Journal of Australian Strength and Conditioning

Eccentric Exercise, Exercise Induced Muscle Damage and the Repeated Bout Effect: A Brief Review.
J. Aust. Strength Cond. 23(3) 74-84. 2015 © ASCA.

Review of the Literature

ECCENTRIC EXERCISE, EXERCISE INDUCED MUSCLE DAMAGE AND THE REPEATED BOUT EFFECT:
A BRIEF REVIEW

Lee A. Bridgeman, MSc, 1, Michael R. McGuigan, PhD, CSCS*D, 1 and Nicholas D. Gill, PhD, 1,2

1Sports Performance Research Institute New Zealand, AUT University, Auckland New Zealand
2New Zealand Rugby Union, Wellington, New Zealand

BLUF

Eccentric training may result in exercise induced muscle damage however, a preconditioning session may protect
against further damage as a result of the repeated bout effect (RBE).

ABSTRACT

Eccentric training has the ability to improve strength and power as well as being a stimulus for hypertrophy gains.
However a possible negative side effect is exercise induced muscle damage, which can have a detrimental effect on
performance. The symptoms and causes of exercise induced muscle damage and the ability of the RBE to protect
against muscle damage are discussed in this review. A search of the literature was conducted for; eccentric; training;
methods; exercise induced muscle damage (EIMD); RBE. After this search 82 papers were selected to form the basis
of this review. The finding of this review suggest if isometric contractions are used as a preconditioning exercise these
should be completed at long muscle lengths with 10 isometric contractions reported to result in the greatest protective
effect. Results of previous studies indicate that 30 repetitions of eccentric contractions at 10 - 40% maximal isometric
strength (low intensity and volume) and ~4 s in duration have resulted in a RBE with little initial damage. Studies that
have investigated low volume maximal eccentric contractions (6 – 24 reps, ~ 4 s in duration) have reported increased
initial EIMD followed by a protective effect against further damage. When utilising maximal eccentric contractions the
protective effect is reported to last up to 6 months in comparison to a low intensity bout that may only offer protection
for 3 weeks. In summary it is suggested athletes should initially complete low intensity low volume eccentric training.
Athletes should then progress to low load maximal or supramaximal eccentric training prior to completing higher volume
sessions to allow the RBE to offer protection against muscle damage.

Key Words - Eccentric, exercise induced muscle damage, repeated bout effect.

INTRODUCTION

Resistance training has previously been reported to lead to improvements in both strength and power resulting in
improved athletic performance (1-3). When developing a programme to improve strength and power applying the
principle of overload should be a key consideration as without this stimulus an athlete’s potential to make improvements
is greatly reduced. It has been reported that the eccentric portion of exercises may not be optimally loaded even if an
athlete is working to their maximum concentrically (4-6). Previous research has consistently demonstrated that subjects
are stronger eccentrically that concentrically (7), thus it is suggested that the principle of overload is not always applied
to the eccentric portion of movements.

The potential benefits of eccentric training are well documented and include; improvements in total strength, concentric
and eccentric strength (5,8-11), increases in hypertrophy (12-14), improvements in jumping power (15,16) and a reduced
risk of injury (17,18). However exercising eccentrically also has the potential to result in exercise induced muscle
damage (EIMD), as a result of athletes completing exercise which they are not accustomed to, which is high in intensity
or long in duration (2,19) and therefore may result in an acute reduction in performance. This brief review aims to outline
the symptoms and causes of EIMD and explain how a bout of preconditioning eccentric exercise can provide a protective
effect against subsequent eccentric training.

METHODS

A search of the literature was conducted for eccentric exercise, EIMD and the RBE. Databases PubMed, CINAHL, Web
of Science and SPORTDiscus to August 2014 were searched for terms linked with Boolean operators (“AND”, “OR”):
eccentric; training; methods; exercise induced muscle damage; repeated bout effect. Papers were selected based on
title, then abstract, then text. Only papers, which specifically addressed the effect of eccentric EIMD in humans and the
RBE, were included in this review. Once these criteria had been applied 82 papers were selected to form the basis of
this review.

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DISCUSSION

Exercise Induced Muscle Damage

The symptoms of EIMD include; decreased muscular strength and power (20), delayed onset muscle soreness (DOMS),
decreased range of motion (ROM) and the leakage of substances such as creatine kinase (CK) into the blood (21).
Acute strength loss after unaccustomed eccentric exercise has been reported to be as high as 50-65% (22,23). This
loss of strength is reported to last 12-72 hours before returning to normal within 5-7 days (22,24). One theory proposed
by Morgan (25) to explain this strength loss is the “popping” sarcomere theory. This theory suggests that muscle
damage is the result of sarcomeres lengthening in a non-uniform fashion when muscle is stretched beyond its optimal
length. When this happens the longest sarcomeres will be the weakest and thus stretched more rapidly becoming even
weaker still. Due to the fact that the weakest sarcomeres are spread out across the myofibril, this non-uniform
lengthening is suggested to result in shearing of myofibrils and lead to damage of the t-tubules. The consequence of
this is that there is a disruption in calcium ion homeostasis and thus damage as a result of tearing of membranes or
opening of stretch activated channels (26,27). Although this initial strength loss may not be desirable some degree of
EIMD may be necessary due to the suggestion that “popping” of the sarcomeres leads to the addition of sarcomeres in
series (27). This is reported to result in less EIMD after future bouts of eccentric exercise (27) and a reduced risk of
injury in particular to the hamstring due to an increase in optimal muscle length (4).

Another potential mechanism for EIMD is the failure of the excitation coupling (E-C) process. It has been suggested that
calcium release is impaired following myofibrillar damage and this results in loss of force (28). Indeed Warren et al. (29)
suggested that impairment in E-C coupling was estimated to result in a 50-75% strength loss in the first 5 days following
an eccentric exercise bout. Although currently there is no consensus as to whether sarcomere damage or E-C coupling
is the main cause of strength loss following eccentric exercise, both are likely to be responsible (26). This was
acknowledged by Morgan and Proske (27) who suggested non-uniform sarcomere lengthening leads to greater force
being applied to the t-tubules which in turn results in greater disruption of the E-C process.

A further consequence of eccentric exercise is DOMS. In a review of DOMS Cheung et al. (30) suggested a model to
explain the mechanisms of DOMS based on previous theories (31-33). In summary, this model suggests that the high
forces that are achieved with eccentric exercise initially result in damage to the muscle tissue and in particular the z-
lines as well as damage being sustained by connective tissue. These initial events are then quickly followed by an
inflammatory response. It is this environment, which is suggested to result in type III and type IV nerve endings becoming
sensitised which produces the feeling of DOMS.

Unaccustomed eccentric exercise is also reported to result in increased muscle membrane permeability and as a
consequence increases in muscle-specific proteins in the circulation. These include; CK, myoglobin, troponin and
myosin heavy chain with CK suggested to be the most commonly measured (26). The mechanisms associated with this
increase in membrane permeability are currently unclear however it has been suggested that these changes may be
linked to mechanical-induced membrane damage (34) or as a result of the activation of stretch-activated Na+ and Ca2+
channels (35).

It has been suggested in a review by Schoenfeld (36) that a degree EIMD may be necessary to increase skeletal muscle
hypertrophy. In this review Schoenfeld (36) suggested that increases in hypertrophy associated with EIMD may be due
to increases in satellite cell activity, an increased inflammatory response, increases in insulin-like growth factor-1
signalling an increase in intracellular water content. Although this would seem a promising proposition for eccentric
exercise, given that it results in the most EIMD and also greater skeletal muscle hypertrophy than other forms of training
(12,37), the evidence to support this causal relationship is equivocal at best. Furthermore it has been suggested that
muscular hypertrophy can be achieved in the absence of EIMD and the negative consequences associated with it (38).
At present the optimal amount of muscle damage required to induce a hypertrophic response is not clear (36). What is
clear from the research however, is that severe EIMD results in acute reductions in strength and power (20). As a
consequence of this, in the short term, an athlete may have to reduce the intensity and volume of their training, which
would result in a decreased training efficiency. Therefore if the aim of a particular block of training is to increase
hypertrophy by utilising eccentric overload it is suggested that moderate rather than severe EIMD may provide the
optimal stimulus (36).

Repeated Bout Effect (RBE)

Although training eccentrically has been shown to be beneficial, athletes and coaches may be concerned with the
negative effects associated with severe bouts of EIMD. It is possible that the effects of EIMD may be reduced after a
bout of similar previous exercise with this termed the RBE (22,23,28,39,40). Utilised and planned for correctly the RBE
is suggested to result in; a faster recovery of muscular function, a reduction in range of movement deficits, reduced
swelling and soreness and smaller increases in muscle blood protein markers of EIMD such as CK (12,22) and has
been reported to last as long as six months (41). A number of protocols have been used to investigate the RBE these
include submaximal and maximal eccentric isokinetic contractions of the elbow flexors (42, 43) and knee extensors (44,
45), drop jumps (46), downhill running (47) and maximal voluntary isometric contractions at long muscle lengths (48).

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The exact mechanisms which allows the RBE to occur are as yet not fully understood although a number of theories
have been proposed (49). One such theory is neural theory, which suggests; increased motor unit activity, increased
slow twitch muscle fibre recruitment and increased motor unit synchronisation are responsible for the RBE (28, 50, 51).
Evidence for neural adaptations is suggested to come from studies where decreased electromyographic (EMG) median
frequency was found in the repeated bout which has been attributed to an increased recruitment of slow twitch motor
units with a decrease in fast twitch motor unit recruitment (29,52,53) or increased motor unit synchronisation (51). In
contrast to these findings, a study investigating EMG analysis of repeated bouts of eccentric exercise reported that there
was no evidence of neural adaptation (54). Nosaka et al. (55) also reported that electrically stimulated forced lengthening
did not support neural adaptation as a reason for the RBE. These authors suggested that the adaptations occur within
the muscle itself. Further support for this was provided by Kamandulis et al. (45) who reported voluntary activation was
similar between two bouts of eccentric exercise with neural adaptations not playing a significant part in the protective
effect. This finding instead was attributed to peripheral adaptations. Thus as yet there is no clear consensus on the
neural contribution to the RBE.

Another potential mechanism for the RBE is cellular theory which proposes that the RBE is the result of; the
strengthening of cell membranes, removal of weak fibres and the adding of sarcomeres in series (49). In studies
investigating the extent of eccentric muscle damage on humans it has been reported that the length of the eccentric
contraction is the critical factor with longer muscle lengths resulting in the most damage (52,56). Thus Morgan (25) and
Proske and Morgan (57) suggested one possible adaptation to eccentric EIMD which may promote a RBE is the addition
of sarcomeres in series which reduces the strain during further eccentric contractions and therefore provide a protective
effect. However in studies investigating the effects of carrying out a second eccentric exercise bout a couple of days
after the initial bout and before full recovery the results indicate that this does not cause further EIMD or cause the
recovery process to slow down (52,58-60). This McHugh et al. (28) suggested casts doubt on Morgan (25) theory as
sarcomeres would have insufficient time to recover.

Disruption to the E-C process has been suggested to result in strength loss after an initial bout of eccentric exercise
(28). However it is suggested that this initial bout also results in the strengthening of the sarcoplasmic reticulum
preventing further damage to E-C process during a repeated bout (43). It should be noted however, that Warren et al.
(29) findings about the large degree of strength loss as result of disruption to E-C process were based on electrically
stimulated contraction in animal models and as yet there is no direct evidence to support this theory as a mechanism
for the RBE (51).

Another reason for the RBE is the suggestion that muscle damage is reduced due to an altered inflammatory response
after the initial eccentric bout (61,62). This adaption in the inflammatory response is reported to explain the lack of further
damage when a second bout of exercise is completed prior to full recovery (28). However McHugh (51) points out that
this reduction in inflammatory response may be simply the result of less mechanical disruption in the repeated bout and
thus less of a stimulus.

Other suggestions as to what is responsible for the RBE focus on mechanical aspects and include increases in passive
and dynamic muscle stiffness (61), adaptations being made to the cytoskeletal proteins desmin and titin to strengthen
the structure of the sarcomere (63) and an increase in intramuscular connective tissue strength which protects against
further damage (64). As detailed above the evidence for the mechanisms for the RBE is at present equivocal. Ultimately
it would appear that one theory is unable to explain the RBE and therefore it is considered likely that each may play its
part in conferring a protective effect (28,51).

EVIDENCE FOR THE REPEATED BOUT EFFECT

Maximal Eccentric Contractions

Several studies (Table 1) have found evidence that utilising maximal eccentric contractions of the elbow flexors can
lead to a RBE. Clarkson and Tremblay (43) found 24 maximal eccentric contractions in untrained participants resulted
in a protective effect against 70 maximal contractions performed 2 weeks later with significant reductions in muscle
soreness, pain and strength loss. Further research by Nosaka et al. (65) found that 2, 6 and 24 maximal eccentric
contractions (3 seconds eccentric action) were able to offer a protective effect against a further 24 maximal eccentric
contractions performed 2 weeks later in untrained participants. Reductions in strength were found to be linked to the
amount of initial contractions and thus was proposed as evidence that the greater the number of eccentric contractions
the greater the EIMD. Therefore this led Nosaka et al. (65) to conclude that a few maximal eccentric contractions may
be preferable as they cause less initial muscle damage. In support of this Howatson et al. (53) found that both 10
contractions and 45 contractions (3 s eccentric action) conferred a protective effect against a further maximal eccentric
session in participants who were resistance trained but not familiar with eccentrically biased exercise. This resulted in
reductions in loss of strength, range of movement and soreness. Thus in agreement with Nosaka et al. (65) this study
found low volume maximal eccentric contractions conferred a protective effect against further EIMD. Of particular
interest potentially to athletes and coaches may be the findings of Nosaka et al. (41) who found that 24 maximal
contractions of the elbow flexors were able to result in a RBE. When completing another bout of 24 maximal eccentric
contractions 6 months and 9 months after the initial bout Nosaka et al. (41) found a faster recovery in maximal isometric
force. Also after 6 months but not 9 they also reported smaller increases in; upper arm circumference, plasma creatine

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kinase activity and T2 relaxation time. In the other group who repeated the initial bout 12 months later no RBE was
found. This led Nosaka et al. (41) to conclude that the RBE lasts at least 6 months after maximal eccentric contractions
of the elbow flexors but is lost between 9 and 12 months.

In summary if athletes are required to complete maximal eccentric contractions, completing low volume maximal
eccentric contractions 2 weeks prior, may confer a protective effect against EIMD which may last as long as 6 months.
A practical example of this would be athletes squatting supramaximal eccentric loads (~110 – 130% concentric 1RM)
with the aid of weight releasers or spotters only performing 5-10 repetitions in the initial training session. This low volume
session may confer a protective effect against EIMD during further maximal eccentric sessions of increased volume. A
further example of this is athletes utilising supramaximal eccentric bench press training to increase strength and
hypertrophy. Using this method the athlete would typically lift 110 – 130% of their concentric 1RM for the eccentric phase
only before spotters return the bar to the starting position. In the first session it is suggested athletes should only
complete 3-5 repetitions to reduce the amount of initial EIMD before increasing the volume in subsequent sessions.
This reduced volume in the first session may be particularly important when implementing this training method due to
the suggestion that eccentric EIMD is greater in the upper body compared to the lower body (66, 67). Thus starting with
a lower volume would provide a protective effect against severe EIMD during future sessions. In addition this low volume
session would reduce the initial amount of eccentric EIMD sustained and therefore allow the athlete to train efficiently
in the days that follow.

Table 1 - Repeated bout effect studies which have used a maximal eccentric conditioning load.

Study Muscle Population Exercise Intervention Results

Group Modality
Brown et Knee Untrained Isokinetic 3 groups performed Soreness reduced after 2nd session
al. (66) extensors subjects dynamometer initial bout of 10, 30 No increase in serum CK after 2nd
N = 24 or 50 max ecc bout in any group
Mean age: 21 contractions of the
years knee extensors.
Followed by 50 max
ecc contractions 3
weeks later
Chen (44) Elbow Untrained Isokinetic 30 maximal ecc All markers of EIMD changed
flexors subjects dynamometer contractions followed following session 1 but no additional
N = 26 3 days later by either EIMD was found after the 2nd bout of
Mean age: 20 70 or 30 max ecc either 70 or 30 max ecc contractions
years contractions
Clarkson et Elbow Untrained Modified arm One arm did 70 max Muscle soreness, pain and strength
al. (54) flexors subjects curl machine ecc contractions other was sig reduced after initial 70 max
N=8 did 24. Followed 2 ecc contractions. 24 max condition
Mean age: 24 weeks later by 70 showed only small changes. After 2nd
years max ecc contractions 70 max session changes were
significantly reduced from initial 70
max bout

Howatson Elbow Untrained Isokinetic 45 or 10 maximal ecc Greater reductions in MVC, ROM and
et al. (45) flexors subjects dynamometer contractions followed increased soreness and CK after
N = 16 2 weeks later by initial ecc45. After 2nd bout of ecc
Mean age: 27 another 45 max ecc exercise RBE present. No sig diff
years contractions between 10 ecc group and 45ecc in
markers of EIMD

Nosaka et Elbow Untrained Modified elbow 2 bouts of 24 max ecc Faster recovery of maximal isometric
al. (40) Flexors subjects flexor exercise contractions of elbow force after 6 and 9 months. Smaller
N = 35 flexors separated by increases in CIR, CK and T2
Mean age: 19 either 6, 9 or 12 relaxation time after 6 months. 12
years months months did not show RBE
Nosaka et Elbow Untrained Modified arm Initial bout of either 2, All groups showed EIMD after initial
al. (24) flexors subjects curl machine 6 or 24 max ecc bout. 6 and 24 max ecc contraction
N = 34 contractions followed groups showed significantly smaller
Mean age: 20 2 weeks later by 24 changes in EIMD in the repeated bout
years max ecc contractions

Ecc – Eccentric Max - Maximum

EIMD – Exercise induced muscle damage MVC – Maximal voluntary contraction
CK – Creatine Kinase ROM – Range of movement
CIR – Circumference

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Submaximal Eccentric Contractions

Whilst maximal intensity eccentric contractions have been reported to result in a RBE studies have also found that low
intensity eccentric contractions can confer a protective effect (Table 2) (42,68-70). Lavender and Nosaka (42) reported
that in untrained participants eccentric contractions (3-4 seconds in duration) of the elbow flexors at 10% maximal
isometric strength provided protection (significantly smaller decreases in MVC, ROM and muscle soreness) against a
greater intensity eccentric contraction (40% MVIC eccentric) two days later. Also whilst investigating low intensity 10%
maximal isometric strength (MVIC) eccentric contractions of the elbow flexors (3 seconds in duration) Chen et al. (68)
reported that this initial bout resulted in no EIMD but offered protection against 30 maximal eccentric contractions in
untrained participants. However, the RBE effect was found to last 2 weeks but 3 weeks later this protective effect was
no longer present.

Another study by Chen et al. (69) with untrained participants found that four bouts of eccentric elbow flexion at 40%
MVIC completed every two weeks and four times resulted in the same protective effect (reductions in ROM deficits,
isometric concentric strength, and plasma CK) against 30 maximal eccentric contractions as two bouts of maximal
eccentric exercise. In addition it was reported that the initial 40% eccentric bout resulted in much less EIMD than the
initial maximal eccentric bout. A further study by Chen et al. (70) investigated the effects of different intensity eccentric
and isometric preconditioning exercises on the RBE in untrained participants. The results of this study showed that
20% MVIC eccentric contractions of the elbow flexors provided a protective effect (reductions in MVIC and concentric
strength losses, upper arm circumference, plasma CK and ROM deficits) lasting 3 weeks but 10% MVIC eccentric
contractions did not. These findings led the authors to conclude that an intensity threshold exists in order for the initial
eccentric exercise bout to confer a protective effect.

The results of the studies investigating the ability of reduced intensity and volume eccentric contractions to protect
against further damage are promising. In summary these preconditioning sessions result in less initial EMID and still
confer a RBE against future maximal eccentric bouts. However, the intensity threshold for this to occur is yet to be fully
elucidated and in comparison to an initial maximal eccentric bout the RBE may not last as long. As a consequence of
this it is suggested that athletes who are about to start maximal and supramaximal eccentric training, or those who have
not done so for a period of time, may initially consider utilising sub-maximal loads. The aim of this submaximal training
is to familiarise the athlete with the movement patterns and timings required during eccentric focused training whilst also
initiating the RBE. It is then suggested that the athlete would complete low volume maximal/supramaximal eccentric
training before increasing to greater working volumes as required. By following this sequence it is suggested an athlete
would be able to take advantage of the RBE to protect them from severe EIMD and the negative consequences
associated with it.

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Table 2 - Repeated bout effect studies which have used a submaximal conditioning load.

Study Muscle Population Exercise Intervention Results

Group Modality
Chen et Elbow Untrained Elbow flexor 4 repeated bout groups 10% ecc did not result in
al. (60) flexors subjects activity with performed 30 10% ecc any EIMD
N = 65 dumbbells contractions of elbow Changes in EIMD
Mean age: flexors either 2 , 7, 14 or 21 markers were significantly
21 days before 30 max ecc smaller for 2, 7 and 14
contractions day group than control
Control group performed after 30 max ecc
max ecc contractions only contractions
Effect attenuated between
1 and 2 weeks
Chen et Elbow Untrained Modified 40% ECC completed 30 No sig differences
al. (61) flexors subjects preacher curl contractions 4 times (bouts between either the 40%
N = 30 separated by two weeks) ecc group or 100% ecc
Mean age: then 100% ecc bout group after the 2nd bout.
22 years Control group performed Changes in ROM, iso con
two max ecc bouts strength and plasma CK
separated by two weeks were reduced after the 2nd
to 4th bout in 40% ecc
group
Chen et Elbow Untrained Elbow flexor Five groups; max ecc, 10% After 2nd bout (30 Max ecc
al. (62) flexors subjects activity with ecc, 20% ecc 90 degree contractions) changes in
N = 65 dumbbells ISO and 20 degree ISO. markers of EIMD (MVIC,
Mean age: Ecc groups performed 30 con strength, ROM, upper
20 years DB contraction of elbow arm circumference,
flexors at respective loads. plasma CK and soreness)
ISO groups performed 30 were smaller for the 20%
ISO contractions ecc and 20 degree ISO
3 weeks later all performed group. But this effect was
30 max ecc contractions smaller than protective
effect of initial max ecc
group

Lavender Elbow Untrained Elbow flexor Subjects in two groups 10- Sig smaller decreases in
et al. flexors subjects activity with 40% ecc or 40% ecc only MVC, ROM and muscle
(63) N = 18 dumbbells 10-40% group completed 6 soreness in 10-40% group
Mean age: sets of 5 reps with DB at compared to 40% only
21 10% MVIC followed 2 days group
later by ecc 40%

Muscle Length
A study by Pettitt et al. (71) investigated the effects of eccentric exercise on the RBE at both short and long lengths.
Initially both the short and long length groups performed 3 x 25 maximal eccentric contractions of the elbow extensors
through a range of movement of 0° to 80° (short length) or between 50° to 130° (long length). After one week both
groups performed eccentric elbow extensions over the full range of movement (0° to 130°). The results of this study
indicated that an initial bout of eccentric exercise at short muscle lengths caused decrements in average extensor torque
production and did not result in a RBE whereas exercise at long lengths did. This was reported to be as a result of the
exercise at long lengths resulting in a change in angle torque relations to longer lengths due to the addition of serialised
sarcomeres. These findings led Pettitt et al. (71) to conclude that exercise at full range of movement would be beneficial
to protective against the effects of eccentric EIMD. Therefore, using the previous example of the athlete completing the
maximal eccentric squatting session, it is suggested that getting them to squat to depth would result in a greater RBE
than if they only completed a quarter squat.

Contraction Velocity
To assess the impact of velocity of eccentric contractons on the RBE Barroso et al. (72) split participants into two
groups; slow contraction velocity (60°s-1) or fast velocity contraction (180°s-1). The participants then completed exercise
bouts every 2 weeks (3 sessions in total) consisting of 30 maximal eccentric contractions of the elbow flexors on an
isokinetic dynometer. The results of this study indicated no significant differences in MVIC strength, range of motion,
muscle soreness or creatine kinase activity. However, Barroso et al. (72) reported significantly smaller changes in these
markers after the second and third bouts in both groups compared to the first group indicating a RBE. As a consequence
of these results Barroso et al. (72) suggested that contraction velocity does not influence the RBE.

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Although the majority of the literature concerning eccentric muscle actions and the RBE focuses on the elbow flexors
there is some evidence that it may be applicable to other musculature of the body and other eccentric modalities. When
performing eccentric maximal eccentric actions of the knee extensors Brown et al. (44) reported that 10, 30 and 50
contractions resulted in reduced force loss after 50 eccentric contractions performed 3 weeks later. Kamandulis et al.
(45) had participants perform 10 sets of 12 maximal voluntary contractions of the knee extensors then after 2 weeks
they performed the same exercise bout. After the 2 nd bout EIMD was reduced and thus the initial session was reported
to result in a protective effect. In a further study investigating the effect of stride length on the RBE, Rowlands et al. (47)
found that a group who ran downhill utilising an understride, overstride and preferred running pattern were able to reduce
strength loss during a 2nd downhill running bout. Whilst the overstride and preferred running stride group perceived less
muscle soreness than in bout 1. Thus it was suggested that a previous bout of downhill running might offer a protective
effect against subsequent downhill eccentric contractions.

Plyometrics
When investigating the effects of EIMD and the RBE utilising drop jumps (DJ) Miyama and Nosaka (73) reported that
performing five sets of 20 DJ from 0.6m provided a protective effect when completing the same DJ protocol eight weeks
later. Miyama and Nosaka (73) found that after the second session there was significantly smaller changes in; maximal
isometric force, muscle soreness, plasma CK activity and vertical jump height. In a further study utilising DJ Miyama
and Nosaka (46) reported that 50 DJ resulted in a larger reduction in loss of muscular function, increased muscle
soreness and increases in plasma CK activity than 10 DJ.

However when these sessions were repeated 2 weeks later it was found that the 10 DJ provided a similar level of
protection as the 50 DJ. This supports previous research, which has found a small number of eccentric contractions can
result in a protective effect. This led Miyama and Nosaka (46) to conclude that a when starting training with DJ a low
number should be used initially as this will prevent severe muscle damage and result in a protective effect. Thus for
athletes who are new to plyometric training it is suggested that the initial sessions are low in volume as this may result
in a protective effect against future high volume sessions.

Isometrics
Another potential mechanism for protection against the effects of EIMD as a result of eccentric contractions is the use
of isometric contractions as preconditioning exercises (48,70). In Chen et al. (48) initial study participants performed
either 2 or 10 maximal voluntary isometric contractions (MVC-ISO) of the elbow flexors at long muscle length (20°
flexion) with no evidence of EIMD post MVC-ISO. Two days later participants completed 30 maximal eccentric isokinetic
contractions and it was reported that both 2 and 10 MVC-ISO provided protection against EIMD. The 10 MVC-ISO was
found to have the greater protective effect than the 2 MVC-ISO conditions. In a follow up study Chen et al. (70) also
found 30 MVC-ISO of the elbow flexors at long muscle lengths (20° flexion) provided a protective effect 3 weeks later
against 30 maximal eccentric contractions. These results led to the suggestion that ISO-MVC at long muscle lengths
should be included as preconditioning exercises when introducing athletes to eccentric training in order to minimize the
effect of EIMD.

Set Configuration
To investigate the effects of the configuration of eccentric training sets and reps Chan et al. (74) carried out a study in
which participants initially completed either 3 x 10 or 10 x 3 maximal eccentric contractions of the elbow flexors. Four
weeks later the same participants completed 20 x 3 maximal eccentric contractions to assess changes in EIMD from
the initial session. The results of this study provided further evidence of the RBE with significant changes in MVC
strength, range of motion, bicep brachii cross-sectional area and muscle soreness from bout 1 to 2. However there were
no differences found between the different set configurations. This led Chan et al. (74) to conclude that the changing of
the set configuration has little effect on muscle damage.

Repeated Bout and Contralateral Effect

Cross education is a term that refers to an increase in strength in the contralateral (untrained) limb following training of
the ipsilateral (trained) limb (16,40). This cross education effect has been proposed to be the result of neural adaptations
(75) and therefore may support neural theory as a mechanism resulting in the RBE. Several studies have investigated
the RBE (Table 3). Connolly et al. (76) first investigated whether this phenomenon was able to transfer the protective
effect of a prior eccentric training session to the contralateral limb. In this study participants stepped up on a box with
one leg (concentric) and then back down using the other leg (eccentric). During the initial trial EIMD was found in the
eccentric trained leg. After two weeks the leg that was previously used to step up (concentric) now became the step
down leg (eccentric). Analysis revealed that there was no difference in strength loss or tenderness between both
sessions in the eccentrically trained limb. This led Connolly et al. (76) to conclude that there was no evidence of a
crossover effect in this study. However further studies investigating cross education in the elbow flexors have found
evidence of cross education with a previous bout of eccentric exercise in the ipsilateral limb providing a protective effect
in the contralateral limb (76-78). The explanation for this cross education effect in the contralateral limb was provided
by Starbuck and Eston (78) who found a reduction in median frequency (MF) in the elbow flexors after the initial session
in both the ipsilateral and contralateral limb. This it was suggested is a consequence of more slow twitch muscle fibres
being recruited initially during a second bout of eccentric exercise with this central adaptation occurring in the untrained
limb resulting in a protective effect (78).

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Although the evidence for the cross education effect and the reasons for its existence are currently equivocal the positive
findings may be of interest to athletes recovering from injury. If an injured limb has to be immobilised training eccentrically
with the uninjured limb may alleviate the effects of EIMD when an athlete returns to training. This therefore may result
in the athlete being able to complete their rehabilitation programme more efficiently and ultimately return to competition
in a timely fashion (4,77).

Table 3 - Results of studies investigating the contralateral effect.

Study Muscle Population Exercise Modality Intervention Results

Group
Connolly Lower Untrained Stepping on and off One leg used to go up No evidence of
et al. (76) Limb subjects of a 46cm box (con) and one leg to contralateral effect found in
N = 12 step down (eccentric) this study
Mean age: for 20mins. 2 weeks
22 years later this was switched
Howatson Elbow Untrained Eccentric Contralateral group Contralateral group showed
et al. (45) Flexors subjects contraction – completed sig reductions during the
N = 16 Isokinetic 3 sets of 15 maximal repeated bout of MVC, CK
Mean age: dynamometer eccentric contractions and muscle soreness
26 years with one arm then 2
weeks later completed
the same exercise
with the other arm
Starbuck Elbow Untrained Eccentric 60 maximal ecc Contralateral arm had
et al. (78) Flexors subjects contraction – contractions of reduced strength loss,
N = 15 Isokinetic ipsilateral arm muscle soreness and
Mean age: dynamometer followed 2 weeks later change in resting arm angle
22 years by 60 maximal ecc
contractions of
contralateral arm
Ecc – Eccentric
Con – Concentric
CK – Creatine Kinase

Trained Athletes
In studies investigating the RBE on trained athletes the results have been less promising (79,80). Falvo et al. (80) and
Falvo et al. (79) investigated the effects of high intensity and volume eccentric bench press on trained athletes. The
subjects in these studies were considered trained if they were able to bench press concentrically at least their own body
weight, had been completing resistance training for at least 6 months and took part in at least one session a week
targeting the pectorals, deltoids and triceps. In both studies the results indicated that no RBE was present and it was
not able to attenuate any decrements in exercise performance (80). This was attributed to the fact that any adaptations
from RBE were already present in resistance trained individuals (79).

In support of these conclusions Newton et al. (81) and Gibala et al. (82) reported that trained participants suffered less
initial EIMD and recovered more quickly from a maximal elbow flexor eccentric bout than untrained participants. It should
be noted however that despite the lack of improvement in performance measures Falvo et al. (80) did report a reduction
in soreness, fatigue and RPE following an initial bout of eccentric exercise. Thus although no performance measures
were improved in trained athletes the potential for a reduction in soreness and tiredness is potentially interesting.

The results of these studies investigating the RBE in trained athletes would appear to indicate that they have developed
a resistance to eccentric EIMD as a consequence of their previous training history (82). However, some degree of
muscle damage does still occur even in trained athletes (82). Thus it is suggested that trained athletes who are about
to implement maximal/supramaximal eccentric training would still benefit from an initial low volume, low intensity session
before progressing to maximal loads and greater volumes.

Table 4 - Recommendations for preconditioning bout to avoid eccentric EIMD.

Maximal Bout Sub Maximal Bout Isometric Bout

24 maximal eccentric contractions 30 eccentric contractions Contractions at long muscle lengths
15 seconds rest between 40% maximal voluntary isometric 10 maximal isometric contractions
contractions contraction strength lasting 3 seconds each in duration
Repeat session every 2 weeks for a 45 seconds rest between
total of 8 weeks contractions

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CONCLUSIONS AND PRACTICAL APPLICATIONS

In summary, eccentric muscle actions may lead to EIMD, which can result in impaired performance. However, a bout of
eccentric or isometric exercise utilised as a preconditioning exercise can confer a protective effect against further EIMD
due to the RBE.

If isometric contractions are used as a preconditioning exercise these should be completed at long muscle lengths with
10 isometric contractions reported to result in the greatest protective effect. Therefore an S&C coach may wish to include
long length low volume isometrics as a stand-alone activity or in conjunction with an eccentric preconditioning bout.
When using an eccentric bout as a preconditioning exercise low volume low intensity exercise can confer a protective
effect. Results of previous studies have demonstrated that 30 repetitions of eccentric contractions at 10 - 40% maximal
isometric strength and ~4 seconds in duration have resulted in a RBE with little initial damage.

When utilising low volume maximal eccentric contractions (6 – 24 reps, ~ 4 s in duration) results have shown increased
initial EIMD followed by a protective effect against further damage due to eccentric exercise. When utilising maximal
eccentric contractions it has been suggested this may lead to a protective effect lasting as long as 6 months in
comparison to a low intensity initial bout which may only confer protection for as little as 3 weeks.

In conclusion it would seem prudent if introducing an athlete to eccentric training to start with low intensity low volume
loads and gradually increase these prior to completing any maximal or supramaximal eccentric training to protect against
them against EIMD.

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