Flexibility for Improved Physiology and Health

The ability to bend without breaking is a powerful skill applicable to many areas of life. At the most basic body level, flexibility may help people keep moving, avoid injury, and maintain their ability to perform the physical activities that they enjoy and that support health and wellness. Workout activities that promote both flexibility and balance such as Pilates, dance, and stretching can positively impact several areas of health, including musculoskeletal health. Research studies suggest that they may also help to improve cardiovascular, cognitive, and mental health.^1-3 A range of movement and exercise programs may be appropriate for patients depending on their medical situation, personal preferences, and health goals. How might patients benefit from incorporating flexibility and balance training into their daily routine or treatment strategy?

Pilates and Stretching

Pilates is a mind-body training that addresses flexibility and balance; helps to improve postural alignment, core strength, and mobility function; and may benefit chronic pain conditions. A 2022 systematic review of seven studies (n=397 participants) found that compared to other relevant exercises, Pilates was significantly effective at reducing back pain, neck pain, and pain associated with knee osteoarthritis and osteoporosis.⁴ Specific to chronic low back pain, a 2022 network meta-analysis of randomized controlled trials (n=9,710 subjects) found that while most of the included exercise interventions showed pain management benefit, the most effective interventions for reducing pain were Pilates, mind-body, and core-based exercises.⁵ In fact, after quantitative ranking analysis, Pilates showed a 93% and 98% likelihood for reducing pain and disability associated with low back pain.⁵ 

Pilates training continues to be studied for a range of other health-related benefits. In addition to its potential for improving balance and helping to reduce fall risk in older adults,⁶ Pilates has most recently been highlighted for several positive health effects, including the improvement of:

• Sleep quality in older adults.⁷
• Depression symptoms in patients with multiple sclerosis⁸ and in older women.³
• Functional mobility and balance performance in patients with Parkinson’s disease.⁹
• Vascular function and blood pressure in populations at risk for hypertension.^10-12

Exercise programs focused specifically on active and passive stretching have also been studied for their health benefits. A 2020 meta-analysis of clinical trials (n=213 participants) suggested that muscle stretching exercises may reduce arterial stiffness and improve vascular endothelial function.¹³ The stretching exercise interventions included in this analysis extended between four and 12 weeks, with session durations and frequencies ranging from 15 to 60 minutes per stretching session, three to seven times per week.¹³ Mechanisms by which stretching improves cardiac autonomic function continue to be clarified. Evidence indicates that increases in baroreflex sensitivity, relaxation, and nitric oxide bioavailability may all play important roles.¹⁴

A 2022 meta-analysis of 18 randomized controlled trials (n=1,184 subjects) investigated the effect of aerobic, resistance, and stretching exercises on pain, depression, and quality of life for patients with fibromyalgia.¹⁵ Among the positive effects of these treatment approaches, stretching exercises were found to reduce pain perception and improve patients’ health-related and overall quality of life.¹⁵ Another chronic pain–related meta-analysis evaluated the effectiveness of stretching exercises on reducing pain associated with knee osteoarthritis.¹⁶ Eighteen randomized controlled trials (n=1,250 participants) were included in the analysis, and overall, per visual analogue scale measurements, stretching exercises significantly reduced osteoarthritis pain in patients.¹⁶

Balance and Ballet

Research studies suggest that different forms of aerobic dance benefit heart and brain health.^17,18 Both balance and flexibility may also improve when engaging in dance therapies. A 2020 meta-analysis of 29 randomized controlled trials found that for older healthy adults, dance-based mind-motor activities were significantly associated with improved balance, mobility, and lower body strength.¹⁹ Further, researchers found a statistically significant 37% reduction in fall risk and a statistically significant 31% reduced rate of falls with these interventions.¹⁹

Ballet is one form of dance that can be practiced at all ages that emphasizes posture, flexibility, and balance. A 2020 systematic review investigating classical ballet training interventions lasting four weeks or longer found that for novice dancers, balance showed the greatest positive change among reported physical outcomes, with 75% of the included studies reporting improvement.²⁰ The benefit of dance therapies, primarily ballet and tango, for stroke patients was evaluated in a 2022 systematic review of eight studies.²¹ While the heterogeneity was high for the included studies, results indicated an overall positive effect of dance therapy on post-stroke body functions such as gait and balance.²¹

Beyond the scope of specific dance modalities, the health benefits of balance training and core conditioning continue to be studied as essential components of comprehensive exercise programs. As an important example, a recent retrospective study that included 453 Veterans (mean age of 67 years; 94% male; 43% white and 50% Black participants) examined the changes in prescription medication utilization after 12 months (three days weekly) of supervised exercise as part of the Veterans Affairs Gerofit Exercise Program.²² This program includes a personalized routine of aerobic, strength, balance, mind-body, and core support training. In the studied cohort, the supervised exercise was associated with reductions in medication usage. Compared to baseline levels, investigators noted the net changes of 33% decrease in both opioids and mental health medications, 38% decrease in cardiac medications, 14% decrease in diabetes medications, and 17% decrease in lipid-lowering medications.²²

Conclusion

In the functional medicine model, modifiable lifestyle factors such as physical activity are essential chronic disease intervention components. Exercise routines and increased movement specifically contribute to improved physiological fitness, and research continues to emphasize the importance of musculoskeletal health and maintaining muscle flexibility for optimal physical function.

Exercise prescriptions that focus on flexibility and balance are among those functional medicine strategies that may be appropriate for a patient’s treatment or prevention plan. These activities can easily fit into therapeutic interventions, and they can be fun for the patient. Personalizing treatments by aligning exercise programs with a patient’s preferences and goals helps patients achieve sustainable health improvements and positive lifestyle change. The IFM Toolkit offers practitioners a wide range of tools and resources, including those specific to exercise, from setting exercise goals and tracking treatment progress to tips for increasing daily movement and sustaining an active lifestyle to resources for wearable fitness devices.

Many different types of physical activities, from stretching to Pilates to high intensity training,²³ are all beneficial for heart health. At IFM’s upcoming Cardiometabolic Advanced Practice Module (APM), learn more about the latest research on cardiovascular and metabolic health and those exercise treatment strategies that effectively address chronic cardiovascular diseases and risk factors.