Resistance Training: A Foundation for Musculoskeletal Health and Longevity

Why Bother with Resistance Training?

As a sports medicine physician, I frequently recommend strength and resistance training as a cornerstone of musculoskeletal health. In my practice, I see many tendon, ligament, and joint issues—many of which are preventable with a foundation of muscle and proper movement patterns. Resistance training not only builds muscle strength but also improves bone density, enhances metabolic health, improves function, and prevents injuries. Ultimately, it will improve quality of life and healthspan. While there are countless other reasons that cannot be covered in a short article, I will summarize the highlights below:

• Improved muscle strength and endurance: As we age, we naturally lose muscle mass and strength. This is referred to as sarcopenia, and can contribute to fragility in old age. Regular resistance training is essential in slowing or even reversing the progression of muscle loss.

• Enhanced bone density: Reduces risk of osteoporosis and fractures. A future post will cover in detail how to preserve bone health while aging.

• Better joint stability, mobility, and function: Improves walking speed, grip strength, and joint range of motion, making everyday activities easier and more efficient and decreasing the likelihood of injuries and falls

• Improved metabolic health: Helps with blood sugar control and manage weight. Muscle cells act as a glucose sink by absorbing and storing glucose. Having more muscle mass increases insulin sensitivity, thereby reducing blood sugar levels and lowering the risk of type 2 diabetes. There is a common misconception that cardiovascular exercise alone is sufficient for effective blood glucose regulation, but without resistance training, its impact is significantly diminished.

• Improved body composition: Increased muscle mass not only enhances physical appearance—a welcomed benefit for most—but also raises your basal metabolic rate. Think about it this way –muscle is expensive for your body to maintain, which is a good thing. This means your body burns more calories at rest, which can support ongoing fat loss.

• Reduced pain: Alleviate symptoms of chronic conditions like arthritis and tendonitis

• Enhanced mental health, mood, and sleep: Contributes to better mood and cognitive function. Not only that, resistance training has been consistently shown to improve sleep quality, duration, and efficiency, often more effectively than aerobic exercise alone.

Research confirms that strength training provides these benefits across all age groups, from adolescents to older adults12.

Understanding the Basics of Strength Training

Strength training involves exercises that cause your muscles to contract against resistance with the expectation of increases in strength, tone, mass, and endurance. The resistance can come from free weights, weight machines, resistance bands, or your own body weight. When properly designed and executed, strength training safely stimulates muscle growth while improving your overall function and quality of life. This guide will help you understand the fundamentals of strength training and how to implement an effective program tailored to your needs.

Key Terminology

Before diving into how to get started or optimizing your program design, let's clarify some common terminology:

• Repetitions (reps): The number of times you perform a specific exercise

• Sets: A group of repetitions

• Resistance/Load: The amount of weight or tension used

• Rest period: Time between sets

• Range of motion: The full movement potential of a joint, from flexion to extension

• Progressive overload: Gradually increasing the weight, frequency, or number of repetitions to continually challenge your muscles

• Repetitions in reserve (RIR): The number of repetitions you could have done in good form at the end of a set

Understanding these concepts will help you understand my recommendations and effectively track your progress.

Fundamental Strategy for Effective Training

Exercise Selection

When time is limited, prioritize exercises that give you the most benefit. Multi-joint (compound) exercises that work several muscle groups simultaneously are more time-efficient and functional than single-joint exercises3. For a complete program, include at minimum:

1. A leg pressing exercise (e.g., squats)

2. An upper-body pulling exercise (e.g., rows or pull-ups)

3. An upper-body pushing exercise (e.g., push-ups or bench press)

These fundamental movements train the major muscle groups and reflect the patterns we use in daily activities3.

Volume and Frequency

There are a lot of variables that affect the recommended volume and frequency, largely based on your current level of fitness, age, and goals (strength vs hypertrophy). Luckily, there is a broad range of programs you could follow that all will lead to good results. Strength and hypertrophy (muscle growth) generally go hand in hand and overlap, but changing the weight and repetition scheme can slightly optimize one over the other. For most people, particularly for those who are new to resistance training, focusing on slightly higher reps in good form with a weight that feels moderate will likely be your best bet.

For hypertrophy:

• Aim for 3-5 working sets per exercise and anywhere from 6-30 repetitions. A comfortable sweet spot for most people would be 8-12, but anywhere in the range is acceptable based on your preferences. Aim for a minimum of 4 sets per muscle group per week, but this can go as high as 16-20 sets per muscle group per week based on your fitness.

For strength:

• To prioritize mainly strength without much hypertrophy, the volume can be much lower, but the weight should be much heavier. Generally, you can do 3-5 sets of 1-5 repetitions. Soreness will generally be less when specifically targeting strength since the volume is lower, but your central nervous system may feel more wiped out due to the strengthening of the neural connections between your brain and muscles, which usually just feels like overall fatigue. For pure strength, you have to push the weight more and the repetitions in reserve at the end of each set need to be lower (perhaps 1-2 RIR). For example, if you choose a weight you could do 10 reps of, but only do 5 thinking you are going to build strength, that isn’t going to cut it! That being said, remember that form is particularly important when the weight is heavier - you want to make sure every repetition is still done correctly to avoid injuries.

For either of these methods, make sure the last few repetitions in each set feel hard! Allow 48 hours of recovery between sessions for the same muscle group13 This approach ensures adequate stimulus for strength and muscle development and the rest allows proper recovery.

Building Your Exercise Program

Assessment and Goal Setting

Before starting any program, assess your:

1. Current fitness level

2. Medical conditions or limitations

3. Specific goals (optimizing for specific sport, pain reduction, functional improvement, general health)

4. Available equipment and time

Setting realistic, measurable goals will help you track progress and stay motivated.

How to Program

It can be overwhelming to start a new program if you are new to resistance training, and given the importance of form in compound lifts, it is usually best to get started with a trainer or individual who can help guide you and ensure you are doing all the movements safely. If you are already familiar with the exercises and resistance training, you will be able to progress on your own if you follow these general concepts. It isn’t possible to set up a generic program to follow given the need for an individualized approach based on your specific workout history and goals.

Frequency: at least 2 non-consecutive days per week for beginners (e.g., Monday, Wednesday, Friday), but can be as high as 5 if advanced.

Intensity: Choose a weight that allows proper form - slightly lower rep/heavier to prioritize strength, slightly higher rep/lighter for hypertrophy, as explained above

Volume: 1-2 sets per exercise for beginners, progressing to up to 5 or more sets per exercise for the advanced

A common training methodology for beginners may be twice a week of the exact same full body workout. As you get used to the training stimulus, you may add days and change the splits. One common way to do this is a 3 day a week plan of: Chest/Back, Shoulders/Arms, Legs. For those who have the time to add an additional day, a 4 day a week plan could consist of Chest/Tri, Back/Bi, Shoulders, Legs. Dedicated core strengthening should also be added in, as I’ve explained in a prior post. As you can see, there are almost infinite ways to be successful, and there is no one right way to do this.

Proper Form and Technique

Proper technique is crucial for effectiveness and safety. General guidelines include:

• Maintain neutral spine alignment during exercises. Please refer to my back pain article regarding proper hip hinging.

• Control movements throughout the full range of motion

• Perform both the lifting (concentric) and lowering (eccentric) phases with control

• Breathe naturally during exercises—exhale during exertion, inhale during return

• Focus on the muscles being worked rather than just moving the weight

An investment in a personal trainer to learn the correct technique will prevent injuries and improve results if you are not familiar with the exercises. The last thing you want is to be out of the gym and behind on your fitness goals due to injuries!

Designing Your Personal Training Plan

Scheduling and Progression

Consistency is key for long-term success. Schedule your workouts like any other important appointment2. Begin with:

• Weeks 1-2: Learning exercises with light weights, focusing on form

• Weeks 3-6: Gradually increase weight while maintaining proper technique

• Weeks 7+: Continue progressive overload by increasing weight or repetitions

Record your workouts to track progress and stay motivated. Research shows that keeping records helps people adhere to strength training programs long-term2.

How to progressive overload

Progressive overload is the gradual increase of stress placed on the body during exercise to continually challenge muscles and promote strength and growth. As you grow stronger, your program should evolve. Progression can include:

1. Increasing weight or resistance

2. Adding more repetitions or sets

3. Decreasing rest periods between sets

4. Incorporating more challenging exercise variations

5. Adding new exercises for greater movement variety

If you plateau, change one variable at a time to continue making progress. If you have really hit a wall, consider taking a deload week where you go much lighter or don’t lift weights at all to reset physically and mentally, and then go back to it.

Remember that muscle is metabolically expensive for our bodies to maintain - they require a lot of glucose, energy, and nutrients. Our bodies are efficient and will adapt to your training program, so it is important to try to continue to overload or change up your workout plan every once in a while, but without being too erratic. Tracking your workouts and weight/rep scheme can be useful in identifying when you are reaching a plateau and need to change something.

Special Considerations

Age-Related Adaptations

For older adults, strength training is particularly valuable but may require modifications:

• Begin with 1-2 sets of 10-15 repetitions

• Use a slower progression in weight increases

• Allow longer rest periods between sets

• Focus on functional movements that translate directly to daily activities

• Pay extra attention to proper warm-up2

Training with Medical Conditions

If you have medical conditions such as hypertension, arthritis, or previous injuries, your training program should be adapted accordingly. A PM&R physician can help design a program that addresses your specific needs while working around limitations.

Time-Efficient Training Approaches

When time is limited, consider these science-backed strategies:

• Supersets: Perform two exercises back-to-back before resting

• Circuit training: Complete a series of exercises with minimal rest between them

• Drop sets: Perform an exercise to fatigue, then immediately reduce the weight and continue

These techniques can reduce workout time by approximately half while maintaining effectiveness, though they may be better for muscle growth than maximal strength development3.

The PREHAB Approach to Warm-Up and Flexibility

1. Exercise-specific warm-up: Performing the planned exercises with lighter weights is essential prior to the first working set to allow the muscles to activate properly and get the blood flowing.

2. Movement preparation: Include mobility exercises that mimic the movements you'll be performing in your workout34

3. While passive stretching has previously been recommended, it really only needs to be prioritized if improved flexibility is a specific goal. Otherwise, simply performing the resistance exercises through the full natural range of motion of each joint is sufficient to maintain and improve mobility. Yoga may also be added for a more active stretching program that includes core strengthening and balance.

This approach maximizes your training time while preparing your body for safe, effective exercise.

The TLDR

Strength training is a powerful tool for improving musculoskeletal health, function, and quality of life. I encourage patients to view strength training not just as exercise but as an investment in their long-term health and independence.

Start with the fundamentals outlined in this guide, focus on proper form and consistent progression, and consult with healthcare professionals when needed. Remember that strength, like any skill, develops through practice and patience. Your body will thank you for the effort you put into maintaining and improving your strength throughout life.

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Rohit Jayakar, MD

About the Author: Rohit Jayakar MD specializes in non-surgical Sports Medicine (Physical Medicine & Rehabilitation). He treats a variety of musculoskeletal injuries, neurological injuries, and pain conditions.