Sports Med
DOI 10.1007/s40279-016-0507-z
REVIEW ARTICLE
Resistance Training as a Tool for Preventing and Treating
Musculoskeletal Disorders
Emmanuel Gomes Ciolac1 • José Messias Rodrigues-da-Silva1
Ó Springer International Publishing Switzerland 2016
Abstract The aging process is characterized by several
physiological, morphological, and psychological alter-
ations that result in a decreased functional and health status
throughout the life span. Among these alterations, the loss
of muscle mass and strength (sarcopenia) is receiving
increased attention because of its association with innu-
merous age-related disorders, including (but not limited to)
osteoporosis, osteoarthritis, low back pain, risk of fall, and
disability. Regular participation in resistance training pro-
grams can minimize the musculoskeletal alterations that
occur during aging, and may contribute to the health and
well-being of the older population. Compelling evidence
suggest that regular practice of resistance exercise may
prevent and control the development of several muscu-
loskeletal chronic diseases. Moreover, resistance training
may also improve physical fitness, function, and indepen-
dence in older people with musculoskeletal disorders,
which may result in improved quality of the years lived. In
summary, regular participation in resistance training pro-
grams plays an important role in aging and may be a pre-
ventive and therapeutic tool for several musculoskeletal
disorders.
& Emmanuel Gomes Ciolac
ciolac@fc.unesp.br
1
Exercise and Chronic Disease Research Laboratory, Physical
Education Department, School of Sciences, São Paulo State
University-UNESP, Av. Engenheiro Luiz Edmundo Carrijo
Coube 14-06, Bauru 17033-360, Brazil
Key Points
Regular participation in resistance training programs
throughout adulthood can minimize age-related
musculoskeletal alterations and reduce their impact
on health and the aging process.
The prophylactic benefits of resistance training
appear to occur by attenuating loss of muscle
strength and mass, improving or reducing loss of
bone mineral density, attenuating the reduction in the
ability to perform daily activities, decreasing the
incidence of osteoarthritis, and improving weight
control and cardiometabolic health.
Resistance training may be an effective treatment for
some of the most common musculoskeletal
disorders. Its main therapeutic benefits include an
increase in muscle strength, a reduction in pain and
improved function in patients with osteoarthritis, low
back pain, or rheumatoid arthritis. Resistance
training may also improve or maintain bone mass
and reduce the risk of falls in patients at risk of
osteoporotic fracture.
1 Introduction
Although modern technology has reduced the need to
produce high levels of muscle strength, the medical and
scientific community has recognized that muscle strength is
a fundamental physical requirement for the maintenance of
health, functional capacity, and quality of life [1]. Pro-
gressive resistance training (an exercise modality that
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gradually increases the external resistance placed upon the
body during training in accordance with improvement in
the individual’s performance) has been long recognized as
the most effective method for developing muscle strength,
power, endurance, and mass (hypertrophy) and for
improving the performance of athletes [1, 2]. However,
recently there has been recognition of the need for resis-
tance training for health promotion and rehabilitation of
chronic diseases in non-athlete populations [3]. The first
investigations demonstrating the benefit of this exercise
modality for rehabilitation date back to the post-World War
II period. Doctors DeLorme and Watkins introduced pro-
gressive resistance exercise programs in the orthopedic
rehabilitation of military veterans [4, 5]. In the second half
of the 1980s, the medical community began to recognize
the potential value of resistance exercise for functional
capacity and other health-related benefits, such as bone
health, basal metabolism, weight control, and health of the
spine [6]. Since then, resistance exercise has been the focus
of numerous studies, which have demonstrated its impor-
tant role in improving physical performance, functional
capacity, independence, psychological well-being, and
quality of life, as well as for preventing and treating several
chronic diseases [6–8]. This manuscript emphasizes the
prophylactic and therapeutic role of resistance exercise,
with a special focus on musculoskeletal disorders.
2 Literature Search Strategy
A narrative review of studies investigating the prophylactic
and therapeutic role of resistance training was carried out
according to a published guideline for writing a narrative
review [9]. We searched PubMed, Web of Science, and
EMBASE databases for articles published between until
July 2015; however, studies could be excluded if similar
information was obtained from more recent studies or
systematic reviews. The search was made by crossing the
terms ‘strength training’, ‘resistance training’, ‘weight
training’, or ‘muscle mass’ with ‘aging’, ‘disease preven-
tion’, ‘elderly’, ‘functional performance’, ‘bone mineral
density’, ‘musculoskeletal diseases’, ‘osteoporosis’, ‘os-
teoarthritis’, ‘low-back pain’, or ‘rheumatoid arthritis’.
Additional studies were found by reviewing the reference
lists from the most relevant published papers located for
this review.
The inclusion criteria included: (1) studies published in
English, Portuguese, or Spanish; (2) some form of resis-
tance training or resistance training-related outcome, such
as strength or muscle mass; (3) assessment of a disease
prevention outcome; (4) assessment of an age-related
impairment; (5) assessment of a treatment/rehabilitation
outcome for osteoarthritis, osteoporosis, low-back pain, or
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E. G. Ciolac, J. M. Rodrigues-da-Silva
rheumatoid arthritis, and (6) both original investigations
(cross-sectional or randomized and non-randomized con-
trolled trials) and systematic reviews. Studies were not
included if adjustments for potential confounders were not
made, or if they had mixed interventions with no attempt to
assess the independent effects of resistance training.
3 The Prophylactic Role of Resistance Training
Skeletal muscle plays an important role in the performance
of daily living physical activities and musculoskeletal
health. However, with aging or disuse, skeletal muscle
decreases its function, leading to several changes that result
in reduced quality of life and health status [10–13]. The
reduction in the ability to produce muscle strength that
accompanies aging starts in the third decade of life [11,
12], and is primarily a result of muscle atrophy (sarcope-
nia), associated with changes in the percentage of intra-
muscular contractile tissue [11–14] and a lower muscle
activation capacity [11, 12, 15–17]. It is well established
that the sarcopenia and loss of muscle strength that
accompany aging result in multifactorial changes that
represent a major public health problem (Fig. 1) [13]. For
example, the loss of muscle strength and fitness accom-
panying sarcopenia decrease the ability to carry out daily
living activities [13, 18, 19] and exercise tolerance [13].
Muscle mass and strength are also associated with bone
mineral density in older adults with sarcopenia, which may
be implicated in the development of osteopenia and its
progression to osteoporosis [12]. In addition, low muscle
mass and strength are also important risk factors for
developing osteoarthritis of the knee [13, 20–23].
The sarcopenia that accompanies aging is also associ-
ated with a reduction in the daily metabolic rate and fat
oxidation [13, 24, 25], and reduces the level of physical
activity and daily energy expenditure [13, 26]. These
alterations are associated with the accumulation of visceral
and total fat in the older population, increasing the risk of
musculoskeletal diseases associated with obesity [27, 28],
as well as cardiovascular diseases, dyslipidemia, and
insulin resistance [13, 29].
However, the regular practice of resistance exercise has
been shown to attenuate the age-related decline in muscle
mass and strength, as well as to reduce its impact on health
and the aging process. In a pioneer study comparing
function and morphology of knee extensors and elbow
flexors muscles in the older population that practiced
resistance training, running, or swimming for more than
10 years, with sedentary older and young individuals, it
was found that resistance-trained older individuals had
muscle cross-sectional area, fiber-type proportion, and
strength similar to those of sedentary young individuals
Resistance Training and Musculoskeletal Disorders
Fig. 1 Schematic of the
consequences of sarcopenia
associated with aging, and the
feedback from its consequences.
Most influences are bi-
directional. ; indicates
reduction, : indicates increase.
Adapted from Ciolac [13], with
permission
[30]. In contrast, older runners and swimmers showed
muscle cross-sectional area, fiber-type proportion, and
strength similar to those of sedentary older individuals,
which suggests that the regular practice of resistance
exercise, unlike running and swimming, can reduce the
muscle function and morphology alterations associated
with the aging process [30].
Skeletal muscles affected by the aging process also
present important adaptations to resistance exercise. Stud-
ies have shown that resistance training increases muscle
strength of older individuals [31–41] and, when performing
the same resistance training program, young and older
individuals show similar strength gains and progression of
training workload [36, 37]. For example, a systematic
review with a meta-analysis of 47 studies (representing
1079 older subjects) showed that resistance exercise
training improved muscle strength by 9.8–31.6 kg in older
adults, which represents a percentage change of *24 % to
*33 %, depending on the muscle group assessed [40]. In a
recent meta-analysis assessing the resistance training dose
response on muscle strength and morphology in older
subjects, resistance training programs with 50–53 weeks of
duration, 70–79 % of the one-repetition maximum of
intensity, a time under tension of 6 s per repetition, and a
rest in between sets of 60 s resulted in greater muscle
strength improvements [38]. The results of this meta-
analysis also suggest that selecting a training frequency of
two sessions per week, a training volume of two to three
sets per exercise, and seven to nine repetitions per set may
also improve the efficacy of resistance training to improve
muscle strength of older subjects [38]. It is important to
note that the resistance training-induced improvements in
muscle strength occur even in very elderly subjects (age
[75 years) [41], or in older subjects training with simple
and limited resistance (i.e., elastic resistance) [39].
Muscle hypertrophy is another adaptation to resistance
exercise found in older individuals [38, 41, 42]. For
example, resistance training performed two to three times a
week promoted increases of 10–62 % in the muscle fiber
diameter after 9–52 weeks of training in older populations
[11, 13]. A recent meta-analysis assessing the effects of
resistance exercise on muscle morphology (cross-sectional
area or volume or thickness of muscles) showed a 1–21 %
increase in muscle mass after training [38]. Similar
improvements (1.5–15.6 %) were also shown in a meta-
analysis assessing the effects of resistance training in sub-
jects aged [75 years [41]. In fact, similar gains in muscle
fiber size were observed when young and older individuals
underwent the same resistance exercise program [43].
Most daily living activities are of relatively short dura-
tion and have greater association with strength and/or
muscle power than aerobic or anaerobic capacity [11, 12,
44, 45]. Thus, it is possible that the maintenance or
reduction of loss of muscle volume/strength through the
regular practice of resistance exercises during aging [30]
may lead to a small reduction in the ability to perform daily
activities [13]. In addition, numerous studies have shown
that older adults improve the performance of daily living
activities with the practice of resistance training [13, 18,
31, 32, 46–48].
Bones and joints are also improved by the regular
practice of resistance training. Cross-sectional studies have
123

shown that athletes participating in sports with high tension
overload and/or impact, such as bodybuilding, weight
lifting, and gymnastics, have higher levels of bone mineral
density than athletes participating in sports with lower
tension and/or impact overload (i.e., swimming), although
the latter still shows higher bone mineral density than their
sedentary peers [49]. Longitudinal studies ranging from 6
to 36 months have also investigated the effect of resistance
exercise on bone mass in previously sedentary women, and
most of them showed increases of 1–5 % in bone mineral
density of the lumbar spine and femur [50]. Furthermore, it
is known that muscle mass is the major determinant of
bone mass during aging, and that to promote the practice of
exercises such as resistance training may also preserve
bone mass [50].
Skeletal muscle plays an important role in absorbing
impact and dynamic stability of the joints [51]. Thus,
muscle dysfunction (low volume, muscle strength, and
endurance) can increase the joint overload and wear.
Accordingly, a longitudinal study showed that in healthy
knees, a strengthened quadriceps offers some protection
against the development of knee osteoarthritis [52]. In
another study, the regional (thigh) and total (whole body)
muscle volume presented a positive correlation with the
volume of knee cartilage, particularly the medial compart-
ment, even after adjustment for bone area [23]. In this same
study, cartilage loss after 2 years of follow-up showed a
negative correlation with muscle volume [23]. Although
there are no controlled studies focused on this issue, it is
suggested that performing resistance training to increase the
muscle volume and capacity (strength and endurance) may
also decrease the incidence of osteoarthritis.
Another important prophylactic role of resistance exer-
cise is related to the daily energy expenditure and weight
control, which may have an indirect effect on muscu-
loskeletal system health. It is known that the basal metabolic
rate and energy expenditure related to physical activity
reduces with aging and, as already mentioned, sarcopenia
plays an important role in this process [13, 24–26]. This
reduction in energy expenditure has a large adverse effect on
body weight maintenance and can lead to the development
of obesity [13, 29, 53], and obesity-related diseases (Fig. 1)
[13], including musculoskeletal disorders [27, 28]. How-
ever, resistance training has been shown to increase basal
metabolic rate and the daily energy expenditure of indi-
viduals of different ages [13], increase the level of daily
living physical activity in older subjects [12, 32], prevent the
accumulation of intra-abdominal fat [54, 55], improve the
lipid profile and insulin sensitivity [56–59], as well as
reduce blood pressure [60, 61]. Thus, resistance training has
been recommended for the prevention and treatment of
obesity [62] and obesity-related diseases [3, 7].
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E. G. Ciolac, J. M. Rodrigues-da-Silva
4 Resistance Training and Osteoarthritis
Resistance training has shown to be an effective method for
the treatment of osteoarthritis. In a literature review of 17
randomized controlled trials examining the effect of
resistance training in patients with knee osteoarthritis, 14
have shown that resistance training reduces pain, eight
have shown that resistance training improves functional
capacity and health, while only three studies showed no
positive effects of resistance training on any of these
variables [63]. Analyzing studies for osteoarthritis of the
hip, the literature was much more sparse, with only two
studies showing that resistance exercise decreases pain,
while one study showed no effect of exercise on disability
[63]. More recent systematic reviews with meta-analyses
confirmed the benefits of resistance training for patients
with osteoarthritis [64–66]. One of these meta-analyses
showed that progressive resistance training, when com-
pared with nonresistance training control groups, has
moderate effect sizes for reducing pain (standardized mean
difference [SMD], -0.35, 95 % confidence interval [CI],
-0.52 to -0.18), improving function (SMD = 0.33; 95 %
CI = 0.18–0.49), and improving knee extension strength
(SMD = 0.33; 95 % CI = 0.12–0.54) [66].
Despite the large number of studies demonstrating the
positive effects of resistance training on pain and func-
tional capacity of patients with osteoarthritis, little is
known about its effect on the progression of the disease.
Only one randomized controlled trial examined the effects
of resistance training in the progression of knee
osteoarthritis by radiographic analysis, and found no dif-
ference between control and resistance-trained groups after
18 months of follow-up [67].
It is important to note that individuals with
osteoarthritis, even the most severe cases, can tolerate
resistance training. A study analyzing the effect of
12 weeks of high-intensity resistance training in individu-
als with severe knee osteoarthritis (patients on a waiting list
for performing high tibial osteotomy) showed substantial
gains in muscle strength of the knee extensors and flexors,
which was associated with a small improvement in self-
efficacy [68]. In this study, no increase in joint pain was
observed during or after exercise sessions [68].
A study by our group also found positive results for
resistance training in patients with severe osteoarthritis [69,
70]. In this study, seven older sedentary women with severe
knee osteoarthritis in one limb and total knee arthroplasty in
the contralateral limb were submitted to a twice-weekly,
progressive resistance training program (nine exercises, one
for each major muscle group), with initial workload at 60 %
of 1 repetition maximum. After 13 weeks of intervention,
we observed increases in muscle strength (30–75 %) [69]
Resistance Training and Musculoskeletal Disorders
and distance walked in 6 min (23 %) [70], reductions in the
time of sit-to-stand (13 %) [70], to raise from the floor
(13 %) [70], and to climb a flight of 15 stairs (16 %) [70], as
well as improvements in unipodal balance [70]. Another
important finding observed in these patients was that the
quadriceps muscle adaptation to resistance training in the
limb without arthroplasty (with greater strength deficit
because of osteoarthritis) was higher than that observed in
healthy young and healthy older subjects (Fig. 2) [69].
Thus, the results of this study may have important clinical
implications because sedentary patients undergoing total
knee arthroplasty, despite the marked reduction in joint pain
[71], do not show improvement in muscle strength and
functional capacity [72–74], even after a long period of
functional adaptation [75].
5 Resistance Training and Osteoporosis
Although the major effects of resistance training on bone
mineral density occur early in adulthood, middle-aged and
older individuals can also improve their bone health by
Fig. 2 Muscle strength (a) and relative resistance training workload
increases curves (b) of older women with total knee arthroplasty and
knee osteoarthritis in the contralateral limb (OKG), older women
without musculoskeletal limitations (OG), and young women without
musculoskeletal limitations (YG), submitted to 13 weeks of resis-
tance training (two sets of 8–12 repetitions in nine exercises).
Training workload was increased by 5 to 10 % whenever two sets of
12 repetitions using proper form and avoiding the Valsalva maneuver
were performed in two consecutive exercise sessions. Data are
practicing in resistance training programs [50, 76, 77]. For
example, in a systematic review assessing the effects of
exercise training on bone mineral density of older subjects,
progressive resistance training seemed to be a powerful
stimulus for improving and maintaining bone mass during
the aging process [77]. Among the studies present in this
review, the best bone mineral density improvements was
achieved through high-intensity resistance training, with
three sessions per week and two to three sets per session
[78]. This systematic review also showed that the efficacy
of the resistance training program is greater when it
extends for at least 1 year, although significant effects can
be observed after 4 or 6 months in some locations of the
body [77].
Randomized controlled trials have also shown that
resistance training increases spine and hip bone mineral
density of women with estrogen deficiency [79–82] or
under hormone replacement therapy [83, 84]. In women
with estrogen deficiency, greater improvements in hip bone
mineral density were found following high- than moderate-
intensity resistance training [80, 81]. Moreover, one of
these studies showed linear correlation between the bone
presented as mean ± standard deviation. There was no significant
difference between OG and YG muscle strength and workload
increase, whereas OKG had greater muscle strength and workload
increase in all exercises. OA osteoarthritic limb, TKA total knee
arthroplasty limb, 1significant difference from OA (p \ 0.05),
2
significant difference from TKA and OA (p \ 0.05), 3significant
difference from OG and YG (p \ 0.05), 4significant difference from
YG (p \ 0.05). Adapted from Ciolac et al. [69], with permission
123

mineral density increase and the amount of weight lifted
during the progressive resistance training program [82].
Because the incidence of osteoporotic fractures in men
does not increase significantly until the eighth or ninth
decade of life, studies analyzing the effect of resistance
training on bone mineral density of elderly men are scarce.
In general, studies show that resistance training-related
bone mineral density increases observed in older men are
similar to those seen in women [50]. However, one study
showed larger increases in heart transplantation men who
underwent 6 months of resistance exercise [85].
Fractures associated with osteoporosis, especially hip
fractures, have devastating effects on functional capacity,
quality of life, and mortality of older individuals [50, 86].
There are no randomized studies analyzing the effect of
resistance training, as well as any other type of exercise, in
reducing fractures. This lack of studies is probably owing
to the difficulty of developing a study with this purpose,
given the large sample size and duration of follow-up
necessary to carry out the observations. However, there is
encouraging evidence from a study with a small sample of
postmenopausal women, where 2 years of resistance
training for the back muscles reduced the incidence of
fractures during the 8 years post-intervention [87]. More-
over, resistance training may also reduce the risk of frac-
tures in older individuals by improving several risk factor
for falls, such as poor balance, muscle weakness, and
abnormalities in walking [34, 82, 88].
6 Resistance Training and Low Back Pain
Randomized controlled trials, systematic reviews, and
medical guidelines, emphasizing the use of exercise in the
treatment of chronic low back pain, have been published to
improve physical function, reduce symptoms, and mini-
mize disability [89–99]. Among the recommended exer-
cises for individuals with chronic low back pain, it seems
that resistance training associated with stretching have the
best results [92, 93]. A recent systematic review showed
that resistance training improves muscle strength, reduces
self-reported pain, and increases functional ability in
patients with chronic low back pain, and thus may be an
effective therapeutic modality in this common condition
[100]. This review also showed that the optimal resistance
training intensity, volume, and contraction type for chronic
low back pain patients is not known because of the widely
differing resistance training methodology employed by the
studies [100].
The positive effect of resistance training seems to result
from the increased muscle strength and endurance of back
and trunk muscles. To increase muscle strength and
endurance through an effective resistance training program
123
E. G. Ciolac, J. M. Rodrigues-da-Silva
may help to protect the low back (or minimize the effect of
injurious events) and to maintain the trunk motor control
by reducing fatigue during daily living activities, which
may thus reduce the risk of high levels of physical stress,
the development of injury, and symptoms in chronic low
back pain patients [49, 100].
7 Resistance Training and Rheumatoid Arthritis
Rheumatoid arthritis is a systemic inflammatory disease
that mainly affects synovial joints. Studies have shown that
most people with rheumatoid arthritis avoid physical
exercises and activities because of a fear of worsening their
pain or of causing pressure on their joints [101]. The pro-
gressive degeneration of the musculoskeletal system pro-
duced by rheumatoid arthritis results in muscle strength
deficits, and a reduction in quality of life and vitality, even
in patients with preserved function [101–109].
However, several studies have examined the effects of
resistance training in individuals with rheumatoid arthritis.
These studies have a wide variation in the period of
training, equipment, and protocol used, as well as in the
inclusion criteria of patients. However, they showed that
resistance training is a feasible and safe intervention for
most of these patients, and promotes significant improve-
ment in muscle strength, functional capacity, pain, quality
of life, psychological status, and fatigue, without exacer-
bating disease activity or joint pain [102–104, 108, 110–
113]. For example, a study comparing the effects of
resistance training plus drug therapy, therapeutic joint
exercises plus drug therapy, and drug therapy alone in
young individuals with rheumatoid arthritis found greater
improvements in pain, disease severity, and muscle
strength in subjects in the resistance training plus drug
therapy group [114]. In accordance with this, systematic
reviews with meta-analyses have confirmed the efficacy of
resistance training alone [115], or in combination with
aerobic exercise [116], in patients with rheumatoid arthri-
tis. One of these meta-analyses included ten randomized
controlled trials (totaling 547 patients), comparing resis-
tance training-based therapy with interventions without
resistance training for the treatment of rheumatoid arthritis
patients, and showed that resistance training significantly
improved isokinetic strength (weighted mean differ-
ences = 23.7 %), isometric strength (weighted mean dif-
ferences = 35.8 %), grip strength (weighted mean
differences = 26.4 %), and disability (weighted mean
differences = 0.22) [115].
Health professionals may underestimate the workload to
be prescribed in resistance training programs for rheuma-
toid arthritis individuals, fearing a potential higher risk of
injury owing to the patients’ progressive joint deterioration,
Resistance Training and Musculoskeletal Disorders
sarcopenia, and loss of function. However, the multiple
comorbidities associated with this disease (cardiovascular
disease, osteoporosis, sarcopenia) outweigh the potential
risk of injury over a properly executed resistance training
program. Moreover, it has been shown that resistance
training programs, even of high intensity, are safe for this
population [108–111, 114]. For example, a randomized
study analyzing the effect of 16 weeks of a three times-
weekly, high-intensity resistance training program
(75–85 % of 1 repetition maximum) in men and women
with rheumatoid arthritis (functional class I or II according
to the criteria of the American College of Rheumatology)
showed improvements in muscle strength, pain (53 %
reduction), functional capacity, and disability in the
patients that performed resistance training, while no
changes in those variables were found in the control group
[113]. In addition, there was no incidence of muscu-
loskeletal or joint injury, as well as deterioration of the
joints affected by the disease, which suggest that high-
intensity resistance training is a safe and effective inter-
vention for patients with rheumatoid arthritis [113]. Con-
sistent with these findings, the above-mentioned meta-
analysis assessing 547 rheumatoid arthritis patients ran-
domized to resistance training-based therapy or interven-
tions without resistance training found that withdrawals
(relative risk = 0.95, 95 % CI = 0.61–1.48) and adverse
events (relative risk = 1.08, 95 % CI = 0.72–1.63) were
well balanced in both groups [115].
Thus, the above-described studies suggest that resistance
training may be an efficient and cost-effective strategy to
control and potentially reduce the limitations of muscle
strength and volume, mobility, and independence associ-
ated with rheumatoid arthritis.
8 Conclusion
Although the aging process is inevitable, regular partici-
pation in resistance training programs can minimize the
musculoskeletal alterations that occur during aging, and
may contribute to the health and well-being of the older
population. Compelling evidence suggests that regular
practice of resistance exercise may prevent and control the
development of several musculoskeletal chronic diseases.
Moreover, resistance training may also improve physical
fitness, function, and independence in older people with
musculoskeletal disorders, which may result in improved
quality of the years lived. Therefore, the data presented in
this review provide convincing evidence that regular par-
ticipation in resistance training programs plays an impor-
tant role in aging and may be a preventive and therapeutic
tool for several musculoskeletal disorders.
Compliance with Ethical Standards
Funding No sources of funding were used to assist in the prepa-
ration of this article.
Conflicts of interest Emmanuel Gomes Ciolac and José Messias
Rodrigues-da-Silva declare that they have no conflicts of interest
relevant to the content of this review.
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