“NO LOAD” resistance training increases functional capacity and muscle size in hospitalized female patients: A pilot study

Abstract

The aim of the present study was to compare the effects of resistance training performed with no external load (NLRT) versus resistance training performed with elastic bands (RTEB) on muscle hypertrophy and functional performance in hospitalized patients. Twenty hospitalized females (age, 59.05±3.2 years; height 163.6±2.5 cm; body mass 70.2±3.6 kgs) were randomly assigned to RTEB or NLRT. Both groups trained three times a week for five weeks. RTEB was performed with elastic bands, while NLRT involved maximum voluntary contractions with no external loads. Biceps brachii, triceps brachii and pectoralis muscle thickness (MT) were measured by ultrasound. Functional performance was measured by the 30s elbow flexion test. MT significantly increased in all muscles tested for both groups, with no differences between groups. Changes ranged from 14 to 38%. Functional performance significantly improved by 42.7% for NLRT and 52.1% for RTEB, with no difference between them. The present results suggest that NLRT might be an efficient, feasible and low-cost strategy to promote morphological and functional benefits in the upper limb of hospitalized patients.

Full text

“NO LOAD” resistance training increases functional capacity and muscle size
Eur J Transl Myol 29 (4): xx1-xx5, 2019
- 1 -
“NO LOAD” resistance training increases functional capacity and
muscle size in hospitalized female patients: A pilot study
Matheus Barbalho (1), Victor Silveira Coswig (2), Martim Bottaro (3), Claudio Andre
Barbosa de Lira (1), Mario Hebling Campos (1), Carlos Alexandre Vieira (1), Paulo
Gentil (1)
(1) Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Goiás,
Brasil; (2) Faculdade de Educação Física. Universidade Federal do Pará, Castanhal, Pará,
Brasil; (3) Faculdade de Educação Física, Universidade de Brasília, Brasília, Distrito Federal,
Brasil
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits
any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Abstract
The aim of the present study was to compare the effects of resistance training performed with no
external load (NLRT) versus resistance training performed with elastic bands (RTEB) on muscle
hypertrophy and functional performance in hospitalized patients. Twenty hospitalized females
(age, 59.05±3.2 years; height 163.6±2.5 cm; body mass 70.2±3.6 kgs) were randomly assigned
to RTEB or NLRT. Both groups trained three times a week for five weeks. RTEB was performed
with elastic bands, while NLRT involved maximum voluntary contractions with no external
loads. Biceps brachii, triceps brachii and pectoralis muscle thickness (MT) were measured by
ultrasound. Functional performance was measured by the 30s elbow flexion test. MT
significantly increased in all muscles tested for both groups, with no differences between groups.
Changes ranged from 14 to 38%. Functional performance significantly improved by 42.7% for
NLRT and 52.1% for RTEB, with no difference between them. The present results suggest that
NLRT might be an efficient, feasible and low-cost strategy to promote morphological and
functional benefits in the upper limb of hospitalized patients.
Key Words: Resistance training; Physical Functional Performance; Hospitalization; Sarcopenia;
Exercise Therapy. Eur J Transl Myol 29 (4): xx1-xx5, 2019
The hospitalization process is characterized by loss of
functionality due to inactivity.1,2 Previous studies
reported a muscle loss of up to 1.5 kg per day in intensive
care units,3 as well as a loss of 4 to 5% of muscular
strength weekly,4 which is directly related to
hospitalization time.5 In some cases, patients are
discharged from the hospital with significant physical
deficits that persist for long periods.6,7 In order to
minimize the negative effects of hospitalization, passive
and early mobilizations in the bed, as well as stretching
are commonly used in intensive care unit or after
discharge.8 However, less is know about the effects of
resistance training (RT) in hospitalized patients. RT may
be an interesting strategy in these patients, since it
promotes benefits in muscle strength, function, and
muscle mass in frail people.9-11 RT is usually performed
with moderate and high loads in order to promote
strength gains and muscular hypertrophy,12 and it often
requires specialized equipment’s, which in many cases is
not feasible in the hospital environment.13 As an
alternative, RT programs have been carried out
effectively with elastic bands, promoting muscle strength
gains in middle to old aged persons.14,15 According to
previous studies, the improvements in functional
performance after RT performed with elastic bands
(RTEB) are similar to those obtained with the use of
machines and free weights.16–18 Elastic bands have gained
popularity because of their low cost, simplicity,
versatility, and portability.19 Another promising low cost
alternative is “NO LOAD” RT (NLRT) that has been
shown to promote high levels of muscle activation,20 and
similar gains in muscle size as traditional RT.21 In
summary, during NLRT the participants are instructed to
perform maximal muscle contractions over the range of
motion without any external load. Based on previous
studies,20,21 NLRT might be a viable strategy to
implement in environments that do not have equipment,
such as intensive care units. The objectives of the present
Accepted paper

“NO LOAD” resistance training increases functional capacity and muscle size
Eur J Transl Myol 29 (4): xx1-xx5, 2019
- 2 -
study were to evaluate muscle size and functional
performance after NLRT in upper limbs of hospitalized
patients and compare it to RTEB.
Materials and Methods
Experimental overview
This study is a parallel randomized clinical trial in which
patients were allocated independently for two
interventions groups from July to September 2017. After
screening for eligibility of patients by inclusion criteria,
a simple random sampling was done following a 1:1
ratio, without restrictions, to define the groups that
received the different treatments: No load resistance
training (NLRT) or resistance training with elastic bands
(RTEB). To enable blind analysis, randomization and
data coding were performed by different researchers. Pre-
intervention measures involved muscle thickness and
functional performance.The experimental protocols were
performed three times a week during five-weeks of
hospitalization, totaling 15 intervention sessions.
Participants
The participants were recruited in two reference
hospitals. Initially, 23 hospitalized women were recruited
after intensive care unit admission, they were informed
of the procedures and potential risks associated with the
study protocol. All participants gave written informed
consent before enrolment. The study was approved by the
University Research Ethics Committee (n.
56907716.5.0000.5083). The inclusion criterion was to
be admitted to the nursing ward, from July to September
2017, to be hospitalized and in the rehabilitation process,
being able to perform the proposed protocol, being able
to ambulate (with/without assistance), being able to
communicate and collaborate with the research team. The
reasons for admission in the rehabilitation sector after
intensive care unit were: heart failure (n = 12),
oncological patients (n = 7), orthopedic fractures (n=4).
The patients were counterbalanced considering the
reasons for admission, so each group would have similar
clinical characteristics. Exclusion criteria included:
multiple fractures, patients who did not want participate
in appropriate rehabilitation, unable to cooperate in the
tests and terminal illness. Those who did not complete all
tests or intervention sessions were excluded (n=1 in the
NLRT group, n=1 in the RTEB group), and one
participant stopped NLRT for considering it
uncomfortable. Twenty participants were included in the
final analysis.
Assessments
Muscle Thickness
Muscle thickness was measured using the ultrasound
method (Toshiba Tossbe model, 7.5 MHz linear
transduction) for the biceps brachii, triceps brachii and
pectoralis major, following the standard procedures
previously suggested.22 For the biceps and triceps brachii,
measurements were taken 60% distal between the lateral
epicondyle of the humerus and the acromion process of
the scapula. Pectoralis major MT was measured four
centimeters below the coracoid process at 60% of the
distance between the acromion process of the scapula and
the middle of the sternum (50% of the distance between
the xyphoid process and the jugular notch). The
procedure was performed once on each subject, pre and
post intervention and performed by the same evaluator,
which was blinded to group allocation and had
experience with method. The intraclass correlation
coefficients was 0.96-0.99 and the CV was 1.8-3.2%.
Functional Performance
Functional performance was evaluate by the 30-second
elbow flexion test, wich involved the greatest number of
elbow flexion and extension that the participant could
perform with a 5-pound weight in 30 seconds.23
Nutritional control
All patients had their meals controlled through a meal
plan divided into three meals per day throughout the
intervention period. The standard dietary plan prescribed
by the hospital dietitian involved 6-8g/kg of
carbohydrate, 0.8-1.2g/kg of protein and 0.8-1.0g/kg of
fat per day.
Training Protocol
The RTEB group performed six exercises for the upper
body in the following order: seated row, seated chest
press, push press, lat pull, elbow extension and elbow
flexion. All exercises were performed with elastic bands
(Kit max, Elastos®, Rio de Janeiro, Brazil), because it
was more practical to implement in a hospital setting and
previous studies showed that it promotes similar results
to machines and free weights.17 Each exercise was
performed with 2 sets of 8 to 12 maximum repetitions and
2 seconds in each phase. Resistance was adjusted by
changing the elastic bands whenever necessary for
maintaining the prescribed number of repetitions. The
NO LOAD training condition was characterized as
voluntarily maximally contracting the muscle through the
full range of motion without the use of external load. The
NLRT group was oriented to contract the muscle at
maximum intensity with a 2-second cadence in each
phase. The participants performed 2 sets of 20 repetitions
maximum per exercise. Considering that previous studies
showed that agonist and antagonist muscle are recruited
to the same extend during NLRT,20 this group performed
seated row/bench press, lat pulldown/shoulder press and
elbow flexion/extension with reciprocal actions. The
exercises were performed within a RPE of 8 to 10 from
the Borg-10 scale.20 Each session was supervised by
Physical Therapy and Physical Education professionals
and care was taken to ensure proper exercise execution.
Statistical analysis
After normality and sphericity tests by Shapiro-Wilk and
Levene’s, respectively, data is presented by mean and
Accepted paper

“NO LOAD” resistance training increases functional capacity and muscle size
Eur J Transl Myol 29 (4): xx1-xx5, 2019
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standard deviation. The paired t-test was performed to
compare pre and post-training for each group. ANCOVA
analysis were performed to compare the post-
interventions results using the pre interventions results as
covariates. Statistical analysis was performed using IBM
SPSS Statistics for Windows, version 22.0 (IBM Japan,
Ltd., Tokyo, Japan), with significance accepted when
p<0.05.
Results
The characteristics of the participants are shown in Table
1 and no differences were found between groups. Table
2 presents the pre and post values for each variable by
groups, where it is evidenced that all variables showed
significant improvements.
Functional Performance
The t test showed that both groups significantly increased
the performance in the 30-seconds elbow flexion and
extension (42.7% for NLRT and 52.1% for RTEB).
Between groups comparisons using ANCOVA revealed
no significant differences.
Muscle Thickness Outcomes
The t test showed that both groups significantly increased
MT biceps (38.71% for NLRT and 38.04% for RTEB),
MT triceps (18.68% for NLRT and 20.0% for RTEB),
and MT pectoral (14.88% for NLRT and 14.17% for
RTEB). Between groups comparisons using ANCOVA
revealed no significant differences for changes in any MT
outcome
Discussion
The present study aimed to compare the effects of RTEB
and NLRT on upper body muscle size and performance
in hospitalized patients. The main results were that both
protocols were equally effective to improve muscular
size and functionality. Our results are in agreement with
Counts at al., 201621 who found similar levels of muscle
activation and hypertrophy in untrained young men
performing NLRT or traditional RT for the elbow
flexors. The present study extended these findings to the
pectoralis major and in hospitalized participants. Our
findings may be supported by the study by Rudroff,
Staudenmann and Enoka,24 which indicate that high
levels of motor units activation produced by repeated
contractions may provide stimuli for muscular
adaptations. Considering the high levels of activation
reported in NLRT exercises,20,21 this might, at least in
part, explain the results.
Table 2. Muscle thickness and functional performance pre and post the training period
NLRT
RTEB
PRE
POST
p
PRE
POST
P
MT Biceps (mm)
9.3±3.0
12.9±2.8
<0.001
9.2±3.1
12.7±3.4
<0.001
MT Triceps (mm)
18.2±2.7
21.6±2.8
<0.001
18.0±2.8
21.6±2.9
<0.001
MT Pectoral (mm)
24.2±2.7
27.8±2.7
<0.001
24.0±2.8
27.4±3.4
<0.001
30-seconds Arm Curl (reps)
10.3±1.3
14.6±2.9
<0.001
9.4±1.0
14.3±2.4
<0.001
Data are presented as mean ± standard deviation. MT: Muscle thickness. Reps: repetitions number. NLRT: No load
resistance training group; RTEB: Resistance training with elastic bands group.
Table 1. Physical characteristics in the training group
NLRT
RTEB
Age (years)
60.5±2.8
57.6±3.2
Height (cm)
163.8±2.5
163.4±2.7
Body mass (kg)
70.1±4.3
70.3±3.1
Data are presented as mean ± standard deviation. SBP: systolic blood pressure. DBP: diastolic blood
pressure. NLRT: No load resistance training group; RTEB: Resistance training with elastic bands group.
Accepted paper

“NO LOAD” resistance training increases functional capacity and muscle size
Eur J Transl Myol 29 (4): xx1-xx5, 2019
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On the other hand, our results on functional performance
are in contrast to the findings by Counts et al.21 since we
found similar gains for RTEB and NLRT. This apparent
divergence might be explained by two factors. Initially,
due to the different characteristics of the participants,
since Counts et al.21 investigated healthy individuals,
while our study involved hospitalized patients in an
intensive care unit, which might present a lower adaptive
threshold. Another point is the test used, Counts et al.21
used the 1RM tests, that is a more specific and similar to
traditional RT, while we used an endurance-oriented
functional performance test. Considering that increases
in performance might be specific,25 this might have
influenced the results.
It is difficult to compare our results with previous studies,
because, to best of our knowledge, we are not aware of
any similar intervention in an intensive care unit.
However, previous studies showed that hospitalization
lead to significant reductions in muscle strength and
mass, reaching 40-48% after three weeks.26 Therefore,
the fact that our participants increased muscle mass and
functionality seem to be of clinical importance.
In summary, our findings suggest that NLRT might be a
feasible strategy to be adopted in hospitals and
rehabilitation centers, since it promoted gains in muscle
size and performance without the need of specific
equipment.
However, one important limitation was training only
upper body muscles. We opted for using only upper body
movements because previous studies involved this
region and many participants reported difficult in
performing NLRT in lower body muscles. Whilst upper
body training might be useful for daily activities
(personal care, feeding, etc …), it would be important in
future studies to extend these findings to lower body
muscles and additional tests.
In conclusion, the present study suggests that
hospitalized can benefit from exercises performed
without external load, with no detrimental effect.
Moreover, our results showed that NLRT promote
similar results, when compared to traditional and widely
applied methods.
List of acronyms
1RM – one repetition maximum
CV – coefficient variation.
DBP - diastolic blood pressure
MT - muscle thickness
NLRT - no external load resistance training
Reps - repetitions number
RPE - rating of perceived exertion
RT - resistance training
RTEB - resistance training performed with elastic bands
SBP - systolic blood pressure
Authors contributions
All named authors contributed in equal part to the
manuscript.
Acknowledgments
We would like to thank all the participants of the study
and their coaches for consenting to provide the data.
Funding No funding was obtained for this project.
Conflict of Interest
The authors declare no conflicts of interest.
Ethical Publication Statement
We confirm that we have read the Journal’s position on
issues involved in ethical publication and affirm that this
report is consistent with those guidelines.
Corresponding Author
Matheus Barbalho, Faculdade de Educação Física e
Dança, Universidade Federal de Goiás – Avenida
Esperança s/n, Campus Samambaia – Goiânia, 74690-
900, Brazil. Phone: +59 62 35211085.
Email: matheussmbarbalho@gmail.com
E-mails of co-authors
Victor Silveira Coswig: vcoswig@gmail.com
Martim Bottaro: martim@unb.br
Claudio Andre Barbosa de Lira:
andre.claudio@gmail.com
Mario Hebling Campos: mariohcampos@gmail.com
Carlos Alexandre Vieira: vieiraca11@gmail.com
Paulo Gentil: paulogentil@hotmail.com
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Submission: August, 08, 2019
Revision received: September 20, 2019
Acceptance: September 22, 2019
Accepted paper