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Unilateral and bilateral exercise movements: Considerations for Program

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Article  in  ACSM s Health & Fitness Journal · May 2018

DOI: 10.1249/FIT.0000000000000390

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 UNILATERAL AND BILATERAL
EXERCISE MOVEMENTS
Downloaded from https://journals.lww.com/acsm-healthfitness by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fB7RKAmTm9TapnL1zlJyQY4iDSyG+f2kZNS77x1AIFs= on 10/09/2018
Considerations for Program Design
by Charles J. Fountaine, Ph.D., FACSM
Apply It!
By reading this article, the health
and fitness professional will:
 Understand neurophysiological
concepts such as the bilateral
deficit, bilateral facilitation, and
cross-education effect and ex-
tend their potential applications
to exercise prescription
 Prescribe bilateral and unilateral
exercises for the appropriate
clientele based on an evidence-
based rationale
Key words: Bilateral Deficit,
Bilateral Facilitation,
Cross-Education Effect, Principle
of Specificity, Resistance Training
Volume 22 | Number 3
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
INTRODUCTION
W
hen tasked with designing a resistance training program for the first
time, one of the biggest challenges that new health and fitness profes-
sionals encounter is understanding all of the different variables that
can be integrated into a resistance training program. This task can
oftentimes feel overwhelming, and for good reason, because it has
been estimated that there are 10 to the 67th power (that’s a 1 followed by 67 zeroes!) of
different workout combinations that can be manipulated when considering all of the of
acute program design variables (1)! Whereas some of the more obvious elements that need
to be addressed include variables such as frequency, intensity, rest periods, and volume,
the decision of what exercises to choose can lead to a plethora of choices. Single-joint or
multiple-joint exercises? Free weights or machines? Open-chain or closed-chain exercises?
Without question, all of the aforementioned exercise choices have a time and place and
can be easily justified or omitted, dependent on the specific needs analysis of a client.
One additional area of exercise selection that has received increased scrutiny as of late
involves the choice of bilateral or unilateral exercises. For many years, bilateral, multiple-
joint barbell exercises such as the back squat, bench press, and deadlift have been staples
of resistance training programs, and for good reason, because exercises such as these are
well established in their efficacy for improving muscle strength, size, and power (2). How-
ever, in many strength and conditioning circles, favoring unilateral exercises over bilateral
exercise has become more prevalent (3–5), with the rationale that bilateral exercises
contribute to a phenomenon known as the bilateral deficit. Thus, unilateral exercises
are more functional and better adhere to the principle of specificity than bilateral exercise
choices. Is the exclusion of bilateral exercises in favor of unilateral exercises a valid
concern that is justified and well supported by research? The purpose of this article
www.acsm-healthfitness.org 11
UNILATERAL & BILATERAL EXERCISE MOVEMENTS

is to examine the pros and cons of bilateral and unilateral of bilateral and unilateral exercises for the lower and upper body via
exercise selection, with the end goal of helping health and a sample push-pull training split using multiple-joint movements.
fitness professionals design programs based on evidence-based
information that can best benefit their respective clientele.
THE BILATERAL DEFICIT
BILATERAL AND UNILATERAL MOVEMENTS Muscular strength has been defined as the maximal amount of
Before we proceed, a few operational definitions are in order. A force that can be generated during a specific movement pattern
bilateral exercise movement is when both limbs are used in unison to at a specified velocity of contraction (8). However, when compar-
contract the muscles, which creates force, and subsequently moves ing the force production between bilateral and unilateral move-
a given load (6). A unilateral exercise movement is when each limb ments, a curious and much less understood phenomenon often
works independently of the other to create the desired movement (6). is observed in which the force produced when the left and right
As with any attempt to classify exercise-based movement pat- limbs simultaneously contract is less than the sum of the forces pro-
terns, there will always be exercises that do not necessarily fit duced from the left and right limbs separately (9). For example, let’s
neatly into a classification scheme. For example, consider upper say an individual was performing a one-repetition maximum
body exercises that use dumbbells. Whereas few would dispute (1RM) effort leg press, resulting in the following maxes: 1) both
that pressing and pulling dumbbell movements performed with legs at the same time, 1 RM = 500 lb; 2) just the right leg,
one arm or in an alternating manner would be classified as uni- 1RM = 280 lb; 3) just the left leg, 1RM = 270 lb. In this hypothetical
lateral exercises, what if the right and left limbs move simulta- scenario, the sum of the right and left legs 1RM (280 + 270 = 550)
neously? For example, if an individual performs a dumbbell is greater than the 1RM of both legs (500 lb) working in unison. In
shoulder press and the right and left limbs concurrently press other words, the total amount of force generated from a single
the dumbbells overhead, both limbs are clearly contracting in bilateral contraction often is less than the total force generated
unison, but because of the dumbbell, each hand is independent by two separate unilateral contractions. Accordingly, this neuro-
of the other. Is this a bilateral or unilateral exercise? Further- muscular anomaly has been termed the bilateral deficit (BLD) (9).
more, lower body exercises that are performed in a split-stance (See Figure for how to calculate and interpret).
position, such as lunges and step-ups, also can be a challenge The BLD is hypothesized to be caused by neural inhibition
to classify. For example, when performing a lunge, although the when two homologous contralateral limbs (e.g., left leg, right
lead leg has been shown to bear ~75% to 85% of the overall load leg) are attempting to simultaneously contract (10). Interestingly,
(7), the trail leg is still needed to successfully execute the move-
ment. Would this exercise be best classified as bilateral or unilat-
eral? Whether the aforementioned exercises are classified as
bilateral or unilateral is largely a matter of semantics because
logical and defensible arguments clearly can be made on either
side. A more centrist approach may be to simply encourage the
health and fitness professional to adopt a consistent method of
dumbbell and lower body exercise classification, acknowledging
that shades of grey certainly do exist, and the classification of
exercises is much more art than science. Table 1 provides examples
Photo courtesy of Trevor Bennion, DHSc. www.fitnphys.photos
TABLE 1: Sample Bilateral and Unilateral Exercises
Movement Pattern Bilateral Unilateral
Lower body push Barbell front squat Step-ups
Lower body pull Good morning Single-leg Romanian
deadlift
Upper body Push-ups Alternating DB bench
horizontal push press
Upper body Inverted row One-arm cable row
horizontal pull
Upper body Barbell shoulder One-arm kettlebell
vertical push press press
Upper body Pull-ups Alternating lat pulldown
vertical pull

12 ACSM’s Health & Fitness Journal ® May/June 2018

Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Figure. How to calculate the bilateral index (BI).
the BLD is not observed when nonhomologous muscle groups
(e.g., left arm, right leg) simultaneously contract (11), suggesting
that neural inhibition is limited to homologous bilateral contrac-
tions (9). In addition, a wide range of factors such as training,
age, motor disorders, fatigue, fiber type and right-left dominance
have each been theorized to contribute a role to the BLD (12). If
the phenomenon of the BLD is largely agreed to be a result of an
alteration or limitation of the neuromuscular system (9,11), what
then are the potential impacts on exercise selection for health and
fitness professionals?
Bilateral deficit – the reduction in force that
accompanies maximal two-limb efforts relative
to maximal single-limb performances (13).
As previously mentioned, the existence of the BLD often is
the rationale provided by many health and fitness professionals
as to why they may feel unilateral exercise movements are supe-
rior to bilateral exercises (3–5). However, previous research that
has examined the difference in force production between bilateral
and unilateral movements paints a much more nuanced picture,
suggesting that the phenomenon of the BLD is actually highly
variable among individuals (9). Whereas the BLD most often is
observed in acute studies that have used untrained subjects per-
forming novel movements, longer term bilateral training tends
to mute the inhibitory effects of the BLD (3,9,11,13,14). Further-
more, in trained athletes, such as rowers and weightlifters who
routinely perform bilateral movements, maximal bilateral force
production can actually be greater than the sum of unilateral forces,
a phenomenon termed bilateral facilitation (9,13), suggesting task
familiarization and specificity of exercise can play a large role
in reducing the effects of the BLD. Therefore, understanding the
individual differences concerning bilateral strength production is
perhaps best viewed along a continuum, ranging from deficit to
facilitation, with some individuals showing no effect, all outcomes
attributable to the wide variability in human subjects (13).
Given the ambiguity and inconsistency surrounding the BLD,
what conclusions, if any, can the health and fitness professional
derive from the research? Based on the results from review arti-
cles on the BLD (3,9,11), here are a few of the major takeaways
and practical implications:
• Lower body movements generally exhibit a greater BLD
than upper body movement. The increased postural sta-
bility requirements needed to produce force in the lower
Volume 22 | Number 3
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
body may contribute to a larger BLD; thus, addressing core
activation in training may be of value (15).
• The magnitude of the BLD tends to increase with the veloc-
ity of contraction during explosive or ballistic movements.
Thus, for individuals training for activities that require
one-legged jumping, addressing high-velocity, low-load
(<30% 1RM) power training may be warranted (16).
• Bilateral training tends to reduce the BLD, whereas uni-
lateral training tends to increase the BLD. Thus, bilateral
training will affect performance on a bilateral task, and
unilateral training will affect performance on a unilateral
task (3). Therefore, the principle of specificity dictates that
the optimal program design needs to reflect the specific
adaptations that are desired (2,17).
• Lack of familiarity with a task often results in a BLD, sug-
gesting the BLD may be larger in untrained versus trained
individuals. It is well understood that the rapid improve-
ments in strength during the early stages of training in
untrained/novice individuals are predominantly due to
neural adaptations, thus training interventions in as little
as 4 weeks may be effective in reducing the BLD (2).
• Minimal studies to date have investigated the relationship
between the BLD and athletic performance or injury, thus
any definitive answers are simply unknown at this time.
TRY THIS AT HOME
In a classic study from 1961, Henry and Smith (20) found
that bilateral maximal handgrip strength was significantly
less than the sum of the maximal right and left handgrip
strength combined. For health and fitness professionals
with access to a handgrip dynamometer, here’s how you
can easily replicate this study! First, to assess your
bilateral grip strength, grip the dynamometer with both
hands, maximally contract, and record your measurement.
After a couple minutes’ rest, grip the dynamometer with
your dominant hand, maximally contract, and record your
measurement. After a few minutes’ rest, repeat the same
process with your nondominant hand. Using the formula
shown in the Figure, calculate your bilateral index. Any
evidence of a bilateral deficit or facilitation? Are there any
potential limitations or confounding factors you might wish
to consider before reaching any conclusions? To assess
lower body strength, repeat the aforementioned steps on a
leg extension or leg press machine.
www.acsm-healthfitness.org 13
UNILATERAL & BILATERAL EXERCISE MOVEMENTS

For individuals not well versed in interpreting research arti-
cles, the aforementioned summaries may lead to feelings of con-
fusion or dissatisfaction at the lack of definitive conclusions. The
tendency to reach a conclusion without fully weighing all possi-
ble options equally, only accepting and interpreting information
that confirms preconceptions, is a type of cognitive bias known
as confirmation bias (18). Preconceived viewpoints can cloud our
ability to look at a situation objectively, especially when we simply
rely on anecdotal or past experiences (19). Does the BLD exist?
Absolutely. However, individual differences and task specificity
create enormous variability among the literature that has investi-
gated the BLD; therefore, any claims as to the superiority of
either unilateral or bilateral training methods are simply not
supported at this time by research. There may certainly be situ-
ations where bilateral exercises may be a better option to uni-
lateral movements and vice versa, but using the BLD as the
scientific rationale that ultimately impacts exercise selection
does not seem to be warranted at this time (3,9,11).
majority of cross-education research has used individuals with
a healthy immobilized limb; therefore, additional randomized
control trials are needed before establishing evidence-based rec-
ommendations for clinical practice (23).
Another promising implementation of the cross-education ef-
fect may be within a clinical setting for individuals who have
suffered a stroke. Approximately 80% to 85% of individuals
recovering from a stroke will have a one-sided muscle weak-
ness, known as hemiparesis, resulting in reduced functional abil-
ity (25). Consequently, occupational and physical therapists have
explored cross-education interventions via resistance training to
restore strength and function from asymmetrical deficits in stroke
patients (24). Early investigations of the cross-education effect in
poststroke rehabilitation have shown initial promise; however,
further trials are needed before definitive conclusions can be
made (25). Whereas the nonclinical health and fitness profes-
sional may not typically work with the aforementioned popula-

THE CROSS-EDUCATION EFFECT

Another interesting neurophysiological phenomenon that may
be of interest to the health and fitness professional is when strength
increases are observed in the contralateral (opposite side) limb after
performing unilateral exercises with the ipsilateral (same side) limb,
a phenomenon most commonly referred to as the cross-education effect
(21). For example, performing bicep curls with the left arm can ac-
tually increase the strength of the right arm! The cross-education
effect has been observed via voluntary muscle contractions, electri-
cal stimulation of muscle, and even via mental practice of muscle
contractions (22). Furthermore, the cross-education effect can oc-
cur in both upper and lower body muscles, in both dynamic and
isometric contractions, and in all ages and sexes (22). A recent
meta-analysis quantified the typical contralateral limb strength
gains to be approximately 11.9% after any form of unilateral tions, the general fitness population is no stranger to aches and
training, with even greater improvements with specific training pains, so when limitations do inevitably arise with clientele, ap-
interventions such as dynamic-isotonic training (15.9%) and eccen- plications of the cross-education effect may be implemented to
tric training (17.7%) (23). Much like the BLD, the exact mecha- maintain training capacity.
nisms of the cross-education effect are not well understood,
but are hypothesized to be as a result of neural adaptations,
complex changes in the contralateral motor pathways, or motor
learning (22).
For healthy individuals, cross-education may seem like a silly Cross-education effect – when training one side
or trivial side effect because why would anyone only train one of the body increases the strength on the other
side of the body? However, the true value and application of
the cross-education effect may be in the world of rehabilitation side of the body (26).
in situations where one limb may be immobilized because of
an injury (24). For example, a football player who breaks his
right hand, which is subsequently placed in a cast, can imple- PROGRAM DESIGN
ment unilateral dumbbell exercises with his left hand to stem Now that we have established some of the neuromuscular phys-
the typical strength loss and muscle atrophy that accompanies iology that can affect bilateral and unilateral movements, let us
the disuse due to immobilization (24). Previous research has now turn our focus to applying this knowledge toward designing
found promising applications of the cross-education effect in in- resistance training programs. According to the 2009 ACSM po-
dividuals with distal fractures or anterior cruciate ligament re- sition stand on resistance training, there is a rich body of evi-
construction (23). However, it is important to note that the dence that supports the inclusion of bilateral and unilateral
14 ACSM’s Health & Fitness Journal ® May/June 2018

Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 2: Sample Workout Template — Total Body Split
Day 1 Day 2
Barbell back squat Split squat
Single leg deadlift Trap bar deadlift
Barbell bench press Alternating dumbbell bench
press
Dumbbell row Seated cable row
Alternating dumbbell shoulder Standing military press
press
Chin-ups One-arm lat pulldown
(both single- and multiple-joint) exercises when designing resis-
tance training programs for novice, intermediate, and advanced
individuals (2). Therefore, the logical next step for the health
and fitness professional is to conduct a needs analysis that is in-
dividualized to his or her respective client’s goals and needs,
while employing ACSM’s evidence-based FITT-VP (F = fre-
quency, I = intensity, T = time, T = type, V = volume, P = pro-
gression) principles of exercise prescription (27). Accordingly,
here are some considerations to think about when deciding
when to prescribe bilateral or unilateral exercises:
• For an individual with limited time, choosing bilateral
movements may be a better choice because of the reduced
time commitment — e.g., 3 sets of 10 repetitions of goblet
squat = 30 total repetitions versus 3 sets of 10 repetitions
of split squats = 60 total repetitions (30 reps right leg, 30
reps left leg).
• Unilateral and bilateral exercises are equally effective at
improving upper and lower body measures of strength
and power; therefore, the inclusion of both are warranted
throughout the course of a training cycle (3).
• For individuals seeking increased activation of the core
musculature, unilateral movements can create a greater core
challenge, especially in the frontal and transverse planes be-
cause alternating or off-set loads require the core muscula-
ture to counter the destabilizing forces acting on it (28) —
e.g., increased demands on the core from an alternating
dumbbell bench press or a one-arm dumbbell bench press.
• Similarly, for individuals seeking increased activation of
the muscles that stabilize the pelvis and knee, unilateral
exercises such as split squats, lunges, step-ups, and single-
leg deadlifts all require greater frontal plane control and
subsequent neuromuscular activity than bilateral exercises
(7). Activation of the muscles of the pelvis and knee can be
increased even further by using asymmetrical or offset
loads in ipsilateral or contralateral progressions — e.g.,
single-leg deadlift on right leg with a dumbbell in the right
hand (ipsilateral) or single-leg deadlift on the right leg with
a dumbbell in the left hand (contralateral).
• However, for individuals with a history of low back pain,
loaded unilateral exercises, especially those that challenge
Volume 22 | Number 3
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
the frontal and transverse planes, may trigger discomfort
because exercises that increase muscle activation also dra-
matically increase the compressive loads on the spine (29).
Therefore, health and fitness professionals working with
individuals with a history of low back pain should progress
very conservatively from sagittal to frontal to transverse
plane challenges to stay within their client’s respective tol-
erance and capacity to training.
• For individuals planning to train each muscle group or
movement pattern at least twice a week, one day could
be dedicated to just bilateral movements, one day could
be dedicated to just unilateral movements, or both bilat-
eral and unilateral movements could be spread out across
the training split (see Table 2 for examples).
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Disclosure: The author declares no conflict of interest and does not have any
financial disclosures.
Charles Fountaine, Ph.D., FACSM, is an associ-
ate professor of Exercise Science at the University of
Minnesota Duluth in Duluth, MN. Dr. Fountaine
teaches courses in research methods and the science
of resistance training. He served as president of the
Northland Chapter of the American College of Sports
Medicine from 2014 to 2016.
BRIDGING THE GAP
The health and fitness professional has a myriad of
options to consider when tailoring a resistance training
program for a client. Through a basic understanding of
the neuromuscular physiology that can affect both
bilateral and unilateral exercises, the health and fitness
professional is encouraged to use an evidence-based
approach to program design and exercise prescription.
Ultimately, the decision of what type of resistance
training exercise movements to implement — bilateral,
unilateral, or a combination of both — will be dependent
on 1) the initial needs analysis and assessments
performed, 2) the goals of the client, and 3) which
exercises will lead to the greatest exercise adherence
and self-efficacy as per ACSM recommendations (30).

16 ACSM’s Health & Fitness Journal ® May/June 2018

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