ 15) Strengthening Exercise (n ¼ 15) Control (n ¼ 15) P value

Pelvic tilt Before 71.73 (5.43) 70.88 (6.59) 70.78 (4.56) 0.519
After 71.67 (5.85) 71.54 (6.87) 69.77 (5.5)
MD (95% CI) 0.12 (-2.46 to 2.23) 0.67 (-2.09 to 3.42) 1.17 (-3.75 to 1.41)
b
P value 0.061 0.087 0.151
SLR test Before 73.76 (8.25) 74.76 (8.25) 69.28 (13.77) 0.920
After 80.87 (9.71) 80.86 (9.72) 79.24 (10.09)
MD (95% CI) 7.79 (2.90e12.67) 7.45 (3.19e11.70) 11.33 (4.10e18.56)
b
P value 0.004 0.002 0.005

Mean (SD) was reported/MD (95% CI): mean difference and 95% confidence interval/SLR: straight leg raising/
a
P value is reported based on the analysis of covariance (ANCOVA/between-group changes) and adjusted for baseline values/
b
P value is reported based on the paired t-test (within-group changes).

Table 3 SLR and pelvic tilt. More studies investigating the effects of different
Correlation between Pelvic tilt and SLR test.
kinds of hamstring exercises on pelvic tilt are recommended.
Group r (before) p-valuea r (after) p-valuea Limitations of the study: We should take human error with the
Static Stretch (n ¼ 15) 0.27 0.296 0.32 0.253 minimal changes/results pre and post study into consideration.
Strengthening Exercise (n ¼ 15) 0.21 0.489 0.54 0.041 Also, hamstring muscle length is not measured directly and indirect
Control (n ¼ 15) 0.18 0.505 0.10 0.740 methods such as angular measurements of unilateral hip flexion
Pearson correlation coefficient (r) was reported/. with the knee extended [straight leg raise (SLR)] or unilateral knee
a
Based on the Pearson correlation test. flexion after knee extension with the hip flexed to 90 (active knee
extension test) are used (Gajdosik et al., 1993). SLR is a nerve root
was measured during trunk forward bending (Norris and test and active knee extension test is a specific hamstring muscle
Matthews, 2006). There is a belief that in those with greater length test. Though, active knee extension test may be better for
hamstring extensibility, during doing trunk flexion with knees assessment, difficulty to do this test increases the tendency to do
extended, there is a tendency towards greater anterior pelvic tilt. SLR test.
However, studies supporting this idea are cross-sectional type in
design and do not include an intervention (Lopez-Minarro et al., 5. Conclusions
2012). Borman reported that 4 weeks of hamstring stretching in
either sitting or standing position increased muscle length but, it For LBP sufferers, both static stretching and strengthening of
did not cause a change in lumbar curvature. (Borman et al., 2011). hamstring muscle in its lengthened position caused elongation and
Therefore, his results are in line with our study in that the inter- extensibility in hamstring muscle and increased SLR test score, but
vention only changed the muscle length and not the pelvic tilt. did not change pelvic tilt angle. So, both of these interventions can
Lo
pez-Min ~ arro in his study found that, improvement of extensi- be used for clinical purposes on the tightened hamstring muscles.
bility of hamstring had no effect on pelvic tilt, neither in the
standing nor in maximal trunk flexion in sitting position and Declaration of competing interest
keeping knees flexed at 90 . He concluded that static stretching of
the hamstring muscle caused only immediate changes in lumbar The authors have no conflict of interests.
lordosis and pelvic tilt angle (Lopez-Minarro et al., 2012). This study
is in agreement with ours that static stretching of hamstring had no Acknowledgments
effect on pelvic tilt (in our study the improvement of extensibility of
hamstring was not correlated to pelvic tilt angle in SS group). This The authors thank the Kermanshah University of Medical Sci-
study only investigated acute effects of stretching in one session, ences for grants to support this research. They also thank the par-
unlike the current study that was conducted in a period. ticipants of the study for their time and dedication.
There is a controversy regarding the relationship between
hamstring muscle length (and extensibility) and pelvic tilt angle. References
Some researchers believe that since this muscle has an attachment
on ischial tuberosity, any change in its length can affect pelvic tilt, Aquino, C.F., Fonseca, S.T., Gonçalves, G.G., Silva, P.L., Ocarino, J.M., Mancini, M.C.,
2010. Stretching versus strength training in lengthened position in subjects
whereas others doubt such kind of direct relationship. Indeed, the with tight hamstring muscles: a randomized controlled trial. Man. Ther. 15,
posterior tilting force is not limited to the hamstring as there are 26e31.
many other muscles that act in a similar way. In fact, changes in the Bellew, S., Ford, H., Shere, E., 2010. The relationship between hamstring flexibility
and pelvic rotation around the hip during forward bending. Plymouth. Stud. J.
hamstring length may only have a specified effect on pelvic rota- Health. Soc. Wrk. 19e29.
tion, i.e. it is not the only determinative factor. Borman, N.P., Trudelle-Jackson, E., Smith, S.S., 2011. Effect of stretch positions on
Anyway, the hamstring is one of the most important muscles in hamstring muscle length, lumbar flexion range of motion, and lumbar curva-
ture in healthy adults. Physiother. Theory Pract. 27, 146e154.
this regard. In the current study, only in the SLP group and especially Boyd, B.S., 2012. Measurement properties of a hand-held inclinometer during
for post-intervention step, the correlations between SLR and pelvic straight leg raise neurodynamic testing. Physiotherapy 98, 174e179.
tilt angle was significant. Because the strengthening exercise for Congdon, R., Bohannon, R., Tiberio, D., 2005. Intrinsic and imposed hamstring
length influence posterior pelvic rotation during hip flexion. Clin. BioMech. 20,
hamstring muscle was applied only in this group, it may be
947e951.
concluded that increased strength of this muscle has had an effect on Czaprowski, D., Leszczewska, J., Kolwicz, A., Pawlowska, P., Kedra, A., Janusz, P.,
pelvic tilt. The matter that a correlations between SLR and pelvic tilt Kotwicki, T., 2013. The comparison of the effects of three physiotherapy tech-
angle was not significant in other groups can be attributed to the lack niques on hamstring flexibility in children: a prospective, randomized, single-
blind study. PloS One 8, e72026.
of strengthening interventions in them. It may make sense that Deguzman, L., Flanagan, S.P., Stecyk, S., Montgomery, M.M., 2018. The immediate
strengthening this muscle causes an increase in correlation between effects of self-administered dynamic warm-up, proprioceptive neuromuscular
20 M. Shamsi et al. / Journal of Bodywork & Movement Therapies 24 (2020) 15e20

facilitation, and foam rolling on hamstring tightness. Athl. Train. Sports Health Marques, C.J., Martin, T., Kochman, A., Goral, A., Lampe, F., Breul, V., Kozak, J., 2018.
Care 10, 108e116. Pelvic tilt angle differences between symptom-free young subjects and elderly
Delisle, A., Gagnon, M., Sicard, C., 1997. Effect of pelvic tilt on lumbar spine geom- patients scheduled for THA: the rationale for tilt-adjusted acetabular cup im-
etry. IEEE Trans. Rehabil. Eng. 5, 360e366. plantation. Open Orthop. J. 12, 364.
Esola, M.A., McClure, P.W., Fitzgerald, G.K., Siegler, S., 1996. Analysis of lumbar spine Mohamed, O., Perry, J., Hislop, H., 2002. Relationship between wire EMG activity,
and hip motion during forward bending in subjects with and without a history muscle length, and torque of the hamstrings. Clin. Biomech. 17, 569e579.
of low back pain. Spine 21, 71e78. Narouei, S., Imai, A., Akuzawa, H., Hasebe, K., Kaneoka, K., 2018. Hip and trunk
Gajdosik, R.L., Rieck, M.A., Sullivan, D.K., Wightman, S.E., 1993. Comparison of four muscles activity during nordic hamstring exercise. J. Exerc. Rehabil. 14, 231.
clinical tests for assessing hamstring muscle length. J. Orthop. Sports Phys. Ther. Nguyen, A.-D., Shultz, S.J., 2007. Sex differences in clinical measures of lower ex-
18, 614e618. tremity alignment. J. Orthop. Sports Phys. Ther. 37, 389e398.
Ghare, S.D., Vijayakumar, M., Vashi, P., Shaikh, L., 2018. Pelvic tilt as a measure OF Norris, C., Matthews, M., 2006. Correlation between hamstring muscle length and
hamstring muscle flexibility sit reach test. Global J. Res. Anal. 6. pelvic tilt range during forward bending in healthy individuals: an initial
Iyer, S., Sheha, E., Fu, M.C., Varghese, J., Cunningham, M.E., Albert, T.J., Schwab, F.J., evaluation. J. Bodyw. Mov. Ther. 10, 122e126.
Lafage, V.C., Kim, H.J., 2018. Sagittal spinal alignment in adult spinal deformity: Ramesh, M., Sivasankar, P., 2014. Comparison of three different physiotherapeutic
an overview of current concepts and a critical analysis review. JBJS reviews 6, interventions in improving hamstring flexibility in individuals with hamstring
e2. tightness. Int. J. Health Sci. Res. 4, 129e134.
Kendall, F.P., McCreary, E.K., Provance, P.G., Rodgers, M., Romani, W.A., 2005. Mus- Rockey, A.M., 2008. The Relationship between Anterior Pelvic Tilt, Hamstring
cles: Testing and Function, with Posture and Pain (Kendall, Muscles). Lippincott Extensibility and Hamstring Strength. The University of North Carolina at
Williams & Wilkins, Philadelphia. Greensboro.
Lopez-Minarro, P.A., Muyor, J.M., Belmonte, F., Alacid, F., 2012. Acute effects of Walker, M.L., Rothstein, J.M., Finucane, S.D., Lamb, R.L., 1987. Relationships between
hamstring stretching on sagittal spinal curvatures and pelvic tilt. J. Hum. Kinet. lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys. Ther. 67,
31, 69e78. 512e516.