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The Effects of Eccentric Training On Lower Limb
The Effects of Eccentric Training On Lower Limb
com
Review
Review
from randomised clinical trials on whether eccentric training (1) sample size (2) participant gender, (3) participant age, (4)
results in meaningful increases in lower limb flexibility when muscle group studied, (5) type of outcome measure used and
compared with another, or no, intervention. (6) inclusion/exclusion criteria (table 1).
Review
Study Sample size Gender Mean age Muscle group Outcome measure Inclusion/exclusion criteria
Blazevich et al54 33 16 M/17 F 23 Quadriceps FL Recreationally active; No lower limb injury; No weight training;
No co-existing medical conditions; Not a manual occupation;
Not exercising vigorously >4 times/week
Duclay et al55 18 All male 23 Calf FL Healthy students; Recreationally active; No neurological injury/
disease; Not engaged in resistance training
Mahieu et al56 64 32 M/32 F 22 Calf ROM Recreationally active; No lower limb injury; Not elite athlete
Nelson and Bandy 57 69 All male 16 Hamstring ROM Tight hamstrings; Not currently increasing their exercise
intensity; No lower limb injury; No low back pain
Potier et al58 22 16 M/6 F 28 Hamstring FL and ROM Not engaged in resistance training; No musculoskeletal injury;
No co-existing medical conditions
Reeves et al59 19 8 M/10 F 71 Quadriceps FL Recreationally active; No musculoskeletal injury; No co-existing
medical conditions; Living independently
DESCRIPTION OF RESULTS
All six studies showed consistent evidence that eccentric train-
ing increases ROM, 56 57 or FL, 54 55 59 or both, 58 irrespective of
the joint or muscle group studied. At the ankle, Mahieu et al 56
reported a significantly greater increase in dorsiflexion (mean
change=+6°) compared with a no-exercise control group (mean
change=+1°). Using ultrasound measurements of FL rather
than ankle joint ROM, Duclay et al 55 reported similar results.
There was a significant increase in FL (mean change=+3.36
mm) at rest after eccentric training, compared to a control
group (mean change=+1.01 mm) which performed no exercise
intervention. 55
Consistent increases in flexibility after eccentric training
were also reported for the hamstrings. Nelson and Bandy57 ran-
domised participants into one of three groups; static stretching,
eccentric training and control (no exercise). Both the eccentric
training (mean change=+12.79 °) and static stretching (mean
change=+12.05°) groups reported significantly larger increases
Figure 2 Flow chart of study identification procedure. in ROM at follow-up compared with the control group (mean
change=+1.67°). Potier et al 58 also studied the hamstrings, and
was the only study to include both FL and ROM as outcome
measures. After the training period, there was a significantly
METHODOLOGICAL STUDY QUALITY greater increase in ROM (mean change=+6.9 °) in the eccen-
All six studies were rated as ‘high quality’ using the PEDro tric training group, compared to the non-exercise control
scale (table 3). All six studies randomly allocated participants group (mean change=−1.8 °). Furthermore, the increase in FL
and involved concealment of allocation. In three studies, par- was significantly larger for the eccentric training group (mean
ticipants were not different at baseline in the main outcome change=+34%), being twice as large as the increase reported in
measure of interest to this review, either FL or ROM. However, the control group (mean change=+17%).
in the other three studies, 54 58 59 baseline differences were pres- Finally, two studies 54 59 examined the effect of eccentric
ent, which could partly explain different responses between training on quadriceps flexibility. Unlike the other four studies,
groups, and this concern is addressed in detail later. Two stud- both of these studies used as the comparison another exercise
ies did not state using an outcome assessor who was blinded to intervention which could increase muscle strength, similar to
group allocation. 57 59 None of the trials blinded the therapists eccentric training. Reeves et al 59 observed a significant increase
or patients, which is almost unavoidable in studies of exercise in FL after eccentric training, which had not been evident dur-
interventions. All six studies reported follow-up measures for ing a 14-week pretraining monitoring period. Furthermore,
Review
Blazevich et al54 1) Eccentric 10 30 Progressed from 6/4 Æ 6/5 Æ 6/6 3 s* 1) 50%-100% 1) Eccentric
2) Concentric E1RM dynamometry
3) Control 2) 50%–100% 2) Concentric
C1RM dynamometry
Duclay et al55 1) Eccentric 7 18 6/6 3s 120% C1RM Eccentric
2) Control (two exercises) dynamometry
Mahieu et al56 1) Eccentric 6 42 15/3 6s N/R Eccentric heel drops
2) Control
Nelson and Bandy 57 1) Eccentric 6 18 6/1 5s N/R 1) Eccentric hip flexion
2) Stretching with knee extended
3) Control 2) Static hamstring
stretching
Potier et al58 1) Eccentric 8 24 8/3 5s 100% E1RM Weights machine
2) Control
Reeves et al59 1) Eccentric 14 42 10/2 1) 3 s 1) 80% E5RM Weights machine for
2) Mixed conc/ecc 2) 2/3 s (two exercises) 2) 80% C5RM both
C1RM, concentric one repetition maximum; E1RM, eccentric one repetition maximum; N/R, not reported.
*Approximation based on detail provided in the study.
BGA, between-groups analysis; 9, meets criteria; X, does not meet criteria; ITTA, intention to-treat analysis; PMV, point measure and variability.
while FL also increased from the baseline in a mixed concen- using indirect ROM measurements defi ned separately as ‘flex-
tric/eccentric training group (mean change=+6 mm, or +8%), ibility’ and ‘stretch tolerance’,60 while recent technological
the increase was significantly greater in the eccentric train- developments have allowed direct measurements of FL. 58 In
ing group (mean change=+16 mm, or +22%). Blazevich et al 54 this review, we considered studies which have evaluated any
included three groups in their study of the quadriceps; an of these measurements before and after eccentric training as
eccentric group, a concentric group and a non-exercise control a measure of ‘flexibility’. The ROM measurements such as
group. Both the eccentric (mean change=+3.1%) and concen- those used in this study are relatively reliable29 61 and clini-
tric (mean change=+6.3%) training groups demonstrated sig- cally applicable. However, it must be acknowledged they may
nificant increases in FL (mean change=+4.2%) after 10 weeks, not accurately represent underlying muscle length, especially
unlike the control group (mean change=−0.3%). However, in biarticular muscles such as those included in these studies.
unlike Reeves et al, 59 FL increased to a greater extent, albeit Obviously other factors can increase ROM, such as a simple
non significantly, in the concentric training group. warm-up, 29 and inconsistency across studies on the use of a
warm-up could influence the magnitude of change in ROM
DISCUSSION observed, although this would not change the overall effec-
Main findings tiveness reported across all muscle groups. Furthermore, in
Consistent evidence in six high-quality studies supported the one study, the baseline differences in ROM between groups
hypothesis that eccentric training is effective at increasing (7.9 °) actually exceeded the increase reported after eccentric
lower limb flexibility. This fi nding was consistent across dif- training (6.9 °).
ferent muscle groups, and using different outcome measures. Analysing FL using ultrasound also involves a degree of
All four studies 54 55 58 59 which examined muscle FL identified error, especially in those studies involving vastus lateralis 54
59 and the hamstrings, 58 where their relatively long FLs 47 55
significant gains in FL following eccentric training, indicating
structural adaptations within the muscle. Similarly, the fi nd- required FL to be estimated using linear extrapolation. This
ings from all three studies 56–58 examining ROM confi rm that may partly explain why there were baseline differences in
increases in ROM occur after eccentric training, irrespective of FL in two studies. 54 59 While the use of a repeated baseline
the muscle group studied. with very little variation supports the measurement proto-
col in one of these studies, 59 a large change in FL among the
Defining and analysing flexibility control group in one study 58 and after the intervention had
Reviewing the literature in this area is complicated by attempts ended in another study, 54 further question the between-day
to defi ne flexibility. Flexibility has traditionally been examined reliability of FL measurement and the similarity of groups
Review
at baseline. This highlights the need for estimates of reli- It is not possible to conclusively establish how the gains
ability or repeated baseline measurements when using this in flexibility observed after eccentric training compare with
approach. 55 59 Furthermore, studying a portion of a muscle those reported for static stretching. The only study in this
group such as vastus lateralis may not necessarily reflect review which compared eccentric training and a static stretch-
accurately the rest of that muscle group.47 Interestingly, ing programme observed no significant difference between
the recent availability of extended field-of-view ultrasound them, with both groups demonstrating large, clinically mean-
(EFOV-US), has confi rmed that the estimation methods used ingful increases in ROM. 57 Given the additional benefits of
in three of the four included studies which examined FL are eccentric training in the development of power and injury
likely to have underestimated FL, and the error involved is prevention,67 68 this questions the benefit of additional static
not consistent across muscle lengths.62 The availability of stretching. However, the increases in ROM after eccentric
EFOV-US appears to be much more reliable and may address training reported in the two studies of the hamstrings are
these concerns.62 Notwithstanding these legitimate method- quite different. 57 58 When the actual exercise programmes are
ological concerns, the fi ndings are remarkably consistent in analysed, the eccentric training used by Nelson and Bandy 57
all studies. was not related to maximal baseline strength, and appears
to be of relatively low load. Despite this, they report a larger
Mechanism of increasing flexibility increase in ROM (12.79 °) than reported by Potier et al 58 (6.9 °)
Sarcomerogenesis remains the most likely mechanism by after longer duration, higher load eccentric training. Since the
which flexibility increases after eccentric training, as has eccentric training used by Nelson and Bandy 57 incorporated
clearly been demonstrated after eccentric training in animal a static hold at end range, their ‘eccentric’ training could be
studies. 39 A prolonged shift in the muscle length-tension considered a mix of traditional eccentric training and static
curve consistently occurs after repeated bouts of eccentric stretching. Therefore, the improvements in flexibility after
training,40 suggesting that muscles adapt to mildly damaging more typical eccentric training in the other five studies may
eccentric training by sarcomerogenesis. This optimises gen- not be as large as those obtained by static stretching. No
eration of torque at more extended joint positions, to limit the other study in this review analysed both ROM and FL. Nelson
potential for muscle damage.44 63 The fi ndings of this review and Bandy 57 did not analyse injury rate or changes in torque
further support this hypothesis, with increases in ROM, 56 57 profi le, such that it is not possible to determine if their pro-
FL, 54 55 59 or both 58 evident after eccentric training. The fact gramme improved these other parameters as effectively as tra-
that changes in both ROM60 and FL 54 appear to be closely ditional eccentric training. There is considerable evidence that
related to changes in the muscle length-tension curve further eccentric training is associated with improvements in peak
support this hypothesis. torque,67 performance,67 muscle length-tension curves63 and
reduced pain and disability.69–72 As a result, even in the event
Clinical implications that eccentric training is not as effective as static stretching in
The magnitude of increase in flexibility after eccentric training increasing flexibility, these other advantages of eccentric train-
appears to be clinically relevant, and in line with the increases ing over static stretching suggest an eccentric component to
observed after static stretching. For example, a recent review 64 training is very important.
demonstrated mean changes of between +6°and +13° in passive The two studies to compare eccentric training with other
knee extension (PKE) ROM following static hamstring stretch- exercise interventions based on strengthening reported dif-
ing, in line with the gains in PKE ROM reported after eccen- ferent fi ndings, despite examining the same muscle (Vastus
tric hamstring training in this review. 57 58 Considering ROM Lateralis) and using the same outcome measure (FL). Both
deficits after hamstring injury are typically less than this, 29 36 studies reported that eccentric training increased FL. However,
these increases appear to be clinically relevant, notwithstand- while Reeves et al 59 reported a greater increase in FL after
ing the fact that all studies in this review involved painfree eccentric training, Blazevich et al 54 observed no significant
participants. Similarly, the increase in dorsiflexion ROM (mean difference between the two training groups, with a trend for
change =+6°) reported by Mahieu et al 56 is relatively large, and greater increases in FL among the concentric training group.
at least matches the increases reported after static stretching.65 While the population in the Reeves et al study 59 was much
It is harder to interpret the clinical relevance of the increases older, which may influence muscular responses to eccentric
in FL seen after eccentric training, other than to note that FL training, 73 the results are very consistent with other studies in
was significantly increased in each muscle group studied this review. The effectiveness of the eccentric training stimu-
to varying degrees. While it is likely that both measures of lus used by Blazevich et al 54 is unclear. Typically, exercise gains
flexibility (ROM and FL) correlate strongly, this has not are magnified in the exercise mode which is trained, such that
yet been clearly established, and the pennation angle of mus- concentric training increases concentric strength more than
cle fibres may influence the relationship. Nevertheless, the eccentric training and vice-versa. 59 74 In contrast, Blazevich
one study which examined both ROM and FL 58 demonstrated et al 54 reported that while the concentric training group dem-
clear improvements in both FL and ROM after eccentric onstrated greater gains in concentric torque than the eccentric
training. training group, there were no between-group differences in
The exact timeframe for improving flexibility with eccen- eccentric torque afterwards. This suggests that the eccentric
tric training is unclear, although sarcomerogenesis is thought training may have been suboptimal, despite being designed
to occur within 10 days of starting eccentric training.63 In this relative to one repetition maximum (1RM) ability. Another
review, eccentric training as short as 6 weeks resulted in signif- concern relates to the baseline between-group differences in
icant increases in flexibility. 56 57 It is unclear if these increases FL, 54 which may also explain why FL continued to increase
in flexibility are maintained after ceasing eccentric training, towards the values of the control group during the detraining
although it is likely that some ongoing eccentric training period. Furthermore, nearly all of the increase in FL occurred
would be needed, similar to gains in flexibility achieved with in the fi rst 5 weeks of the 10-week training programme, before
static stretching. 33 35 66 a further slight increase in FL after training ceased. This data
Review
Review
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Br J Sports Med 2012 46: 838-845 originally published online April 20,
2012
doi: 10.1136/bjsports-2011-090835
These include:
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Notes