䢇

Research Report

Lengthening the Hamstring Muscles

Without Stretching Using “Awareness
Through Movement”
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Background and Purpose. Passive stretching is widely used to increase muscle

flexibility, but it has been shown that this process does not produce long-term
changes in the viscoelastic properties of muscle as originally thought. The
authors tested a method of lengthening hamstring muscles called “Awareness
Through Movement” (ATM) that does not use passive stretching. Subjects.
Thirty-three subjects who were randomly assigned to ATM and control groups
met the screening criteria and completed the intervention phase of the study.
Methods. The ATM group went through a process of learning complex active
movements designed to increase length in the hamstring muscles. Hamstring
muscle length was measured before and after intervention using the Active
Knee Extension Test. Results. The ATM group gained significantly more
hamstring muscle length (⫹7.04°) compared with the control group
(⫹1.15°). Discussion and Conclusions. The results suggest that muscle length
can be increased through a process of active movement that does not involve
stretching. Further research is needed to investigate this finding. [Stephens J,
Davidson J, DeRosa J, et al. Lengthening the hamstring muscles without
stretching using “Awareness Through Movement.” Phys Ther. 2006;86:1641–
1650.]

Key Words: Awareness Through Movement, Feldenkrais method, Hamstring, Muscle lengthening, Stretching.

James Stephens, Joshua Davidson, Joseph DeRosa, Michael Kriz, Nicole Saltzman
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Physical Therapy . Volume 86 . Number 12 . December 2006 1641

T
he hamstring muscles are important contribu- A variety of methods have been used to increase ham-
tors to the control of human movement and are string muscle flexibility, including static stretch,14 pro-
involved in a wide range of activities from prioceptive neuromuscular facilitation,15 dynamic range
running and jumping to forward bending dur- of motion,16 and active motion in the neural slump
ing sitting or standing and a range of postural control position.17 None of these methods, however, uses a
actions. Hamstring muscle strains are the most common process of active motion without pushing or holding at
muscle injuries in athletes.1 The proposed etiology end-range to achieve its intended results.
includes insufficient flexibility, strength (force-
generating capacity) impairment or imbalance, and dys- “Awareness Through Movement” (ATM) is a process of
synergic contraction that can place excessive strain on verbally guiding a person through an activity during
the hamstring muscles.2 Static stretching of the ham- which movements usually are performed slowly and
string muscles, to maintain flexibility and improve per- gently. It is thought that this process facilitates the
formance,2– 4 has been proposed as a proactive and learning of strategies for improving organization and
preventive strategy and is now in common use. Studies coordination of body movement by developing spatial
with collegiate football players5 and military basic train- and kinesthetic awareness of body-segment relationships
ees2,6 document the success of this strategy in reducing at rest and during motion, awareness of ease of move-
the rates of lower-extremity injuries. ment, reducing effort in action, and learning the feeling
of longer muscles in action.18,19 This process has been
Reduced hamstring muscle flexibility has been impli- shown to improve balance and coordination in people
cated in lumbar spine dysfunction, with a number of with multiple sclerosis20 and balance and mobility in
studies7–10 showing a strong positive correlation between people with chronic cardiovascular accident.21
decreased hamstring flexibility and low back pain. Other
researchers10 –13 have suggested that hamstring muscle There has been limited study of this approach to ham-
function in a variety of movements is part of a coordi- string muscle lengthening. Researchers in Australia
nated motor program and thus the appropriate periods found no effect of ATM on hamstring muscle length
of lengthening and shortening and perhaps even the with a very brief intervention.22,23 The purpose of our
degree of lengthening itself may be a learned part of the study was to test the hypothesis that ATM can be used
motor control process. effectively to increase the active length of the hamstring

J Stephens, PT, PhD, CFP, is Assistant Professor, Physical Therapy Department, College of Health Professions, Temple University, 3307 N Broad
St, Philadelphia, PA 19140 (USA). Dr Stephens is a Certified Feldenkrais Practitioner (CFP) and member of the Feldenkrais Guild of North
America (FGNA). He has served as Chair of the Research Committee of FGNA. There are no financial ties. Address all correspondence to Dr
Stephens at: [email protected].

J Davidson, PT, DPT, CSCS, is Sports Physical Therapist, Golf Performance Specialist, and Certified Strength and Conditioning Specialist, The
Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia, King of Prussia, Pa.

J DeRosa, PT, MSPT, is Owner/Physical Therapist, Eastern Shore Physical Therapy, Linwood, NJ.

M Kriz, PT, MSPT, is Staff Physical Therapist, Bonita Springs Sports and Physical Therapy, Bonita Springs, Fla.

N Saltzman, PT, MSPT, is Physical Therapist, Physical Therapy Consultant Group, Scottsdale, Ariz.

Dr Stephens provided concept/idea/research design and institutional liaisons. Dr Davidson provided data collection. Dr Stephens, Dr Davidson,
and Mr Kriz provided writing, data analysis, project management, facilities/equipment, clerical support, and consultation (including review of
manuscript for submission). Assistance with writing, data analysis, and clerical support also was provided by Mr DeRosa and Nicole Saltzman. The
authors acknowledge the assistance of Melinda Bartscherer, who facilitated institutional relations in her role as Acting Chair of the Institute for
Physical Therapy Education at Widener University when the study was done and Jeff Lidicker, PhD, at the College of Health Professions, Temple
University, for his assistance with statistical analysis.

This study was approved by the Widener University Committee for the Protection of Human Subjects.

This research, in part, was presented as a poster at PT 2000: Annual Conference and Scientific Exposition of the American Physical Therapy
Association; June 5– 8, 2000; Cincinnati, Ohio.

This article was received July 1, 2004, and was accepted August 11, 2006.

DOI: 10.2522/ptj.20040208

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 ўўўўўўўўўўўўўўўўўўўўўў
muscles. We chose to look at active length because we ATM group was made up of 7 male and 11 female
believe that this measure is more meaningful than subjects who ranged in age from 22 to 36 years
passive length in relation to normal functional move- (25.9⫾3.8) (X⫾SD) and had a pretest hamstring muscle
ment and motor control. length measurement of 141.96⫾7.89 degrees. The con-
trol group was made up of 6 male and 9 female subjects
Method and Materials who ranged in age from 21 to 27 years (23.9⫾1.9) and
had a pretest hamstring muscle length measurement of
Subjects
140.66⫾8.19 degrees. There were no statistically signifi-
Fifty-one subjects were recruited using posters and word
cant differences between ATM and control groups based
of mouth from the population of graduate students and
on age, sex, or pretest hamstring muscle length.
faculty at the Widener University, Chester, Pa, campus.
The purpose of the study was explained, and volunteers
Instrumentation
signed an informed consent form approved by the
Active knee extension hamstring muscle length was
Widener University Committee for the Protection of
measured as the highest value in the range of knee
Human Subjects.
extension using a PEAK Motus motion analysis system.*
Accuracy of angle measurement for this system has been
Subjects qualified for the study if they did not have a
reported to be less than 0.1 degree, with an intraclass
history of orthopedic problems, including surgery or
correlation coefficient (ICC) of .99.24 An S-VHS Pana-
injury to the back, pelvis, or lower extremities or neuro-
sonic CL-700 digital video camera was placed 7.6 m
logic dysfunction (eg, multiple sclerosis, cerebral palsy,
(25 ft) from each subject and centered on a line
or peripheral neuropathy) within 1 year from the begin-
perpendicular to the plane of motion of the subject’s
ning of the study. Subjects also were excluded from the
knee. Movement was recorded on a Sanyo editing S-VHS
study if they had an active knee extension angle greater
recorder at 60 frames per second and digitized using
than 165 degrees (full extension⫽180 degrees) mea-
PEAK Motus software. An alignment apparatus similar to
sured using a quick-screen active knee extension test in
that described by Scholz and Millford24 was constructed
which the subject lay supine with the hip flexed to 90
of 3.81-cm (1.5-in) diameter PVC pipes. Two vertical
degrees and actively extended the knee.17 If active knee
uprights 0.91 m (3 ft) in length were connected by a
extension was judged to fall outside of the desired range
crossbar. The footings of each upright were secured to a
as marked on a plexiglass template, based on visual
standard plinth by 2 Stanley Quick Grips.† Reliability of
assessment, subjects were excluded.
knee angle measurements was determined using ICCs
(2,3). A set of 3 repeated measurements from each
Seven of the 51 subjects did not meet the screening
subject was used for pretest and posttest calculations.
criteria because their hamstring muscle length exceeded
The pretest ICC was .976, and the posttest ICC was .995.
the maximum standard. Six subjects withdrew for per-
sonal reasons before group assignment. The remaining
Experimental Procedures
38 subjects were randomly assigned to a group that
received ATM intervention (ATM group [n⫽20]) or a Measurement protocol. The hamstring muscle length of
group that received no intervention (control group all subjects who met the screening requirements was
[n⫽18]). Five subjects (2 in the ATM group and 3 in the measured using the Active Knee Extension Test
control group) were dropped from the study after group (AKET)25 1 week prior to beginning the intervention.
assignment. Two of these subjects left the graduate Hamstring muscle length was measured again 1 to 2 days
program, 2 subjects missed the final data collection after the end of the intervention period. Subjects were
because of sickness or travel commitments, and 1 subject positioned supine on a standard 0.9-⫻1.8-m (3-⫻6-ft)
withdrew because of an acute ankle sprain sustained plinth under the alignment apparatus. A 10.2-cm-wide
while running during the period of the study. Thirty- (4-in-wide) Velcro strap‡ was placed around the subject
three subjects (18 in the ATM group and 15 in the at the level of the anterior superior iliac spine to stabilize
control group) met the screening criteria and com- the pelvis and lumbar spine. An additional 10.2-cm-wide
pleted the intervention phase of the study. Velcro strap was placed over the left thigh to stabilize the
pelvis and left lower extremity. The subjects’ right hip
All subjects were asked to refrain from beginning any was flexed to 90 degrees until the anterior thigh was just
new physical activity, including hamstring muscle touching the crossbar of the alignment apparatus.
stretching, that had not been part of their regular
activity prior to the 3-week period of the intervention.
Subjects in the ATM group were asked to perform a * Peak Performance Technologies Inc, 7388 S Revere Pkwy, Suite 901, Centen-
15-minute ATM session 5 times per week guided by an nial, CO 80112. The Panasonic camera and Sanyo VCR were obtained as part of
audiotaped ATM lesson sequence. Subjects in the con- the PEAK Motus system.
†
Stanley Tools Group, 480 Myrtle St, New Britain, CT 06053.
trol group performed their regular daily activities. The ‡
Velcro USA Inc, 406 Brown Ave, PO Box 5218, Manchester, NH 03103.

Physical Therapy . Volume 86 . Number 12 . December 2006 Stephens et al . 1643

 continued for the collection of 6 full repetitions for the
pretest and posttest for each subject. Repetitions 4
through 6 only were used as measures of hamstring
muscle length to allow all subjects the same amount of
practice and warm-up time before the measured trials.
Subject data were identified by number only, and the
researcher responsible for determining knee angle from
the PEAK data was not aware of the group to which each
subject was assigned.

Intervention. The ATM intervention was given over a

3-week period and consisted of an initial group training
lesson and a home practice program. All subjects in the
ATM group participated in the initial 30-minute class-
room lesson targeting movements of the right lower
extremity. The lesson consisted of an introduction plus 3
movement segments, with each segment covering varia-
tions of movements requiring lengthening of the ham-
string muscle in different postural configurations. This
lesson was recorded on audiotape, and a copy was given
to each subject in the ATM group for independent
Figure 1. home practice during the course of the study. The
Setup for measuring hamstring muscle length using PEAK Motus motion
analysis system.
Appendix gives a description of the audiotaped ATM
lessons.

Reflecting markers 2.54 cm (1 in) in diameter were Each segment of the lesson began and ended with a body
placed on the subjects’ right lower extremity over the scan in the supine position. This scan was designed to
greater trochanter, the middle of the lateral joint line of make subjects aware of their quality of neuromuscular
the knee, and the lateral malleolus. Proper alignment of control, including the rate and depth of breathing, the
the right thigh parallel to the vertical post of the level of neuromuscular system tension throughout the
alignment apparatus and perpendicular to the horizon- body from the jaw to the feet, and the effort involved in
tal surface of the plinth was verified using the video simple movements such as rolling the leg left and right.
monitor (Fig. 1). The first movement segment began with the subjects
lying on their left side. In the second movement seg-
Subjects were told to maintain the position of the ment, subjects sat in a long-sitting position. The third
anterior thigh in light contact with the crossbar of the movement segment was done in the standing position,
alignment apparatus. They were permitted to use a towel beginning with the hips and knees flexed and the pelvis
wrapped around the posterior right thigh just proximal posteriorly tilted. In each segment, movements were
to the knee throughout the test procedure to maintain suggested in which subjects flexed and extended the
anterior thigh contact with the crossbar. The starting right knee, tilted the pelvis forward and back, and
position for the test was with the anterior thigh touching rotated the right hip with the head and upper extremi-
the crossbar of the alignment apparatus and the right ties in various positions. The goal was for subjects to
knee in a relaxed and fully flexed position. One repeti- learn to extend the knee, medially (internally) rotate the
tion of a knee extension movement consisted of moving extending leg, and anteriorly tilt the pelvis at the same
the knee into extension until a feeling of resistance from time, an organization of movements designed to
the stiffness of the hamstring muscle stopped the move- lengthen the hamstring muscle from both ends.
ment and then returning to the starting position. Sub-
jects were told to begin a series of extension movements As with all other movements in the lesson, these move-
when one of the researchers gave a “go” signal and to ments were done slowly and continuously, with the
continue until a “stop” signal was given. Movements were subjects resting when tired, and within a comfortable
paced at one per 2 seconds using a watch and giving range of movement, noticing when effort in other areas
verbal cues of “up” during the extension phase and of the body interfered with these specific movement
“down” during the flexion phase of the movement. The intentions and trying to reduce those efforts and breathe
timer gave a “ready” signal 3 seconds before the begin- easily through the entire process. Subjects were told
ning of the procedure. The researcher responsible for explicitly not to push into the end-range of knee exten-
data collection began recording with the PEAK system sion as they might if they were doing active or passive
just before the beginning of the first repetition and

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end-range stretching. Variations of the options of rotat- Table 1.
ing the hip medially and laterally (externally), extending Change in Hamstring Muscle Length Measured in Degreesa
and flexing the knee, and tilting the pelvis were sug-
gested. Subjects in the ATM group were asked to use the Group Time X SD
guidance of the audiotaped ATM lesson sequence until ATM (n⫽18) Pretest 141.96 7.89
they were comfortable with the process of exploring the Posttest 149.00 7.40
movements suggested, at which time they could proceed Control (n⫽15) Pretest 140.66 8.19
without the guidance of the audiotape. All subjects were Posttest 141.81 7.61
asked to keep an activity log that included leisure and a
Full extension⫽180 degrees. ATM⫽Awareness Through Movement.
exercise activities and for the ATM group also included
the frequency and duration of their ATM practice. Table 2.
Two-Factor Analysis of Variance With One Repeated Measure (Time)
Data Analysis and Hamstring Muscle Length as the Dependent Variable
The dependent variable of interest was hamstring mus-
cle length as measured by the maximum active knee df F P
extension angle. Three trials per subject from each Group 1 2.807 .104
measurement session were recorded, and the mean was Time 1 17.779 ⬍.001a
used for data analysis. A 2-factor repeated analysis of Group ⫻ time 1 9.177 .005a
variance (ANOVA) (group ⫻ time) was used with time as a
Significant difference.
the single repeated measure.26 An alpha level of .05 was
used as the criterion for significance of difference.
(X⫽12.9°, range⫽9.1°–17.5°). One person representing
Subjects in the ATM group practiced independently each of these levels was interviewed using open-ended
over a period of 3 weeks and differed widely from each questions to assess their understanding of and experi-
other in their number of practice sessions and total ence and strategies in practicing the ATM lessons. These
minutes practiced. Furthermore, because all subjects in qualitative data were used to help interpret the quanti-
the ATM group did not follow the same practice sched- tative data collected.
ule, their postintervention hamstring muscle length
measurements were done with different periods of delay Results
following the time of their final practice session. To The mean change in hamstring muscle length in the
assess the possible effects of these practice and delay ATM group was ⫹7.04 degrees compared with the
variables on the outcome measure of hamstring muscle control group change of ⫹1.15 degrees (Tab. 1). There
length, a post hoc multiple regression analysis was done.26 was a significant increase in hamstring muscle length
The number of practice sessions, total minutes of prac- over time and an interaction of group ⫻ time, indicating
tice, and delay (in days) were used as independent an increase in hamstring muscle length in the ATM
variables with the dependent variable of hamstring mus- group compared with the control group (P⫽.005)
cle length change within the ATM group. In this analysis, (Tab. 2, Fig. 2).
a significance level of ⬍.05 would indicate that the
independent variable made a significant contribution to Table 3 shows the number of practice sessions, total
the prediction of the outcome measure of hamstring minutes of practice, and change in hamstring muscle
muscle length change. All statistical analyses were done length for each subject in the ATM group. There was
using SPSS version 11.0.4 for Macintosh.§ wide variation in the amount of practice among subjects.
The range for number of sessions was 7 to 18, and total
At the end of the intervention period, subjects in the minutes of practice ranged from 80 to 300 over the
ATM group were asked the question: “From your expe- 3-week period of the intervention. The delay between
rience of ATM, would you say that this process is the last practice session and the final hamstring muscle
different from stretching, as you understand it?” After length measurement ranged from 1 to 10 days. The
the hamstring muscle length change analysis was com- regression analysis (Tab. 4) showed that there was no
pleted, subjects in the ATM group were divided into 3 significant effect on hamstring muscle length change in
levels based on the amount of muscle length change. the ATM group as a result of number of practice
Five subjects achieved no change in muscle length sessions, the total number of minutes of practice, or
(X⫽0.1°, range⫽ ⫺3.4°–2.6°). Six subjects achieved a amount of delay between the last practice session and
moderate amount of change (X⫽6.1°, range⫽4.6°– the final hamstring muscle length measurement.
6.8°). Seven subjects achieved a large amount of change

§
SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Physical Therapy . Volume 86 . Number 12 . December 2006 Stephens et al . 1645

 Table 4.
Within-Group Multiple Regression Analysis of Effects of Practice
(Number of Practice Sessions and Minutes of Practice) and Posttest
Measurement Delay With Hamstring Muscle Length as the Dependent
Variable for Subjects in the “Awareness Through Movement” Group

Variable B SE Beta t P

No. of practice 0.1910 0.7620 0.2496 0.2507 .8054

sessions
No. of minutes of 0.0202 0.0462 0.4207 0.4367 .6685
practice
Posttest measurement 0.2276 0.6060 0.0841 0.3756 .7125
delay (d)

Figure 2.
Interaction plot for means test. ATM⫽“Awareness Through Movement.” 3 possible problems with their study that might explain
their observation of no change in hamstring muscle
Table 3. length. First, the subjects may not have had enough
Data for Number of Practice Sessions, Total Minutes of Practice, opportunity within their intervention process to perform
Posttest Measurement Delay, and Muscle Length Change for Subjects ATM lessons directed toward lengthening the hamstring
in the “Awareness Through Movement” Group
muscles. Their intervention included 4 ATM lessons, but
only 1 ATM lesson was directed toward lengthening ham-
No. of Total Posttest Muscle
string muscles. The specificity of training concept27 sug-
Subject Practice Minutes of Measurement Length
No. Sessions Practice Delay (d) Change (°) gests that it is unlikely that lessons directed only toward
other muscle groups, movements, or areas of the body
32 12 275 1 17.5 would contribute in any significant way to lengthening the
19 11 165 1 15.1 hamstring muscles. Although some practitioners of Felden-
50 8 125 2 13.6
4 12 120 1 13.1 krais method claim that significant changes can be
11 12 180 1 11.3 observed from a single lesson,28 there is no published
1 7 105 2 10.3 literature documenting that such changes are stable over
33 11 180 2 9.1 any length of time greater than a few hours. We agree with
16 13 210 1 6.8 James and colleagues’ suggestion that a single session may
45 14 210 1 6.6
49 11 135 8 6.6 not have been sufficient to produce stable change.22 There-
9 13 195 2 6.2 fore, we designed our intervention to be carried out over a
24 10 230 1 5.6 3-week period with the number of intervention sessions
38 8 80 2 4.6 similar to what has been used in published studies using
35 7 105 10 2.6 other approaches (Tab. 5).
26 NAa NA 2 1.3
23 18 300 1 0.0
41 7 135 1 0.0 Second, James et al22 thought that their subjects may
51 18 260 1 ⫺3.4 have had some negative preconceived ideas about the
Mean 11.3 177.1 2.2 7.0 usefulness of ATM, and therefore may have not cooper-
a
“NA” indicates subject did not turn in activity report. ated fully with the intention of the intervention. We
cannot rule out this possibility in our subjects. Although
most of our subjects were physical therapist students, as
Discussion
were James and colleagues’ subjects, some of them had
Outcome and Stretching Literature heard of the Feldenkrais method but had no prior
The data suggest that selected ATM lessons are an experience or other specific knowledge.
effective method of increasing active hamstring muscle
length and flexibility. This is the first time that a method Third, James et al22 suggested that, because the motor
that does not involve stretching has been shown to pattern of the hamstring muscle lesson used during the
increase muscle length. intervention was not the same as that used in measuring
the outcome of training, a pattern was learned in the
The only previously published research on the effect of lesson that did not transfer to the test measure. This
ATM on hamstring muscle lengthening showed that the possibility is refuted by our results. Our intervention
effects of ATM were no different from the effects seen in offered 3 different forms of hamstring muscle lengthen-
a wait-list control group or a relaxation training control ing activity, none of which was the same as the test
group over the study period.22,23 James et al22 suggested measure. In our training audiotape, we suggested that

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Table 5.
Hamstring Muscle Stretch Literature Resultsa

Article, Year of Publication N Groups and Time Results Rate of Gain (°/wk)

Worrell et al,3 1994 19 2 groups (SS, PNF) SS⫽8.0° SS⫽2.7°

4 ⫻ 20 s/d PNF⫽9.5° PNF⫽3.2°
5 d/wk
15 sessions in 3 wk
Webright et al,17 1997 40 2 groups (SS, NBS) SS⫽8.9° SS⫽1.5°
2/d ⫻ 7 d/wk NBS⫽10.2° NBS⫽1.7°
84 sessions in 6 wk
Bandy et al,16 1998 58 3 groups (CON, SS, DROM) CON⫽0.7° SS⫽1.9°
CON: no stretch SS⫽11.4° DROM⫽0.7°
SS: 1 ⫻ 30 s/d, 5 d/wk DROM⫽4.3°
DROM: 6 ⫻ 5 s/d, 5 d/wk
Decoster et al,29 2004 28 2 groups (standing SS, supine SS) Stand⫽9.1° Stand⫽3.1°
3/d ⫻ 3 wk Supine⫽8.4° Supine⫽2.7°
Current study 33 2 groups (CON, ATM) CON⫽1.1° CON⫽0.4°
CON: no stretch ATM⫽7.0° ATM⫽2.4°
ATM: 15 min/d, 5 d/wk
15 sessions in 3 wk
a
All studies used the Active Knee Extension Test (AKET) to measure hamstring muscle length and did intervention 5 days per week over some period of weeks.
SS⫽static stretch, PNF⫽proprioceptive neuromuscular facilitation, NBS⫽nonballistic stretch, DROM⫽dynamic range of motion, CON⫽control, ATM⫽“Awareness
Through Movement.”

subjects learn all 3 forms and choose for themselves taught. There are 2 reasons why we think that our
which forms they would practice. We made this choice subjects did ATM and not stretching. First, we instructed
based on pilot data that suggested that the 3 different all subjects in the ATM group during the training session
forms of practice might produce equivalent results. This to be sure that they understood the difference between
idea is supported by recent data showing that 2 methods ATM and stretching and that movements in the ATM
of static hamstring muscle stretching—1 standing and 1 lessons were to be done slowly, not held at the end-range
supine— had equivalent outcomes.29 Thus, we did not and with no strain at the end-range. We audiotaped this
control this variable and do not know exactly what instruction session and gave subjects a copy of the
subjects did in this regard. Subjects may have selected audiotape to guide their practice sessions at home.
any 1 form or some combination of the 3 forms over the
training period. Second, we asked subjects on an exit survey: “From your
experience of Awareness Through Movement, would
The results reported here compare favorably with you say that this process is different from stretching as
accepted methods of stretching that have been reported you understand it? If yes, please briefly describe the
in the literature. Table 5 shows a representative sample differences.” Ninety-four percent (17/18) of the subjects
of studies published between 1994 and 2004 all of which in the ATM group stated that ATM was different from
used the same method of measuring outcome, the stretching. Representative comments describing the dif-
AKET. These data indicate that ATM is comparable to ference were: “slower and more repetitive”; “I concen-
commonly used stretching methods in the rate and trated more on the movements”; “when I stretch, I just
amount of hamstring muscle length gain that is pro- go through the motions”; “didn’t stress my back, felt
duced over similar periods of time. fluid”; “moving rather than static”; “did not hold as in a
stretch”; “more difficult because using muscle groups
Limitations and Future Research together that do not normally seem related”; “didn’t
One of the limitations of our study is that we did not use experience the customary burn associated with stretch-
a stretching control group. We made this choice based ing”; “didn’t feel as if I had exercised at all”; “more
on the fact that there is a large amount of literature on sensing where the muscle was and whether it was length-
various methods of hamstring muscle stretching that ening from my awareness”; “not prolonged as in stretch-
would serve as a valid comparison. This allowed us to ing . . . more of a movement pattern”; and “lots of move-
maximize our sample size for experimental subjects. ment involved.” Subject 32, who had the largest muscle
length gain at 17.5 degrees, said that the movements
We did not monitor the practice of our subjects. Thus, were difficult at first and that he strained, causing
there was a concern that they may have slipped into a discomfort that persisted into the next day. After the first
familiar pattern of doing stretching rather than ATM as week, he stopped pushing the limits, did fewer and

Physical Therapy . Volume 86 . Number 12 . December 2006 Stephens et al . 1647

smaller movements, and began to notice changes such as means of preventing hamstring muscle injury or, more
the back pain that he usually experienced in class was generally, muscle injury. Second, static stretching tra-
eliminated. Subject 38, who had a low intermediate gain ditionally has been included in warm-ups preceding
at 4.6 degrees, said that he never was able to master the athletic performance, especially where recruitment of
side-lying movements and that coordinating difficult explosive power is involved. However, there has been
movements caused a strain. He also said that ATM felt very little study of the efficacy of this practice. The
like stretching except that it also incorporated the findings of recent studies suggest that running or
anterior pelvic tilt, which was difficult. Subject 51, who jumping performance either is not enhanced by32,33 or is
had the lowest length gain at ⫺3.4 degrees, also had the negatively affected by34,35 stretching prior to perfor-
longest hamstring muscles at the outset. She stated that mance. Research comparing the results of ATM with
she mastered the movements but was surprised that she stretching prior to running or jumping types of power
qualified for the study because she was not aware that performance would be a useful addition to our knowledge.
her hamstring muscles were short. From these procedures A third area is adherence to exercise programs among
and comments, we conclude that the subjects were adher- people who have low pain tolerance. In our pilot work and
ent to the process in which we instructed them and did not in this study, subjects reported that the ATM process is
do stretching, with one possible exception (subject 38). more gentle, less of a strain, and generally less painful than
stretching. These reports suggest that there may be better
Another limitation may be the practical aspect of the adherence with the use of ATM in elderly people and
amount of practice time that was required to produce an people who have chronic pain or low pain and stress
outcome. In our study, subjects practiced an average of tolerance. Some support for this idea comes from Phipps
15 minutes per session-day compared with 30 seconds et al,36 who conducted a retrospective study of a group of
per session-day in the study by Bandy et al16 or 80 people between 20 and 77 years of age with a history of
seconds per session-day in the study by Worrell et al,3 as treatment for chronic pain that included components
described in the procedures noted in the studies cited in of ATM or yoga. Eighty-five percent of these people
Table 5. Why would anyone want to spend 15 minutes reported reduction of pain problems, and more than 75%
when equivalent results could be obtained more quickly? reported continuing to use ATM and yoga techniques on
We have shown here that, within the ranges of duration their own 2 years after the end of their inpatient programs.
(7–18 sessions) and number of minutes (80 –300) that More research in this area is suggested.
our subjects practiced (Tab. 3), these variables did not
have an effect on the amount of hamstring muscle Finally, the ATM process is different from stretching. It
length change that occurred (Tab. 4). In an unpub- is important to understand what its mechanism might
lished pilot study exploring whether ATM practice time be. Because mechanical explanations seem unlikely
could be reduced, we have found that equivalent results here, neural mechanisms should be considered. It has
may be achieved with as little as 15 seconds to 2 minutes been shown that the stretch reflex can be regulated by
per session-day, which is well within the time range of the operant conditioning,37–39 patterned sensory stimula-
stretching protocols. Further research is needs to be tion,40 and skill training.41– 44 Further research into the
done to investigate this possibility. possible effects of ATM on the stretch reflex or other
neural mechanisms would be enlightening.
There has been an interest in describing ATM as a
process of motor learning.30,31 Unfortunately, our study Conclusions
was not done using a formal motor learning design, We have shown that hamstring muscles can be length-
which would have included a number of muscle length ened by a method that does not involve stretching.
measurements during the acquisition period followed by Further research is needed to describe this process, to
post-acquisition retention or transfer tests after some identify people who might benefit from it, and to
delay.27 Because of this design difference, we cannot assess understand the mechanisms through which it may work.
our result in terms of motor learning as some practitioners
of ATM would like. This is also an area for future research. References
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Appendix.
Summary of “Awareness Through Movement” Lessons

Introduction Sitting Lesson:

• Pay attention to whole-body patterns of movement involving multiple • Sit in a long-sitting position with legs a comfortable distance apart and
body segments. lean back on hands, if needed.
• Do movements with the idea of exploring the possibilities about how • Place a towel roll under the knees as needed.
they might be done. • From this starting position, learn the coordination of combining knee
• Become aware of efforts made in all areas of the body and try to extension, hip medial rotation, and anterior pelvic tilting and of
reduce effort. combining knee flexion, hip lateral rotation, and posterior pelvic
• Do 5 to 10 repetitions of a movement, then rest. tilting.
• Movements should be done slowly and easily without pushing or • As possible, slide the hands forward down the legs with the knee
holding at end-range. extension component of the movement.
• At regular intervals, do a process of scanning by lying in a supine • Rest as needed. Scan at regular intervals.
position and noticing any changes in body-segment relationships,
muscle tone, breathing, or ease of small movements. Standing Lesson:
• Do an equal amount of movement with each leg. • Stand with feet a comfortable distance apart.
• Demonstrate an anterior tilt of the pelvis by placing forearm or towel • Flex the hips and knees and bend forward reaching the hands to touch
roll under the lumbar spine. somewhere comfortably below the knees.
• From this starting position, learn the coordination of combining knee
Initial Lengthening Concept extension, hip medial rotation, and anterior pelvic tilting and of
• Practice pelvic tilting without anything under the back. combining knee flexion, hip lateral rotation, and posterior pelvic
• Add movements of knee flexion and extension to the pelvic tilting. tilting.
• Do knee flexion, hip lateral (external) rotation, and posterior pelvic • As possible, slide the hands farther down the legs with the knee
tilting together and knee extension, hip medial (internal) rotation, and extension component of the movement.
anterior pelvic tilting together. • Rest as needed. Scan at regular intervals.

Side-lying Lesson:
• Lie on the left side with the head in the hand or otherwise resting
comfortably.
• Abduct the right leg and flex the hip and knee to a 90°/90° position.
• Reach the right hand to the right knee.
• From this starting position, learn the coordination of combining knee
extension, hip medial rotation, and anterior pelvic tilting and of
combining knee flexion, hip lateral rotation, and posterior pelvic
tilting.
• Slide the hand farther down the leg as reaching becomes easier.
• Repeat lying on the right side. Rest as needed. Scan at regular
intervals.

1650 . Stephens et al Physical Therapy . Volume 86 . Number 12 . December 2006