# Motor performance, motor impairments, and quality of life after eccentric resistance training in neurological populations: A systematic review and meta-analysis

Guillaume Le Sant, Thomas Lecharte, Valentin Goreau, Antoine Nordez, Raphaël Gross, Thomas Cattagni

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Guillaume Le Sant, Thomas Lecharte, Valentin Goreau, Antoine Nordez, Raphaël Gross, et al., Motor performance, motor impairments, and quality of life after eccentric resistance training in neurological populations: A systematic review and meta-analysis. NeuroRehabilitation, 2023, pp.1-18.
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# Motor performance, motor impairments, and quality of life after eccentric resistance training in neurological populations: A systematic review and meta-analysis

Guillaume Le Sant<sup>a,b,*</sup>, Thomas Lecharte<sup>a</sup>, Valentin Goreau<sup>a,b</sup>, Antoine Nordez<sup>a,c</sup>, Raphaël Gross<sup>a</sup> and Thomas Cattagni<sup>a</sup>

**Abstract.**

**BACKGROUND:** Many overlapping factors impair motor performance and quality of life in neurological patients. Eccentric resistance training (ET) has potential benefits for improving motor performance and treating motor impairments better than some traditional rehabilitation approaches.

**OBJECTIVE:** To estimate the effect of ET in neurological settings.

**METHODS:** Seven databases were reviewed up to May 2022 according to PRSIMA guidelines to find randomized clinical trials involving adults with a neurological condition, who underwent ET as set by the American College of Sports Medicine. Motor performance (main outcome) was assessed as strength, power and capacities during activity. Secondary outcomes (impairments) were muscle structure, flexibility, muscle activity, tone, tremor, balance and fatigue. Tertiary outcomes were risk of fall, and self-reports of quality of life.

**RESULTS:** Ten trials were included, assessed using Risk of Bias 2.0 tool, and used to compute meta-analyses. Effective effects in favour of ET were found for strength and power, but not for capacities during activity. Mixed results were found for secondary and tertiary outcomes.

**CONCLUSION:** ET may be a promising intervention to better improve strength/power in neurological patients. More studies are needed to improve the quality of evidence underlying changes responsible for these results.

**Keywords:** Resistance training, physical therapy, exercise, neurological condition

**1. Introduction**

Degradation of motor performance is a major contributor to disability (WHO, 2011) and reduced

quality of life in individuals with neurological conditions (Eng et al., 2009; Ramari et al., 2020; Skinner et al., 2015). Naturally, recovering motor performance is rated as a top aspiration by people after a stroke (Stroke Association, 2021), Spinal Cord Injury (SCI) (van Middendorp et al., 2016), Cerebral Palsy (CP) (Cook et al., 2022), Parkinson Disease (PD) (Bowring et al., 2022), or Multiple Sclerosis (MS) (Chiu et al., 2019).

<footnote><sup>a</sup>Movement - Interactions – Performance (MIP), CHU Nantes, University of Nantes, Nantes, France</footnote>

<footnote><sup>b</sup>School of Physiotherapy, IFM3R, Saint-Sébastien-sur-Loire, France</footnote>

<footnote><sup>c</sup>Institut Universitaire de France (IUF), Paris, France</footnote>

<footnote>*Address for correspondence: Guillaume Le Sant, School of Physiotherapy of Nantes (IFM3R), 54 Rue la Baugerie, Saint-Sébastien-sur-Loire F-44230, France. E-mail: guillaume.le-sant@univ-nantes.fr.</footnote>
Many overlapping factors impair motor performance in individuals with neurological conditions (Gracies, 2005a, 2005b; Graham et al., 2016; McLoughlin, 2018). Deficits in neural function and changes in motor unit properties (Klein et al., 2010; Thomas et al., 2014), involuntary muscle activity/spasms/tremor (McLoughlin, 2018), tissue remodelling and atrophy (Gorgey & Dudley, 2007; Handsfield et al., 2022; Hunnicutt & Gregory, 2017), decreases in joint mobility and muscle fascicle length due to contractures (Nuckolls et al., 2020) or rigidity (Wijemanne & Jankovic, 2019), and increased levels of fatigue (Kluger et al., 2013) worsen motor capacities over time.

Resistance training has turn become a key inter-
vention of neuro-rehabilitation for a wide variety of
conditions over time (Aravind et al., 2019; Hornby et
al., 2020; National Insitute for Health and Care Excel-
lence, 2022; Osborne et al., 2022). Despite improving
strength, ‘conventional’ programs using ‘concentric’
muscle contractions might have limited effects on
aforementioned motor impairments. Recently, Davis
et al. (2020) highlighted the potential relevance to use
‘eccentric’ muscle contractions in neurological set-
tings. Eccentric resistance training (ET) has a greater
positive effect on neuromuscular function (e.g. mus-
cle activation), muscle size, fascicle length and joint
flexibility compared to other types of exercises in
healthy individuals (Blazevich, 2019; Diong et al.,
2022; Douglas et al., 2017a, 2017b). Therefore, ET
has a very large spectrum of plausible benefits that
could be relevant to many individuals living with con-
sequences of a neurological condition. The practice of
ET provides a unique opportunity to improve motor
performance while addressing major motor impair-
ments simultaneously. For instance, ET is assumed to
produce greater gains in muscle strength and volume
(hypertrophy) while it may also regulate the balance
between agonist/antagonist muscle neuromechanical
output (i.e. paresis and hyperactivities). Moreover,
because of the greater mechanical loading involved
in active lengthening, ET exercises could be relevant
in treating the relative shortness in muscle fasci-
cle length and joint contractures. ET requires less
metabolic demands for the same amount of work than
concentric training, making it of particular interest
for patients with neurological disorders experienc-
ing high levels of fatigue and/or cardiorespiratory
issues. Evidence suggests that ET can be used safely
in neurological settings (Folkerts et al., 2017; LaS-
tayo et al., 2014). Therefore, ET holds promise
for improving motor performance and simultane-

ously addressing major motor impairments, during
neuro-rehabilitation settings. However, the scientific
evidence regarding its benefits for patients is not clear,
yet.

This review primary aimed to evaluate the effec-
tiveness of ET on motor performance in neurological
populations. This review also focused on the effec-
tiveness of ET on motor impairments (secondary
objective), and on patients’ health-related quality of
life (tertiary objective). We also aimed to evaluate
effect modifiers such as the type of disease (neuro-
logical injury, neuro-degenerative disease), the initial
motor capacities, and intervention delivery (e.g.
standalone/included/added to rehabilitation, compli-
ance with the American College of Sports Medicine
(ACSM) position stand for resistance training inter-
ventions (American College of Sports Medicine,
2009).

## 2. Methodology

This systematic review was carried out accord-
ing to the Cochrane Handbook (Higgins, 2022),
and the Preferred Reporting Items for Systematic
Reviews and Meta-analysis (Moher et al., 2009).
This study, as a literature review, is exempt from
Institutional Review Board approval. The proto-
col was pre-registered on PROSPERO database (n°
CRD42021283908) for transparency.

2.1. *Literature search*

A PICOS (Patient, Intervention, Comparison, Out-
comes, Study type) framework was used to develop
literature-searching strategies and keywords. Seven
databases were searched to find published, ongo-
ing or unpublished trials (grey literature) from their
inception with no time restriction, initially started by
PubMed, and adapted for use in the other databases
(PEDro, Embase, Cochrane Library, ClinicalTri-
als.gov, Scopus, Web of Science). Reference lists
of published systematic reviews and authors’ per-
sonal libraries were searched to confirm the retrieval
of appropriate studies. An iterative process which
involved team meetings was employed to define rel-
evant search keywords that would capture relevant
records. For that purpose, keywords, search strate-
gies, and reference lists of included studies from
relevant reviews from the field (resistance training in
neurological populations, eccentric resistance train-
ing) were explored, so as authors’ libraries to ensure
an optimal search strategy for each database. The keywords used for each criterion are listed in Table 1, and their association for each database (search strategy) is detailed in Supplementary File 1. Because all the objectives of this review might be answered by results from randomized clinical trials (RCT), we followed the recommendations of the Cochrane Handbook (Higgins, 2022) to restrict our research to RCT only. Trials were excluded if training corresponded to ‘functional or task oriented’ exercises (e.g. downhill walking), because these interventions tend to influence multiple parameters like motor control, skill, speed and endurance, which are not primary targeted by resistance training interventions.

## 2.2. Study selection

The selection was conducted on the open access online tool CADIMA (Kohl et al., 2018) in May 2022. Before initiating the selection, a random sample of 10 studies based on retrieved list of studies was screened by two reviewers (GLS and TL) to assess the consistency of criteria assessment, followed by a discussion between reviewers on the reasons for inclusion/exclusion, using the eligibility criteria list (Table 1). Then, the same reviewers independently removed duplicate, screened the titles and abstracts, and read the full-text of articles to determine their eligibility. At each stage of the process (titles/abstracts, full texts), every document was thoroughly examined to identify relevant information for inclusion/exclusion. In most cases, the eligibility criteria could be found in the methods section of the abstract or full-text, which provided details on the population, interventions/comparators, outcomes, and study methodology (RCT or not). At every stage of the process (duplicates, titles and abstract, full-text), a consistency check was done between both reviewers to reach a consensus. Discrepancies were resolved if required during a meeting with a third reviewer (TC) before proceeding to the next step.

## 2.3. Data extraction and synthesis

A data collection form adapted from Cochrane Collaboration (2022) was used for collecting data from retrieved studies. Information about eligibility, method (i.e., participants, intervention/comparator, outcomes) and results were extracted by two reviewers independently (GLS and TL) and cross-checked to produce a merged collection form. If information

was not available in the published papers, further precisions were requested from the corresponding author. Data extracted characterized the population, study protocol and outcomes for experimental and comparator groups. For a complete listing of collected parameters, please refer to Table 2. Because the effects of eccentric resistance training are of particular interest for a large variety of neurological conditions, and not specific to a particular situation, different populations were included and categorized as ‘neuro-injured’ (e.g. stroke) or ‘neuro-degenerative’ (e.g. multiple sclerosis). We used a customized form adapted from Hendrey et al. (2018) study to assess adherence to ACSM position stand for resistance training: frequency, intensity, type, repetitions, sets, progression, specificity and pattern, of the exercises used in the ET program (American College of Sports Medicine, 2009) (Supplementary File 5).

## 2.4. Assessment of characteristics of trials

The risk of bias was assessed using The Cochrane risk of bias (RoB) 2.0 tool (Sterne et al., 2019) independently by two reviewers (GLS and TL). A third reviewer was involved (TC) if a consensus could not be reached. RoB 2.0 is structured into signalling questions evaluating five bias domains in RCTs arising from: the randomisation process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. The overall RoB for the study synthetizes the bias from each domain to an overall judgment qualified as ‘some concerns’, ‘low’ or ‘high’.

## 2.5. Data analysis

The replicability of the search strategy was assessed by the kappa statistic ($\kappa$), with levels of agreements defined as: no agreement (0.00<$\kappa$), slight (0.00≤$\kappa$≤0.19), fair (0.20≤$\kappa$≤0.39), moderate (0.40≤$\kappa$≤0.59), substantial (0.60≤$\kappa$≤0.79), almost perfect (0.80≤$\kappa$≤1) (Sim & Wright, 2005). For each outcome of each RCT, pre- and post-intervention scores were used. When multiple measures were reported for a same construct in a RCT, the one best reflecting the outcome was used (Higgins, 2022) (see Supplementary File 2). Data were converted when necessary (e.g. confidence intervals to standard deviation) using Cochrane RevMan software (The Cochrane Collaboration. Review Manager, RevMan, Version 5.4, 2020).
<table><caption>Table 1
Criteria used for inclusion of the studies</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td>Category</td><td>Eligibility criteria</td></tr><tr><td>Population</td><td>Adults>18 years old<br>Diagnosis of a neurological injury or neuro-degenerative disease<br>Corresponding keywords: "Demyelinating Autoimmune Diseases, CNS"[Mesh], "Central Nervous System Diseases"[Mesh], "Motor Neuron Disease"[Mesh], "Trauma, Nervous System"[Mesh]</td></tr><tr><td>Intervention</td><td>Resistance training including eccentric contractions, defined as a progressive exercising program by the American College of Sports Medicine (≥4 weeks, twice a week, against an external load)<br>Corresponding keywords: Eccentric, "lengthening contraction", "lengthening exercise"</td></tr><tr><td>Comparator</td><td>other forms of resistance programs (e.g. concentric), another form of rehabilitation (no progressive resistance program), or control (no rehabilitation)<br>Corresponding keywords: rehab*, train*, exercise, physiother*</td></tr><tr><td>Outcomes</td><td>Motor performance (primary objective): maximal strength, maximal power, clinical exercises/tests (e.g. gait)<br>Motor impairment (secondary objective): muscle structure, muscle activity, muscle tone, joint flexibility, fatigue<br>Health-related quality of life (tertiary objective): risk of fall, and self-reports of health condition/behaviour<br>Corresponding keywords: (none, left open to ensure the greatest possibility of finding results on outcomes)</td></tr><tr><td>Design/study type</td><td>Randomized clinical trials</td></tr><tr><td>Other</td><td>Language: publications in English, French or Spanish<br>Full/Published reports accessible for data extraction</td></tr></tbody></table>

Data were pooled to generate random-effects meta-analyses when at least two studies could be retrieved for an outcome. The critical value for statistical significance was set at 0.05. Analyses were reported as standardised mean differences (SMD) and 95% confidence interval (95% CI). The thresholds of the effect size of generated SMD were: 0.2 (small), 0.5 (medium), 0.8 (large). Subgroup analyses were performed based on aforementioned categorization (neuro-injured, neuro-degenerative) to explore the effect of the origin of central nervous system damage on the results. Heterogeneity between trials was examined using the I² test with values of >25% and 50% indicative of moderate and high heterogeneity, respectively (Higgins, 2022). When SMD for a trial was large, we explored the possible causes of heterogeneity by omitting one at a time individual studies, and stratifying by participants initial motor capacities (Higgins, 2022). Results were summarised descriptionally when data could not be pooled.

The quality of evidence (QoE) in relation to each outcome was rated using the approach developed by the GRADE collaboration (GRADE, 2013). Six domains are evaluated through GRADE approach: study design, RoB, indirectness, inconsistency, imprecision and publication bias. Four levels of evidence can be attributed: 'high', 'moderate', 'low', and 'very low'. For each outcome, a sequential analysis

system was used (Balshem et al., 2011) (described in Supplementary File 3).

## 3. Results

The review followed the registered protocol except that effect modifiers that were examined as categorical factors in sensitivity analyses.

### 3.1. Flow of trials through the review

The search identified a total of n=407 papers (310 excluding duplicates). After screening titles and abstracts, we identified 42 studies as potentially eligible (n=3 awaiting classification) (κ=0.94). After inspecting the full reports, 10 RCTs were found eligible for inclusion (κ=0.94) (Fig. 1). The reasons for exclusion have been summarised in Supplementary File 4.

### 3.2. Characteristics of the included trials

Detailed characteristics of the studies are depicted in Table 2.
<table><caption>Table 2
Main characteristics of the included studies</caption><thead><tr><th>Study</th><th>Condition</th><th>Population (n of participants)</th><th>Intervention: Eccentric Training (ET)</th><th>Comparator (COMP)</th><th>Relevant outcome measures</th></tr></thead><tbody><tr><td rowspan="10">Lattouf (2021)</td><td rowspan="10">Stroke</td><td>Setting: patients in an outpatient service (country: np)</td><td>Muscles: KE, KF</td><td>usual rehabilitation</td><td>Participation: -</td></tr><tr><td>ET (19)</td><td>Format: added to usual rehabilitation</td><td>- Prevention of complications</td><td>Activity: gait</td></tr><tr><td>Delay from injury: 11.6 ± 4.1 months</td><td>Content: horizontal leg press</td><td>- Stimulation of motor skills</td><td>Function: strength, spasticity</td></tr><tr><td>Age: 65.1 ± 11.2 y</td><td>concentric phase (both legs)+eccentric phase (paretic leg only); velocity: np.</td><td>- Management of spasticity</td><td>Structure: -</td></tr><tr><td>Initial characteristics: 0.84 ± 0.76 (MAS)</td><td></td><td>- Transfers, balance displacement and functional acquisition</td><td></td></tr><tr><td>Initial motor capacities: 0.46 ± 0.69<sup>a</sup></td><td></td><td>- Therapeutic education</td><td></td></tr><tr><td>(max-selected walking speed, 10mWT), coded 'moderate'<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>COMP (18)</td><td></td><td>Dose: session: 2 sets x [5 reps x 40% 1RM]+1 set x [5 reps x 60% 1RM]</td><td></td></tr><tr><td>Delay from injury: 12.3 ± 5.4 months</td><td>frequency: 3/wk</td><td></td><td></td></tr><tr><td>Age: 68.7 ± 12.4 y</td><td>duration: 4 wks</td><td></td><td></td></tr><tr><td>Initial characteristics: 0.72 ± 0.83 (MAS)</td><td>Range of movement for training: np</td><td></td><td></td></tr><tr><td>Initial motor capacities: 0.51 ± 0.68<sup>a</sup></td><td></td><td></td><td></td></tr><tr><td>(max-selected walking speed, 10mWT), coded 'moderate'<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td>Progressivity: np</td><td></td><td></td></tr><tr><td rowspan="10">Kadkhodaie (2020)</td><td rowspan="10">Parkinson's Disease</td><td>Setting: patients in an outpatient service (Iran)</td><td>Muscles: EF, WF, WE</td><td>no intervention (control)</td><td>Participation: -</td></tr><tr><td>ET (11)</td><td>Format: standalone</td><td></td><td>Activity: -</td></tr><tr><td>Delay from diagnostic: 61.2 ± 38.4 months</td><td>Content: weighted training balls fixed to participants hand or forearm</td><td></td><td>Function: amplitude of hand tremor</td></tr><tr><td>Age: 67.8 ± 9.6 y</td><td>Eccentric only (concentric performed by therapist)</td><td></td><td>Structure: -</td></tr><tr><td>Initial characteristics: 2.3 ± 1.0 (H&Y)</td><td></td><td></td><td></td></tr><tr><td>Initial motor capacities: -</td><td></td><td></td><td></td></tr><tr><td>COMP (10)</td><td></td><td>Dose: session: 3 sets x 10 reps</td><td></td></tr><tr><td>Delay from diagnostic: 67.2 ± 70.8 months</td><td>1 session (RPE = 10-11)</td><td></td><td></td></tr><tr><td>Age: 67.4 ± 6.8 y</td><td>2 sessions (RPE = 12-14)</td><td></td><td></td></tr><tr><td>Initial characteristics: 2.3 ± 0.8 (H&Y)</td><td></td><td></td><td></td></tr><tr><td>Initial motor capacities: -</td><td></td><td></td><td></td></tr><tr><td></td><td></td><td>frequency: 3/wk</td><td></td><td></td></tr><tr><td></td><td></td><td>duration: 6 wks</td><td></td><td></td></tr><tr><td></td><td></td><td>Range of movement for training: np</td><td></td><td></td></tr><tr><td></td><td></td><td>Velocity of movement: np</td><td></td><td></td></tr><tr><td></td><td></td><td>Progressivity: heavier weights to keep a constant intensity level</td><td></td><td></td></tr></tbody></table>

(Continued)
<table><caption>Table 2
(Continued)</caption><thead><tr><th>Study</th><th>Condition</th><th>Population (n of participants)</th><th>Intervention: Eccentric Training (ET)</th><th>Comparator (COMP)</th><th>Relevant outcome measures</th></tr></thead><tbody><tr><td rowspan="10">Dibble (2015)</td><td rowspan="10">Parkinson's Disease</td><td>Setting: patients in an outpatient service (USA)</td><td>Muscles: HE, KE, AE</td><td>multi-component rehabilitation program</td><td>Participation: health status</td></tr><tr><td>ET (20)</td><td>Format: included in a multi-component rehabilitation program</td><td>- warm-up exercises (bicycle or treadmill)</td><td>Activity: gait</td></tr><tr><td>Delay from diagnostic: 96.0 ± 53.8 months</td><td></td><td>- flexibility training (mobility exercises)</td><td>Function: strength</td></tr><tr><td>Age: 66.0 ± 14.8 y</td><td></td><td>- balance training (static/dynamic stability training)</td><td>Structure: quadriceps volume</td></tr><tr><td>Initial characteristics: 2.0 (2 to 4) (H&Y On)</td><td>Content: COMP, with eccentric training on ergometer targeting lower extremity extensors</td><td>- upper extremity concentric resistance training (exercise machine)</td><td></td></tr><tr><td>Initial motor capacities: 558.07 ± 182.49 m (6MWT), coded 'good<sup>b</sup></td><td></td><td>- concentric ergometer training (NuStep)</td><td></td></tr><tr><td>COMP (21)</td><td>Dose: session: 15 minutes frequency: 2/wk duration: 12 wks</td><td></td><td></td></tr><tr><td>Delay from diagnostic: 68.4 ± 50.8 months</td><td>Range of movement for training: np</td><td></td><td></td></tr><tr><td>Age: 70.7 ± 9.2 y</td><td>Progressivity: variation in workload to maintain a RPE at 13</td><td></td><td></td></tr><tr><td>Initial characteristics: 2.0 (1 to 4) (H&Y On)</td><td></td><td></td><td></td></tr><tr><td>Initial motor capacities: 485.99 ± 158.95 m (6MWT), coded 'good<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td rowspan="10">Clark (2013)</td><td rowspan="10">Stroke</td><td>Setting: np (USA)</td><td>Muscles: HE, HF, KE, KF, AE, AF</td><td>concentric resistance training (using the same dose as ET)</td><td>Participation: -</td></tr><tr><td>ET (18)</td><td>Format: standalone</td><td></td><td>Activity: gait</td></tr><tr><td>Delay from injury: 13.3 ± 4.9 months</td><td></td><td></td><td>Function: strength, power, muscle activity</td></tr><tr><td>Age: 63.2 ± 10.6 y</td><td>Content: isokinetic training<sup>c</sup></td><td></td><td>Structure: -</td></tr><tr><td>Initial characteristics: 77.3 ± 9.4 (F-M)</td><td></td><td></td><td></td></tr><tr><td>Initial motor capacities: 0.37 ± 0.18 m/s (self-selected walking speed), coded 'moderate'<sup>b</sup></td><td>Dose: session: sets of 10 repetitions wk 1: 9 sets (3x30°/s, 3x90°/s, 3x150°/s) wk 2: 9 sets (3x 60°/s, 3x 120°/s, 3x180°/s) wk 3: 12 sets (4x90°/s, 4x150°/s, 4x210°/s) wk 4: 9 sets (3x60°/s, 3x150°/s, 3x210°/s) wk 5: 9 sets (3x30°/s, 3x90°/s, 3x150°/s)</td><td></td><td></td></tr><tr><td>COMP (17)</td><td></td><td></td><td></td></tr><tr><td>Delay from injury: 12.8 ± 4.7 months</td><td>frequency: 3/wk</td><td></td><td></td></tr><tr><td>Age: 59.7 ± 10.9 y</td><td>duration: 5 wks</td><td></td><td></td></tr><tr><td>Initial characteristics: 80.9 ± 7.1 (F-M)</td><td></td><td></td><td></td></tr><tr><td>Initial motor capacities: 0.39 ± 0.25 m/s (self-selected walking speed), coded 'moderate'<sup>b</sup></td><td>Range of movement for training: np</td><td></td><td></td></tr><tr><td></td><td></td><td>Velocity of movement: see dose</td><td></td><td></td></tr><tr><td></td><td></td><td>Progressivity: np</td><td></td><td></td></tr></tbody></table>
<table><tr><td>Hayes (2011)</td><td>Multiple Sclerosis</td><td>Setting: patients in an outpatient service (USA)<br/>ET (10)<br/>Delay from diagnostic: 149.9 ± 113.8 months<br/>Age: 48.0 ± 11.9 y<br/>Initial characteristics: 5.2 ± 1.0 (EDSS)<br/>Initial motor capacities: 248 ± 169 m (6MWT), coded 'good'<sup>b</sup><br/>COMP (9)<br/>Delay from diagnostic: 142.2 ± 87.6 months<br/>Age: 49.7 ± 11.0 y<br/>Initial characteristics: 5.3 ± 1.0 (EDSS)<br/>Initial motor capacities: 372 ± 266 m (6MWT), coded 'good'<sup>b</sup></td><td>Muscles: HE, KE, AE<br/>Format: added to usual rehabilitation<br/>Content: eccentric training on ergometer targeting lower extremity extensors (eccentron)<br/>Dose:<br/>session: 45 to 60 minutes<br/>wk 1: 1–5 min (RPE = 7)<br/>wk 2: 1–5 min (RPE = 9)<br/>wk 3: 11–14 min (RPE = 11)<br/>last 8 wks: 11–14 min (RPE = 13)<br/>frequency: 3/wk<br/>duration: 12 wks<br/>Range of movement for training: from 10° to 90° of knee flexion<br/>Velocity of movement: pedal cadence: 15 to 20 rotations per minute<br/>Progressivity: variation in workload to maintain a RPE from 11 to 13</td><td>usual rehabilitation<br/>– aerobic training (NuStep, horizontal stepper)<br/>– lower extremity stretching (hamstring, quads, triceps surae)<br/>– upper extremity strength training (machines and free weights)<br/>– balance exercises (standing on a wobble board while maintaining balance for both a side-to-side and front-to-back perturbation)</td><td>Participation: -<br/>Activity: gait, risk of fall<br/>Function: strength, balance, fatigue<br/>Structure: -</td></tr><tr><td>Dibble (2009)</td><td>Parkinson's Disease</td><td>Setting: patients in an outpatient service (USA)<br/>ET (10)<br/>Delay from diagnostic: 73.2 ± 46.8 months<br/>Age: 64.3 ± 9.6 y<br/>Initial characteristics: 2.5 ± 0.5 (H&Y)<br/>Initial motor capacities: 1.74 ± 0.33 m/s (max-selected walking speed, 10mWT), coded 'good'<sup>b</sup><br/>COMP (9)<br/>Delay from diagnostic: 78.0 ± 51.6 months<br/>Age: 67.0 ± 10.2 y<br/>Initial characteristics: 2.5 ± 0.7 (H&Y)<br/>Initial motor capacities: 1.71 ± 0.34 m/s (max-selected walking speed, 10mWT), coded 'good'<sup>b</sup></td><td>Muscles: HE, KE<br/>Format: included in a multi-component rehabilitation program<br/>Content: eccentric training on ergometer targeting lower extremity extensors (eccentron)<br/>Dose:<br/>session: 5 to 30 minutes<br/>wk1: 2/wk, 3–5 min (RPE = 7)<br/>wk2: 3/wk, 5 min (RPE = 9)<br/>wk3: 3/wk, 5–10 min (RPE = 11)<br/>wk4: 3/wk, 10–15 min (RPE = 11–13)<br/>wk 5–12: 3/wk, 15–30 min (RPE = 13)<br/>frequency: 2–3/wk<br/>duration: 12 wks<br/>Range of movement for training: np<br/>Velocity of movement: np<br/>Progressivity: variation in workload to obtain a RPE = 13 (wk 5 to 12)</td><td>multi-component rehabilitation program<br/>– warm-up exercises (bicycle or treadmill)<br/>– flexibility training (mobility exercises)<br/>– balance training (static/dynamic stability training)<br/>– upper extremity concentric resistance training (exercise machine)<br/>– concentric ergometer training (NuStep)</td><td>Participation: quality of life<br/>Activity: gait, risk of fall<br/>Function: strength<br/>Structure: -</td></tr></table>

(Continued)
<table><caption>Table 2
(Continued)</caption><tbody><tr><td>Dibble (2006)</td><td>Parkinson's Disease</td><td>Setting: patients in an outpatient service (USA)<br>ET (10)<br>Delay from diagnostic: 73.2 ± 46.8 months<br>Age: 64.3 ± 9.6 y<br>Initial characteristics: 2.5 ± 0.5 (H&Y)<br>Initial motor capacities: 575.12 ± 142.37 m<br>(6MWT), coded 'good<sup>b</sup>'<br>COMP (9)<br>Delay from diagnostic: 78.0 ± 51.6 months<br>Age: 67.0 ± 10.2 y<br>Initial characteristics: 2.5 ± 0.7 (H&Y)<br>Initial motor capacities: 544.72 ± 133.13 m<br>(6WMT), coded 'good<sup>b</sup>'<br>Muscles: HE, KE<br>Format: included in a multi-component rehabilitation program<br>Content: eccentric training on ergometer targeting lower extremity extensors (eccentron)<br>Dose:<br>session: 5 to 30 minutes<br>wk1: 2/wk, 3–5 min (RPE = 7)<br>wk2: 3/wk, 5 min (RPE = 9)<br>wk3: 3/wk, 5–10 min (RPE = 11)<br>wk4: 3/wk, 10–15 min (RPE = 11–13)<br>wk 5–12: 3/wk, 15–30 min (RPE = 13)<br>frequency: 2–3/wk<br>duration: 12 wks<br>Range of movement for training: np<br>Velocity of movement: np<br>Progressivity: variation in workload to obtain a RPE = 13 (wk 5 to 12)</td><td>multi-component rehabilitation program<br>– warm-up exercises (bicycle or treadmill)<br>– flexibility training (mobility exercises)<br>– balance training (static/dynamic stability training)<br>– upper extremity concentric resistance training (exercise machine)<br>– concentric ergometer training (NuStep)</td><td>Participation: -<br>Activity: gait<br>Function: strength<br>Structure: quadriceps volume</td></tr><tr><td>Engardt (1995)</td><td>Stroke</td><td>Setting: patients in an outpatient service (Sweden)<br>ET (10)<br>Delay from injury: 26.5 ± 10.3 months<br>Age: 62.2 ± 7.6 y<br>Initial characteristics: 81 (68 to 97) (F-M)<br>Initial motor capacities: 0.81 ± 0.18 m/s<br>(self-selected walking speed, 30mWT), coded 'good<sup>b</sup>'<br>COMP (10)<br>Delay from injury: 27.8 ± 12.0 months<br>Age: 64.6 ± 6.2 y<br>Initial characteristics: 78 (70 to 86) (F-M)<br>Initial motor capacities: 0.65 ± 0.20 m/s<br>(self-selected walking speed, 30mWT), coded 'moderate<sup>b</sup>'<br>Muscles: KE<br>Format: standalone<br>Content: eccentric training on isokinetic dynamometer (exclusively on knee extensors)<br>Dose:<br>session: up to 15 sets of 10 reps<br>angular velocities: pyramidal (60, 120, 180, 120, 60)<br>frequency: 2/wk<br>duration: 6 wks<br>Range of movement for training: from 10° to 100° of knee flexion<br>Velocity of movement: see dose<br>Progressivity: variation in workload to obtain a RPE = 13 (wk 5 to 12)</td><td>concentric resistance training (using the same dose as ET)</td><td>Participation: -<br>Activity: gait<br>Function: strength, balance/posture, muscle activity<br>Structure: -</td></tr></tbody></table>
<table><tbody><tr><td>Fernandez-Gonzalo (2016)</td><td>Stroke</td><td>Setting: np (Spain)<br>ET (16)<br>Delay from injury: 42 ± 43.2 months<br>Age: 61.2 ± 9.8 y<br>Initial characteristics: 28.1 ± 1.8 (MMSE)<br>Initial motor capacities: 20.3 ± 14.5 s (TUG), coded 'severe'<br>COMP (16)<br>Delay from injury: 51.6 ± 58.8 months<br>Age: 65.7 ± 12.7 y<br>Initial characteristics: 27.7 ± 2.3 (MMSE)<br>Initial motor capacities: 17.6 ± 14.8 s (TUG), coded 'severe'<sup>b</sup></td><td>Muscles: KE<br>Format: standalone<br>Content: eccentric training on eccentric ergometer (YoYo)<br>Dose:<br>session: 4 sets x 7 reps<br>Angular velocities: pyramidal (60, 120, 180, 120, 60)<br>frequency: 2/wk<br>duration: 12 wks<br>Range of movement for training: from 0° to 70° of knee flexion<br>Velocity of movement: see dose<br>Progressivity: variation of the workload to maintain maximal intensity</td><td>no intervention (control)<br>Participation: quality of life<br>Activity: balance, risk of fall<br>Function: strength, spasticity<br>Structure: quadriceps volume</td></tr><tr><td>Lee (2013)</td><td>Stroke</td><td>Setting: patients in an inpatient service (Korea)<br>ET (10)<br>Delay from injury: np<br>Age: 53.40 ± 9.71 y<br>Initial characteristics: np<br>Initial motor capacities: 0.37 ± 0.33 m/s (self-selected walking speed), coded 'moderate'<sup>b</sup><br>COMP (10)<br>Delay from injury: np<br>Age: 53.86 ± 10.56 y<br>Initial characteristics: np<br>Initial motor capacities: 0.41 ± 0.19 m/s (self-selected walking speed), coded 'moderate'<sup>b</sup></td><td>Muscles: HF, HE<br>Format: added to usual rehabilitation<br>Content: Eccentric training on isokinetic dynamometer<br>Dose:<br>session: 60 minutes (5 minutes warm up)<br>4 sets x 8 reps<br>frequency: 3/wk<br>duration: 6 wks<br>Range of movement for training: np<br>Velocity of movement: see dose<br>Progressivity: np</td><td>usual rehabilitation (not described)<br>Participation: -<br>Activity: risk of fall, gait<br>Function: strength<br>Structure: -</td></tr></tbody></table>

Abbreviations: Muscle groups: AE/AF ankle extensors/flexors, EE/EF elbow flexors/extensors, KE/KF knee extensors/flexors, HE/HF hip extensors/flexors, WE/WF wrist extensors/flexors; BBS: Berg Balance Scale; EDSS: Expanded Disability Status Scale; FAC: Functional Ambulation Category; F-M: Fugl-Meyer assessment of sensorimotor function; FSS: Fatigue Severity Scale; H&Y: Hoehn & Yahr Scale; MAS: Modified Ashworth; MDS-UPDRS III: Movement Disorders Society Unified Parkinson's Disease Rating Scale; MMSE: mini mental state examination; MRI: Magnetic Resonance Imaging; MVC: maximum voluntary contraction; np: non precised; rep: repetitions; RM: repetition maximum; RPE: rating of perceived exertion; SF-36: Short-Form 36; TUG: timed-up and go test; VAS: visual analogue scale; wk: week; y: years; 10mWT: 10 Metres Walk Test; 30mWT: 30 Metres Walk Test; 6MWT: 6 Minutes Walk Test. a: Calculated from time values provided in the original paper (speed = 10/time). b: Previous research in neurological populations (Kubo et al., 2020; Moore et al., 2018; Quinn et al., 2013) had proposed cuts-offs to reflect 'good', 'moderate', and 'severe' motor performance capacities for 10mWT ('good' > 0.8 m/s, 'moderate' between 0.4 and 0.8 m/s, 'severe' < 0.4 m/s, 6MWT ('good' > 448 m, 'moderate' between 225 m and 448 m, 'severe' < 225 m), TUG ('good' < 12 sec, 'moderate' between 12 s and 14 s, 'severe' < 14 sec), respectively. c: The study of Clark (2013) was a staged intervention: part 1 (resistance training, 5 weeks) followed by part 2 (gait training, 3 weeks). Only data from part 1 were considered. Kubo, H., et al. (2020). Reference value of 6-minute walk distance in patients with sub-acute stroke. Top Stroke Rehabil, 27(5), 337-343. doi: 10.1080/10749357.2019.1704372. Moore, J. L., et al. (2018). A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE. J Neurol Phys Ther, 42(3), 174-220. doi: 10.1097/NPT.0000000000000229. Quinn, L., et al. Outcome Measures Subgroup of the European Huntington's Disease, N. (2013). Reliability and minimal detectable change of physical performance measures in individuals with pre-manifest and manifest Huntington disease. Phys Ther, 93(7), 942-956. doi: 10.2522/ptj.20130032.
<figure><img src="image_2.png" /><figcaption>Fig. 1. Flow of trials through the review. a Some trials displayed multiple reasons for exclusion. b Authors contacted with no responses.</figcaption></figure>

### 3.2.1. Participants

The 10 RCTs involved 260 participants, mean age ranged from 48.0 to 70.7 years, at chronic stages of their respective condition (11.6 to 149.9 months): a neurological injury (stroke, n = 141) (Clark & Patten, 2013; Engardt et al., 1995; Fernandez-Gonzalo et al., 2016; Lattouf et al., 2021; Lee & Kang, 2013); a degenerative condition: PD (n = 100) (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009; Kad-

khodaie et al., 2020), and MS (n = 19) (Hayes et al., 2011). All participants were followed in a trial during which they could be assigned prospectively to a group allocating to a single intervention (ET or comparative intervention).

### 3.2.2. Intervention

ET targeted the lower limb in 9 studies (Clark & Patten, 2013; Dibble et al., 2015; Dibble et al., 2006;
Dibble et al., 2009; Engardt et al., 1995; Fernandez-Gonzalo et al., 2016; Hayes et al., 2011; Lattouf et al., 2021; Lee & Kang, 2013), and the upper limb in 1 study (Kadkhodaie et al., 2020). ET was multi-segmental in 7 studies (Clark & Patten, 2013; Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009; Hayes et al., 2011; Kadkhodaie et al., 2020; Lattouf et al., 2021), and targeted one joint in 3 studies (Engardt et al., 1995; Fernandez-Gonzalo et al., 2016; Lee & Kang, 2013). Exercises were performed on an isokinetic dynamometer in 3 studies (Clark & Patten, 2013; Engardt et al., 1995; Lee & Kang, 2013), a fitness/exercise machine in 6 studies (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009; Fernandez-Gonzalo et al., 2016; Hayes et al., 2011; Lattouf et al., 2021), and free-weights in 1 study (Kadkhodaie et al., 2020). ET was added (Hayes et al., 2011; Lattouf et al., 2021; Lee & Kang, 2013) or included (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009) to rehabilitation care in 6 studies, or proposed as a standalone intervention in 4 studies: compared to concentric training (Clark & Patten, 2013; Engardt et al., 1995) or to control (no intervention) (Fernandez-Gonzalo et al., 2016; Kadkhodaie et al., 2020). The ET program lasted from 4 to 12 weeks, with a frequency of 2.5 sessions/week. However, the trials remained unclear in their description and manipulation of exercise variables: repetitions of movement to failure or not, velocity and range of movement at which exercise were performed (Table 2 and Supplementary File 5).

### 3.2.3. Outcome measures

Motor performance was assessed as maximal strength by measuring force or torque in 8 studies [isometrically (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009; Fernandez-Gonzalo et al., 2016; Hayes et al., 2011); or dynamically (Engardt et al., 1995; Fernandez-Gonzalo et al., 2016; Lattouf et al., 2021; Lee & Kang, 2013)], power in 2 studies (Clark & Patten, 2013; Fernandez-Gonzalo et al., 2016), and gait capacities in 8 studies [distance (Dibble et al., 2015; Dibble et al., 2006; Hayes et al., 2011; Lattouf et al., 2021); velocity (Clark & Patten, 2013; Dibble et al., 2009; Engardt et al., 1995; Hayes et al., 2011; Lattouf et al., 2021; Lee & Kang, 2013)]. Regarding motor impairments, muscle structure was quantified using MRI in 3 studies as muscle size (Dibble et al., 2015) or volume (Dibble et al., 2006; Fernandez-Gonzalo et al., 2016); muscle activity using surface electromyography (sEMG) in 2 studies (Clark & Patten, 2013; Engardt et al., 1995), muscle tone in 2

studies via modified Ashworth Scale (Fernandez-Gonzalo et al., 2016; Lattouf et al., 2021), frequency of hand tremor in one study (Kadkhodaie et al., 2020), balance in 3 studies [bodyweight distribution (Hayes et al., 2011) or Berg Balance Test (Engardt et al., 1995; Fernandez-Gonzalo et al., 2016)] and fatigue in one study [Fatigue Severity Scale, Hayes et al. (2011)]. Finally, the risk of fall was measured in 4 studies using Time Up and Go test (Dibble et al., 2009; Fernandez-Gonzalo et al., 2016; Hayes et al., 2011; Lee & Kang, 2013), and 3 trials reported a self-measurement of global health status [using the generic Short-Form 36 scale Fernandez-Gonzalo et al. (2016); or disease-specific Parkinson's Disease Questionnaire-39 (Dibble et al., 2015; Dibble et al., 2009)] (Supplementary File 2).

### 3.2.4. Quality of included trials

The RoB was variable for each domain as described in Fig. 2. Globally, only 20% of the studies reported an overall 'low' RoB ($κ=1.00$) (Fig. 2).

## 3.3. Effect of ET on motor performance

The effect of ET on strength was examined by pooling data from 8 studies: 4 studies in persons with stroke (Engardt et al., 1995; Fernandez-Gonzalo et al., 2016; Lattouf et al., 2021; Lee & Kang, 2013), and 4 studies in neuro-degenerative conditions: 3 in PD (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009), and 1 in MS (Hayes et al., 2011). The effect size was moderate (SMD 0.58, CI95% 0.30 to 0.87, *p* < 0.0001; I²=0%) in favour of ET, with no effect of the subgroup (Fig. 3A). When stratifying by the type of ET delivery, the effect of ET on strength was still significant: ET as a standalone intervention (SMD 0.79, CI95% -0.13 to 1.08, *p* = 0.009; I²=0%) or ET included/added into a rehabilitation program (SMD 0.52, CI95% 0.20 to 0.84, *p* = 0.002; I²=0%). Without the trial reporting a large effect size (Fernandez-Gonzalo et al., 2016), ET still improved strength (SMD 0.53, CI95% 0.23 to 0.84, *p* = 0.0005; I² = 0%). The QoE was very low for the effect of ET on strength (Supplementary File 2).

The effect of ET on power was examined by pooling outcomes from 2 studies in persons with stroke delivering ET as a standalone intervention (Clark & Patten, 2013; Fernandez-Gonzalo et al., 2016). The effect size was large (SMD 0.98, CI95% 0.32 to 1.63, *p* = 0.003; I² = 0%) in favour of ET (Fig. 3B). It was not possible to test the effect of subgroup, the type of ET delivery, or initial motor capacities due to the
<figure><img src="image_3.png" /><figcaption>Fig. 2. Risk of Bias of the included trials assessed using the Cochrane Risk of Bias 2 tool.</figcaption></figure>

<figure><img src="image_4.png" /></figure>

<figure><img src="image_5.png" /><figcaption>Fig. 3. Standardised mean difference (95% CI) of effect of eccentric resistance training versus comparator (usual rehabilitation, or control) on strength (n = 194) (A) or power (n = 63) (B) immediately after the intervention (n = 194).</figcaption></figure>

number of studies. The QoE was rated as very low for the effect of ET on power (Supplementary File 3).

The effect of ET on gait was examined by pooling outcomes from 8 studies: 4 studies in persons with stroke (Clark & Patten, 2013; Engardt et al., 1995; Lattouf et al., 2021; Lee & Kang, 2013) and 4 studies in patients with MS (Dibble et al., 2015; Dibble et al., 2006; Dibble et al., 2009; Hayes et al.,

2011). The effect size was 0.27 (CI95% -0.22 to 0.75, *p* = 0.28; *I*² = 65%) which was not significant (Fig. 4). There was no effect of the subgroup, the initial motor capacities on the result: participants with 'moderate' capacities (SMD 0.28, CI95% -0.47 to 1.02, *p* = 0.46; *I*² = 73%) or 'good' capacities (SMD 0.25, CI95% -0.48 to 0.99, *p* = 0.67; *I*² = 67%). There was no effect of the type of ET delivery on the result: ET as stan-
<figure><img src="image_6.png" /><figcaption>Fig. 4. Standardised mean difference (95% CI) of effect of eccentric resistance training versus comparator (usual rehabilitation, or control) on gait immediately after the intervention (n = 209).</figcaption></figure>

dalone intervention (SMD –0.21, CI95% –0.74 to 0.33, *p* = 0.44; *I*² = 70%) or ET included/added into a rehabilitation program (SMD 0.44, CI95% –0.17 to 1.05, *p* = 0.70; *I*² = 69%). The QoE was rated as very low for the effect of ET on gait (Supplementary File 3).

### 3.4. Effect of ET on secondary outcomes

The effect of ET on muscle structure was examined by pooling outcomes from 3 studies in persons with stroke (Fernandez-Gonzalo et al., 2016) and with MS (Dibble et al., 2015; Dibble et al., 2006). The effect size was 0.79 (CI95% –0.02 to 1.60, *p* = 0.06; *I*² = 66%) which was not significant. There was no effect of the subgroup on the result (Supplementary File 6A). It was not possible to test the effect of the type of ET delivery, or initial motor capacities due to the number of studies. The QoE was rated as very low for the effect of ET on muscle structure (Supplementary File 3).

The effect of ET on knee extensors sEMG activity during maximal knee extensions was examined by pooling outcomes from 2 studies in persons with stroke (Clark & Patten, 2013; Engardt et al., 1995). The effect size was 0.67 (CI95% –0.26 to 1.59, *p* = 0.16; *I*² = 63%) which was not significant (Supplementary File 6B). It was not possible to test the effect modifiers due to the number of studies. The QoE was rated as very low for the effect of ET on muscle activity (Supplementary File 3). Additionally, the study of Engardt et al. (1995) did not find differences

in knee flexors' muscle activity during maximal knee extensions (i.e., acting as antagonists).

The effect of ET on spasticity was examined by pooling outcomes from 2 studies in persons with stroke (Fernandez-Gonzalo et al., 2016; Lattouf et al., 2021). The effect size was –0.15 (CI95% –0.63 to 0.33, *p* = 0.55; *I*² = 0%) which was not significant (Supplementary File 6C). It was not possible to test the effect modifiers due to the number of studies. The QoE was rated as very low for the effect of ET on muscle spasticity (Supplementary File 3). Kadkhodaie et al. (2020) did not report between-group differences on hand tremor in PD (SMD 0.83, CI95% –0.07 to 1.73).

The effect of ET on balance was examined by pooling outcomes from 3 studies in persons with stroke (Engardt et al., 1995; Fernandez-Gonzalo et al., 2016) and persons with MS (Hayes et al., 2011). The effect size was 0.66 (CI95% –1.33 to 2.66, *p* = 0.51; *I*² = 93%) which was not significant. There was no 'subgroup' effect on the result (Supplementary File 6D). The QoE was rated as very low for the effect of ET on balance (Supplementary File 3).

Finally, Hayes et al. (2011) did not report between-group differences in self-perceived fatigue on daily function in people with MS (Fatigue Severity Scale, MD = 0.44, CI95% –0.36 to 1.24).

### 3.5. Effect of ET on tertiary outcomes

The effect of ET on risk of fall was examined by pooling outcomes from 2 studies in persons with
stroke (Fernandez-Gonzalo et al., 2016; Lee & Kang, 2013), 1 study in patients with PD (Dibble et al., 2009), and 1 study in patients with MS (Hayes et al., 2011). The effect size was medium (SMD –0.67, CI95% –1.11 to –0.23, *p* = 0.003; I² = 0%) in favour of ET (Supplementary File 6E). There was no ‘subgroup’ effect of the on the result. The effect size was improved when participants had a ‘severe’ or ‘moderate’ motor impairment (SMD –0.82, CI95% –1.41 to –0.23, *p* = 0.007; I² = 0%) and not significant when participants had ‘good’ initial motor capacities (SMD –0.49, CI95% –1.30 to 0.31, *p* = 0.23; I² = 33%). When trials with a large effect size were omitted one-by-one (Dibble et al., 2009; Fernandez-Gonzalo et al., 2016; Lee & Kang, 2013), the overall result was reduced but still in favour of ET (all SMD and CI95%<–0.60, –1.13 to –0.07, all p-values<0.01). However, the result was not significant when at least two of these trials were omitted (see Supplementary File 6E for further details). The QoE was rated as very low for the effect of ET on risk of fall (Supplementary File 3).

Three trials (Dibble et al., 2015; Dibble et al., 2009; Fernandez-Gonzalo et al., 2016) assessed participants' perceptions of their quality of life in relation to their health status. It was not possible to pool their data. Qualitatively, the 'perception of pain' on SF-36 scale was better improved after ET in persons with stroke (SMD 0.96, CI95% 0.16 to 1.74) (Fernandez-Gonzalo et al., 2016). In people with PD, Dibble et al. (2009) reported that ET improved the 'global index' subsection of Parkinson Disease Questionnaire (PDQ-39) (SMD –1.26, CI95% –2.26 to –0.25), but this result was not confirmed in a later study (no data reported) (Dibble et al., 2015).

## 4. Discussion

This systematic review provided evidence that ET improves motor performance, especially maximal strength and power, in neurological populations. The effect of ET on secondary outcomes (motor impairments) and tertiary outcomes (health-related quality of life) were not consistent. However, the overall QoE was very low due to a high RoB, small sample sizes generating imprecisions across the studies. The moderate to large effect size for strength is in accordance with conclusions of previous reviews applying ‘conventional’ resistance training programs in neurological populations : stroke injury [SMD = 0.99, CI95% 0.28 to 1.70 Veldema and Jansen (2020);

0.98, 95% CI 0.67 to 1.29, Dorsch et al. (2018)]; CP [0.26, CI95% 0.04 to 0.48, Merino-Andres et al. (2022)]; MS [0.36, 0.18 to 0.55, Andreu-Caravaca et al. (2022); 0.45, CI95% 0.18 to 0.72, Jorgensen et al. (2017)]; PD [1.9, CI95% 0.55 to 3.24, Yang and Wang (2023)].

Also, gait was the only activity assessed in the retrieved studies of this review (n = 8/10). We did not find evidence of superiority of ET over the comparator in improving gait, which is consistent with the findings from previous reviews in neurological populations where either distance or velocity were not better improved after a ‘conventional’ resistance training program (Braz de Oliveira et al., 2021; Dorsch et al., 2018; Merino-Andres et al., 2022; Veldema & Jansen, 2020). However, a recent review in PD populations reported a better positive effect on a disease-specific impairment: freezing during gait [SMD = 0.55, CI95% 0.16 to 0.95, Yang and Wang (2023)]. We did not retrieve trials assessing changes in freezing in PD, after ET. However, when considering their initial gait capacities (distance or velocity), the participants of the trials of the present review were probably at a too ‘moderate-to-low’ degree of walking disability (Table 2) to expect a carry-over of strength on activity (Dorsch et al., 2021). Another reason might be related to the specificity of the intervention to target the most important muscle groups for walking and/or not using fast-enough muscle contractions to match the physiological needs for gait (Williams et al., 2019).

Resistance training is a complex intervention with many variables that can affect its benefits through different neural and structural adaptations. For instance, performing rapid muscle contractions might be more beneficial for optimizing neural plasticity and muscle activation while slow muscle contractions would better promote hypertrophy (Coratella, 2022; Scott et al., 2016). An optimal program would ideally fit individual needs and impairments. It is difficult to appreciate to in the present review in which extent the intervention optimized neural or structural adaptations for improving strength was related to the initial impairments of the participants. For instance, different movement velocities could be used among the retrieved studies' protocols (Table 2). Also, motor impairments were not consistently followed in the retrieved studies (30% only). The trial of Fernandez-Gonzalo et al. (2016) in persons with stroke was the only trial assessing neural and structural outcomes in addition to strength. This study reported increases of strength and muscle volume in favor of the ET
group, while muscle tone remained unchanged for both groups. These findings would mean that ET would be of particular interest to promote hypertrophy for improving strength. Dibble et al. (2006) also reported a better increase after ET in quadriceps muscle size of patients with PD in addition to strength gain. However, this result was not confirmed later (Dibble et al., 2015) and muscle activity was not measured in those trials. A trial conducted in children with CP (not included in this review) (Reid et al., 2010) reported strength gains after ET associated with a decrease in antagonist muscle co-activation. Taken together, different mechanisms (neural, structural) could be involved to improve strength after ET.

Muscle tone and balance were not be better improved after ET (Supplementary File 5), like found in ‘conventional’ resistance training programs (Merino-Andres et al., 2022; Veldema & Jansen, 2020). Surprisingly, no trials investigated joint flexibility, muscle length or stiffness despite the popularity of contractures and rigidity in individuals with neurological conditions, that are associated with changes in musculo-tendinous structure and/or mechanical properties (intrinsic level of stiffness) (Diong et al., 2012; Hoang et al., 2021; Kwah et al., 2012; Le Sant et al., 2019; Lieber & Friden, 2019). Once developed, contractures enhance the overall degradation of motor performance and disability (Ada et al., 2000; Barber et al., 2017). These features are difficult to address in neuro-rehabilitation where classical approaches using stretching exercises fail to produce clinical worthwhile results (Harvey et al., 2017; Lecharte et al., 2020; Svane et al., 2021). A recent review reported that ET offer an opportunity to improve joint range of motion and muscle fascicle length in healthy populations (Diong et al., 2022). A feasibility study in a small sample of MS patients reported clinical gains in joint flexibility after an ET (Manca et al., 2020). These preliminary results need to be confirmed in future studies, in order to identify the morphological and biomechanical adaptations underpinning the clinical outcomes.

In order to provide evidence-based strategies in clinical contexts future studies should include neuropsych physiological and structural outcomes in their assessments to understand how adaptations following ET: i) differ/conform to ‘conventional’ resistance training programs; ii) influence the severity of motor impairments and disability. A greater understanding of the distinct neurological and/or architectural adaptations following strength training would lead

to more personalized exercise prescription for this population.

The main strength of this review was to comprehensively examine motor performance, motor impairments, and disability across different neurological conditions, by considering a person’s functioning in terms of body functions and structures, activities and participations (health-related quality of life), rather than just strength. We also considered ACSM guideline for resistance training to determine an ‘optimal’ program that would increase strength (Supplementary File 5). However, the studies focused on the lower limb (90% of the trials) and for individuals at chronic phases of their condition (Table 2). Based on that, it is not possible to conclude on the effects of ET on upper limb motor performance, for acute/subacute populations, or in patients with different conditions (e.g. CP, SCI). Moreover, despite positive results for strength after ET, the precise estimate of the mode of delivery (and comparator) is difficult to appreciate, because of the number of studies retrieved. Future trials are needed to estimate how much more (or less) effective eccentric training is than usual rehabilitation, and to determine its optimal dose-effect. Finally, we excluded trials using task-oriented exercises such as backward gait-training (Hosl et al., 2018), whose tend to influence motor control, skill, speed, endurance, and not only strength. Ballistic training offers opportunities (Williams et al., 2022) but might be more suitable when the goal of training is to improve the rate of force production (Williams et al., 2019). Also, ballistic training might not isolate the specific effect of ET which was beyond the scope of this review. Future trials should compare different types of resistance training regarding the specific needs of the activity, in order to determine to most effective approach of resistance training.

## 5. Conclusion

This systematic review shows that ET is likely to improve motor performance in neurological conditions. Because this result is based on a very-low quality of evidence, future studies are needed to provide robust evidence and to precise the magnitude of this finding. These studies would use larger samples of participants, and test ET in acute populations and/or with more severe capacities. The effect of ET on clinical parameters that have useful implications in neurologically-impaired populations, such as joint flexibility also needs further investigation.
## Conflict of interest

GLS is supported by a grant from the French Ministry of Health (PHRIP, n° PHRIP-21-0031). Funders had no role in design and conduct of the research; collection, management, data analysis and interpretation; and preparation; review, or approval of the manuscript or the decision to submit for publication. None of the other authors have any competing interests.

## Acknowledgments

The authors have no acknowledgments.

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**Supplementary File 1. Search strategy, by database.**

**Search Strategy for PubMed**

1. "Demyelinating Autoimmune Diseases, CNS"[Mesh]

2. "Central Nervous System Diseases"[Mesh]

3. "Motor Neuron Disease"[Mesh]

4. "Trauma, Nervous System"[Mesh]

5. OR 1-4

6. Eccentric

7. "lengthening contraction"

8. "lengthening exercise"

9. OR 6-8

10. Rehab*

11. Train*

12. Exercise

13. Physiother*

14. OR 10-13

15. 5 AND 9 AND 14

**Search Strategy for PEDro**

1. eccentric ti.ab

2. neurology sub.

3. 1 AND 2

**Search Strategy for EMBASE**

1. 'eccentric muscle contraction'/exp

2. 'eccentric muscle contraction'

3. OR 1-2

4. 'central nervous system disease'/exp

5. 'central nervous system disease'

6. 'motor neuron disease'/exp

7. 'motor neuron disease'

8. 'nervous system injury'/exp

9. 'nervous system injury'

10. 'demyelinating disease'/exp

11. 'demyelinating disease'

12. OR 4-11

13. 'rehabilitation'/exp

14. 'rehabilitation'

15. 'training'/exp

16. 'training'

17. 'exercise'/exp

18. 'exercise'

19. 'physiotherapy'/exp

20. 'physiotherapy'

21. OR 13-20

22. 3 AND 12 AND 21

**Search Strategy for Cochrane**

1. Eccentric
2. MeSH descriptor: [Rehabilitation] explode all trees

3. MeSH descriptor: [Demyelinating Autoimmune Diseases, CNS] explode all trees

4. MeSH descriptor: [Central Nervous System Diseases] explode all trees

5. MeSH descriptor: [Motor Neuron Disease] explode all trees

6. MeSH descriptor: [Trauma, Nervous System] explode all trees

7. OR 2-6

8. MeSH descriptor: [Neurological Rehabilitation] explode all trees

9. Exercise

10. Train*

11. OR 8-10

12. 1 AND 7 AND 11

## Search Strategy for Scopus

1. Eccentric

2. Neurological

3. Train*

4. Exercise

5. Rehab*

6. OR 3-5

7. 1 AND 2 AND 5

## Search Strategy for Web of Science

1. ALL=(eccentric)

2. ALL=(exercise)

3. ALL=(training)

4. ALL=(rehabilitation)

5. OR 2-4

6. ALL=(neurological)

7. 1 AND 5 AND 6

## Search Strategy for ClinicalTrials registry

1. Condition or disease : Neurological Diseases or Conditions

2. Intervention/treatment : eccentric

3. Eligibility criteria : adult/older adult

4. Study type: interventional (clinical trial)

5. 1 AND 2 AND 3 AND 4 AND 5
**Supplementary File 2.** Rationale to reduce comparisons within studies.

<table><thead><tr><th rowspan="2">Study</th><th colspan="3">Outcomes (tools/scales used for assessment)</th></tr><tr><th>Motor Performance</th><th>Motor impairments</th><th>Health related quality of life</th></tr></thead><tbody><tr><td>Lattouf (2021)</td><td>KE strength more/less affected side (1 RM estimated)<br/>Gait (10mWT, 6MWT) [keep : 10mWT as most recommended tool]</td><td>Spasticity (Modified Ahsworth Scale)<sup>a</sup></td><td></td></tr><tr><td>Kadkhodaie (2020)</td><td></td><td>Hand tremor (frequency, at rest, most symptomatic hand)</td><td></td></tr><tr><td>Dibble (2015)</td><td>KE strength phase ON/FF, more affected side (isometric MVC) [keep: phase ON]<br/>Gait (6MWT, Functional Gait Assessment) [keep : 6MWT as most recommended tool]</td><td>QF CSA (MRI)</td><td>Health status (PDQ-39)</td></tr><tr><td>Clark (2013)</td><td>KE Power (60°/sec,120°/sec,180°/sec, eccentric/concentric) [keep : 60°/sec eccentric, as most usual velocity used]<br/>Gait (6 Gait cycles, self/max velocity) [keep : max velocity as most recommended tool]</td><td>RF, VM muscle activity (EMG 60°/sec,120°/sec,180°/sec, eccentric/concentric) [keep : VM muscle activity as most related to strengthening intervention, -60°/sec]</td><td></td></tr><tr><td>Hayes (2011)</td><td>KF/KE, HF/HE, DF, sum of lower-limb muscles strength (MVC, bilateral) [keep : sum of lower-limb muscles]<br/>Gait (10mWT self/max velocity, 6MWT) [keep : 10mWT max velocity as most recommended tool]</td><td>Balance (BBS)</td><td>Risk of Fall (TUG)<br/>Fatigue (FSS)</td></tr><tr><td>Dibble (2009)</td><td>KE strength more/less affected side (isometric MVC) [keep : more affected side]<br/>Gait (10mWT)</td><td></td><td>Health status (PDQ-39)</td></tr><tr><td>Dibble (2006)</td><td>KE strength more/less affected side (isometric MVC) [keep : more affected side]<br/>Gait (6MWT)</td><td>QF, RF, VI, VL, VM Volume (MRI) [keep : QF volume]</td><td>Risk of Fall (TUG)</td></tr><tr><td>Engardt (1995)</td><td>KE strength more affected side (MVC 60°/sec,120°/sec,180°/sec, eccentric/concentric) [keep : 60°/sec eccentric, as most usual velocity used]<br/>Gait (30 m self/max velocity) [keep : max velocity as most recommended tool]</td><td>KE/KF muscle activity (EMG 60°/sec,120°/sec,180°/sec, eccentric/concentric) [keep : 60°/sec eccentric, as most usual velocity used]<br/>Posture rising/sitting down (body weight distribution) [keep : rising]</td><td></td></tr><tr><td>Fernandez-Gonzalo (2016)</td><td>KE+HE strength more/less affected side (isometric and dynamic MVC) [keep : more affected side, dynamic]</td><td>QF Volume (MRI) QF average/maximal CSA (MRI) [keep: QF average CSA]<br/>Spasticity (Modified Ahsworth Scale)</td><td>Risk of Fall (TUG, talking while walking test)<br/>[keep : TUG as most recommended tool]</td></tr></tbody></table>
<table><thead><tr><th></th><th>KE+HE power more/less affected side [keep : more affected side]</th><th>Balance (BBS)<br>Spasticity (MAS)</th><th>Health status (SF-36)</th></tr></thead><tbody><tr><td>Lee (2013)</td><td>HF/HE strength more affected (dynamic MVC, 90°/sec) [keep : within-study analysis : HF/HE]<br>Gait (velocity)</td><td></td><td>Risk of Fall (TUG)</td></tr></tbody></table>

Abbreviations: BBS: Berg Balance Scale; CSA: cross sectional area; DF: dorsiflexors; FSS: Fatigue Severity Scale; HE/HF: hip extensors/flexors; KE/KF: knee extensors/flexors; MRI: magnetic resonance imaging; MVC: Maximum Voluntary Contraction; PDQ-39: Parkinson's Disease Questionnaire-39; QF: *quadriceps femoris*; RF: *rectus femoris*; RM: Repetition Maximum; SF-36: Short-From 36 health survey; TUG: Time Up and Go test; VI: *vastus intermedius*; VL: *vastus lateralis*; VM: *vastus medialis*; 6MWT: 6 minutes walk test; 10mWT: 10 metre walk test.

<footnote>ª data provided by the authors</footnote>
**Supplementary File 3.** Level of evidence according to the GRADE

Six domains are evaluated through GRADE approach: study design, RoB, indirectness, inconsistency, imprecision and publication bias.

Four levels of evidence can be attributed: ‘high’, ‘moderate’, ‘low’, and ‘very low’.

For each outcome, a sequential analysis system was used.

Each outcome was initially as ‘high’ since only RCTs were included in this review.

The QoE was downgraded to ‘moderate’, ‘low’ or ‘very low’ level using the categories:

i) RoB: ≥50% of trials had a RoB 2.0 overall judgment as ‘high’ (-2 levels) or ‘some concerns’ (-1 level);

ii) ii) inconsistency: substantial heterogeneity by a visual inspection in the forest plots (I² statistic value >50% meaning substantial heterogeneity) (-1 level);

iii) iii) indirectness: substantial differences exist between the target population and samples from RCTs included in this review about the population, the intervention, or the outcomes measured (-1 level);

iv) iv) imprecision: a wide confidence interval of the averaged result (-1 level) or based on a total sample size < 800 participants (-1 level);

v) v) publication bias: by visualisation of the funnel plot (-1 level).

GRADE. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. 2013.

Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. Journal of clinical epidemiology 2011; 64(4):401-406.

Guyatt G, Oxman AD, Kunz R, et al. Corrigendum to GRADE guidelines 6. Rating the quality of evidence-imprecision. J Clin Epidemiol 2011;64:1283-1293. Journal of clinical epidemiology 2021; 137:265.
Eccentric resistance training vs comparator on physical function: strength

The GRADE approach was applied to the pooled analysis of 8 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on the strength of muscles (P<0.0001 ; pooled standardised mean difference: 0.58; 95% CI 0.30 to 0.87).

<table><tr><td>Overall result:</td><td>eccentric resistance training may improve muscle strength in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 6/8 (75%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns' or 'high'.</td></tr><tr><td>Inconsistency of results</td><td>We did not downgrade the evidence due to heterogeneity of included studies as the heterogeneity between trials was not significant (P=0.93, I<sup>2</sup>=0%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=164&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_7.png" /></figure>
Eccentric resistance training vs comparator on muscle function: power

The GRADE approach was applied to the pooled analysis of 2 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on the power of muscles (P=0.003; pooled standardised mean difference: 0.98; 95% CI 0.32 to 1.63).

<table><tr><td>Overall result:</td><td>eccentric resistance training may improve muscle power in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 1/2 (50%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns'.</td></tr><tr><td>Inconsistency of results</td><td>We did not downgrade the evidence due to heterogeneity of included studies as the heterogeneity between trials was not significant (P=0.22, I²=33%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=63&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_8.png" /></figure>
Eccentric resistance training vs comparator on gait

The GRADE approach was applied to the pooled analysis of 8 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on gait (P=0.28; pooled standardised mean difference: 0.27; 95% CI -0.22 to 0.75).

<table><tr><td>Overall result:</td><td>eccentric resistance training may not improve gait in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 7/8 (100%) of studies in the meta-analysis had a RoB 2.0 judgment as ‘some concerns’ or ‘high’.</td></tr><tr><td>Inconsistency of results</td><td>We downgraded the evidence due to heterogeneity of included studies as the heterogeneity between trials was high (p=0.005; I²=65%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=209&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_9.png" /></figure>

<table><thead><tr><th>Subgroups</th></tr></thead><tbody><tr><td>Neuro-injury</td></tr><tr><td>Neuro-degenerative</td></tr></tbody></table>
Eccentric resistance training vs comparator on muscle structure (volume)

The GRADE approach was applied to the pooled analysis of 3 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on muscle structure (volume) (P=0.06; pooled standardised mean difference: 0.79; 95% CI -0.02 to 1.60).

<table><tr><td>Overall result:</td><td>Eccentric resistance training may not improve muscle structure in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We did not downgrade the evidence as 2/3 (67%) of studies in the meta-analysis had a RoB 2.0 judgment as 'high'.</td></tr><tr><td>Inconsistency of results</td><td>We downgraded the evidence by one level as the heterogeneity between trials was substantial (I²=66%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=54&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_10.png" /></figure>

<table><thead><tr><th>Subgroups</th></tr></thead><tbody><tr><td>Neuro-injured</td></tr><tr><td>Neuro-degenerative</td></tr></tbody></table>
Eccentric resistance training vs comparator on muscle activity

The GRADE approach was applied to the pooled analysis of 8 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on muscle activity (P=0.16; pooled standardised mean difference: 0.67; 95% CI -0.26 to 1.59).

<table><tr><td><strong>Overall result:</strong></td><td>eccentric resistance training may not improve muscle activity in neurological populations</td></tr><tr><td><strong>Level of evidence:</strong></td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td><strong>Risk of Bias</strong></td><td>We downgraded the evidence by one level as 1/2 (50%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns' or 'high'.</td></tr><tr><td><strong>Inconsistency of results</strong></td><td>We did not downgrade the evidence due to heterogeneity of included studies as the heterogeneity between trials was not significant (P=0.10, I<sup>2</sup>=63%).</td></tr><tr><td><strong>Indirectness of evidence</strong></td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td><strong>Imprecision</strong></td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=54&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td><strong>Publication bias</strong></td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_11.png" /></figure>

<figure><img src="image_12.png" /></figure>
Eccentric resistance training vs comparator on muscle spasticity

The GRADE approach was applied to the pooled analysis of 8 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on muscle tone (spasticity) (P=0.55; pooled standardised mean difference: -0.15; 95% CI -0.63 to 0.33).

<table><tr><td>Overall result:</td><td>eccentric resistance training may not improve muscle spasticity in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 1/2 (50%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns'.</td></tr><tr><td>Inconsistency of results</td><td>We did not downgrade the evidence due to heterogeneity of included studies as the heterogeneity between trials was not significant (P=0.79, I²=0%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=66&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_13.png" /></figure>
Eccentric resistance training vs comparator on balance

The GRADE approach was applied to the pooled analysis of 3 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on balance (P=0.51; pooled standardised mean difference: 0.66; 95% CI -1.33 to 2.66).

<table><tr><td>Overall result:</td><td>eccentric resistance training may not improve balance in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 2/3 (100%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns'.</td></tr><tr><td>Inconsistency of results</td><td>We downgraded the evidence due to heterogeneity of included studies as the heterogeneity between trials was very high (p&lt;0.001, I<sup>2</sup>=93%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=68&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_14.png" /></figure>
Eccentric resistance training vs comparator on risk of fall

The GRADE approach was applied to the pooled analysis of 4 trials investigating the effects of eccentric resistance training compared to a control intervention/usual rehabilitation on risk of fall (P=0.003; pooled standardised mean difference: -0.67; 95% CI -1.11 to -0.23).

<table><tr><td>Overall result:</td><td>eccentric resistance training may improve gait in neurological populations</td></tr><tr><td>Level of evidence:</td><td>Very low certainty</td></tr><tr><td colspan="2">We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.</td></tr><tr><td>Risk of Bias</td><td>We downgraded the evidence by one level as 3/4 (75%) of studies in the meta-analysis had a RoB 2.0 judgment as 'some concerns' or 'high'.</td></tr><tr><td>Inconsistency of results</td><td>We did not downgrade the evidence due to heterogeneity of included studies as the heterogeneity between trials was not significant (P=0.22, I<sup>2</sup>=33%).</td></tr><tr><td>Indirectness of evidence</td><td>Since we only included similar studies in terms of population, intervention, comparator and outcome, we did not downgrade the evidence based on this criterion.</td></tr><tr><td>Imprecision</td><td>We downgraded the evidence by two levels due to imprecision as the meta-analysis had n=87&lt;800 participants analysed, and a wide CI interval.</td></tr><tr><td>Publication bias</td><td>We did not downgrade the evidence for publication bias since examination of funnel plot did not suggest serious small study effects.</td></tr></table>

Shading indicates the items that were downgraded.
<figure><img src="image_15.png" /></figure>
**Supplementary File 4. List of excluded studies and reasons for exclusion.**

<table><thead><tr><td>Title</td><td>Author</td><td>Year</td><td>DOI</td><td>Population</td><td>Intervention</td><td>Comparator</td><td>Outcome</td><td>Design</td><td>Other</td><td>Stage</td></tr></thead><tbody><tr><td>Eccentric rehabilitation induces white matter plasticity and sensorimotor recovery in chronic spinal cord injury.</td><td>Faw, TD; Lakhani, B; Schmalbrock, P; Knopp, MV; Lohse, KR; Kramer, JLK; Liu, H; Nguyen, HT; Phillips, EG; Bratasz, A; Fisher, LC; Deibert, RJ; Boyd, LA; McTigue, DM; Basso, DM</td><td>2021</td><td>10.1016/j.expneurol.2021.113853</td><td>X</td><td>X</td><td></td><td>X</td><td></td><td></td><td>FT</td></tr><tr><td>Coexistence of neuronal intranuclear inclusion disease and amyotrophic lateral sclerosis: an autopsy case.</td><td>Sugiyama, A; Takeda, T; Koide, M; Yokota, H; Mukai, H; Kitayama, Y; Shibuya, K; Araki, N; Ishikawa, A; Isose, S; Ito, K; Honda, K; Yamanaka, Y; Sano, T; Saito, Y; Arai, K; Kuwabara, S</td><td>2021</td><td>10.1186/s12883-021-02306-5</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr><tr><td>Relationship between bone strength index of the hemiparetic tibial diaphysis and muscle strength in people with chronic stroke: influence of muscle contraction type and speed.</td><td>Yang, Z; Miller, T; Pang, MYC</td><td>2021</td><td>10.1007/s00198-020-05716-2</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr><tr><td>Magnetization Transfer Ratio and Morphometrics of the Spinal Cord Associates with Surgical Recovery in Patients with Degenerative Cervical Myelopathy.</td><td>Paliwal, M; Weber, KA 2nd; Hopkins, BS; Cantrell, DR; Hoggarth, MA; Elliott, JM; Dahdaleh, NS; Mackey, S; Parrish, TD; Dhaher, Y; Smith, ZA</td><td>2020</td><td>10.1016/j.wneu.2020.09.148</td><td></td><td>X</td><td>X</td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>A New Surgical Approach for the Management of Acute Corneal Hydrops Complicated With Corneal Perforation.</td><td>Petrelli, M; Cohen, J; Hashemi, K; Brentzelos, MA; Kymionis, GD</td><td>2020</td><td>10.1097/ICO.00000000002377</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr><tr><td>Comparative analysis of power, work and muscle activation during weight-stack and iso-inertial flywheel resistance exercise in young adults with cerebral palsy.</td><td>von Walden, F; Hjalmarsson, E; Reimeringer, M; Kvist, O; Raffalt, PC; Pontén, E; Fernandez-Gonzalo, R</td><td>2020</td><td>10.2340/16501977-2682</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Effect of Eccentric Strength Training on Elbow Flexor Spasticity and Muscle Weakness in People With Multiple Sclerosis: Proof-of-Concept Single-System Case Series.</td><td>Manca, A; Martinez, G; Aiello, E; Ventura, L; Deriu, F</td><td>2020</td><td>10.1093/ptj/pza055</td><td></td><td></td><td>X</td><td></td><td>X</td><td></td><td>T/A</td></tr><tr><td>Sensitivity analysis of muscle properties and impact parameters on head injury risk in American football.</td><td>Mortensen, JD; Vasavada, AN; Merryweather, AS</td><td>2020</td><td>10.1016/j.jbiomech.2019.109411</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr><tr><td>Implementation of a Virtual Reality rendered in Portable Devices for Strabismus Treatment based on Conventional Visual Therapy.</td><td>Cepeda-Zapata, LK; Romero-Soto, FO; Diaz de Leon, VA; Roa-Huertas, JL; Naal-Ruiz, NE; Ibarra-Zarate, D; Alonso-Valerdi, LM</td><td>2019</td><td>10.1109/EMBC.2019.8857222</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr><tr><td>Visual search and target detection during simulated driving in Parkinson's disease.</td><td>Ranchet, M; Morgan, JC; Akinwuntan, AE; Devos, H</td><td>2020</td><td>10.1016/j.aap.2019.105328</td><td></td><td>X</td><td></td><td>X</td><td></td><td></td><td>FT</td></tr><tr><td>Effects of downslope walking on Soleus H-reflexes and walking function in individuals with multiple sclerosis: A preliminary study.</td><td>Hoque, M; Borich, M; Sabatier, M; Backus, D; Kesar, T</td><td>2019</td><td>10.3233/NRE-192701</td><td></td><td></td><td>X</td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>EMG-Based Characterization of Walking Asymmetry in Children with Mild Hemiplegic Cerebral Palsy.</td><td>Di Nardo, F; Strazza, A; Mengarelli, A; Cardarelli, S; Tigrini, A; Verdini, F; Nascimbeni, A; Agostini, V; Knaflitz, M; Fioretti, S</td><td>2019</td><td>10.3390/bios9030082</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td></td><td>T/A</td></tr></tbody></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>Spinal subependymoma surgery: do no harm. Little may be more!</td><td>Soleiman, HA; Ironside, J; Kealey, S; Demetriades, AK</td><td>2020</td><td>10.1007/s10143-019-01128-x</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Ultrasound-Guided Percutaneous Electrical Nerve Stimulation of the Radial Nerve for a Patient With Lateral Elbow Pain: A Case Report With a 2-Year Follow-up.</td><td>Soleiman, HA; Ironside, J; Kealey, S; Demetriades, AK</td><td>2019</td><td>10.2519/jospt.2019.8570</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Effects of backward-downhill treadmill training versus manual static plantarflexor stretching on muscle-joint pathology and function in children with spastic Cerebral Palsy.</td><td>Hösl, M; Böhm, H; Eck, J; Döderlein, L; Arampatzis, A</td><td>2018</td><td>10.1016/j.gaitpo.st.2018.07.171</td><td></td><td></td><td></td><td>X</td><td></td><td>T/A</td></tr><tr><td>Strength and Step Activity After Eccentric Resistance Training in Those With Incomplete Spinal Cord Injuries.</td><td>Stone, WJ; Stevens, SL; Fuller, DK; Caputo, JL</td><td>2018</td><td>10.1310/sci17-00052</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Ambulation and physical function after eccentric resistance training in adults with incomplete spinal cord injury: A feasibility study.</td><td>Stone, WJ; Stevens, SL; Fuller, DK; Caputo, JL</td><td>2019</td><td>10.1080/10790268.2017.1417804</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Long-Term Regular Eccentric Exercise Decreases Neuropathic Pain-like Behavior and Improves Motor Functional Recovery in an Axonotmesis Mouse Model: the Role of Insulin-like Growth Factor-1.</td><td>Martins, DF; Martins, TC; Batisti, AP; Dos Santos Leonel, L; Bobinski, F; Belmonte, LAO; Mazzardo-Martins, L; Cargnin-Ferreira, E; Santos, ARS</td><td>2018</td><td>10.1007/s12035-017-0829-3</td><td>X</td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Effects of Classic Progressive Resistance Training Versus Eccentric-Enhanced Resistance Training in People With Multiple Sclerosis.</td><td>Patrocinio de Oliveira, CE; Moreira, OC; Carrión-Yagual, ZM; Medina-Pérez, C; de Paz, JA</td><td>2018</td><td>10.1016/j.apmr.2017.10.021</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>The Subclinical Cardiomyopathy of Friedreich's Ataxia in a Pediatric Population.</td><td>Plehn, JF; Hasbani, K; Ernst, I; Horton, KD; Drinkard, BE; Di Prospero, NA</td><td>2018</td><td>10.1016/j.cardfa il.2017.09.012</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>FT</td></tr><tr><td>Mechanisms contributing to gait speed and metabolic cost in children with unilateral cerebral palsy.</td><td>Pinto, TPS; Fonseca, ST; Gonçalves, RV; Souza, TR; Vaz, DV; Silva, PLP; Mancini, MC</td><td>2018</td><td>10.1016/j.bjpt.2017.06.015</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Consideration of Dose and Timing When Applying Interventions After Stroke and Spinal Cord Injury.</td><td>Basso, DM; Lang, CE</td><td>2017</td><td>10.1097/NPT.00000000000165</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Effects of Exercise on Type 2 Diabetes Mellitus-Related Cognitive Impairment and Dementia.</td><td>Callisaya, M; Nosaka, K</td><td>2017</td><td>10.3233/JAD-161154</td><td>X</td><td>X</td><td></td><td>X</td><td></td><td>T/A</td></tr><tr><td>Extrarenal rhabdoid tumor presented with an immobile arm in a one-year-old boy.</td><td>Chung, C; Liu, YL; Cheng, CJ; Hsieh, KLC; Tsai, ML; Wong, TT</td><td>2017</td><td>10.1016/j.brain dev.2017.04.001</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Medial gastrocnemius and soleus muscle-tendon unit, fascicle, and tendon interaction during walking in children with cerebral palsy.</td><td>Barber, L; Carty, C; Modenese, L; Walsh, J; Boyd, R; Lichtwark, G</td><td>2017</td><td>10.1111/dmcn.13427</td><td></td><td>X</td><td></td><td></td><td>X</td><td>T/A</td></tr><tr><td>Effectiveness and feasibility of eccentric and task-oriented strength training in individuals with stroke.</td><td>Folkerts, MA; Hijmans, JM; Elsinghorst, AL; Mulderij, Y; Murgia, A; Dekker, R</td><td>2017</td><td>10.3233/NRE-171433</td><td></td><td></td><td></td><td></td><td>X</td><td>T/A</td></tr><tr><td>Blink-associated contralateral eccentric saccades as a rare sign of unilateral brain injury.</td><td>Zivi, I; Bertelli, E; Bilotti, G; Clemente, IA; Saltuari, L; Frazzitta, G</td><td>2017</td><td>10.1212/WNL.000000000003484</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Contractile behavior of the medial gastrocnemius in children with bilateral</td><td>Hösl, M; Böhm, H; Arampatzis, A; Keymer, A; Döderlein, L</td><td>2016</td><td>10.1016/j.clinbi omech.2016.05.008</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>spastic cerebral palsy during forward, uphill and backward-downhill gait.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Is better preservation of eccentric strength after stroke due to altered prefrontal function?</td><td>Hedlund, M; Lindström, B; Sojka, P; Lundström, R; Boraxbekk, CJ</td><td>2016</td><td>10.1080/135547<br>94.2015.113023<br>2</td><td>X</td><td>X</td><td></td><td></td><td>X</td><td>T/A</td></tr><tr><td>Increased spinal reflex excitability is associated with enhanced central activation during voluntary lengthening contractions in human spinal cord injury.</td><td>Kim, HE; Corcos, DM; Hornby, TG</td><td>2015</td><td>10.1152/jn.0107<br>4.2014</td><td></td><td>X</td><td></td><td></td><td>X</td><td>T/A</td></tr><tr><td>Simulated activity but real trauma: a systematic review on Nintendo Wii injuries based on a case report of an acute anterior cruciate ligament rupture.</td><td>Müller, SA; Vavken, P; Pagenstert, G</td><td>2015</td><td>10.1097/MD.00<br>0000000000064<br>8</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>A systematic review and meta-analysis of strength training in individuals with multiple sclerosis or Parkinson disease.</td><td>Cruickshank, TM; Reyes, AR; Ziman, MR</td><td>2015</td><td>10.1097/MD.00<br>0000000000041<br>1</td><td></td><td></td><td></td><td></td><td>X</td><td>FT</td></tr><tr><td>Energy flow analysis of the lower extremity during gait in persons with chronic stroke.</td><td>Novak, AC; Li, Q; Yang, S; Brouwer, B</td><td>2015</td><td>10.1016/j.gaitpo<br>st.2014.12.018</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr><tr><td>Homocysteine-induced attenuation of vascular endothelium-dependent hyperalgesia in the rat.</td><td>Joseph, EK; Green, PG; Ferrari, LF; Levine, JD</td><td>2015</td><td>10.1016/j.neuro<br>science.2014.10<br>.056</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Forward stair descent with hybrid neuroprosthesis after paralysis: Single case study demonstrating feasibility.</td><td>Bulea, TC; Kobetic, R; Audu, ML; Schnellenberger, JR; Pinault, G; Triolo, RJ</td><td>2014</td><td>10.1682/JRRD.<br>2013.12.0257</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Long-term efficacy and complications of black diaphragm intraocular lens implantation in patients with traumatic aniridia.</td><td>Qiu, X; Ji, Y; Zheng, T; Lu, Y</td><td>2015</td><td>10.1136/bjoph<br>thalmol-2014-<br>305581</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Defining success in infant penetrating keratoplasty for developmental corneal opacities.</td><td>Medsinge, A; Speedwell, L; Nischal, KK</td><td>2014</td><td>10.3368/aoj.64.<br>1.81</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>A biomechanical cause of low power production during FES cycling of subjects with SCI.</td><td>Szecsi, J; Straube, A; Fornusek, C</td><td>2014</td><td>10.1186/1743-<br>0003-11-123</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr><tr><td>Muscle activation varies with contraction mode in human spinal cord injury.</td><td>Kim, HE; Thompson, CK; Hornby, TG</td><td>2015</td><td>10.1002/mus.24<br>285</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Understanding stand-to-sit maneuver: implications for motor system neuroprostheses after paralysis.</td><td>Chang, SR; Kobetic, R; Triolo, RJ</td><td>2014</td><td>10.1682/JRRD.<br>2013.12.0264</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr><tr><td>Evaluation of fixation pattern and reading ability in patients with Leber hereditary optic neuropathy.</td><td>Altpeter, EK; Blanke, BR; Leo-Kottler, B; Nguyen, XN; Trauzettel-Klosinski, S</td><td>2013</td><td>10.1097/WNO.<br>0b013e31829d1<br>f5b</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Machine-based morphologic analysis of glioblastoma using whole-slide pathology images uncovers clinically relevant molecular correlates.</td><td>Kong, J; Cooper, LAD; Wang, F; Gao, J; Teodoro, G; Scarpace, L; Mikkelsen, T; Schniederjan, MJ; Moreno, C S; Saltz, JH; Brat, DJ</td><td>2013</td><td>10.1371/journal<br>.pone.0081049</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Visual contrast sensitivity deficits in 'normal' visual field of patients with homonymous visual field defects due to stroke: a pilot study.</td><td>Clatworthy, PL; Warburton, EA; Tolhurst, DJ; Baron, JC</td><td>2013</td><td>10.1159/000354<br>810</td><td></td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Influence of contraction type, speed, and joint angle on ankle muscle weakness in Parkinson's disease: implications for rehabilitation.</td><td>Pang, MY; Mak, MK</td><td>2012</td><td>10.1016/j.apmr.<br>2012.06.004</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>Transfer effects of training-induced visual field recovery in patients with chronic stroke.</td><td>Bergsma, DP; Elshout, JA; van der Wildt, GJ; van den Berg, AV</td><td>2012</td><td>10.1310/tsr1903-212</td><td>X</td><td>X</td><td>X</td><td>X</td><td>FT</td></tr><tr><td>Effects of intensive physical rehabilitation on neuromuscular adaptations in adults with poststroke hemiparesis.</td><td>Andersen, LL; Zeeman, P; Jørgensen, JR; Bech-Pedersen, DT; Sørensen, J; Kjær, M; Andersen, JL</td><td>2011</td><td>10.1519/JSC.0b013e31822a62ef</td><td>X</td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Increased power generation in impaired lower extremities correlated with changes in walking speeds in sub-acute stroke patients.</td><td>Brincks, J; Nielsen, JF</td><td>2012</td><td>10.1016/j.clinbiomech.2011.08.007</td><td>X</td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Oculomotor behavior of hemianopic chronic stroke patients in a driving simulator is modulated by vision training.</td><td>Bergsma, DP; Leenders, MJA; Verster, JC; van der Wildt, GJ; van den Berg, AV</td><td>2011</td><td>10.3233/RNN-2011-604</td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr><tr><td>Tremor during movement correlates well with disability in people with essential tremor.</td><td>Norman, KE; D'Amboise, SN; Pari, G; Héroux, ME</td><td>2011</td><td>10.1002/mds.23811</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Recovery of visual-field defects after occipital lobe infarction: a perimetric study.</td><td>Çelebisoy, M; Çelebisoy, N; Bayam, E; Köse, T</td><td>2011</td><td>10.1136/jnnp.2010.214387</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Visual field expansion after visual restoration therapy.</td><td>Marshall, RS; Chmayssani, M; O'Brien, KA; Handy, C; Greenstein, VC</td><td>2010</td><td>10.1177/0269215510362323</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Low resonance frequency vibration affects strength of paretic and non-paretic leg differently in patients with stroke.</td><td>Tihanyi, J; 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Le Sant et al - Eccentric training in neurological patients

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Mak, MKY</td><td>10.1016/j.hkpj. 2011.08.026</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td><td></td></tr><tr><td>Atrophy and intramuscular fat in specific muscles of the thigh: Associated weakness and hyperinsulinemia in stroke survivors</td><td>Ryan, AS; Buscemi, A; Forrester, L; Hafer-Macko, CE; Ivey, FM</td><td>10.1177/154596 8311408920</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td><td></td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>The positive effect of mirror visual feedback on arm control in children with Spastic Hemiparetic Cerebral Palsy is dependent on which arm is viewed</td><td>Smorenburg, ARP; Ledebt, A; Feltham, MG; Deconinck, FJA; Savelsbergh, GJP</td><td>10.1007/s00221-011-2789-6</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Chemodenervation of the antagonist muscle</td><td>Gaber, TA; Azer, A; Basu, B; Mannemela, S</td><td>10.1007/s00415-011-6026-9</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Analgesics and Anti-inflammatory Medications in Sports: Use and Abuse</td><td>Feucht, CL; Patel, DR</td><td>10.1016/j.pci.2010.02.004</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Upper limb targeted complex rehabilitation with mechanotherapy in acute stroke patients</td><td>Samsygina, OM; Ivanova, GE; Kovrazhkina, EA</td><td>10.1159/000321-266</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Elbow Tendinopathy and Tendon Ruptures: Epicondylitis, Biceps and Triceps Ruptures</td><td>Rineer, CA; Ruch, DS</td><td>10.1016/j.jhsa.2009.01.022</td><td>X</td><td>X</td><td>X</td><td>X</td><td>FT</td></tr><tr><td>Disorders of the Achilles tendon</td><td>Duerden, JD; Keeling, JJ</td><td>10.1097/BCO.0b013e3282f379ad</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>One session of whole body vibration increases voluntary muscle strength transiently in patients with stroke</td><td>Tihanyi, TK; Horváth, M; Fazekas, G; Hortobágyi, T; Tihanyi, J</td><td>10.1177/026921-5507077814</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Functional output improvement in FES cycling by means of forced smooth pedaling</td><td>Szeci, J; Krause, P; Krafczyk, S; Brandt, T; Straube, A</td><td>10.1249/mss.0b013e3180334966</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>The Safety and Feasibility of High-Force Eccentric Resistance Exercise in Persons With Parkinson's Disease</td><td>Dibble, LE; Hale, T; Marcus, RL; Gerber, JP; LaStayo, PC</td><td>10.1016/j.apmr.2006.05.016</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Reproducibility analysis of isokinetic strength measurements of shoulder and elbow muscles in subjects with spinal cord injury</td><td>Kakebeeke, TH; Lechner, HE; Handschin, C</td><td>10.3233/ies-2005-0215</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Eccentric exercise in patients with chronic health conditions: a systematic review</td><td>Roig M; Shadgan B; Reid WD</td><td>2008</td><td>X</td><td>X</td><td>X</td><td>X</td><td>FT</td></tr><tr><td>Uphill and downhill walking in multiple sclerosis: a randomized controlled trial [with consumer summary]</td><td>Samaei A; Bakhtiary AH; Hajihasani A; Fatemi E; Motaharinezhad F</td><td>2016</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>One session of whole body vibration increases voluntary muscle strength transiently in patients with stroke [with consumer summary]</td><td>Tihanyi TK; Horvath M; Fazekas G; Hortobagyi T; Tihanyi J</td><td>2007</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Effects of concentric and eccentric control exercise on gross motor function and balance ability of paretic leg in children with spastic hemiplegia</td><td>Park SI; Kim M-S; Choi JD</td><td>2016</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Effects of backward-downhill treadmill training versus manual static plantarflexor stretching on muscle-joint pathology and function in children with spastic cerebral palsy [with consumer summary]</td><td>Hosl M; Bohm H; Eck J; Doderlein L; Arampatzis A</td><td>2018</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Effects of high resistance training in patients with myotonic dystrophy</td><td>Tollback A; Eriksson S; Wredenberg A; Jenner G; Vargas R; Borg K; Ansved T</td><td>1999</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>The effect of a high resistance exercise program in slowly progressive neuromuscular disease</td><td>Kilmer DD; McCrory MA; Wright NC; Aitkens SG; Bernauer EM</td><td>1994</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td>Physical activity and exercise for chronic pain in adults: an overview of Cochrane</td><td>Geneen LJ; Moore RA; Clarke C; Martin D; Colvin LA; Smith BH</td><td>2017</td><td>X</td><td>X</td><td>X</td><td>X</td><td>FT</td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>reviews (Cochrane review) [with consumer summary]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Effectiveness of surgical and non-surgical management of crouch gait in cerebral palsy: a systematic review [with consumer summary]</td><td>Galey SA; Lerner ZF; Bulea TC; Zimbler S; Damiano DL</td><td>2017</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td></td><td>FT</td></tr><tr><td>Efficacy of gait training using a treadmill with and without visual biofeedback in patients after stroke: a randomized study</td><td>Druzbicki M; Guzik A; Przysada G; Kwolek A; Brzozowska-Magon A</td><td>2015</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Combined effects of Botulinum toxin and casting treatments on lower limb spasticity after stroke</td><td>Farina S; Migliorini C; Gandolfi M; Bertolasi L; Casarotto M; Manganotti P; Fiaschi A; Smania N</td><td>2008</td><td></td><td>X</td><td>X</td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson's disease</td><td>Fisher BE; Wu AD; Salem GJ; Song J; Lin C-HJ; Yip J; Cen S; Gordon J; Jakowec M; Petzinger G</td><td>2008</td><td></td><td>X</td><td>X</td><td></td><td></td><td></td><td>FT</td></tr><tr><td>A randomized controlled trial of early surgery in Duchenne muscular dystrophy</td><td>Manzur AY; Hyde SA; Rodillo E; Heckmatt JZ; Bentley G; Dubowitz V</td><td>1992</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>FT</td></tr><tr><td>Reduction of spasticity in cerebral palsy using feedback of the tonic stretch reflex: a controlled study</td><td>O'Dwyer N; Neilson P; Nash J</td><td>1994</td><td></td><td>X</td><td>X</td><td></td><td>X</td><td></td><td>T/A</td></tr><tr><td>Blood Flow Restriction Exercise for Those With SCI</td><td>McDaniel, J</td><td>2021</td><td></td><td>X</td><td>X</td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Effects of Flywheel Exercise on Muscle and Walking Function in Teenagers and Young Adults With Cerebral Palsy</td><td>Fernandez Gonzalo, R</td><td>2017</td><td></td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Investigation of the Effects of Selective Exercise Training in Multiple Sclerosis</td><td>Firat, T</td><td>2021</td><td></td><td></td><td></td><td></td><td>X</td><td></td><td>FT</td><td>no data available</td></tr><tr><td>Intensive cycle ergometer training improves gait speed and endurance in patients with Parkinson's disease: a comparison with treadmill training</td><td>Arcolin, I; Pisano, F; Delconte, C; Godi, M; Schieppati, M; Mezzani, A; Picco, D; Grasso, M; Nardone, A</td><td>2016</td><td>10.3233/RNN-150506</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Training and Parkinson's</td><td>Signorile, J</td><td>2018</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Botulinum Toxin Type A and Kinesitherapy of Post-stroke Patients</td><td>Melo, A</td><td>2009</td><td></td><td>X</td><td></td><td>X</td><td></td><td></td><td>T/A</td></tr><tr><td>Comparison of Concentric or Eccentric Virtual Reality Training Program in Subacute-stroke Patients With Hemispatial Neglect</td><td>Deog Young, K</td><td>2020</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Eccentric Contraction-based Resistance Exercise for Chronic Stroke Patients</td><td>Lim, JY</td><td>2020</td><td></td><td></td><td></td><td></td><td>X</td><td></td><td>FT</td><td>no data available</td></tr><tr><td>Improving Stretching Interventions for Children With Cerebral Palsy</td><td>O'Brien TD</td><td>2016</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>FT</td></tr><tr><td>Stretching in Children and Adolescents With Spastic Cerebral Palsy</td><td>Kruse, A</td><td>2020</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>FT</td></tr><tr><td>Progressive Functional Strength Training in Unilateral Spastic Cerebral Palsy</td><td>Kara, OK</td><td>2015</td><td></td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td></tr><tr><td>Amblyopia and Stereoptic Games for Vision</td><td>Steffen, H</td><td>2021</td><td></td><td>X</td><td>X</td><td>X</td><td></td><td>X</td><td>T/A</td></tr><tr><td>Treadmill in the Rehabilitation of Parkinsonian Gait</td><td>Tassorelli, C</td><td>2019</td><td></td><td>X</td><td></td><td></td><td>X</td><td></td><td>T/A</td></tr><tr><td>Radial Extracorporeal Shock Wave Therapy for Spastic Plantar Flexor Muscles in Young Children With Cerebral Palsy</td><td>Jia, F</td><td>2016</td><td></td><td>X</td><td></td><td></td><td>X</td><td></td><td>T/A</td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>Tendon Vibrations Effect on Upper Limb Motor Recovery After Recent Stroke</td><td>Yelnik, A</td><td>2021</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Intervention Assessing the Role of Exercise Program and Nutrition Supplement for Sarcopenia</td><td>Chan, R</td><td>2017</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Effects of Sleep Deprivation on Blood Hormones and Inflammatory Status After Exercise Induced-muscle Damage</td><td>Mello, MT</td><td>2013</td><td></td><td>X</td><td></td><td>X</td><td>X</td><td>T/A</td><td></td></tr><tr><td>The Effects of Functional Power Training on Frail and Pre-frail Community - Dwelling Older Adults in Singapore</td><td>Wee, SL</td><td>2020</td><td></td><td>X</td><td></td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Study of Epicutaneously Applied Ketoprofen Transfersome® Gel With or Without Combination With Oral Celecoxib for the Treatment of Muscle Pain Induced by Eccentric Exercise</td><td>X pert Med GmbH</td><td></td><td></td><td>X</td><td></td><td></td><td>X</td><td>T/A</td><td></td></tr><tr><td>Different Proprioceptive Neuromuscular Facilitation (PNF) Technique in Patients With Knee Osteoarthritis</td><td>Can, F</td><td>2021</td><td></td><td>X</td><td>X</td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Effect of Open Kinetic Chain Shoulder Exercises on Scapulothoracic Muscle Activity on Stable and Unstable Ground</td><td>Canli, K</td><td>2022</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Exercises With Elastic Bands and Stability in Proprioception and Strength in Female Athletes of Taekwondo</td><td>Investigación en Hemofilia y, Fisioterapia</td><td>2020</td><td></td><td>X</td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Somatosensory Dysfunction as the Underlying Mechanism of Upper Limbs Motor Blocks in People With Parkinson's Disease</td><td>Nieuwboer, A</td><td>2016</td><td></td><td></td><td>X</td><td></td><td>X</td><td>T/A</td><td></td></tr><tr><td>Vibrational-proprioceptive Resistance Exercise Training Versus Neuromuscular Electrical Stimulation Training in Elderly People With Muscle Weakness</td><td>Kern, H</td><td>2014</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Pilates Method in People With HAM/TSP</td><td>Pedreira, E</td><td>2018</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Effect of Body Suspension and Tilting Exercises in Parkinson's Disease</td><td>De Oliveira, CB</td><td>2016</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Whole-body Electromyostimulation in Inpatient Rehabilitation</td><td>Mooren, F</td><td>2020</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Functional Vision in TBI</td><td>Schuchard, R</td><td>2013</td><td></td><td></td><td>X</td><td></td><td>X</td><td>T/A</td><td></td></tr><tr><td>Detection and Treatment of Sarcopenia and Myosteatosis in Older African Americans</td><td>Harris-Love, M</td><td>2021</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Kabat Technique and Neuromuscular Effect in Patients With Bell's Palsy</td><td>Saeed, A</td><td>2020</td><td></td><td>X</td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Contralateral Strength-training After Anterior Cruciate Ligament (ACL) Reconstruction</td><td>Maffiuletti, NA</td><td>2015</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Effects of Eccentric Training Intervention in Older Adults</td><td>Lim, JY</td><td>2019</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Somatic Yoga and Meditation for Cancer Survivors With Pain From Neuropathy</td><td>Galantino, ML</td><td>2019</td><td></td><td>X</td><td>X</td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Two Resistance Training Protocols to Reduce the Risk of Falls in Parkinson's Disease</td><td>Intzandt, B</td><td>2016</td><td></td><td></td><td>X</td><td></td><td>X</td><td>T/A</td><td></td></tr></table>
Le Sant et al - Eccentric training in neurological patients

<table><tr><td>The Effect of Isokinetic Strengthening Training</td><td>Cheng, YY</td><td>2022</td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Mobility Training Using a Bionic Knee Orthosis in Patients Chronic Post-Stroke: A Case Series</td><td>Byl, NN</td><td>2011</td><td></td><td>X</td><td></td><td>X</td><td></td><td>T/A</td><td></td></tr><tr><td>The Effect of the Reverse Nordic Curl Exercise on Quadriceps Femoris Muscles Injury Rate Among Soccer Players</td><td>Al Attar, WSA</td><td>2021</td><td>X</td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Resistance Exercise Modify Cardiovascular Responses of Professors During Teaching and Sleep</td><td>Teixeira-Araujo, AA</td><td>2014</td><td>X</td><td>X</td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>High Intensity Interval Training in Chronic Stroke Patients</td><td>Smania, N</td><td>2016</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Low-Volume Interval Training and Resistance Exercise in Individual With Stroke</td><td>Abd Manaf, MH</td><td>2021</td><td></td><td></td><td></td><td>X</td><td></td><td>FT</td><td>no data available</td></tr><tr><td>Effects of Variable Load Exercise on Aging Atrophy</td><td>Pisot, R</td><td>2020</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Physical Exercises for Temporomandibular Disorders</td><td>Bernhardt, O</td><td>2022</td><td>X</td><td></td><td></td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Efficacy of Exercise on Post Needling Soreness</td><td>Fernández-de-las-Peñas, C</td><td>2019</td><td>X</td><td></td><td></td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Exercise and Neuroprotection in Older Persons With Multiple Sclerosis</td><td>Jørgensen, MLK</td><td>2024</td><td></td><td></td><td></td><td></td><td>X</td><td>T/A</td><td>no data available</td></tr><tr><td>Metabolic Health in Individuals With Spinal Cord Injury (SCI)</td><td>Yarar-Fisher, C</td><td>2022</td><td></td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Maximizing Mechanisms of Muscle Hypertrophy to Combat Sarcopenia in Older Adults</td><td>Stec, MJ</td><td>2012</td><td>X</td><td></td><td></td><td>X</td><td></td><td>T/A</td><td></td></tr><tr><td>Muscle Damage and Disuse Atrophy</td><td>University of Exeter</td><td>2019</td><td>X</td><td>X</td><td></td><td></td><td></td><td>FT</td><td></td></tr><tr><td>Muscle Weakness and Post-traumatic Knee OA</td><td>Chmielewski, T</td><td>2013</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Daily Undulating Periodization Methods With Parkinson's Disease</td><td>Signorile, JF</td><td>2019</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Structural and Metabolic Determinants of Sarcopenia and the Efficacy of Concentric vs. Eccentric Exercise Training</td><td>Narici, MV</td><td>2017</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Effects of Parmigiano Reggiano on Muscle and Inflammatory Response to Eccentric Resistance Training in Older Adults</td><td>Moro, T</td><td>2022</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Effects of High-velocity Resistance Training and Creatine Supplementation in Healthy Aging Males</td><td>Candow, DG</td><td>2018</td><td>X</td><td>X</td><td></td><td>X</td><td></td><td>T/A</td><td></td></tr><tr><td>Reducing Falls With RENEW in Older Adults Who Have Fallen</td><td>Lastayo, PC</td><td>2014</td><td>X</td><td></td><td></td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Eccentric Resistance Training in Adults with and without Spinal Cord Injuries</td><td>Stone, W J; Stevens, SL; Fuller, DK; Caputo, JL</td><td></td><td></td><td></td><td>X</td><td></td><td></td><td>T/A</td><td></td></tr><tr><td>Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial</td><td>Rodriguez, K; Garcia, SA; Spino, C; Lepley, LK; Pang, Y; Wojtys, E; Bedi, A; Angelini, M; Ruffino, B; Bolley, T; Block, C; Kellum, J; Swartout, A; Palmieri-Smith, RM</td><td>2020</td><td>10.1093/ptj/pza a169</td><td>X</td><td></td><td></td><td></td><td>T/A</td><td></td></tr></table>
Le Sant et al - Eccentric training in neurological patients

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Le Sant et al - Eccentric training in neurological patients

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Le Sant et al - Eccentric training in neurological patients

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Le Sant et al - Eccentric training in neurological patients

<table><thead><tr><th colspan="2">EXPERIMENTAL LENGTHENING CONTRACTIONS</th><th></th><th></th><th></th><th></th><th></th><th></th><th></th><th></th><th></th></tr></thead><tbody><tr><td colspan="2">Early response of heat shock proteins to functional overload of the soleus and plantaris in rats and mice</td><td>Huey, KA; Burdette, S; Zhong, H; Roy, RR</td><td>2010</td><td>10.1113/expphy siol.2010.05469 2</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td colspan="2">Immunohistochemical myofiber typing and high-resolution myofibrillar lesion detection in LR White embedded muscle</td><td>Thompson, JL; Vijayan, K; Riley, DA</td><td>2000</td><td>10.1002/1097- 0029(20000615 )49:6&lt;589::AID - JEMT9&gt;3.0.CO ;2-8</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td colspan="2">Mechanisms Mediating Vibration-Induced Chronic Musculoskeletal Pain Analyzed in the Rat</td><td>Dina, OA; Joseph, EK; Levine, JD; Green, PG</td><td>2010</td><td>10.1016/j.jpain. 2009.08.007</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr><tr><td colspan="2">Genetic deletion of trkB.T1 increases neuromuscular function</td><td>Dorsey, SG; Lovering, RM; Renn, CL; Leitch, CC; Liu, XY; Tallon, LJ; Sadzewicz, LD; Pratap, A; Ott, S; Sengamalay, N; Jones, KM; Barrick, C; Fulgenzi, G; Becker, J; Voelker, K; Talmadge, R; Harvey, BK; Wyatt, RM; Vernon-Pitts, E; Zhang, C; Shokat, K; Fraser-Liggett, C; Balice-Gordon, RJ; Tessarollo, L; Ward, CW</td><td>2012</td><td>10.1152/ajpcell. 00469.2010</td><td>X</td><td>X</td><td>X</td><td>X</td><td>X</td><td>T/A</td></tr></tbody></table>

T/A: title/abstract; FT: full text
<table><caption>**Supplementary File 5.** Adherence scoring for the ACSM guideline recommendations for resistance training, from Hendrey et al (2018).</caption><thead><tr><th></th><th>Frequency</th><th>Intensity</th><th>Type of exercise</th><th>Specificity</th><th>Repetitions</th><th>Sets</th><th>Patterns</th><th>Progressivity</th><th>TOTAL</th></tr></thead><tbody><tr><td>Rating</td><td>0 : &lt; 2d/wk<br>1 : ≥ 2d/wk</td><td>0 : RM/ max force : not determined<br>0 : not based on ACSM guidelines<br>1 : adapted and adjusted to participant</td><td>0 : not all major muscle groups<br>1 : all major muscle groups</td><td>0 : no<br>0.5 : partially, RoM or contraction type<br>1 : RoM and contraction type</td><td>0 : not adapted/precised<br>1 : precised</td><td>0 : not detailed<br>1 : adapted to objective</td><td>0 : &lt;1-2 minutes (between sets), or &lt;48h (between sessions)<br>0.5 : partially, between sets or sessions<br>1 : between sets and between sessions</td><td>0 : no progression or reported<br>1 : progression</td><td></td></tr><tr><td>Study</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lattouf 2021</td><td>1</td><td>1</td><td>0</td><td>0.5</td><td>1</td><td>1</td><td>0.5</td><td>0</td><td>5</td></tr><tr><td>Kadkhodaie 2020</td><td>1</td><td>1</td><td>0</td><td>1</td><td>0</td><td>1</td><td>1</td><td>1</td><td>6</td></tr><tr><td>Dibble 2015</td><td>1</td><td>1</td><td>0</td><td>0.5</td><td>0</td><td>0</td><td>0.5</td><td>1</td><td>4</td></tr><tr><td>Clarke 2012</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>8</td></tr><tr><td>Hayes 2011</td><td>1</td><td>0</td><td>1</td><td>0.5</td><td>0</td><td>0</td><td>1</td><td>1</td><td>4.5</td></tr><tr><td>Dibble 2009</td><td>1</td><td>1</td><td>0</td><td>0.5</td><td>0</td><td>0</td><td>0.5</td><td>1</td><td>4</td></tr><tr><td>Engardt 1995</td><td>1</td><td>1</td><td>0</td><td>0.5</td><td>0</td><td>0</td><td>1</td><td>1</td><td>4.5</td></tr><tr><td>Fernandez-Gonzalo 2016</td><td>1</td><td>0</td><td>0</td><td>0.5</td><td>1</td><td>1</td><td>0.5</td><td>0</td><td>3.5</td></tr><tr><td>Lee 2013</td><td>1</td><td>0</td><td>0</td><td>0.5</td><td>1</td><td>1</td><td>0.5</td><td>0</td><td>4</td></tr><tr><td>Dibble 2006</td><td>1</td><td>1</td><td>0</td><td>0.5</td><td>0</td><td>0</td><td>0.5</td><td>1</td><td>4</td></tr></tbody></table>

Hendrey G, Holland AE, Mentiplay BF, Clark RA, Williams G. Do Trials of Resistance Training to Improve Mobility After Stroke Adhere to the American College of Sports Medicine Guidelines? A Systematic Review. Archives of physical medicine and rehabilitation. 2018;99(3): 584-597 e51
**Supplementary File 6.** Standardised mean difference (95% CI) of effect of eccentric resistance training versus comparator (usual rehabilitation, or control) on muscle structure (A, n=83), muscle activity (B, n=54), spasticity (C, n=68), balance (D, n=66), and risk of fall (E, n=77) immediately after the intervention.

A

<figure><img src="image_16.png" /></figure>

B

<figure><img src="image_17.png" /></figure>

C

<figure><img src="image_18.png" /></figure>

D

<figure><img src="image_19.png" /></figure>
Eccentric training in neurological patients

E

<figure><img src="image_20.png" /></figure>

Additional analyses on overall effect

Large effect studies.

All studies – not Fernandez-Gonzalo (2016): -0.60 [-1.13, -0.07]

All studies – not Lee (2013): -0.62 [-1.12, -0.12]

All studies – not Dibble (2009): -0.60 [-1.10, -0.11]

Initial severity of motor impairment

All studies – not 'severe' motor impairment: -0.60 [-1.13, -0.07]

All studies – not 'good' motor impairment: -0.82 [-1.41, -0.23]

All studies – not 'severe' and 'moderate' motor impairment: -0.49 [-1.30, 0.31]