Children who use wheelchairs or have cerebral palsy are particularly prone to poor flexibility.³⁵ Sitting in a wheelchair for much of the day causes tightness in the hamstrings and low back.³⁶ Children with juvenile rheumatoid arthritis also lose a substantial amount of flexibility as their condition worsens. The one group of children who will probably not need to work on their flexibility are children with Down syndrome. Most children with Down syndrome are extremely flexible.³⁷

In a study by Agre and coworkers on children with spina bifida, lower extremity flexibility was most severely affected by ambulatory status.²³ Children who never ambulated had the most contractures while those who walked full-time had minimal to no measurable joint contracture. The investigators concluded that stretching exercises are very important for children who use wheelchairs for ambulation, and that a good stretching program may lead to prevention of problems in later life, such as with personal hygiene and transfer capabilities. Olney and coworkers also noted that good range of motion was needed at the ankle joint in children with spastic hemiplegia so that muscular contraction can be effective in generating power and improving gait.²⁸

Kravitz and Heyward list several benefits that can be derived from a flexibility program as noted in Table 1.³⁸ Flexibility should be an integral part of the warm-up and cool-down components of a fitness program. It is recommended that the warm-up begin with a mild cardiovascular activity that raises the temperature of the blood, tendons, ligaments, and muscles. Stationary cycling with arms or legs, or light walking or wheeling are good suggestions. Emphasis should be placed on the tight muscle groups, which in many children who use wheelchairs or have cerebral palsy, are the hip flexors, adductors, internal rotators and plantar flexors. Children with cerebral palsy often have tight shoulder adductors, flexors and internal rotators as well.