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2-2017

Eccentric Exercise Program Design: A

Periodization Model for Rehabilitation
Applications
Michael O. Harris-Love
George Washington University

Bryant Seamon

Tomas I. Gonzales

Haniel J. Hernandez

Donte Pennington
See next page for additional authors

Follow this and additional works at: http://hsrc.himmelfarb.gwu.edu/sphhs_exer_facpubs

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APA Citation
Harris-Love, M. O., Seamon, B., Gonzales, T. I., Hernandez, H. J., Pennington, D., & Hoover, B. (2017). Eccentric Exercise Program
Design: A Periodization Model for Rehabilitation Applications. Frontiers in Physiology, (). http://dx.doi.org/10.3389/
fphys.2017.00112

This Journal Article is brought to you for free and open access by the Exercise and Nutrition Sciences at Health Sciences Research Commons. It has
been accepted for inclusion in Exercise and Nutrition Sciences Faculty Publications by an authorized administrator of Health Sciences Research
Commons. For more information, please contact [email protected].
Authors
Michael O. Harris-Love, Bryant Seamon, Tomas I. Gonzales, Haniel J. Hernandez, Donte Pennington, and
Brian Hoover

This journal article is available at Health Sciences Research Commons: http://hsrc.himmelfarb.gwu.edu/sphhs_exer_facpubs/88

 Eccentric Exercise Program Design: A Periodization
Model for Rehabilitation Applications
Michael Harris-Love1, 2, 3*, Bryant A. Seamon1, 4, Tomas I. Gonzales1, Haniel J. Hernandez1,
4
, Donte Pennington1, 5, Brian M. Hoover1

1
Clinical Research Center - Human Performance Research Unit, Washington DC VA
Medical Center, USA, 2Geriatrics and Extended Care Service/Research Service,
Washington DC VA Medical Center, USA, 3Milken Institute School of Public Health, The
George Washington University, USA, 4Physical Medicine & Rehabilitation Service,
Washington DC VA Medical Center, USA, 5College of Medicine, Howard University, USA
Submitted to Journal:

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Frontiers in Physiology

Specialty Section:
Exercise Physiology

ISSN:
1664-042X

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Article type:
Hypothesis & Theory Article

Received on:

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15 Sep 2016

Accepted on:
10 Feb 2017

Provisional PDF published on:

10 Feb 2017

Frontiers website link:

www.frontiersin.org

Citation:
Harris-love M, Seamon BA, Gonzales TI, Hernandez HJ, Pennington D and Hoover BM(2017) Eccentric
Exercise Program Design: A Periodization Model for Rehabilitation Applications. Front. Physiol.
8:112. doi:10.3389/fphys.2017.00112

Copyright statement:
© 2017 Harris-love, Seamon, Gonzales, Hernandez, Pennington and Hoover. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (CC BY). The use,
distribution and reproduction in other forums is permitted, provided the original author(s) or
licensor are credited and that the original publication in this journal is cited, in accordance with
accepted academic practice. No use, distribution or reproduction is permitted which does not
comply with these terms.
This Provisional PDF corresponds to the article as it appeared upon acceptance, after peer-review. Fully formatted PDF
and full text (HTML) versions will be made available soon.

Frontiers in Physiology | www.frontiersin.org

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 1 Eccentric Exercise Program Design:
2 A Periodization Model for Rehabilitation Applications
3

4 Michael O. Harris-Love1, 2, 3 *, Bryant A. Seamon1,4, Tomas I. Gonzales1, Haniel J. Hernandez1,4,

5 Donte Pennington1,5, and Brian M. Hoover1
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1
7 Muscle Morphology, Mechanics and Performance Laboratory, Clinical Research Center - Human
8 Performance Research Unit, Veterans Affairs Medical Center, Washington DC, USA
2
9 Geriatrics and Extended Care Service/Research Service, Veterans Affairs Medical Center,
10 Washington DC, USA
3
11 Department of Exercise and Nutritional Sciences, Milken Institute School of Public Health, The
12 George Washington University, Washington DC, USA
4
13 Physical Medicine & Rehabilitation Service, Veterans Affairs Medical Center, Washington DC,
14 USA
5
15 Howard University, Department of Physiology and Biophysics, College of Medicine, Washington
16 DC, USA
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19 *Correspondence: Dr. Michael O. Harris-Love, Muscle Morphology, Mechanics and Performance

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20 Laboratory, Clinical Research Center - Human Performance Research Unit, Veterans Affairs Medical

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21 Center, 50 Irving St NW, 11G, Washington, DC 20422, USA.

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[email protected] (ResearcherID/ORCID: 0000-0002-1842-3269)

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Keywords: eccentric exercise, periodization, rehabilitation, physical therapy, isokinetic exercise,
muscle performance, muscle strength
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 Periodization and eccentric exercise
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32 Short running title: Periodization and eccentric exercise
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34 Manuscript Category: Hypothesis and Theory (Frontiers in Physiology – Striated Muscle
35 Physiology)
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This is a provisional file, not the final typeset article 2

 Periodization and eccentric exercise

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38 Abstract

39 The applied use of eccentric muscle actions for physical rehabilitation may utilize the framework of
40 periodization. This approach may facilitate the safe introduction of eccentric exercise and appropriate
41 management of the workload progression. The purpose of this data-driven Hypothesis and Theory
42 paper is to present a periodization model for isokinetic eccentric strengthening of older adults in an
43 outpatient rehabilitation setting. Exemplar and group data are used to describe the initial eccentric
44 exercise prescription, structured familiarization procedures, workload progression algorithm, and
45 feasibility of the exercise regimen. Twenty-four men (61.8 ±6.3 years of age) completed a 12-week
46 isokinetic eccentric strengthening regimen involving the knee extensors. Feasibility and safety of the
47 regimen was evaluated using serial visual analog scale (VAS, 0-10) values for self-reported pain, and
48 examining changes in the magnitude of mean eccentric power as a function of movement velocity.
49 Motor learning associated with the familiarization sessions was characterized through torque-time
50 curve analysis. Total work was analyzed to identify relative training plateaus or diminished exercise
51 capacity during the progressive phase of the macrocycle. Variability in the mean repetition interval

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52 decreased from 68% to 12% during the familiarization phase of the macrocycle. The mean VAS

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53 values were 2.9 ±2.7 at the start of the regimen and 2.6 ±2.9 following 12 weeks of eccentric strength
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training. During the progressive phase of the macrocycle, exercise workload increased from 70% of

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the estimated eccentric peak torque to 141% and total work increased by 185% during this training

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phase. The slope of the total work performed across the progressive phase of the macrocycle ranged
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from -5.5 to 29.6, with the lowest slope values occurring during microcycles 8 and 11. Also, mean

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power generation increased by 25% when eccentric isokinetic velocity increased from 60 deg s-1 to
90 deg s-1 while maintaining the same workload target. The periodization model used in this study for
eccentric exercise familiarization and workload progression was feasible and safe to implement
within an outpatient rehabilitation setting. Cyclic implementation of higher eccentric movement
velocities, and the addition of active recovery periods, is featured in the proposed theoretical
63 periodization model for isokinetic eccentric strengthening.

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 Periodization and eccentric exercise
67 Introduction
68
69 The use of eccentric muscle actions for the purpose of therapeutic exercise has gained greater
70 acceptance in light of the growing evidence that positive adaptations can result without incurring
71 excessive muscle damage (LaStayo et al., 2007; Lindstedt, 2016; Lindstedt et al., 2001). Older adults
72 and individuals with chronic conditions often have limited exercise tolerance and may require
73 specialized exercise programming provided by rehabilitation professionals. The ability to elicit
74 muscle and neural adaptations to exercise in people with compromised metabolic and cardiovascular
75 capacity makes eccentric exercise an intriguing training option. Rehabilitation interventions featuring
76 eccentric exercise appear to have similar efficacy and safety to concentric training for the
77 management of conditions such as coronary artery disease, musculoskeletal conditions such as
78 tendinopathies and knee osteoarthritis (OA), as well as chronic neurodegenerative diseases such as
79 Parkinson disease (Dibble et al., 2006; Gluchowski et al., 2015; Gur et al., 2002; Roig et al., 2008).
80 Moreover, there is some evidence to suggest that the gradual introduction and progression of
81 eccentric training loads result in large strength gains in older adults without incurring adverse
82 changes in serum creatine kinase, tumor necrosis factor-α, or other clinical markers of muscle
83 damage (LaStayo et al., 2007). While eccentric training has been shown to be an effective form of
84 therapeutic exercise, at risk populations such as older adults may be more susceptible to muscle
85 injury or impaired recovery in response to a bout of high force muscle actions (Gluchowski et al.,
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2015; Lovering and Brooks, 2014). These competing risks and benefits highlight the need to codify

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principles of eccentric exercise program design in order to promote the safe and effective
implementation of this strengthening method.

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90 Program design for strength training involves the organization of exercise volume and intensity for
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the purpose of attaining a specific performance goal. Among the most frequently used approaches to

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program design is periodization (Fleck, 2011; Lorenz et al., 2010). Periodization is a general method

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of dividing a training regimen into discrete phases marked by systematic loading and recovery
phases. These training phases have been traditionally structured in accordance to an annual calendar
or the timing of competitive sporting events, and are further defined by periods of exercise specificity
and skill acquisition (Miranda et al., 2011; Rhea and Alderman, 2004; Stone et al., 1981). All forms
of program design involving progressive resistance exercise (PRE) require an initial exercise
98 prescription. Professional organizations and scientific societies such as the National Strength and
99 Conditioning Association (NSCA) and the American College of Sports Medicine (ACSM) provide
100 guidance on establishing an appropriate exercise prescription (American College of Sports Medicine,
101 2014; Haff, 2012). Core elements of the exercise prescription include workload assignment, exercise
102 frequency and duration, workload progression, and exercise mode. The broad goals of the exercise
103 prescription for strength training are identifying an appropriate workload and volume to promote safe
104 exercise participation, improving musculoskeletal heath and general fitness, and preventing the onset
105 and severity of chronic disease and geriatric syndromes (American College of Sports Medicine,
106 2014). The exercise prescription for strength training certainly shares many of the elements of
107 program design. Nevertheless, the components of the exercise prescription concerning the safe
108 assignment of workload and selection of exercise mode rise in importance when introducing older
109 adults or those with physical limitations to a formalized exercise routine.
110 It has been noted that rehabilitation interventions involving strength training are often absent of clear
111 guidelines on specific training variables and rarely incorporate periodization into the exercise
112 program (Lorenz et al., 2010). Noting the need for rehabilitation programs to better integrate formal
113 elements of exercise program design, Hoover and colleagues (2016) have stated that, “Periodization
114 principles should be an integral part of sport physical therapy training and lexicon.” This observation

This is a provisional file, not the final typeset article 4

 Periodization and eccentric exercise

115 is even more pronounced when considering the lack of formal program designs for eccentric training
116 (Murtaugh and Ihm, 2013). While the roles of eccentric muscle actions in biomechanics and strength
117 training have been studied for decades (Dudley et al., 1991; Lindstedt, 2016), the exercise
118 prescription and exercise programming specific to this type of muscle action have been less explored.
119 These elements of the eccentric PRE regimen have important implications for both athletic training
120 and general rehabilitation. This Hypothesis and Theory paper is a data-driven approach to examine
121 the feasibility and safety of the applied use of eccentric muscle actions for the purpose of physical
122 rehabilitation. The objectives of this study are to consider an approach to the initial eccentric exercise
123 prescription in outpatient rehabilitation settings, and propose an eccentric exercise periodization
124 model featuring a decision algorithm for workload adjustments when using accommodating
125 resistance devices. In addition, data from older exercise participants are used to examine the potential
126 impact of the eccentric power-velocity relationship on training variables within a periodization model
127 involving isokinetic exercise.
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130 Materials and Methods
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132 Participants. This longitudinal pilot study was conducted to determine the feasibility of a periodized

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133 eccentric strength training program involving older adults with musculoskeletal impairments. Thirty-

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134 eight people were successfully screened for inclusion into the study and 25 people enrolled with one

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135 person failing to complete the study due to conflicting time commitments. Therefore, 24 community-
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dwelling veterans completed participation in the study at the Washington DC Veterans Affairs
Medical Center (DC VAMC) Clinical Research Center. All of the participants were older men (age:

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mean = 61.8 years, SD = 6.3 years; height: mean =178.6 cm, SD = 8.4 cm; weight: mean = 102.7 kg,

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139 SD = 15.0 kg; BMI: mean = 32.3, SD = 5.1) with knee osteoarthritis confirmed by physician

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140 assessment and radiological report (Kellgren–Lawrence grade: median = 3, interquartile range = 2 –

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141 3). The sample included 23 African-American participants and 1 Caucasian participant. All enrolled
142 participants reported that they were not receiving physical therapy treatment or participating in a
143 formal exercise program, and they were categorized as being untrained (no regular bouts of exercise
144 for at least 30 min in duration, with a frequency > 3 times per week, over a period of > 3 consecutive
145 months). The study was approved by the DC VAMC Research and Development Institutional
146 Review Board and registered with Clinicaltrials.gov (NCT02098096). Signed informed consent was
147 obtained from all study participants prior to data collection.
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149 Procedures. The eccentric strength training and peak torque assessments were completed using an
150 isokinetic dynamometer (Biodex System 4, Biodex Medical Systems, Shirley, NY) as previously
151 described (Hernandez et al., 2015). Isokinetic data for peak torque, total work, and mean power were
152 obtained at a sample rate of 100 Hz using the Biodex System 4 Advantage software. Torque-time
153 curves were reviewed to check for movement artifacts and to ensure that recorded force values were
154 obtained at the specified angular velocity. Gravity correction was calculated prior to testing and
155 exercise sessions with the participant’s knee extended in the terminal testing position while the
156 relaxed limb was fastened to the attachment pad. Gravity correction factors varying > 10% from the
157 baseline value were recalculated until consistent measurements were obtained within acceptable
158 limits. The cushion deceleration parameter was maintained at the lowest setting to ensure that
159 maximal movement time would be spent at the specified angular velocity. System checks and
160 calibration procedures were performed per the manufacturer’s guidelines. The primary data
161 collection activities for this study are broadly categorized as strength testing and eccentric strength
162 training procedures.

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164 Strength testing. All participants were tested in a seated position in the dynamometer chair. The
165 dynamometer chair was adjusted for proper seat height, backrest angle and position, and chair
166 position relative to the powerhead location, height, and angle of orientation. Participant positioning
167 and dynamometer chair adjustments were used to attain 90 degrees of hip flexion and knee flexion
168 prior to testing, with the lateral femoral condyle aligned with the dynamometer shaft axis of rotation.
169 Positioning was attained and checked using the measurement guides on the dynamometer chair,
170 powerhead, and base, along with palpation of bony landmarks at the knee joint, and inclinometer
171 measures of joint position. The dynamometer attachment for knee extension/flexion strength testing
172 was used during the conduct of the tests and the attachment pad height was adjusted for each
173 participant to be approximately 3 cm proximal to the calcaneus. This positioning approach for the
174 attachment pad avoids potentially painful or distracting contact of the apparatus with the calcaneus
175 during terminal knee flexion. The participants were stabilized in the dynamometer chair to prevent
176 compensatory motions and promote reproducible testing sessions. The stabilization straps of the
177 dynamometer chair were fastened at the shoulders, pelvis, and ipsilateral thigh. The knee attachment
178 stabilization strap was fastened to the ipsilateral lower leg at the level of the attachment pad. All
179 participant and dynamometer positions were recorded in order to replicate the testing conditions
180 during subsequent testing and exercise visits.
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Muscle strength was assessed via isokinetic dynamometry at 60 deg s-1 and 180 deg s-1 using
methods from previously published protocols (Harris-Love, 2005; Pincivero et al., 1997). Reciprocal

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isokinetic knee extension and flexion testing was conducted within a range of motion (ROM) of

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185 approximately 90 to 100 degrees, depending on participant tolerance and the available passive ROM.

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186 These ROM limits, also ensured that terminal extension did not exceed 10 degrees in order to protect

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187 the knee joint at the end ROM of the dynamometer excursion. Participants completed five maximal
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repetitions at the selected angular velocity with the tested limb tested in a random order.
Approximately one minute of rest was provided between the five-repetition testing bouts.
Participants were allowed to stabilize their trunk with their hands on the dynamometer handles, but
were instructed to not attempt to pull their trunk forward during testing. Visual feedback was
provided to the participant from the torque-time curve depicted on the dynamometer computer
screen, and verbal cuing was provided as needed concerning attempted compensatory motions during
testing. Warm up activity involving four to six repetitions of submaximal isokinetic knee extension
195 and flexion at 180 deg s-1 was performed with each limb before engaging in maximum volitional
196 repetitions. A familiarization session was provided to each participant prior to strength testing to
197 orient each person to isokinetic testing and obtain the dynamometer chair positioning settings. This
198 session also provided the opportunity to determine if strength testing would result in any lower
199 extremity pain or discomfort given the clinical population involved in the study. The peak torque was
200 derived from the mean value of the highest three peak torque values from the five-repetition test.
201 Participants were instructed to perform the testing movement as forcefully and rapidly as possible
202 while avoiding the Valsalva maneuver. Similar approaches to strength assessment have been found to
203 be reliable by other investigators (intraclass correlation coefficients, ICCs, exceeding .92 with an
204 estimated measurement error of 8%) in younger and older adults (Hartmann et al., 2009; Pincivero et
205 al., 1997). Also, the investigators’ laboratory reliability is acceptable for isokinetic knee
206 extension/flexion strength testing in the 60 deg s-1 and 180 deg s-1 conditions as conducted in this
207 study. Intraclass correlation coefficients (ICC2,1) range from .97 to .99 (df = 30; p < .001, with lower
208 bound 95% confidence intervals that range between .95 to .99) and a standard error of the
209 measurement up to 21.0 N m, in a cohort of older African American adults (Harris-Love, 2016,
210 unpublished data). The same two investigators conducted all of the strength assessment and eccentric
211 strength training sessions.
This is a provisional file, not the final typeset article 6
 Periodization and eccentric exercise

212
213 Eccentric strength training. The eccentric PRE program for the knee extensors and flexors was 12
214 weeks in duration with two scheduled training bouts per week, for a total of 24 training sessions as
215 previously reported (Harris-Love, 2005; Hernandez et al., 2015). At least one day of rest was
216 required between training sessions. Participant positioning and warm up activities prior to the
217 exercise bouts were identical to the procedures used during the strength assessment sessions for this
218 study. The Biodex System 4 dynamometer settings for the exercise sessions were also similar to the
219 settings used for strength assessment with the notable exception of the operation mode. The reactive
220 eccentric exercise mode was used for reciprocal knee extension and flexion. This mode of isokinetic
221 exercise requires the participant to exert at least 10% of the assigned torque limit (approximately 22.5
222 N m to 44.5 N m above the targeted workload in this study) in order to engage the mechanized
223 motion of the dynamometer powerhead shaft. The concentric peak torque values were used to
224 calculate the estimated isokinetic eccentric peak torque for the initial workload assignment
225 (Hernandez et al., 2015). This approach was taken as a precaution given the arthritic conditions
226 within the older men featured in our sample who were untrained and naïve to the eccentric muscle
227 action exercise stimulus:
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229 τecc = (τcon)(1.35)
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where τ = torque obtained at 60 deg s-1 or 180 deg s-1, ecc = eccentric, and con = concentric.

In summarizing the periodization approach used in this study, the entire 12-week regimen constituted

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233 the initial “macrocycle”. The macrocycle was designed to introduce the exercise stimulus to

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234 individuals naïve to eccentric training and advance their program to include workloads sufficient to
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optimally induce skeletal muscle adaptations. “Mesocycles” typify extended phases of specific
training that may last a few weeks to approximately two months. In this exercise program, the first

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mesocycle constituted an introductory period of eccentric training and included the familiarization
and acclimatization phases of the macrocycle (i.e., the first three weeks of training). The second
mesocycle included the progression phase in its entirety as the workload and movement velocity
were systematically increased until the end of the regimen. “Microcycles” are brief training periods
that may last three to seven days, and were used in this program to represent two non-consecutive
242 exercise sessions within a one-week period (Lorenz et al., 2010). A phased introduction to the
243 exercise stimulus and manipulation of program variables such as workload, volume, and repetition
244 speed (e.g., angular velocity) provides a systematic approach to minimizing the risks and maximizing
245 the benefits associated with eccentric strength training.
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247 The initial eccentric training phases of the periodized eccentric training program included a one-week
248 familiarization phase to allow the participants to experience the muscle recruitment patterns
249 associated with isokinetic eccentric exercise, followed by a two-week acclimatization phase to
250 induce the muscle action history-dependent protective response to subsequent eccentric muscle
251 actions under similar or progressively higher workloads. Selected data was obtained from the
252 familiarization phase to reflect the motor learning that occurs over the initial exercise sessions.
253 Previous investigators have noted that basic temporal data may reflect the pattern of torque curves
254 (Watkins and Harris, 1983). Consequently, the mean repetition interval (sec) was measured from the
255 peak torque value of each knee extension repetition and also expressed as a coefficient of variation
256 (CV) value (Figure 1).
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258 Following these early phases of training to become oriented to isokinetic eccentric strengthening, the
259 participants began the progression phase. Exercise during microcycle 4 through microcycle 12 was
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260 centered on inducing training adaptations using incremental adjustments in exercise workload. The
261 safe adjustment of the target workload was aided by the use of a progression algorithm that allows
262 for workload modification following each exercise session. The patterns of the torque-time curves
263 are monitored in real-time during the exercise bouts to detect excessive declines in torque in any of
264 the exercise sets. Torque-time curves with an observed decline >25% of the target workload (for > 2
265 consecutive repetitions following verbal cueing) denotes significant fatigue based on a priori
266 decision criteria. This magnitude of intra-session fatigue resulted in the workload goal being
267 decreased by approximately 5% for the next exercise session. Similar declines of the torque-time
268 curves that were greater than 10%, but less than 25%, of the target workload resulted in the retention
269 of a stable workload goal in the subsequent exercise session. Lastly, completion of the all sets
270 meeting the target workload with an absent or minimal torque decline (< 10%) resulted in a 5%
271 increase in the target workload during the subsequent exercise session (Figure 2). The eccentric
272 training regimen featured 3 sets of 10 repetitions from microcycle 1 to microcycle 5. The exercise
273 volume was then progressed from 3 sets to 4 sets from microcycle 6 to microcycle 12, with the
274 movement speed transitioning from 60 deg s-1 to 90 deg s-1 between microcycle 7 and microcycle 9.
275 The late phase training sessions from microcycle 10 to microcycle 12 included all exercise sets at 90
276 deg s-1. Pilot work within the laboratory suggested that eccentric angular velocities faster than 90 deg
277 s-1 would have been difficult to complete for untrained clinical populations who were also unfamiliar
278 with the mode of exercise.
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The selection of the initial limb to be exercised was random, and the completion of each set was

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proceeded by one minute of recovery time. Visual and verbal feedback was provided in a similar

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282 manner as the strength assessment sessions, and also included verbal cuing to address exercise

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283 technique issues, if needed. In addition, verbal cueing was used to determine if a participant could

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284 attain the visual workload targets if diminished torque-time curves were observed in real time.
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Visual analog scale (VAS, 0-10) values for self-reported musculoskeletal pain of the lower extremity
were documented prior to each exercise session (Gallasch and Alexandre, 2007). Moreover, verbal
communication between the participant and the tester was used to determine the presence of any
discomfort during the exercise session or upon its completion. Following each exercise session, any
instance excessive fatigue based on the torque-time curves was noted, the updated workload targets
were documented in the exercise log, and total work was recorded. In addition, knee extensor peak
torque and mean power attained during the eighth microcycle were analyzed since the exercise
292 volume was evenly divided between two sets each at the 60 deg s-1 to 90 deg s-1 condition with the
293 same visual torque targets at both angular velocity settings. Data concerning the eccentric power-
294 velocity relationship obtained during exercise may provide insight about how to best manipulate the
295 isokinetic angular velocity as an element of the periodization program. Taken together, the review of
296 the VAS values, basic exercise adherence data, and mean power-velocity data help to inform the
297 feasibility of the periodized eccentric strengthening regimen. The initial macrocycle and general
298 workload progression scheme used in this study is provided in Table 1.
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300 Data Analysis. Descriptive statistics were used to convey participant characteristics, and exemplar
301 and aggregate data regarding exercise performance, VAS values, and exercise adherence. Parametric
302 data are expressed as means and standard deviations (SD), and non-parametric data are shown as
303 median values with the interquartile range. The participants’ motor performance exhibited during the
304 eccentric isokinetic exercise was examined from exemplar data and conveyed as the variability (i.e.,
305 coefficient of variation, CV) of the knee extensor mean repetition interval times. The change in the
306 total work values observed during the progression phase of the eccentric exercise program was also
307 evaluated. These delta values were generated in the 60 deg s-1 condition and used to compare
308 individual participant performance, and facilitate the visual depiction of the data. Slope analysis of
This is a provisional file, not the final typeset article 8
 Periodization and eccentric exercise

309 the total work values was assessed across two consecutive microcycles (e.g., a total of four exercise
310 sessions), in a serial fashion, within the progressive phase of the eccentric training program in order
311 to identify an increase, decrease, or plateau in exercise capacity. The analysis of consecutive
312 microcycles has value since markers of eccentric muscle damage, including residual delayed onset
313 soreness, could have a precipitating event followed by observed deleterious effects that overlap with
314 two training weeks (Kanda et al., 2013; Lavender and Nosaka, 2007).
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316 Inferential statistics were used to evaluate velocity-dependent muscle performance outcomes.
317 Eccentric torque-velocity and power-velocity relationships were derived from the torque and power
318 values attained from two intra-session eccentric exercise sets at 60 deg s-1 and 90 deg s-1.
319 Consequently, paired t-tests were used for the analysis of difference concerning the torque and power
320 values across each testing condition (Portney and Watkins, 2009). Peak torque and mean power data
321 were further characterized by scaling the values to the 60 deg s-1 testing condition and then visually
322 depicting the proportional change in values in the 90 deg s-1 testing condition using a radar graph.
323 Analyses from the dominant limb data are presented given that the general statistical findings in this
324 report were not dependent on limb dominance (as determined by the participant limb preference to
325 kick a ball based on self-report). Statistical analyses were performed using PASW Statistics for
326 Windows, Version 18.0 (SPSS Inc., Chicago, IL, USA). The α level was set at .05, and two-tailed p

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327 values < .05 were considered significant for all inferential statistics.

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Results

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The supervised eccentric exercise program was well-tolerated by the study participants and the study

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333 was conducted without incurring an intervention-related serious adverse event. One non-study related

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334 adverse event was reported due to the death of a patient several months following the intervention

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335 period. However, 29% of those successfully screened for inclusion into the study opted to not
336 participate. Completion of the regimen required the completion of 24 exercise visits and 3 assessment
337 visits over a 12-week period. The reasons provided by enrolled subjects for their non-participation
338 were “scheduling issues”, “job demands”, and anticipated “difficulty with appointments”. Regarding
339 those that chose to participate in the study, their mean VAS values for musculoskeletal pain were 2.9
340 ±2.7 at the start of the regimen and 2.6 ±2.9 upon completion of eccentric strength training program.
341 Also, during the progressive phase of the macrocycle, exercise workload increased from 70% of the
342 estimated eccentric peak torque to 141% and total work increased by 185% during this training
343 phase.
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345 Regarding muscle performance measures, the findings for the knee flexors were similar to the knee
346 extensors. Therefore, the analysis of the data for the knee extensors is provided to characterize the
347 periodized eccentric strengthening program and feasibility of the regimen. The exemplar data shown
348 in Figure 1 reflects the transition in the motor performance observed during the familiarization phase
349 of the eccentric isokinetic exercise program. Intra-session force-time curves exhibiting the lowest
350 magnitude of variability were used for the comparisons. The session one eccentric knee extension
351 mean repetition interval time was 3.27 s (SD = 2.22; CV = 68%) and the corresponding session two
352 mean repetition interval time was 5.58 s (SD = .69; CV = 12%).
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354 Aggregate data was used to better understand the change in eccentric exercise capacity over time.
355 The total eccentric work delta values for the 60 deg s-1 condition were indexed to the performance
356 data attained during the beginning of the progression phase. The total work increased from the index

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357 value of 100% to the final value of 285% at the end of the eccentric strength training regimen (Figure
358 3). The slope of the progressive phase total work values was 13.4 (SD = 11.6; range = -5.5 – 29.6).
359 The first plateau noted in the eccentric total work values occurred at the start of the eighth microcycle
360 (slope = 4.48 – 6.18), and the only negative slope (-5.45) was detected at the start of eleventh
361 microcycle.
362
363 The velocity-dependent behavior in eccentric torque and power generation within the sample was
364 also explored. During the comparison of eccentric peak torque at 60 deg s-1 versus 90 deg s-1 during
365 the eighth microcycle, the former was 166.8 N m (SD = 78.1 N m) and the latter was 179.9 N m (SD
366 = 80.2 N m). Regarding a similar comparison for mean power generation, these values were 78.3 W
367 (SD = 47.6 W) at 60 deg s-1 and 103.9 W (SD = 56.9 W) at 90 deg s-1 (p < .0001; Figure 4).
368
369
370 Discussion
371
372 The periodization model presented in this study for eccentric exercise familiarization and workload
373 progression was feasible and safe to utilize within an outpatient rehabilitation setting based on our
374 preliminary results. The implementation of this regimen served to highlight important considerations
375 concerning the use of accommodating resistance devices for the purpose of eccentric strength
376
377
378

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training, and the use of this approach in clinical populations.

si
379 The Eccentric Exercise Prescription and the Initial Mesocycle

i
380
381
382
383
384
385
386
387
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Exercise “intensity” is a term frequently used to denote the exercise workload as a proportion of the
one-repetition maximum (1RM). However, exercise intensity is also impacted by intra-session rest

P
periods and other factors that influence the subjective and objective effort needed to complete a
training session. The overall “load” experienced by an athlete or a patient is the sum total of the work
performed via the conditioning sessions along with the demands of skills-based training and
additional physical activities (Hoover et al., 2016; Lorenz and Morrison, 2015; Stone et al., 1981).
Nevertheless, the primary component of exercise intensity within the context of the exercise
388 prescription is the relative intensity or assigned “workload” (expressed as a percentage of 1RM).
389 Special attention should be afforded to patients with orthopedic conditions with significant joint
390 pathology or neurological disorders with sequalae that include excessive fatigue when considering
391 workload assignment and familiarization to the eccentric training stimulus.
392
393 Eccentric Workload Assignment for Patient Populations. A measured approach should be used in
394 establishing the initial eccentric exercise prescription in rehabilitation settings. True 1RM testing is
395 widely recognized as a critical task in the determination of the targeted workload. However, there are
396 instances where caution or relative contraindications may prevent 1RM testing in older adults and
397 those with chronic conditions. Testing protocols and predictive equations for the 1RM value by
398 Brzycki and others have been successfully used for patient populations in order to circumvent the
399 challenge of true 1RM testing (McNair et al., 2011). The issue of 1RM testing is further complicated
400 during the assessment for active muscle lengthening in people that are new to resistance exercise
401 involving eccentric muscle actions. While pre-intervention eccentric 1RM values have been obtained
402 in previous studies involving relatively healthy adults (Roig et al., 2008), there are instances where
403 the relative disease severity may rule out this approach (American College of Sports Medicine,
404 2014). Additionally, initial testing modes involving maximal eccentric strength testing and exercise
405 may cause excessive muscle damage and delayed onset muscle soreness (DOMS) that may adversely
This is a provisional file, not the final typeset article 10
 Periodization and eccentric exercise

406 affect participant adherence and could further impair those with pre-existing physical limitations
407 (Parr et al., 2009). The use of estimated eccentric 1RM values have been proposed in lieu of fully
408 validated eccentric predictive 1RM equations (Harris-Love, 2005; Hernandez et al., 2015). Estimated
409 eccentric peak torque values have been derived from the estimated eccentric/concentric peak torque
410 differential reported by other investigators (Dudley et al., 1991). Peak eccentric force and torque
411 estimates vary widely based on the method of assessment and the muscle groups tested, and may be
412 approximately 20% to 100% higher than concentric values (Enoka, 1996; Hortobagyi et al., 2001;
413 Kelly et al., 2015). In addition, the applied use of adjusted peak eccentric torque estimates ranging
414 from 35% to 40% have been explored in patient populations (Harris-Love, 2005; Hernandez et al.,
415 2015). Higher cofactors could be considered for use in other patient populations based on their
416 exercise tolerance, joint integrity associated with the agonist/antagonist muscle groups, and general
417 training goals. Underestimates of eccentric peak torque are possible when using cofactors below 1.5,
418 but this may be an appropriate constraint for rehabilitation interventions. Also, the exercise workload
419 ultimately rises to the ability of the individual patient during the iterative progression phase of the
420 macrocycle. A comparison of cofactors used to determine peak eccentric torque estimates was
421 beyond the scope of this study. However, the participants exhibited a decline in total work upon
422 transitioning from a 70% to 80% of the estimated eccentric peak torque (Figure 3) early in the
423 progressive phase of training. This suggests that use of a higher cofactor for the peak eccentric torque

l
424 estimates may have resulted in workload targets too difficult to attain for the study participants.

a
425 Nevertheless, additional work remains to be done to develop and cross-validate predictive equations

n
426 for eccentric 1RM values in various patient populations and in samples that properly account for age

sio
427 and gender effects (Kellis et al., 2000).

428
429
430

vi
“First Do No Harm.” Previous investigators have shown that prior muscle action history influences
subsequent physiological responses to eccentric loading (Margaritelis et al., 2015; McHugh et al.,

r o
1999; Nosaka et al., 2001). Adaptations involving the skeletal muscle ultrastructure and the ability to

P
431 withstand oxidative stress may occur in response to submaximal eccentric loading (Deyhle et al.,
432 2016; Lima and Denadai, 2015). In addition, preliminary evidence suggests that this protective effect
433 is associated with benign or modestly elevated inflammatory activity, rather than a diminished
434 inflammatory response, and may be an adaptation to aid the recruitment of immune cells (Deyhle et
435 al., 2016). This view is consistent with the observation that the post-exercise presence of
436 macrophages may aid the recovery of skeletal muscle following eccentric exercise bouts (Tidball and
437 Wehling-Henricks, 2007). Moreover, DOMS may be disassociated from the post-exercise
438 inflammatory response since increased chemokine levels accompany the successful inducement of
439 the “repeated bout effect” (Deyhle et al., 2016). The repeated bout effect represents the ability of
440 skeletal muscle to resist exercise-induced damage following a preceding exposure to the exercise
441 stimulus. Intentional use of the repeated bout effect is now an accepted precept of eccentric exercise
442 programming (Flann et al., 2011; Gluchowski et al., 2015; Margaritelis et al., 2015) and it remains a
443 core element of the applied use of eccentric muscle actions as a form of therapeutic exercise.
444
445 The magnitude of the repeated bout effect may be a function of the time course from the exposure
446 stimulus to the exercise stimulus, range of motion used during the initial exposure stimulus, volume
447 of the exposure stimulus, age of the participant, and muscle action type employed (Lavender and
448 Nosaka, 2006; Lima and Denadai, 2015). The ideal period between the exposure stimulus and
449 progressively higher levels of loading may be within two to four days when considering factors such
450 as DOMS and markers of muscle damage such as creatine kinase activity (Lima and Denadai, 2015).
451 However, extended periods of the repeated bout effect, based on the criterion of force production and
452 other measures of muscle status, have been conferred by higher levels of eccentric exposure stimuli

11
 Periodization and eccentric exercise
453 (Nosaka et al., 2001). An initial exposure to eccentric exercise via high workloads is problematic for
454 those undergoing rehabilitation. Therefore, submaximal eccentric or isometric muscle actions with
455 incremental loading over multiple sessions may be used to prepare patients for an eccentric PRE
456 regimen. In this study, we reported that the participants had fairly stable VAS values for
457 musculoskeletal pain (VAS values were 2.6 ±2.9 at the highest workload targets during Week 12).
458 Our findings are in agreement with other investigators (LaStayo et al., 2007) regarding the use of
459 gradual eccentric loading to minimize DOMS in older adults. In the proposed periodization model,
460 we have formalized an approach to the volume and time course of the submaximal eccentric exercise
461 bouts (within the first mesocycle) using an isokinetic mode of strength training. This structured
462 approach to the first mesocycle may aid task performance and facilitate the acquisition of protective
463 adaptations with minimal deleterious effects.
464
465 Beyond the Repeated Bout Effect. The initial exposure to eccentric muscle actions has value beyond
466 the repeated bout effect. The proposed periodization macrocycle includes a distinct phase for gaining
467 familiarization with eccentric exercise. This early phase of training includes important components of
468 motor learning related to the mode of exercise and the control of movements involving active muscle
469 lengthening. In addition, the participants begin to attempt incrementally higher workloads as they
470 transition from the familiarization phase to the acclimatization phase. Distinct differences exist
471 between the neural control of eccentric and concentric muscle actions. In untrained individuals, full
472
473
474
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activation of muscle is difficult to achieve during voluntary eccentric muscle actions in comparison

n a
to concentric muscle actions (Aagaard et al., 2000; Amiridis et al., 1996; Kellis and Baltzopoulos,

o
1998). This may be due to spinal (Pinniger et al., 2000) and supraspinal (Gruber et al., 2009)

si
475 mechanisms that constrain motor unit discharge rates to protect against potential muscle damage

i
476 caused by high eccentric force levels. Importantly, muscle action-specific differences in motor unit

v
477 excitability may be influenced by the activation of different cortical areas during eccentric exercise in
478
479
480
481
482
483
484
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comparison to concentric exercise (Kwon and Park, 2011). Also, despite the relative retention of
eccentric muscle strength with advancing age (Power et al., 2012), cortical activation patterns for
movements involving eccentric muscle actions may become impaired in older adults (Yao et al.,
2014). These observed neurological changes may contribute to age-related movement deficits with
tasks that involve significant contributions from actively lengthening muscle groups (Chung-Hoon et
al., 2016).

485 The preliminary observations gleaned from the participants in this study suggest that a substantial
486 decrease in motor performance variability occurs between the start of the familiarization phase to the
487 start of the acclimatization phase. This interpretation is based on the gradual normalization of the
488 torque-time curve features during the early weeks of training. The exemplar data shown in the Figure
489 1 shows the variability typically seen in the torque-time curves that result from submaximal eccentric
490 muscle activity during a basic isokinetic knee extension and flexion task (CV = 68% during the 2nd
491 set of session 1 vs 12% during the 3rd set of session 2). The ability to produce eccentric torque-time
492 curves with minimal variability differs across individuals, but is generally attained within the first
493 one to three microcycles of the eccentric exercise program. This learning process may also be
494 facilitated by the low target eccentric workload during the early phases of the regimen, and the
495 knowledge of performance gleaned from visual feedback provided by the dynamometry system
496 computer monitor.
497
498
499 The Eccentric Power-Velocity Paradox
500

This is a provisional file, not the final typeset article 12

 Periodization and eccentric exercise

501 The power-velocity relationship for eccentric muscle actions differs greatly in comparison with
502 concentric muscle actions, and has important implications for eccentric exercise programming
503 (Figure 5). Tom McMahon and Jason Harry’s memorable description of “the dark side of the force-
504 velocity curve” aptly describes the altered behavior of contractile tissue during eccentric muscle
505 actions (Lindstedt et al., 2001). This depiction largely captures the observation of sustained high
506 eccentric peak force generation with increasing movement velocity in contrast with concentric
507 muscle actions. However, McMahon and Harry’s insight also extends to the unique attributes of
508 power generation during eccentric muscle actions. Unlike concentric muscle actions, power appears
509 to increase at very high velocities without an appreciable loss of peak force when active muscles
510 lengthen. Peak force immediately decreases upon transitioning from isometric to concentric muscle
511 actions, and the parabolic curve in muscle power predictably rises as velocity increases, but
512 eventually declines at relatively high velocities (Figure 5). This observed physiologic decline in
513 concentric muscle power has been attributed to the time course required for maximal concentric
514 muscle activation and suboptimal actin/myosin cross-bridge mechanics at high velocities (Cramer et
515 al., 2002; Demura and Yamaji, 2006; Hutchins et al., 1998; Power et al., 2015). However, in
516 considering the eccentric power-velocity paradox, eccentric muscle actions may bias skeletal muscle
517 towards maximal power generation at high velocities. This unique feature of eccentric muscle actions
518 may be attributable to the viscoelastic properties of the muscle-tendon complex, the inherent

l
519 properties of sarcomeric cytoskeleton proteins such as titin and myomesin that may serve to aid

a
520 energy conservation, and active force enhancement via the hypothesized Ca2+ dependent binding in

n
521 the N2A region of titin (Agarkova and Perriard, 2005; Gautel and Djinovic-Carugo, 2016;

sio
522 Nishikawa, 2016).
523
524
525
526

o vi
The eccentric power-velocity relationship was assessed using the study participants’ knee extension
exercise data. The progression phase of the initial macrocycle included a gradual increase in the

r
angular velocity of the eccentric exercise with the isokinetic parameters increasing from 60 deg s-1 to

P
527 90 deg s-1 over the course of the final mesocycle (Table 1). While peak torque was expected to
528 remain stable between the two exercise conditions, it did exhibit a modest increase of 7%. Studies
529 conducted by other investigators have shown both unchanging or increasing peak torque values
530 secondary to higher movement velocities, and training status may be a potential factor in the
531 variation of force or torque levels (Cramer et al., 2002; Hortobágyi and Katch, 1990; Power et al.,
532 2015). Velocity-dependent muscle performance may also vary for different muscle groups based on
533 the joint type and mode of testing (Mayer et al., 1994). Given the increased propensity of subjects to
534 exceed the visual torque targets at high velocities, the observed increase in peak torque in this study
535 may be due to the limitations of the test conditions rather than a significant deviation of the expected
536 eccentric force-velocity relationship. Regarding the power-velocity relationship, the mean power
537 attained by the participants was 25% higher at 90 deg s-1 in comparison to the 60 deg s-1 condition
538 (Figure 4). This increase in power exceeds what could be attributed to the low magnitude of
539 difference in peak torque at 90 deg s-1 and appears to be similar to the findings from other
540 investigators (Cramer et al., 2002; Wu et al., 1997). While this study was conducted under controlled
541 conditions, the present findings were derived from exercise data, so order effects may influence the
542 interpretation of the findings. Nevertheless, the reported power data appear to be consistent with the
543 expected eccentric power-velocity relationship.
544 The initial eccentric exercise macrocycle included progressive increases in workload and movement
545 velocity to obtain post-exercise adaptations in muscle strength and power. The mean age of the study
546 participants was nearly 62 years, and age-related decreases in both muscle strength and power have
547 been implicated in the increased incidence of mobility limitations and falls in older adults (Clynes et

13
 Periodization and eccentric exercise
548 al., 2015). Higher velocity strengthening regimens – using both concentric and eccentric muscle
549 actions – have been proposed as an activity-based strategy to counteract these adverse changes in
550 muscle performance via exercise specificity (Caserotti et al., 2008; Power et al., 2015). However,
551 unlike with concentric muscle actions, increased movement velocity during eccentric muscle actions
552 may significantly affect exercise intensity even when program variables such as workload and
553 repetitions remain unchanged. Practitioners should be aware that peak eccentric muscle torque or
554 force may remain high during activities designed to maximize the production of peak eccentric
555 power.
556
557 An Eccentric Exercise Macrocycle for Accommodating Resistance: the Progression Phase
558
559 The lower levels of anaerobic fatigue noted with repeated eccentric muscle actions in comparison to
560 concentric muscle actions (Enoka, 1996; Ratamess et al., 2016), coupled with the use of
561 accommodating resistance devices, invites unique challenges regarding workload progression and
562 exercise stoppage criteria for eccentric strengthening regimens.
563
564 Accommodating Resistance and the Decision Algorithm for Workload Adjustments. Isoinertial
565 exercise using free weights or machines that utilize stack weights remain the dominant mode of
566
567
568
l
strength training (Cotterman et al., 2005). However, many rehabilitation facilities and sports

a
medicine clinics feature instrumented variable resistance devices for the assessment of motor

o n
performance and as a primary or adjunctive method of strength training for patients. Fundamental

si
569 differences exist between isoinertial and variable resistance exercise (Avrillon et al., 2016). Variable

i
570 resistance exercise performed on devices such as cam-based machines provide altered resistance

v
571 levels throughout the range of motion. The application of variable resistance is designed in a manner

o
572 presumed to optimize the skeletal muscle length-tension relationship (Frost et al., 2010). Isokinetic
573
574
575
576
577
578
579
P r
exercise avoids the limitations of cam designs that may not be ideal for a given participant’s body
proportions, and instead employs a strategy of constraining motion via selected peak angular
velocities (Hislop and Perrine, 1967). Forms of variable resistance exercise such as isokinetics and
ergometry provide accommodating resistance and thus allow motion to continue unabated even if
participants are unable to meet target workload levels. During a fatiguing bout of isoinertial exercise,
the participant will reach repetition failure (or produce a partial repetition) and cease the exercise
activity. In contrast, fatiguing bouts of isokinetic or ergometry exercise are typically characterized by
580 a decline in peak torque or watts (without a loss of joint excursion) over the course of a predefined
581 number of repetitions or a fixed training period. As a result, identifying repetition “failure”, missed
582 workload targets, or an inability to meet volume or total work goals during isokinetic or ergometry
583 exercise requires readily available data and an algorithm to make workload adjustments.
584
585 Exercise regimens involving the use of accommodating resistance may require the acquisition and
586 interpretation of intra-session anaerobic fatigue data to calculate appropriate workload adjustments.
587 Visual torque targets were used to aid the decision algorithm featured in this study for workload
588 adjustments as shown in Figure 2. Computer-assisted isokinetic dynamometry allows for the real-
589 time assessment of torque-time curves and participant visual feedback concerning the prescribed
590 workload. The isokinetic dynamometer used in this study allowed for the entry of torque limits as a
591 safety precaution during the exercise sessions. Individuals typically cannot consistently attain their
592 intra-session workload goal if the safety torque limit value is too close to the visual torque target
593 value. Safety torque limits may be established up to 50 N m above the prescribed workload to ensure
594 that the device safety mechanism does not unnecessarily impede exercise performance within
595 acceptable workload parameters. Adjustments in the target workload and movement velocity may
This is a provisional file, not the final typeset article 14
 Periodization and eccentric exercise

596 also be used to aid patient safety and optimize the load progression within each microcycle of a
597 periodized eccentric training regimen.
598
599 Finally, incorporating a decision algorithm for workload adjustments and exercise stoppage based on
600 reported pain is a critical component of eccentric exercise programming involving patient
601 populations. The exercise stoppage criterion was a VAS pain score of > 8 given that adults with
602 musculoskeletal impairments can have relatively high baseline levels of pre-activity pain that do not
603 preclude exercise participation. Nonetheless, a large proportional increase of exercise-related pain in
604 patients with low baseline VAS pain ratings may merit exercise cessation even if their absolute pain
605 level is below the stoppage criterion. Therefore, the implementation of strength training programs for
606 the rehabilitation of patients with chronic conditions should continue to involve the consultation of
607 the interdisciplinary health professional team.
608
609 Assessing the Progression Phase of the Macrocycle. Notably, the inclusion of the familiarization,
610 acclimatization, and progression phases within the macrocycle suggest that the proposed
611 periodization model is designed for individuals that are new to eccentric exercise. People with
612 minimal training experience may exhibit relatively fast adaptations to strength exercise in
613 comparison to those with extensive training experience (Mangine et al., 2015), and the workload is

l
614 often progressed following each exercise bout or microcycle as needed (Beurskens et al., 2015;

a
615 Unhjem et al., 2015). The choice to use a relatively low cofactor to calculate the estimated eccentric

n
616 peak torque used for workload assignment, coupled with the general fatigue resistance exhibited by

sio
617 actively lengthening muscles, informed the decision to use a common linear PRE progression in this
618 study. While there is some evidence to support the use of non-linear program designs for optimal
619
620
621
i
strength gains (Fleck, 2011; Miranda et al., 2011), the findings are equivocal and the use of complex

o v
periodization schemes confer little advantage to untrained individuals with general strengthening

r
goals (Lorenz et al., 2010). Nevertheless, periodized strength training regimens may be more

P
622 effective than non-periodized programs (Rhea and Alderman, 2004), and formal loading and
623 recovery phases are key elements within the structure of the macrocycle (Lorenz and Morrison,
624 2015). Optimal recovery phases for eccentric training regimens are ill defined. It is not fully
625 understood if the recovery phases for eccentric strength training differ from conventional PRE
626 programs given the high torque output and decreased anaerobic fatigue associated with eccentric
627 muscle actions.
628
629 Aggregate data from the study participants were used to examine the progression phase of the
630 eccentric training regimen in order to determine when the cyclic use of decreased loading should be
631 integrated into the mesocycle. The eccentric exercise performance of the participants was assessed by
632 an examination of the work-time line graph obtained during the progression phase of the regimen. It
633 was presumed that relatively level slopes were an indicator of a training plateau, and that negative
634 slopes denoted periods of decreased exercise capacity. In reviewing the progressive phase of the
635 program, consecutive slope values < 10 calculated across a span of microcycles occurred only at the
636 midpoint and endpoint of the mesocycle. Slope values (4.48 – 6.18) indicating a relative plateau in
637 the attained total work occurred following the completion of four microcycles with visual torque
638 targets set at > 70% of the estimated eccentric peak torque (Figure 3). The need for a recovery period
639 within a mesocycle following three to five weeks of training is not uncommon for conventional PRE
640 regimens (Lorenz et al., 2010), and may also be suitable for eccentric PRE regimens with exercise
641 intensity and volume levels similar to those used in this study. The only negative slope value detected
642 within the progressive phase of the program was during the last two microcycles featuring the highest
643 visual torque targets (nearly 150% of the initial estimated eccentric peak torque value). The instance

15
 Periodization and eccentric exercise
644 of the relative decline in attained total work may have been influenced by the high workload targets,
645 the higher estimated eccentric peak power associated with faster angular velocities, and the potential
646 need for a recovery period at the midpoint of the mesocycle. High velocity movements across all
647 exercise sets was a feature of the last three microcycles of the progression phase. The total work
648 attained predictably increased during the initial eccentric training sessions that included all exercises
649 performed at 90 deg s-1 (points P13 to P15 on Figure 3), so the introduction of increased movement
650 velocity alone does not explain the subsequent incident decline in exercise capacity. However, the
651 collective increase in exercise demands related to peak power generation and progressively rising
652 workload targets can certainly contribute to blunted exercise adaptations or diminished performance
653 over an extended period of time. Although a rebound from the decline in total work is noted in the
654 aggregate data (points P17 to P18 on Figure 3), the pattern of the work-time line graph shows that the
655 decline in total work occurs four microcycles after the start of the preceding exercise performance
656 plateau. This observation may indicate that the use of recovery periods after four microcycles of
657 progressive workload and movement velocity increases may benefit eccentric exercise programs
658 similar to the one used in this study. The information obtained from the progression phase work-time
659 data was used to revise the proposed eccentric exercise periodization model as shown in Table 2.
660
661
662 Implications and Limitations of the Proposed Eccentric Exercise Periodization Model
663
664
665

n al
The workloads used at the outset of the progression phase (70% of the estimated eccentric peak

o
torque) are consistent with the recommendations of the ACSM, but it should be noted that

si
666 investigators have recently cited the efficacy of low workload/high volume in trained and untrained

i
667 adults for increases in hypertrophy and strength (American College of Sports Medicine, 2014;
668
669
670
671
672
673
674
r v
Morton et al., 2016). Use of alternate exercise workload and volume programming may require

o
mesocycle phases and recovery periods that differ from the findings of this report. These elements of

P
the eccentric exercise regimen would also be impacted by the addition of other skills-based sports or
rehabilitation activities since these physical demands are typically considered within the structure of
the periodized program. The eccentric exercise regimen described in this study included the
structured progression of both the workload and the movement velocity. Therefore, the separate
effect of these variables on the exercise performance and estimated recovery periods cannot be
675 determined from the data provided. Also, the descriptive use of exemplar data was used to illustrate
676 participant exercise performance during the familiarization phase of the eccentric exercise program in
677 this Theory and Hypothesis report. These observations, and reports on general program efficacy, will
678 require follow up in subsequent clinical studies.
679 The isokinetic dynamometry used in this work, like all modes of exercise, has advantages and
680 disadvantages that may vary based on individual training goals and the selected patient population.
681 While exercise machines have been subject to criticism for not sufficiently reflecting multi-planar
682 movement, isokinetic strengthening has shown some carryover effects to functional activities
683 (Ratamess et al., 2016). Isokinetic strength training offered a high degree of utility in this
684 investigation since it provided visual feedback regarding exercise performance, torque limits to
685 enhance eccentric exercise safety, and the controlled increase of workloads while using only
686 eccentric muscle actions. The singular use of isokinetic dynamometry as exercise for the knee
687 extensors and flexors was for the purposes of this study, and does not reflect a comprehensive
688 rehabilitation plan of care. In addition, a potential limitation of this work is that the range of angular
689 velocities used for the eccentric exercise differed from the standard speeds used by our laboratory for
690 strength assessment. Also, the contraindications for conventional strength training and eccentric

This is a provisional file, not the final typeset article 16

 Periodization and eccentric exercise

691 exercise using external loads are critical to consider when providing the exercise prescription, and are
692 beyond the scope of this report.
693
694 Comparing the implemented periodized eccentric strengthening regimen to other approaches to
695 periodization was beyond the scope of this report. It is also important to emphasize that key
696 differences exist among forms of eccentric strength training. Strength training regimens involving
697 eccentric muscle actions should be conceptualized as two distinct types of exercise based on the
698 Lindstedt model of a spring in series with a damper: activities that involve maximal acceleration and
699 the potential recovery of elastic recoil energy, and activities which are largely characterized by net
700 forces that result in deceleration and the absorption of elastic recoil energy (Lindstedt et al., 2001).
701 The periodized eccentric strengthening program presented in this report involved participants
702 eliciting eccentric torque in an effort to decelerate the motion generated by the dynamometer.
703 Additional approaches have been considered regarding the structure and progression scheme for
704 exercise involving eccentric muscle actions and rapid force development to aid the latter phases of
705 physical rehabilitation (Davies et al., 2015). Lastly, the findings of this report are limited by the
706 participant sample and different conclusions may be reached in exercise groups featuring people with
707 different comorbidities.
708

l
709

a
710 Conclusions

n
711
712
713
714

sio
The eccentric training periodization model introduced in this report includes allowances for patient
safety and motor learning during the early phases of the macrocycle. In addition, the challenge of

vi
detecting and monitoring missed workload targets when using accommodating resistance exercise

o
715 was highlighted in this work. A criterion-based method was presented to manage workload

r
716 adjustments through the assessment of intra-session anaerobic fatigue. Eccentric exercise performed

P
717 at higher velocities resulted in increased power generation without an abatement of peak torque in the
718 study participants. This characteristic of the eccentric power-velocity curve may be manipulated as a
719 training variable to modify exercise intensity or optimize exercise specificity. The anaerobic fatigue
720 rate and power-velocity relationship for eccentric muscle actions differs greatly in comparison with
721 concentric muscle actions. Nevertheless, the need for exercise recovery periods relative to training
722 intensity for eccentric PRE may be similar to the recommendations for conventional PRE programs.
723 The periodized eccentric training model proposed in this report was informed by the progression
724 phase work-time data. The model features recommended recovery periods after every four
725 microcycles with incremental workload progressions (Table 2). Additional investigation is needed to
726 determine the efficacy of the reported eccentric exercise program in older adults with chronic
727 conditions. The continued development of periodization approaches based the eccentric exercise
728 paradigm may lead to testable hypotheses concerning optimal progression algorithms, recovery
729 phases, and target workloads for eccentric strength training used in the management of selected
730 chronic conditions or the rehabilitation of athletic injuries.
731
732

17
 Periodization and eccentric exercise
733 Acknowledgments

734 Funding for this project was provided by the VA Office of Academic Affiliations (OAA; 38 U.S.C
735 7406) and the VA Office of Research and Development (ORD), with additional support from the
736 VA/ORD Rehabilitation R&D Service (1IK2RX001854-01). Any opinions or recommendations
737 expressed in this publication are those of the authors and do not necessarily reflect the view of the
738 U.S. Department of Veterans Affairs or the U.S. Department of Health and Human Services.
739
740
741 Author Contributions
742
743 MH was responsible for the study design; HH, BS, MH, and TG performed the study procedures;
744 MH, TG, BS, DP, and HH were responsible for data management and verification; MH and TG
745 analyzed the data; MH prepared figures; MH, BS, TG, HH, DP and BH collaborated on the data
746 interpretation; MH, BS, TG, HH, DP, and BH drafted the manuscript MH, BS, TG, HH, DP, and BH
747 edited and revised the manuscript; MH, BS, TG, HH, DP, and BH approved final draft.
748
749

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This is a provisional file, not the final typeset article 18

 Periodization and eccentric exercise

750

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940
941
942

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This is a provisional file, not the final typeset article 24

943 Tables
944
945 Table 1. Initial Eccentric Training Macrocycle. The primary features of the periodized eccentric strength training program include
946 introductory training phases to allow for motor learning related to eccentric isokinetic exercise and submaximal, incremental exposure of the

l
947 training stimulus in order to induce the repeated bout effect. The second mesocycle incorporates the progression phase of the exercise

a
948 regimen for the systematic increase in workload and movement velocity.

n
949

vi sio MACROCYCLE – INITIAL

Familiarization

Micro 1 P r o Acclimatization

Mesocycle1

Micro 2

Low target workload

Micro 3 Micro 4
Initial
training
Micro 5 Micro 6 Micro 7
Progression

Mesocycle 2

Micro 8 Micro 9 Micro 10

Progressive increase in target workload
Micro 11 Micro 12

and power generation

workload
-1 -1 -1
60 deg s , 60 deg s , 60 deg s , -1 -1 -1
-1 -1 -1 -1 -1 -1 90 deg s , 90 deg s , 90 deg s ,
45 deg s , 60 deg s , 60 deg s , 60 deg s , 60 deg s , 60 deg s , 3 x 10 2 x 10 1 x 10
-1 -1 -1 4 x 10 4 x 10 4 x 10
3 x 10 3 x 10 3 x 10 3x10 3 x 10 4 x 10 90 deg s , 90 deg s , 90 deg s ,
1 x 10 2 x 10 3 x 10

Target Eccentric Workload (% Peak Torque) and Progression

40% – 50% 50% 60% 70% ± 5% ± 5% ± 5% ± 5% ± 5% ± 5% ± 5% ± 5%

Attained Eccentric Workload (% Peak Torque)

40% 50% 60% 70% 75% 85% 95% 105% 113% 125% 132% 141%

950 Micro, microcycle; deg, degrees; s, second.

951 Baseline estimated eccentric peak torque based on concentric peak torque at 60 deg s-1and a conversion factor of 1.35; the workload adjustment
952 algorithm was applied after each session from microcycle 5 to microcycle 12.
 Periodization and eccentric exercise

953 Table 2. Revised Eccentric Training Macrocycle. The featured periodized strength training program is proposed as an approach to
954 introduce isokinetic eccentric training in outpatient rehabilitation settings. The program revisions were informed by the participant exercise
955 data featured in this study. The findings suggested that the use of active recovery periods following four consecutive microcycles (with
956 conditional workload adjustments) would improve the structure of the program. Also, in an effort to avoid extended plateaus or decreased
957 performance, use of non-linear cycling of the movement velocity was incorporated to better manage exercise intensity towards the end of the
958 progression phase microcycles.
959

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si
MACROCYCLE – REVISED

Familiarization

r o vi
Acclimatization Progression

Micro 1

45 deg s ,
3 x 10
-1
P
Mesocycle1

Micro 2

Low target workload

3 x 10
Micro 3

-1
60 deg s ,
Micro 4
Initial
training
workload

3 x 10
-1
60 deg s ,
Micro 5

60 deg s ,
4x10
-1
Mesocycle 2A

Micro 6

3 x 10
90 deg s-1,
Micro 7

2 x 10
90 deg s-1,
Micro 8
Progressive increase in target workload
and power generation
60 deg s-1, 60 deg s-1, 60 deg s-1,
1 x 10
90 deg s-1,
Micro 9
Active
recovery

–
Micro 10

60 deg s-1,
4x10
Micro 11

60 deg s-1,
3 x 10
90 deg s-1,
Mesocycle 2B

Micro 12

and power generation

60 deg s-1,
2 x 10
90 deg s-1,
Micro 13
Progressive increase in target workload

60 deg s-1,
1 x 10
90 deg s-1,
Micro 14
Active
recovery

–
1 x 10 2 x 10 3 x 10 1 x 10 2 x 10 3 x 10

Target Eccentric Workload (% Peak Torque) and Progression

40% – 50% 50% 60% 70% ± 5% ± 5% ± 5% ± 5% – ± 5% ± 5% ± 5% ± 5% –

960 Micro, microcycle; deg, degrees; s, second.

961 The workload adjustment algorithm may be applied after each session from microcycle 5 to microcycle 14 (excluding active recovery periods).
962

26
This is a provisional file, not the final typeset article
 963 Figure Legends

964 Figure 1: Eccentric torque-time curves during the familiarization phase of the strength training
965 program. The exemplar data shows the transition in the isokinetic eccentric motor performance (in
966 the 45 degree/s exercise condition) observed during the familiarization phase of the strength training
967 program. The torque-time curve for knee extension and flexion observed during session one exhibits
968 a high degree of variability based on the eccentric knee extension mean repetition interval time
969 (coefficient of variation, CV = 68%). However, this variability decreases by the end of the
970 familiarization phase during session two (CV = 12%).
971
972
973 Figure 2: Workload adjustments based on the eccentric torque-time curves relative to the
974 visual torque targets. Strengthening exercise involving the use of accommodating resistance
975 requires an assessment of intra-session anaerobic fatigue data to make appropriate workload
976 adjustments. The line graphs depict exemplar torque-time curves for eccentric knee extensor
977 exercise. The torque targets include: Line A – the designated exercise workload, Line B – this
978 dashed line is the lower-bound ±10% tolerance level for the acceptable attainment of peak torque

l
979 during each repetition, and Line C – the indicator of peak torque levels that fall 25% below the

a
980 designated exercise workload. The left panel captures a successful exercise set that would result in a

n
981 5% increase in the designated workload, whereas, the right panel reveals additional markers of
982
983
984

sio
anaerobic fatigue, but not fatigue levels that reach the criterion limit of 25%. The exercise
performance shown on the right panel would result in the maintenance of the designated workload for

vi
the subsequent exercise session.

o
985

r
986

P
987 Figure 3: Adjusted total work values attained during the progression phase of the strength
988 training program. Eccentric total work (60 degrees/s) during the progression phase of the initial
989 exercise program was indexed to the values attained at the start of the 5% workload increments
990 during the fifth microcycle, and proportional change in the total work values were graphed until the
991 end of the exercise program (†progression phase sessions 3 through 18; i.e., P3 – P18). The total
992 work increased from the index value of 100% to the final value of 285% at the end of the eccentric
993 strength training regimen, and isolated periods of diminished exercise performance were identified as
994 potential points in the exercise program suitable for an active recovery period. (τ, torque; error bars =
995 SE, standard error)
996
997
998 Figure 4: Relative change in eccentric peak torque and mean power while using a fixed
999 workload target during 60 deg s-1 and 90 deg s-1 isokinetic knee extension exercise. The
1000 velocity-dependent behavior in eccentric torque and power generation are depicted in the radar graph.
1001 Torque and power data are indexed to the values obtained during the 60 deg s-1 condition (e.g.,
1002 100%, as shown in the innermost circle and centerline values) and the participant identification
1003 numbers are listed along the periphery of the circle. The participants used the same workload targets
1004 during exercise at both isokinetic speeds. The data attained during the 90 deg s-1 condition show that
1005 the attained peak torque values were comparable to those recorded during the 60 deg s-1 condition (Δ
1006 7%). However,a greater proportional difference in mean power generation was noted in the 90 deg s-1
1007 condition in comparison to the 60 deg s-1 condition (Δ 25%) within the sample. (deg, degrees; s,
1008 seconds)
 Periodization and eccentric exercise
1009
1010
1011 Figure 5: Velocity-dependency of eccentric peak torque and mean power. The power-velocity
1012 relationship for eccentric muscle actions differs greatly in comparison with concentric muscle actions
1013 as shown in the idealized graph. Peak concentric power is attained at intermediate velocities and peak
1014 torque levels, whereas, peak eccentric power rises precipitously with increasing velocities and fairly
1015 stable high peak torque levels. (The indeterminate physiologic decline in power at the highest
1016 velocities is denoted by the terminal bar on the dashed trajectory line.) (con, concentric; max,
1017 maximum)
1018
1019
1020
1021

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This is a provisional file, not the final typeset article 28

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