Theme Issue: Exercise and Sports

Basic Principles Regarding Strength, Flexibility, and

Stability Exercises
William Micheo, MD, Luis Baerga, MD, Gerardo Miranda, MD

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

INTRODUCTION
Strength, flexibility, and stability are physiologic parameters associated with health-related
physical fitness. Each of these parameters affects health in general, modifies the risk of
injury, determines how an injury is treated, and affects performance in activities of daily
living and sports (Figure 1) [1]. These parameters are affected by individual phenotype, age,
deconditioning, occupational activity, and formal exercise. Loss of strength, flexibility, and
stability can be prevented or reduced with targeted exercise programs [2,3]. The timing,
dosage, and frequency of exercise programs to address age/inactivity-related decline or
injury-associated acquired deficits in these parameters have received increased interest in
the medical literature during the past 20 years. However, the definition of optimal exercise
and the efficacy of specific exercise and rehabilitation programs in different populations
remain undefined.
Clinicians managing patients with neurologic conditions and musculoskeletal and sports
injuries should understand the basic concepts of clinical exercise physiology and the role of
W.M. Physical Medicine, Rehabilitation and
exercise as a medical treatment. In this article, we will discuss definitions and basic concepts Sports Medicine Department and Sports Med-
of strength, flexibility, and stability, review the medical literature as it relates to the icine Fellowship Program, University of Puerto
effectiveness of training each area, and discuss the role of each in the prevention and Rico, School of Medicine, Medical Sciences
Campus, PO Box 365067, San Juan, PR
treatment of injury. Appropriate exercise prescriptions for each area also will be addressed. 00936-5067. Address correspondence to
W.M.; e-mail: wmicheo@usa.net
Disclosure: nothing to disclose
STRENGTH L.B. Physical Medicine, Rehabilitation and
Sports Medicine Department and Sports Medi-
Basic Concepts cine Fellowship Program, University of Puerto
Rico, School of Medicine, San Juan, PR
Strength is the maximum force or tension that a muscle or a muscle group can generate with Disclosure: nothing to disclose
a single contraction [4,5]. The extent of muscle strength loss with age, inactivity, injury, and G.M. Physical Medicine, Rehabilitation and
immobilization depends on impaired neuromuscular activation and reduced muscle vol- Sports Medicine Department and Sports Med-
icine Fellowship Program, University of Puerto
ume [6]. Pain, joint effusion, and angle of immobilization are factors associated with Rico, School of Medicine, San Juan, PR
arthrogenic muscle inhibition and reduced strength after injury [7]. Sarcopenia or loss of Disclosure: nothing to disclose

PM&R 2012 by the American Academy of Physical Medicine and Rehabilitation

1934-1482/12/$36.00 Vol. 4, 805-811, November 2012 805
Printed in U.S.A. http://dx.doi.org/10.1016/j.pmrj.2012.09.583
806 Micheo et al
Stability
Strength Flexibility
Physical Fitness
Injury Risk
Treatment
Performance
Figure 1. Components of health-related physical fitness.
muscle mass in elderly patientswhich may be associated
with a lack of physical activity, altered gene expression,
hormonal changes, or cell apoptosisis one of the factors
associated with reduced strength, frailty, and disability with
advancing age [8].
The type of muscle actions used in strengthening pro-
grams can be divided into static (isometric) or dynamic
(concentric, eccentric) contractions [3]. Static exercise can be
used early in rehabilitation programs after injury and as an
initial component of a strengthening program in very weak
individuals. In this type of muscle action, force is produced
without joint movement, strength gains are limited to the
angle in which the joint is exercised, and exercise usually is
not performed in functional positions. Dynamic exercise has
a concentric component in which muscle is shortened as it
contracts and an eccentric component in which muscle
lengthens as it produces force. Concentric actions accelerate
joints and produce greater torque with slow contractions.
Conversely, eccentric contractions decelerate the articula-
tions involved in the movement, resulting in high force
production, and they are more likely to result in muscle
micro or macro damage, as well as delayed-onset muscle
soreness. Eccentric muscle contractions typically are associ-
ated with muscle and tendon injury in high-demand activi-
ties such as competitive sports [9].
The kinetic chain is defined as a link system in which
segments respond to force in a sequential and predictable
fashion. A closed kinetic chain (CKC) condition exists when
the distal segment is fixed or meets enough resistance to
restrain free motion. CKC exercise emphasizes the sequential
movement and placement of functionally related joints, a
stable base for functional movement patterns, and efficient
control and transfer of applied loads. These CKC exercise
programs increase agonist/antagonist muscle co-contraction,
reduce joint shear force, and minimize joint displacement
and ligament strain [10,11]. In open kinetic chain (OKC)
activities, the distal portion of the extremity is free to move.
OKC exercises can target isolated muscle groups, act on a
STRENGTH, FLEXIBILITY, AND STABILITY EXERCISES
single joint, and can be used to recruit muscles that are
inhibited (Table 1) [11]. For example, in considering
strengthening exercises for knee pain, OKC exercises create
more shear force stress on the anterior cruciate ligament,
whereas CKC exercises increase patellofemoral compressive
force. Both can be useful in selected situations, that is, OKC
for isolated muscle recruitment and CKC for more function-
ally based strengthening.
Improvement in strength associated with a resistance ex-
ercise program is the result of a combination of neural adap-
tations and changes in muscle structure. In the first 4 weeks
of training, neural adaptations include increased motor unit
recruitment and synchronization, as well as a crossed train-
ing effect in the opposite limb. With a continuous training
stimulus, increased muscle fiber size occurs, particularly of
type II muscle fibers [5,12].
Research Results
The health benefits of increasing strength and improving
muscular fitness have been well established. Greater levels of
strength are associated with better cardiometabolic risk fac-
tor profiles, lower risk of all-cause mortality, lower risk of
developing functional limitations, and improved bone mass,
as well as bone strength [13]. In older adults, exercise pro-
grams that include resistance training can increase active life
expectancy by limiting the progression of chronic disease and
disabling conditions and can lead to cognitive and psycho-
logical benefits [8].
The role of strengthening exercise in the prevention of
injury also has been studied. Strengthening programs that
emphasize eccentric exercises have been shown to be effec-
tive in the prevention of hamstring injuries in soccer players
[14]. Core muscle and hip strengthening and neuromuscular
training with an emphasis on strengthening have been shown
to prevent back and groin injuries in athletes and anterior
cruciate ligament injury in young females, especially those
under 18 years of age [15-17].
With aging, muscle weakness that is not reversed has been
identified as a predictor of knee osteoarthritis onset and
Table 1. Comparison of closed kinetic chain exercise versus
open kinetic chain exercise
Closed Kinetic Chain Open Kinetic Chain
Exercise Exercise
Distal segment fixed or meets Distal segment free to move
resistance to motion Isolates single joints
Sequential movement of Facilitates contraction of
functionally related joints inhibited muscles
Increased agonist/antagonist Allows emphasis on
co-contraction concentric and eccentric
Reduced joint shear forces muscle action
and ligament strain Prepares muscle for
Provides stable base for integrated functional
functional movement activities
PM&R
progression. Strength deficits in elderly persons lead to
slower walking speeds and difficulty with climbing stairs
[8,18,19].
Clinical Application
Recommendations for strengthening programs will vary de-
pending on the specific population. Programs can be de-
signed for healthy adults of any age, persons with injury or
medical illness, and athletes. Components of a strengthening
program include frequency, duration, and intensity.
The intensity of the exercise program usually is deter-
mined by the concept of one repetition maximum (1 RM),
which is the maximal load that can be lifted throughout the
full range of motion (ROM) once [2,3]. For novice to inter-
mediate exercisers, moderate intensity (60%-70% of 1 RM) is
used for training, and for more advanced exercises, heavy
intensity (80% of the 1 RM) is used. Older or disabled
persons or persons starting training after an injury usually
start with light intensity (40%-50% of 1 RM, or exercising to
the point of fatigue). Resistance training should be performed
2 to 3 times per week, major muscle groups should be
addressed, and the patient should perform concentric and
eccentric muscle actions for 2 to 4 sets, although a single set
also has been shown to be effective in producing strength
gains similar to multiple sets [20]. Between 8 and 15 repeti-
tions to fatigue are used to improve strength in most adults,
and a weight that can be lifted 15 to 20 times is recom-
mended to improve muscle endurance or resistance to task-
specific fatigue [13].
FLEXIBILITY
Basic Concepts
Flexibility is the ROM in a joint or in a group of joints; it is
influenced by muscles, tendons, and bones and is described
as the degree to which muscle length permits movement over
the joint in which it has influence. The musculotendinous
unit (MTU) plays a major role in ROM and is directly related
to stiffness and tension provided by passive and dynamic
components. The static component of connective tissue has
viscoelastic properties, such as elasticity and viscosity,
whereas the dynamic component of tension is provided by
neural reflex activity of the muscle [21].
A flexibility or stretching program is aimed at increasing
the ROM of specific joints or groups of joints [21]. Stretching
results in elongation of soft tissues and an increase in muscle
length, which affects the stiffness and energy-storing proper-
ties of the soft tissue. A more compliant MTU allows for the
effective storage and release of elastic energy, thus facilitating
performance within a stretch-shortening cycle. A stiffer MTU
Vol. 4, Iss. 11, 2012 807
transfers the energy to the bones faster, resulting in a quicker
movement of the joint [22].
Static stretching techniques involve the application of
slow and passive stretching, whereas dynamic stretching
involves the repeated gradual transition from one body posi-
tion to another with a progressive increase in reach and ROM
[13]. Some studies suggest that each static stretch should be
maintained for 20-30 seconds to facilitate connective tissue
elongation [21,23]. Proprioceptive neuromuscular facilita-
tion requires a combination of steps that include a static
stretch, an isometric contraction and relaxation, and then
another static stretch.
Research Results
Traditionally, warm-up activities and stretching protocols
have been recommended to persons before and/or after per-
forming physical activities. It is theorized that warm-up and
stretching prevent muscle injuries by increasing the elasticity
of muscles and smoothing muscle contractions. However,
improper or excessive stretching and warm-up can predis-
pose one to muscle injury [24]. In several studies, authors
have investigated the effect of muscle stretching on the risk of
exercise-related injury. The general consensus is that stretch-
ing in addition to precompetition warm-up does not affect
the incidence of overuse injuries [25-28]. A systematic re-
view suggests that muscle stretching performed either (1)
before or after exercise or (2) before and after exercise does
not produce clinically important reductions in delayed-onset
muscle soreness in healthy adults [29].
Another topic of discussion associated with flexibility
training is the effect of stretching on performance. A recent
review of the literature suggests that no clear answer to this
question has been ascertained because of the variety of pro-
tocols and methodology reported in the published literature
[30]. Several studies demonstrate that static stretch impairs
performance, specifically in muscle strength and to a lesser
extent in power, especially when a static stretch is performed
immediately before an athletic event. Stretches of longer
duration (60 seconds) are particularly associated with
these effects on performance. Other authors argue that find-
ings of these studies do not apply to athletes who perform
warm-up and stretching routines that are different from those
studied [27]. Conversely, in a substantial number of articles,
different stretching and warm-up protocols are used that
show no detrimental effects on performance [31]. A shorter
duration of stretching followed by a general warm-up before
physical activity may decrease the detrimental effect of
stretching on performance [32].
Comparison of types of stretching led to the suggestion
that dynamic stretching has greater applicability to enhance
power and performance when compared with static stretch-
ing. In several studies, authors have examined the acute effect
of passive stretching, dynamic stretching, and no stretching
808 Micheo et al
on sprinting performance at different distances. It appears
that passive static stretching before a race decreases sprint
performance even when combined with dynamic stretches
compared with a solely dynamic stretch approach [33-37].
The incorporation of a dynamic stretching program in the
warm-up and in the daily preseason training regimen for at
least 4 weeks produces longer-term and sustained power,
strength, muscular endurance, anaerobic capacity, and agil-
ity performance enhancement [37-39].
The effectiveness of stretching programs in rehabilitation
protocols has not been established. Stretching programs have
physiological benefits, such as increased blood flow to the
tissues and increases in the speed of muscular contractions
and nerve transmissions [21]. Stretches of longer than 30
seconds duration with lower force provide increased toler-
ance to stretch, improve flexibility of the hamstrings, and
improve quadriceps eccentric contraction, particularly when
combined with a warm-up [39-41]. In the workplace, a
preshift stretching protocol for 90 days in a production
factory resulted in an injury rate reduction and increased
participant compliance [42].
Clinical Application
An individualized flexibility plan that takes into account
compliance, general knowledge of warm-up and cool-down
techniques, physical activity, and general fitness level of the
individual should be implemented [26,43]. In healthy adults,
flexibility programs should be performed 2 to 3 days per
week, with the person stretching to the point of discomfort
but not beyond as he or she performs 3 repetitions of 10 to 30
seconds duration hold and works on major muscle-tendon
units. Isolated hamstring stretching, with the hip flexed to
90 and the knee extended, and gastrocnemius stretching,
with the knee in extension and the ankle in dorsiflexion, are
examples of commonly prescribed static exercises. Older
persons and persons focusing on a particular muscle group
may benefit from stretches lasting 30-60 seconds. Proprio-
ceptive neuromuscular facilitation techniques use a 3- to
6-second submaximal muscle contraction followed by 10 to
30 seconds of stretching [13].
For sports activity, a warm-up should be composed of a
submaximal intensity aerobic activity followed by large am-
plitude dynamic stretching, which may include plyometric
exercises in which an eccentric muscle action precedes a
concentric contraction; the warm-up is then completed with
sport-specific dynamic activities [31,44]. In sports with high
stretch-shortening cycles, such as gymnastics and tae-
kwondo, persons may perform short-duration static stretches
in a pre-exercise routine without compromising maximal
muscle performance [30,44]. The timing for static stretching
remains controversial. Some persons argue that the stretch-
ing protocol should occur within the 15 minutes before the
activity to receive the most benefit, whereas other persons
emphasize stretching after exercise [30].
STRENGTH, FLEXIBILITY, AND STABILITY EXERCISES
STABILITY
Basic Concepts
Joint stability is achieved by the combination of static and
dynamic components. Static stability refers to the structural
stability achieved passively by such structures as bones,
capsules, and ligaments. Dynamic stability refers to the neu-
romuscular control of the skeletal muscle affecting a joint to
maintain its center of rotation in response to perturbation.
Stability is defined as the state of a joint remaining or
promptly returning to proper alignment through an equal-
ization of forces [45].
Dynamic stability depends on central nervous system
(CNS) control, which is achieved through feedback and
feed-forward mechanisms that require adequate motor plan-
ning at the level of the motor cortex and cerebellum [46].
During feedback control, an unexpected perturbation is
sensed by mechanoreceptors in the capsule, ligaments, ten-
dons, and muscles of the affected joint. This signal travels to
the CNS, where an appropriate motor response is formulated
to counteract the perturbation and maintain stability. Al-
though feedback control is based on a reaction to a perturba-
tion, feed-forward control is an anticipatory motor plan to
maintain stability before a predicted perturbation [45,47].
The concepts of stability can be applied to the spine and to
peripheral joints. Two main models of spinal stability have
been described: the muscle capacity model and the con-
trol model [47]. The muscle capacity model is a static model
based on muscle strength and endurance sufficient to main-
tain stability of the spine for a prolonged period. The co-
contraction of abdominals and back extensors serve as guy
wires to maintain the spine in a neutral, stable position, and
contraction of the transverse abdominis causes a hooplike
stress that increases intra-abdominal pressure and in turn
confers added stability to the spine. This model does not
account for the dynamic changes and neuromuscular control
needed to stabilize the spine during activity and movement of
the spine and limbs [47].
When an unexpected perturbation occurs, the CNS initi-
ates a response to compensate for the instability generated by
the perturbation; this response is altered in patients with
chronic low back pain [48]. In a study by Hodges [47],
activation of deep and superficial trunk muscles was re-
corded before limb movements. The deep muscles (the trans-
verse abdominis and multifidi) fired independently of the
direction of force. These muscles are thought to maintain
intersegmental stability, which is independent of the direc-
tion of limb movement. Activation of superficial muscles,
such as the internal and external oblique muscles and erector
spinae, was linked to the direction of the limb movement.
These muscles make use of their mechanical advantage to
provide support for the spine during the asymmetric loads
generated during limb movements [47].
PM&R
Research Results
Although a strong theoretical basis exists for stability training
in injury prevention and injury management, data to support
this principle are sparse. With respect to core stability, stud-
ies have been performed that link core weakness to increased
lower extremity injuries, and several studies suggest that low
back pain alters the control mechanisms of the spine [49,50].
Altered activation patterns occur during trunk repositioning
tests in patients with low back pain when compared with
control subjects, and several different studies have docu-
mented altered position sense in persons with low back pain,
segmental instability, and radiculopathy as a result of herni-
ated nucleus pulposus [48,51-53]. Nevertheless, specific
core stability programs for prevention of injury have not been
well studied [54].
A review of the literature shows a few randomized con-
trolled trials testing the efficacy of core strengthening pro-
grams on low back pain. Reduced pain scores and functional
improvements have been shown in patients with spondylol-
ysis or spondylolisthesis who performed core stability when
compared with control subjects [55]. Hides et al [56] dem-
onstrated that patients who performed abdominal and mul-
tifidi co-contractions after an acute low back pain episode
had significantly lower recurrences of low back pain at 1 and
3 years when compared with the control group. In other
studies, authors have questioned the superiority of core
stabilization exercise to generalized strengthening or conven-
tional physiotherapy in the treatment of low back pain
[57,58]. One of the challenges of interpreting the available
research on stability is that it is almost impossible to separate
the components of stability training from strength training.
The concept of dynamic stability for injury prevention and
injury management has been suggested in most joints, in-
cluding the ankle, knee, and shoulder [59-61]. It also has
been suggested in the elderly population as a means to reduce
pain from degenerative joint disease and to improve balance
[62,63]. Some studies suggest that neuromuscular training
may reduce injuries, including several studies in which au-
thors demonstrate the reduced incidence of knee injuries in
female athletes with preseason neuromuscular training com-
pared with untrained athletes [49,64].
Clinical Application
Although it is outside the scope of this article to present
dynamic stability exercise prescriptions for different periph-
eral joints and the spine, we will outline basic concepts to
follow when designing a stability program. The first step is to
carefully evaluate the patient and assess his or her current
functional level and functional goals. Stability and balance
programs in healthy adults should be performed 2 to 3 days
per week, particularly for older adults who want to improve
function and prevent falls [13].
Vol. 4, Iss. 11, 2012 809
Table 2. Exercise progression in a stability program
Early Phase Later Phases
Exercises should be simple and Progressively integrate
segmented segments into
Segmentation complex movement
Reduce complex skill into parts Increase speed
Practice parts independently Add multiaxial loads
Simplification Increase specificity by
Reduce speed replicating demands
Reduce postural loads of goal activities
Reduce attention demands
Modified from Baerga-Varela and Abru-Ramos [65].
When one is designing the early phase of the program, the
motor learning concepts of segmentation and simplification
are applied. Segmentation involves reducing a complex skill
into parts, which are practiced independently and are pro-
gressively integrated into a complex movement. The exer-
cises are simplified by reducing the speed, postural loads,
and attention demands. Single muscles are isolated with the
goal of awakening the muscle. The next step is to combine
several muscles in simple movements in stable positions and
in a single cardinal plane (eg, sagittal, coronal, or transverse).
As the patient progresses, the difficulty is increased by in-
creasing speed, adding multidirectional movements, adding
off-axis loads in all cardinal planes, and adding progressively
unstable surfaces [47,54,65]. The different exercises are de-
signed to try to replicate activities performed by the patient to
increase the specificity of the exercise (Table 2) [65]. How-
ever, it is important to progress to a higher level of stability
challenge only when a patient has mastered the previous
level, being careful not to add external instability onto inter-
nal instability.
SUMMARY
Strength, flexibility, and stability are physiologic parameters
associated with physical fitness, health, musculoskeletal in-
jury risk, injury treatment, and performance in activities of
daily living. A decrease of these parameters is associated with
advancing age, inactivity, injury, and medical illness and
varies from person to person. Normal muscle strength and
fitness is associated with health benefits, injury protection,
improved psychological and cognitive function, and reduc-
tion of disability later in life. Static flexibility programs can
improve joint ROM, may improve performance in some
sports that require prominent use of the stretch shortening
cycle, appear to reduce muscle strength and power after a
prolonged static stretch, and have not been shown to prevent
musculoskeletal injuries. Dynamic flexibility programs im-
prove power and have been shown to improve performance.
Joint stability and neuromotor control of the trunk and
extremities may lead to reduced ankle, knee, and shoulder
injuries, improved patterns of muscle firing, and improve-
ment in low back pain. Finally, exercise programs recom-
810 Micheo et al
mended to improve health, function, and performance
should include components of strength, flexibility, and sta-
bility in an integrated fashion.
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