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Gavin Publishers
Gavin Journal of Orthopedic Research and Therapy
Volume 2016; Pages 5
Shaw I et al.
1
www.gavinpublishers.org
Research Article
Keywords
Rehabilitation; Resistance training, Sports Injuries; Strength
training; Weight training
Introduction
Resistance Training’s (RT) benecial relationship to health
factors and chronic disease has been recognized only recently
[1,2]. Prior to 1990, RT was not a part of the recommended
guidelines for exercise training and/or rehabilitation for either
the American Heart Association or the American College of
Sports Medicine (ACSM) [3]. Many individuals now perform
RT as a part of their routine conditioning programs to increase
mainly muscular strength and hypertrophy [1,4]. Despite RT’s
proven ability to increase a multitude of physical parameters,
such as muscular strength, power, hypertrophy, and muscular
endurance, RT is oen overlooked in its role in injury
prevention and rehabilitation [5].
Review of the Role of Resistance Training and Muscu-
loskeletal Injury Prevention and Rehabilitation
Ina Shaw1, Brandon S Shaw1*, Gregory A Brown2 and Ardalan Shariat3
1Department of Sport and Movement Studies, University of Johannesburg, Doornfontein, Republic of South Africa
2Department of Kinesiology and Sports Sciences, University of Nebraska Kearney, Kearney, USA
3Department of Occupational Health, University Putra Malaysia, Selangor, Malaysia
Abstract
Many individuals perform Resistance Training (RT) as a part of their routine conditioning
programs to increase muscular strength and/or hypertrophy. However, RT is oen overlooked in its
role in musculoskeletal injury prevention and rehabilitation. is is problematic in that RT results
in many adaptations, such as an increased bone mass, lean mass and tensile strength that could
aid in the prevention and rehabilitation of musculoskeletal injuries. e aim of this review is to
demonstrate that RT should be considered an integral component, in any exercise program designed
to prevent and rehabilitate musculoskeletal injuries. To date, most of the limited original studies,
reviews and meta-analysis on RT and musculoskeletal injuries have focused on one particular
intervention, injury type/location, sport or studied other relatively narrowly dened research
questions, eectively not allowing for a full quantication of intervention eect estimates. is review
demonstrated a dearth of literature regarding the role of RT in musculoskeletal injury prevention
and rehabilitation. It also focuses on the preventive eect of several dierent forms of RT revealing
novel and interesting information, enabling proposals for future directions in the eld of
musculoskeletal injury prevention and rehabilitation using RT. Findings of this review specically
indicate that while high-intensity strength-type resistance training plays an essential role in the
prevention and rehabilitation of musculoskeletal injuries, more user-friendly forms of RT, such as
hypertrophy RT and muscular endurance RT need to be examined. While this review advocates the
role of RT in the prevention and rehabilitation of musculoskeletal injuries both for its safety and
ecacy, further examination and quantication of specic RT exposures and a dierentiation of
acute and overuse outcome eect estimates is still lacking.
*Corresponding author: Brandon S Shaw, Department of Sport and Movement Studies, University
of Johannesburg, Doornfontein, Republic of South Africa, Tel: +27 115596789; E-mail: brandons@
uj.ac.za
Citation: Shaw I, Shaw BS, Brown GA, Shariat A (2016) Review of the Role of Resistance Training
and Musculoskeletal Injury Prevention and Rehabilitation. Gavin J Orthop Res er 2016: 1-5.
Received: 26 April, 2016; Accepted: 18 May, 2016; Published: 01 June, 2016
Volume 2016; Issue 1 2
Citation: Shaw I, Shaw BS, Brown GA, Shariat A (2016) Review of the Role of Resistance Training and Musculoskeletal Injury Prevention and Rehabilitation.
Gavin J Orthop Res er 2016: 1-5.
While the utilization of RT for injury prevention is not
a new concept [6], many athletes, and health and tness
professionals still do not see RT as a necessary addition to an
injury prevention and/or rehabilitation workout plan [5].
While some clinicians do understand and incorporate RT for its
benets relating to injury prevention and rehabilitation, this
lack of emphasis on RT in a clinical setting has also resulted
in limited scientic evidence for RT’s eectiveness in injury
prevention and/or rehabilitation workout plans [5].
However, those few studies that have examined RT’s role in
injury prevention and/or rehabilitation, have conrmed that
the incorporation of RT in athletic training decreases the
risk and severity of injury [5]. Although injuries are never
completely unavoidable due to the physically demanding
nature of sports, there are ways to reduce the risk and severity
of such injuries by progressively increasing the tensile strength
of connective tissue. is includes injuries that are sustained
through contact situations such as tackles in American
football and rugby, and non-contact injuries which are oen
more preventable. Studies reporting the direct eect of RT on
injury prevention and/or rehabilitation are limited. However,
the physiological adaptations on bone, connective tissue and
muscle do imply enhanced protection against injury and re
injury for individuals engaging in RT [6].
Physiological adaptations to resistance training
Several adaptations to RT could aid in the prevention and
rehabilitation of musculoskeletal injuries. Specically, RT may
promote growth and/or increases in the structural integrity
of ligaments, tendons, tendon to bone and ligament to bone
junction strength, joint cartilage and the connective tissue
sheaths within muscle [5].
Decreases in muscle mass and subsequent reductions in
muscle strength not only results in a loss of functional ability,
but also increases the risk for musculoskeletal injury [7]. RT
programs may then reduce the risk for musculoskeletal injuries
related to muscle imbalance, expressed as either as a bilateral
comparison or an agonist to antagonist ratio. Correction of an
existing imbalance through a RT program is important in
reducing the individual’s risk for muscle injury [6].is agonist
to antagonist ratio constitutes an element of functional
specicity of a joint, but is subject to numerous factors of
variations such as the joint considered, dominance, sex, age,
physical activity, and velocity of movement. is ratio has been
supposed to constitute a clinical element in the functional
analysis of the joint, and provide either an index of the risk
of developing certain sports injuries, or a guide control in the
modalities of rehabilitation [8].
To date, there has been little research conducted on the
direct eect of RT on connective tissue adaptations. ose
studies that have done so have reported increases in both the
size and strength of tendons and ligaments [7]. In this regard,
tendons and ligaments have been shown to respond to RT by
increased metabolism, thickness, and strength [9]. In addition,
research demonstrates that damaged tendons and ligaments
regain strength at a faster rate when RT is performed aer
the damage has occurred [9]. Further, while collagen content
increases with training, comparisons between untrained
individuals and bodybuilders suggest that the increase in
collagen content is proportional to the increases in muscle size.
us, increases in muscle mass are likely met by increases in
the size and strength of the connective tissue [7], leading to an
increased tensile strength.
Studies involving humans and animal models have also
demonstrated that RT can cause increased bone mineral
content and therefore may aid in prevention of skeletal injuries.
Bone tissue has the ability to remodel and adapt to the physical
stresses imposed on it. In general, physically active individuals
have been found to be at a reduced risk for osteoporosis,
fractures or other ailments related to bone deterioration [7],
possibly as a result of an increased bone density and turnover.
Although bone will respond to many types of training
programs, studies demonstrate that exercise, such as RT and
those with high strain or impact such as running or jumping,
provide the greatest osteogenic eect [7].
Rationale for resistance training
RT provides a multitude of benets [10,11] and is
particularly benecial for improving the function of most
cardiac, frail, and elderly patients, who benet substantial-
ly from both upper- and lower-body exercise [10,12]. While
the introduction of RT for athletic performance, and general
health and tness are well known, the eect and mechanisms
of RT on musculoskeletal injury prevention and rehabilitation
has not yet been well documented.
With regards to musculoskeletal injury prevention, many
acute muscle strain injuries are thought to occur during the
eccentric phase of sudden, forceful muscle actions [13]. In
addition, repeated eccentric muscle actions during exercise are
also thought to contribute to microscopic muscle and tendon
damage, leading to chronic muscle strains, muscle rupture
and tendinopathy [13]. In terms of musculoskeletal injury
rehabilitation, trauma to the musculoskeletal system due to
injury or surgery oen leads to relative inactivity of the aected
area. is disuse then results in muscular atrophy and
weakness of the aected muscle groups [14], eectively
necessitating the need for strength RT and hypertrophy RT.
Previous studies suggest that a major benet of RT is learning
to coordinate the dierent muscle groups involved in the
training movement rather than intrinsic increases in strength of
the muscle group being trained [15], implying that coordinat-
ed muscles are capable of smoothly decelerating joint motions
even if the muscles themselves are relatively weak. e most
common cause of impaired neuromotor coordination is prior
injury. As a protection against further injury, the central
nervous system creates an alternate pattern of muscle
recruitment, referred to as a motor engram, to avoid stressing
the damaged so tissues [16]. If adequate rehabilitation does
3Volume 2016; Issue 1
Citation: Shaw I, Shaw BS, Brown GA, Shariat A (2016) Review of the Role of Resistance Training and Musculoskeletal Injury Prevention and Rehabilitation.
Gavin J Orthop Res er 2016: 1-5.
not take place, this motor engram then persists long aer
the injury has healed predisposing an individual to re injury.
In this regard, RT has been found to enhance motor neuron
excitability and induce synaptogenesis, both of which assist in
enhancing communication between the nervous system and
the muscles [17].
Specially, a study was undertaken of injury rate and time
lost to rehabilitation in a cohort of high-school athletes and
determined that all athletes utilizing RT as part of their exercise
program suered an injury rate of 26.2% compared to 72.4%
of those that did not [18]. In addition, the authors found that
the rehabilitation ratio (time lost to rehabilitation due to injury
per number of athletes performing in the studied group) was
2.02 days in those who utilized RT compared to 4.82 days for
those not engaging in RT. As such, that study demonstrated
fewer and less severe injuries in individuals engaging in RT. In
addition, those individuals engaging in RT were able to return
to sport much sooner.
Safety of resistance training
Several case study reports and retrospective questionnaires
have demonstrated that in many clinical and educational
contexts, RT is presumed to be dangerous [19]. However, there
is no convincing evidence that RT is particularly perilous, with
the majority of literature indicating that RT is markedly safer
than many other sports and exercise modes, especially when
supervised by qualied professionals [18]. Resistance training
is even considered both safe and benecial in the elderly [20],
and in those with low- (younger individuals, asymptomatic
with no more than 1 risk factor threshold) to moderate-disease
(older individuals with 2 or more risk factors) risk [21].
Types of resistance training
It is typically believed that high loads and low repetitions
are best to increase muscular strength, while lower loads and
higher repetitions are best to increase muscle endurance [7].
However, this over implication of RT program design, by not
only the general population but also by health professionals,
limits optimal physiological and physical adaptations [1]. As
RT encompasses a myriad of subtypes of exercise, it is essential
for clients, patients, and health and tness professionals to
understand and dierentiate between these subtypes as they
have dierent impacts on injury prevention and/or rehabilita-
tion [5]. In this regard, strength RT training requires training at
a load of 85% or more of one Repetition Maximum (1RM) for
6 or less repetitions of 2-6 sets with rest periods of 2-5 minutes,
power (single-eort) RT training requires training at a load of
80-90% 1RM performed at maximum speed for 1-2 repetitions
of 3-5 sets with rest periods of 2-5 minutes, power (multiple-ef-
fort) RT training requires training at a load of 75-85% 1RM
performed at maximum speed for 3-5 repetitions of 3-5 sets
with rest periods of 2-5 minutes, hypertrophy RT training
requires training at a load of 67-85% 1RM for 6-12 repetitions
of 3-6 sets with rest periods of 30 seconds to 1.5 minutes, and
muscular endurance RT training requires training at a load of
67% or less of 1RM for 12 or more repetitions of 2-3 sets with
rest periods of 30 seconds or less [22].
Prescription for patients with musculoskeletal
injury
While it appears that RT may have a signicant role in the
prevention and rehabilitation of musculoskeletal injuries, it
is also clear from the literature that there is no single optimal
design of RT for all populations and/or conditions [5].
Although RT programs using heavy weights yield high levels of
muscle activation, there may be a need for alternative types of
RT dependent on the individual, aims of the RT programme,
type of musculoskeletal injury, disorder, surgery and/or agonist
and antagonist muscle strength imbalances.
When designing musculoskeletal injury prevention and
rehabilitation programs, RT program design should focus
on all necessary RT subtypes. Muscle endurance RT training
will enhance a muscles’ ability to work repeatedly without
fatiguing and becoming injured/reinjured. In addition,
while heavy/strength RT exercises should be included in
musculoskeletal rehabilitation programs to induce sucient
levels of neuromuscular activation to stimulate muscle growth
and strength, even low-load (hypertrophy and muscle
endurance) RT can increase the elasticity of tendon-aponeuro-
sis structures [9]. Importantly, RT programs for the restoration
of connective tissue, such as ligaments should focus on
eccentric muscle actions [23], since eccentric actions generate
more tension, less waste products (and less chemical irritation
of nerves), and require lower oxygen consumption and lower
energy requirements than concentric work [24]. In recent years,
eccentric exercise has been used in rehabilitation to manage a
host of conditions, such as tendinopathies, muscle strains, and
in Anterior Cruciate Ligament (ACL) rehabilitation [24].
However, the collagen metabolism in healthy tendons seems
not to be aected by eccentric training [23], possibly limiting
eccentric training role in the prevention of connective tissue
injuries. In addition, where signicant muscle atrophy has
occurred as a result of injury or surgery, conventional
hypertrophy-RT should take place to restore muscle bulk [15].
Studies have also previously shown changes in muscle strength
following RT to be specic to the length and speed at which the
muscle has been trained [15].
Further, training isolated muscle groups may not be the
most eective way of increasing functional performance in an
attempt to prevent and rehabilitate musculoskeletal injuries as
the major adaptations are task-specic [15]. As such, health
and tness professionals should also make use of sport, cross
training and/or motion specic RT exercises as these may
reduce the incidence and recurrence of various types of
injuries, especially overuse injuries [6]. is is essential since
RT has been found to be the only modiable risk factor that
signicantly contributes to the incidence of sport injuries [25].
To further prevent injuries, health and tness professionals
should perform range of motion exercises to reduce muscle
Volume 2016; Issue 1 4
Citation: Shaw I, Shaw BS, Brown GA, Shariat A (2016) Review of the Role of Resistance Training and Musculoskeletal Injury Prevention and Rehabilitation.
Gavin J Orthop Res er 2016: 1-5.
tightness [26]. Prior to the implementation of RT musculo-
skeletal injury and rehabilitation programs, it is essential to
screen individuals for agonist and antagonist muscle strength
imbalances. is may assist the professional in identifying
those individuals possessing a predisposition for injury or
re-injury. Resistance training may then be performed to
correct the imbalance and therefore reduce the incidence of
injury or the recurrence of an earlier injury [6]. Specically,
Askling et al., [27] found that just one to two days weekly of
eccentric hamstring exercises for 10 weeks, works eectively, in
maintaining muscle group balance.
Further, in the case of musculoskeletal injury rehabilita-
tion, RT program design should be tailored to the appropriate
stage/phase of rehabilitation, namely early-phase, mid-phase
and late- or nal-phase [28]. In early-phase rehabilitation, the
aim is to progressively load the damaged tissue and restore its’
tensile strength. As such, RT in this phase should take the form
of gentle exercises, such as muscle endurance RT, which allows
the damaged tissue to heal. Mid-phase rehabilitation should
involve progressively increasing RT load, in the form of strength
training, and diculty (from machines to free weights) to
progressively load the connective and bone tissue in an attempt
to develop tensile strength. is increased tensile strength
would then produce a healed tissue that will be able to
better withstand the stresses and strains of daily life, exercise
and sporting demands [28]. e Late- or nal-phase of
rehabilitation should focus on increasingly functional RT with
appropriate volume and intensity, whether it be hypertrophy,
strength or power RT, to ensure adequate tissue adaptation.
e aim of this phase is to eectively and eciently return to
activities of daily living, occupational demands and/or the
specic sport during which the injury occurred and it is
essential to perform RT exercises that replicate activities and
movements in that activity, occupation and/or sport [28].
Conclusion
To date most of the limited original studies, reviews and
meta-analysis on RT and musculoskeletal injuries have focused
on one particular intervention, injury type/location, sport or
studied other relatively narrowly dened research questions.
is is problematic in that although these studies demonstrate
RT may have an eect on musculoskeletal injuries, these
narrowly dened research studies do not allow for a full
quantication of intervention eect estimates. As such, while
this review advocates the role of RT in the prevention and
rehabilitation of musculoskeletal injuries both for its safety and
ecacy, further examination and quantication of specic RT
exposures and a dierentiation of acute and overuse outcome
eect estimates is still lacking.
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