Theme Issue: Exercise and Sports

Basic Principles Regarding Strength, Flexibility, and Stability Exercises

William Micheo, MD, Luis Baerga, MD, Gerardo Miranda, MD
Abstract: Strength, exibility, and stability are physiologic parameters associated with health-related physical tness. Each of these domains affects health in general, the risk of injury, how an injury is treated, and performance in activities of daily living and sports. These domains are affected by individual phenotype, age, deconditioning, occupational activity, and formal exercise. Decits or loss of strength, exibility, and stability can be prevented or reduced with exercise programs. Normal muscle strength has been associated with general health benets, increased life expectancy, psychological benets, prevention of illness, and reduction of disability in older adults. Static exibility programs have been shown to improve joint range of motion and tolerance to stretch but do not appear to reduce the risk of musculoskeletal injury and may impair muscle performance immediately after a static stretch. Dynamic exibility, on the other hand, may enhance power and improve sports-specic performance. Stability training leads to improved balance and neuromuscular control, may prevent injury to the knee and ankle joints, and can be used for treatment of patients with low back pain. PM R 2012;4:805-811

INTRODUCTION
Strength, exibility, and stability are physiologic parameters associated with health-related physical tness. Each of these parameters affects health in general, modies the risk of injury, determines how an injury is treated, and affects performance in activities of daily living and sports (Figure 1) [1]. These parameters are affected by individual phenotype, age, deconditioning, occupational activity, and formal exercise. Loss of strength, exibility, and stability can be prevented or reduced with targeted exercise programs [2,3]. The timing, dosage, and frequency of exercise programs to address age/inactivity-related decline or injury-associated acquired decits in these parameters have received increased interest in the medical literature during the past 20 years. However, the denition of optimal exercise and the efcacy of specic exercise and rehabilitation programs in different populations remain undened. Clinicians managing patients with neurologic conditions and musculoskeletal and sports injuries should understand the basic concepts of clinical exercise physiology and the role of exercise as a medical treatment. In this article, we will discuss denitions and basic concepts of strength, exibility, and stability, review the medical literature as it relates to the effectiveness of training each area, and discuss the role of each in the prevention and treatment of injury. Appropriate exercise prescriptions for each area also will be addressed.

W.M. Physical Medicine, Rehabilitation and Sports Medicine Department and Sports Medicine Fellowship Program, University of Puerto Rico, School of Medicine, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067. Address correspondence to W.M.; e-mail: wmicheo@usa.net Disclosure: nothing to disclose L.B. Physical Medicine, Rehabilitation and Sports Medicine Department and Sports Medicine Fellowship Program, University of Puerto Rico, School of Medicine, San Juan, PR Disclosure: nothing to disclose G.M. Physical Medicine, Rehabilitation and Sports Medicine Department and Sports Medicine Fellowship Program, University of Puerto Rico, School of Medicine, San Juan, PR Disclosure: nothing to disclose

STRENGTH Basic Concepts

Strength is the maximum force or tension that a muscle or a muscle group can generate with a single contraction [4,5]. The extent of muscle strength loss with age, inactivity, injury, and immobilization depends on impaired neuromuscular activation and reduced muscle volume [6]. Pain, joint effusion, and angle of immobilization are factors associated with arthrogenic muscle inhibition and reduced strength after injury [7]. Sarcopenia or loss of
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Stability Strength
Physical Fitness Injury Risk Treatment Performance

Flexibility

Figure 1. Components of health-related physical tness.

single joint, and can be used to recruit muscles that are inhibited (Table 1) [11]. For example, in considering strengthening exercises for knee pain, OKC exercises create more shear force stress on the anterior cruciate ligament, whereas CKC exercises increase patellofemoral compressive force. Both can be useful in selected situations, that is, OKC for isolated muscle recruitment and CKC for more functionally based strengthening. Improvement in strength associated with a resistance exercise program is the result of a combination of neural adaptations and changes in muscle structure. In the rst 4 weeks of training, neural adaptations include increased motor unit recruitment and synchronization, as well as a crossed training effect in the opposite limb. With a continuous training stimulus, increased muscle ber size occurs, particularly of type II muscle bers [5,12].

muscle mass in elderly patientswhich may be associated with a lack of physical activity, altered gene expression, hormonal changes, or cell apoptosisis one of the factors associated with reduced strength, frailty, and disability with advancing age [8]. The type of muscle actions used in strengthening programs can be divided into static (isometric) or dynamic (concentric, eccentric) contractions [3]. Static exercise can be used early in rehabilitation programs after injury and as an initial component of a strengthening program in very weak individuals. In this type of muscle action, force is produced without joint movement, strength gains are limited to the angle in which the joint is exercised, and exercise usually is not performed in functional positions. Dynamic exercise has a concentric component in which muscle is shortened as it contracts and an eccentric component in which muscle lengthens as it produces force. Concentric actions accelerate joints and produce greater torque with slow contractions. Conversely, eccentric contractions decelerate the articulations involved in the movement, resulting in high force production, and they are more likely to result in muscle micro or macro damage, as well as delayed-onset muscle soreness. Eccentric muscle contractions typically are associated with muscle and tendon injury in high-demand activities such as competitive sports [9]. The kinetic chain is dened as a link system in which segments respond to force in a sequential and predictable fashion. A closed kinetic chain (CKC) condition exists when the distal segment is xed or meets enough resistance to restrain free motion. CKC exercise emphasizes the sequential movement and placement of functionally related joints, a stable base for functional movement patterns, and efcient control and transfer of applied loads. These CKC exercise programs increase agonist/antagonist muscle co-contraction, reduce joint shear force, and minimize joint displacement and ligament strain [10,11]. In open kinetic chain (OKC) activities, the distal portion of the extremity is free to move. OKC exercises can target isolated muscle groups, act on a

Research Results
The health benets of increasing strength and improving muscular tness have been well established. Greater levels of strength are associated with better cardiometabolic risk factor proles, lower risk of all-cause mortality, lower risk of developing functional limitations, and improved bone mass, as well as bone strength [13]. In older adults, exercise programs that include resistance training can increase active life expectancy by limiting the progression of chronic disease and disabling conditions and can lead to cognitive and psychological benets [8]. The role of strengthening exercise in the prevention of injury also has been studied. Strengthening programs that emphasize eccentric exercises have been shown to be effective in the prevention of hamstring injuries in soccer players [14]. Core muscle and hip strengthening and neuromuscular training with an emphasis on strengthening have been shown to prevent back and groin injuries in athletes and anterior cruciate ligament injury in young females, especially those under 18 years of age [15-17]. With aging, muscle weakness that is not reversed has been identied as a predictor of knee osteoarthritis onset and
Table 1. Comparison of closed kinetic chain exercise versus open kinetic chain exercise Closed Kinetic Chain Exercise Distal segment xed or meets resistance to motion Sequential movement of functionally related joints Increased agonist/antagonist co-contraction Reduced joint shear forces and ligament strain Provides stable base for functional movement Open Kinetic Chain Exercise Distal segment free to move Isolates single joints Facilitates contraction of inhibited muscles Allows emphasis on concentric and eccentric muscle action Prepares muscle for integrated functional activities

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progression. Strength decits in elderly persons lead to slower walking speeds and difculty with climbing stairs [8,18,19].

Clinical Application
Recommendations for strengthening programs will vary depending on the specic population. Programs can be designed for healthy adults of any age, persons with injury or medical illness, and athletes. Components of a strengthening program include frequency, duration, and intensity. The intensity of the exercise program usually is determined by the concept of one repetition maximum (1 RM), which is the maximal load that can be lifted throughout the full range of motion (ROM) once [2,3]. For novice to intermediate exercisers, moderate intensity (60%-70% of 1 RM) is used for training, and for more advanced exercises, heavy intensity (80% of the 1 RM) is used. Older or disabled persons or persons starting training after an injury usually start with light intensity (40%-50% of 1 RM, or exercising to the point of fatigue). Resistance training should be performed 2 to 3 times per week, major muscle groups should be addressed, and the patient should perform concentric and eccentric muscle actions for 2 to 4 sets, although a single set also has been shown to be effective in producing strength gains similar to multiple sets [20]. Between 8 and 15 repetitions to fatigue are used to improve strength in most adults, and a weight that can be lifted 15 to 20 times is recommended to improve muscle endurance or resistance to taskspecic fatigue [13].

transfers the energy to the bones faster, resulting in a quicker movement of the joint [22]. Static stretching techniques involve the application of slow and passive stretching, whereas dynamic stretching involves the repeated gradual transition from one body position to another with a progressive increase in reach and ROM [13]. Some studies suggest that each static stretch should be maintained for 20-30 seconds to facilitate connective tissue elongation [21,23]. Proprioceptive neuromuscular facilitation requires a combination of steps that include a static stretch, an isometric contraction and relaxation, and then another static stretch.

Research Results
Traditionally, warm-up activities and stretching protocols have been recommended to persons before and/or after performing physical activities. It is theorized that warm-up and stretching prevent muscle injuries by increasing the elasticity of muscles and smoothing muscle contractions. However, improper or excessive stretching and warm-up can predispose one to muscle injury [24]. In several studies, authors have investigated the effect of muscle stretching on the risk of exercise-related injury. The general consensus is that stretching in addition to precompetition warm-up does not affect the incidence of overuse injuries [25-28]. A systematic review suggests that muscle stretching performed either (1) before or after exercise or (2) before and after exercise does not produce clinically important reductions in delayed-onset muscle soreness in healthy adults [29]. Another topic of discussion associated with exibility training is the effect of stretching on performance. A recent review of the literature suggests that no clear answer to this question has been ascertained because of the variety of protocols and methodology reported in the published literature [30]. Several studies demonstrate that static stretch impairs performance, specically in muscle strength and to a lesser extent in power, especially when a static stretch is performed immediately before an athletic event. Stretches of longer duration ( 60 seconds) are particularly associated with these effects on performance. Other authors argue that ndings of these studies do not apply to athletes who perform warm-up and stretching routines that are different from those studied [27]. Conversely, in a substantial number of articles, different stretching and warm-up protocols are used that show no detrimental effects on performance [31]. A shorter duration of stretching followed by a general warm-up before physical activity may decrease the detrimental effect of stretching on performance [32]. Comparison of types of stretching led to the suggestion that dynamic stretching has greater applicability to enhance power and performance when compared with static stretching. In several studies, authors have examined the acute effect of passive stretching, dynamic stretching, and no stretching

FLEXIBILITY Basic Concepts

Flexibility is the ROM in a joint or in a group of joints; it is inuenced by muscles, tendons, and bones and is described as the degree to which muscle length permits movement over the joint in which it has inuence. The musculotendinous unit (MTU) plays a major role in ROM and is directly related to stiffness and tension provided by passive and dynamic components. The static component of connective tissue has viscoelastic properties, such as elasticity and viscosity, whereas the dynamic component of tension is provided by neural reex activity of the muscle [21]. A exibility or stretching program is aimed at increasing the ROM of specic joints or groups of joints [21]. Stretching results in elongation of soft tissues and an increase in muscle length, which affects the stiffness and energy-storing properties of the soft tissue. A more compliant MTU allows for the effective storage and release of elastic energy, thus facilitating performance within a stretch-shortening cycle. A stiffer MTU

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on sprinting performance at different distances. It appears that passive static stretching before a race decreases sprint performance even when combined with dynamic stretches compared with a solely dynamic stretch approach [33-37]. The incorporation of a dynamic stretching program in the warm-up and in the daily preseason training regimen for at least 4 weeks produces longer-term and sustained power, strength, muscular endurance, anaerobic capacity, and agility performance enhancement [37-39]. The effectiveness of stretching programs in rehabilitation protocols has not been established. Stretching programs have physiological benets, such as increased blood ow to the tissues and increases in the speed of muscular contractions and nerve transmissions [21]. Stretches of longer than 30 seconds duration with lower force provide increased tolerance to stretch, improve exibility of the hamstrings, and improve quadriceps eccentric contraction, particularly when combined with a warm-up [39-41]. In the workplace, a preshift stretching protocol for 90 days in a production factory resulted in an injury rate reduction and increased participant compliance [42].

STABILITY Basic Concepts

Joint stability is achieved by the combination of static and dynamic components. Static stability refers to the structural stability achieved passively by such structures as bones, capsules, and ligaments. Dynamic stability refers to the neuromuscular control of the skeletal muscle affecting a joint to maintain its center of rotation in response to perturbation. Stability is dened as the state of a joint remaining or promptly returning to proper alignment through an equalization of forces [45]. Dynamic stability depends on central nervous system (CNS) control, which is achieved through feedback and feed-forward mechanisms that require adequate motor planning at the level of the motor cortex and cerebellum [46]. During feedback control, an unexpected perturbation is sensed by mechanoreceptors in the capsule, ligaments, tendons, and muscles of the affected joint. This signal travels to the CNS, where an appropriate motor response is formulated to counteract the perturbation and maintain stability. Although feedback control is based on a reaction to a perturbation, feed-forward control is an anticipatory motor plan to maintain stability before a predicted perturbation [45,47]. The concepts of stability can be applied to the spine and to peripheral joints. Two main models of spinal stability have been described: the muscle capacity model and the control model [47]. The muscle capacity model is a static model based on muscle strength and endurance sufcient to maintain stability of the spine for a prolonged period. The cocontraction of abdominals and back extensors serve as guy wires to maintain the spine in a neutral, stable position, and contraction of the transverse abdominis causes a hooplike stress that increases intra-abdominal pressure and in turn confers added stability to the spine. This model does not account for the dynamic changes and neuromuscular control needed to stabilize the spine during activity and movement of the spine and limbs [47]. When an unexpected perturbation occurs, the CNS initiates a response to compensate for the instability generated by the perturbation; this response is altered in patients with chronic low back pain [48]. In a study by Hodges [47], activation of deep and supercial trunk muscles was recorded before limb movements. The deep muscles (the transverse abdominis and multidi) red independently of the direction of force. These muscles are thought to maintain intersegmental stability, which is independent of the direction of limb movement. Activation of supercial muscles, such as the internal and external oblique muscles and erector spinae, was linked to the direction of the limb movement. These muscles make use of their mechanical advantage to provide support for the spine during the asymmetric loads generated during limb movements [47].

Clinical Application
An individualized exibility plan that takes into account compliance, general knowledge of warm-up and cool-down techniques, physical activity, and general tness level of the individual should be implemented [26,43]. In healthy adults, exibility programs should be performed 2 to 3 days per week, with the person stretching to the point of discomfort but not beyond as he or she performs 3 repetitions of 10 to 30 seconds duration hold and works on major muscle-tendon units. Isolated hamstring stretching, with the hip exed to 90 and the knee extended, and gastrocnemius stretching, with the knee in extension and the ankle in dorsiexion, are examples of commonly prescribed static exercises. Older persons and persons focusing on a particular muscle group may benet from stretches lasting 30-60 seconds. Proprioceptive neuromuscular facilitation techniques use a 3- to 6-second submaximal muscle contraction followed by 10 to 30 seconds of stretching [13]. For sports activity, a warm-up should be composed of a submaximal intensity aerobic activity followed by large amplitude dynamic stretching, which may include plyometric exercises in which an eccentric muscle action precedes a concentric contraction; the warm-up is then completed with sport-specic dynamic activities [31,44]. In sports with high stretch-shortening cycles, such as gymnastics and taekwondo, persons may perform short-duration static stretches in a pre-exercise routine without compromising maximal muscle performance [30,44]. The timing for static stretching remains controversial. Some persons argue that the stretching protocol should occur within the 15 minutes before the activity to receive the most benet, whereas other persons emphasize stretching after exercise [30].

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Research Results
Although a strong theoretical basis exists for stability training in injury prevention and injury management, data to support this principle are sparse. With respect to core stability, studies have been performed that link core weakness to increased lower extremity injuries, and several studies suggest that low back pain alters the control mechanisms of the spine [49,50]. Altered activation patterns occur during trunk repositioning tests in patients with low back pain when compared with control subjects, and several different studies have documented altered position sense in persons with low back pain, segmental instability, and radiculopathy as a result of herniated nucleus pulposus [48,51-53]. Nevertheless, specic core stability programs for prevention of injury have not been well studied [54]. A review of the literature shows a few randomized controlled trials testing the efcacy of core strengthening programs on low back pain. Reduced pain scores and functional improvements have been shown in patients with spondylolysis or spondylolisthesis who performed core stability when compared with control subjects [55]. Hides et al [56] demonstrated that patients who performed abdominal and multidi co-contractions after an acute low back pain episode had signicantly lower recurrences of low back pain at 1 and 3 years when compared with the control group. In other studies, authors have questioned the superiority of core stabilization exercise to generalized strengthening or conventional physiotherapy in the treatment of low back pain [57,58]. One of the challenges of interpreting the available research on stability is that it is almost impossible to separate the components of stability training from strength training. The concept of dynamic stability for injury prevention and injury management has been suggested in most joints, including the ankle, knee, and shoulder [59-61]. It also has been suggested in the elderly population as a means to reduce pain from degenerative joint disease and to improve balance [62,63]. Some studies suggest that neuromuscular training may reduce injuries, including several studies in which authors demonstrate the reduced incidence of knee injuries in female athletes with preseason neuromuscular training compared with untrained athletes [49,64].

Table 2. Exercise progression in a stability program Early Phase Exercises should be simple and segmented Segmentation Reduce complex skill into parts Practice parts independently Simplication Reduce speed Reduce postural loads Reduce attention demands Later Phases Progressively integrate segments into complex movement Increase speed Add multiaxial loads Increase specicity by replicating demands of goal activities

Modied from Baerga-Varela and Abru-Ramos [65].

When one is designing the early phase of the program, the motor learning concepts of segmentation and simplication are applied. Segmentation involves reducing a complex skill into parts, which are practiced independently and are progressively integrated into a complex movement. The exercises are simplied by reducing the speed, postural loads, and attention demands. Single muscles are isolated with the goal of awakening the muscle. The next step is to combine several muscles in simple movements in stable positions and in a single cardinal plane (eg, sagittal, coronal, or transverse). As the patient progresses, the difculty is increased by increasing speed, adding multidirectional movements, adding off-axis loads in all cardinal planes, and adding progressively unstable surfaces [47,54,65]. The different exercises are designed to try to replicate activities performed by the patient to increase the specicity of the exercise (Table 2) [65]. However, it is important to progress to a higher level of stability challenge only when a patient has mastered the previous level, being careful not to add external instability onto internal instability.

SUMMARY
Strength, exibility, and stability are physiologic parameters associated with physical tness, health, musculoskeletal injury risk, injury treatment, and performance in activities of daily living. A decrease of these parameters is associated with advancing age, inactivity, injury, and medical illness and varies from person to person. Normal muscle strength and tness is associated with health benets, injury protection, improved psychological and cognitive function, and reduction of disability later in life. Static exibility programs can improve joint ROM, may improve performance in some sports that require prominent use of the stretch shortening cycle, appear to reduce muscle strength and power after a prolonged static stretch, and have not been shown to prevent musculoskeletal injuries. Dynamic exibility programs improve power and have been shown to improve performance. Joint stability and neuromotor control of the trunk and extremities may lead to reduced ankle, knee, and shoulder injuries, improved patterns of muscle ring, and improvement in low back pain. Finally, exercise programs recom-

Clinical Application
Although it is outside the scope of this article to present dynamic stability exercise prescriptions for different peripheral joints and the spine, we will outline basic concepts to follow when designing a stability program. The rst step is to carefully evaluate the patient and assess his or her current functional level and functional goals. Stability and balance programs in healthy adults should be performed 2 to 3 days per week, particularly for older adults who want to improve function and prevent falls [13].

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mended to improve health, function, and performance should include components of strength, exibility, and stability in an integrated fashion.

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