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Article Influence of hand grip in resistance-training exercises on the triceps

brachii activation: A narrative review

Article in Journal of Physical Education and Sport · October 2024

DOI: 10.7752/jpes.2024.10272

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Journal of Physical Education and Sport ® (JPES), Vol. 24 (issue 10), Art 272, pp. 1456 - 1464, October 2024
online ISSN: 2247 - 806X; p-ISSN: 2247 – 8051; ISSN - L = 2247 - 8051 © JPES
Original Article

Influence of hand grip in resistance-training exercises on the triceps brachii

activation: A narrative review

SALVADOR VARGAS-MOLINA1, IVÁN CHULVI-MEDRANO2*, DIEGO A. BONILLA3, MANUEL

GARCÍA-SILLERO4
1,5
Body Composition and Biodynamic Laboratory, Faculty of Education Sciences, University of Málaga,
SPAIN;
1,2
Research Division, Dynamical Business & Science Society – DBSS International SAS, 110311 Bogotá,
COLOMBIA
2
Prevention and Health in Exercise in Sport (PHES). Department of Physical and Sports Education. Faculty of
Physical, Activity and Sport Sciences, University of Valencia, SPAIN
4
Research Group in Physical Activity, Sports and Health Sciences (GICAFS), Universidad de Córdoba, 230002
Montería, COLOMBIA

Published online: October 31, 2024

Accepted for publication: October 15, 2024
DOI:10.7752/jpes.2024.10272

Abstract
Introduction: When you perform an exercise to only one joint of your body, a change in the axis line can have
significant effects on the extent that agonist muscle is activated. In this review, the authors critically present an
analysis of potential injury risks by certain triceps brachii exercises. Hand positioning (pronation/supination) was
suggested to influence activation of the long, medial and lateral heads of the Triceps Brachii. Yet, assessing the
medial head activation with surface electromyography is still impossible as it cannot be recorded because of its
anatomical situation. Secondly, some exercises can strain or damage passive tissues that are hard to be felt and
thus will not alarm the exception but may deteriorate as time goes by until an injury is generated. Materials and
Methods: The aim of this review to illustrate beneficial and contrary hand position changes, during different
triceps brachii exercises with appropirate health aspects. This type of analysis aims to maximize congruence and
coaxial alignment across joints, taking into account any overloading effects on certain ligaments which could
potentially increase injury risk. Results: There is currently limited evidence in the literature supporting that one
grip hand (pronated or supinated) target certain heads of the triceps brachii either more than other heads.
However, a neutral hand grip might reduce injury risk and provide the most stability. As a result this positioning
might additionally have advantage Conclusions: The single-joint triceps brachii strengthening exercises were
categorized into three levels (good, moderate to good and poor) according joint safety and efficacy in this
review. Nevertheless, the analysis did not account for stretch placement through exercises which may have
stronger potential to increase hypertrophy.
Keywords: Strength training; exercise movement techniques; muscle strength; musculoskeletal pain;
muscle hypertrophy; sports injury

Introduction
Resistance training in the upper limb is organized using push-and-pull exercises (Vargas et al., 2019).
Pushing exercises mainly involve the pectoralis major, deltoids in its clavicular portion, and triceps brachii (TB),
as these exercises approach and move away dynamically and in unison, acting as agonists or synergists (Gottlob,
2008). Although there are several studies on the involvement of these muscles in trunk movements (e.g., bench
press) (Lauver, Cayot, & Scheuermann, 2016; Rodriguez-Ridao, Antequera-Vique, Martin-Fuentes, & Muyor,
2020; Saeterbakken, Mo, Scott, & Andersen, 2017), few have focused on single-joint exercises. The single-joint
push exercise involves elbow extension, in which the agonist muscle is the TB. Anatomically, the TB has three
clearly differentiated fascicles: medial, lateral, and long heads (A. Ali et al., 2015), which can function
independently (Madsen et al., 2006).
The influence of different angles of the shoulder and elbow joints on the ability of the TB to produce an
extension moment of the shoulder joint has also been investigated (Landin & Thompson, 2011). In this regard,
the surface electrical activity of musculoskeletal tissue (sEMG) and inverse kinematics are used to assess the
functional capacity of the three heads by comparing muscle strength and activity at various angles of shoulder
flexion (Kholinne et al., 2018). Moreover, differences in cognitive stress have been observed between the heads
of the triceps (Hussain, Sundaraj, & Subramaniam, 2020). Furthermore, functional activities associated with
activities of daily life involve the medial, lateral, and long heads (Srinath, Corey, Nitz, & Uhl, 2015). Although
the three heads have different functions and can be activated more intensely depending on the movement

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Corresponding Author: IVÁN CHULVI-MEDRANO, E-mail: [email protected]
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performed (they can be targeted individually), the three triceps muscle are involved (although activation levels
vary) during elbow extension (Hussain, Sundaraj, Subramaniam, & Lam, 2020).
Certain beliefs derived from traditional body building have been assumed when the aim is to optimize
TB activation and muscle hypertrophy. For example, it has been proposed that i) higher activation of the TB
lateral head is reached when the thumb points upward (neutral grip), ii) more emphasis is placed on the long
head through the internal part of the triceps with a pronate grip, and iii) supine grip will evoke higher activation
of the medial head (Schwarzenegger, 1992). The only investigation to our knowledge is the one proposed by
Villalba et al. (2024), where they evaluated the hand position, prone or supine with two different handles, handle
vs. standard padded pulley strap, on the long and lateral head. In this case, there was more electrical activity with
the supine hand for the long head. However, with the pronated position there were no significant differences.
Subsequently, Professor Tesch (2001) applied nuclear magnetic resonance to analyze the contribution of
the different TB heads to the main exercises. In the book describing the results, neither the sample nor the
methodology is described, but for this review, it is emphasized that with neutral grip and shoulder flexion intense
muscular implications are obtained (as defined in his original text) (Tesch, 2001, page 80). In his compilation he
includes overhead triceps extension with reverse grip in which the lateral and medial head only obtain the rating
of moderate muscle involvement. In another inverted grip exercise, the unilateral pulley pulldowns do show
intense muscle activity in all heads (Tesch, 2001).
However, scientific evidence focused on TB muscle activity in different variants of exercise movement
remains limited and is even less regarding the hand position when performing different exercises. While sEMG
has been studied in relation to supination and pronation in the elbow flexors (Naito et al., 1995) or forearm
musculature (Bader et al., 2018; Gordon, Pardo, Johnson, King, & Miller, 2004), there is limited research to date
evaluating sEMG in the different variations used in TB exercises. The aim of this review was to explore whether
the position of the hand in single-joint exercises for TB can generate more risks than benefits when the objective
is to focus on a certain head.

Functional anatomy and performance

Joint physiology distinguishes two different functions in the elbow joint:) prono-supination, which
affects the superior radioulnar joint, and b) flexion-extension through the humerus-ulnar and humerus-radial. In
flexion, the biceps brachii, brachialis, and brachioradialis are mainly involved and in extension the TB is the
main component (Kapandji, 2006). Furthermore, elbow extension is minimally reinforced by the anconeus
(Tortora, 2005).
The lateral head of TB originates on the posterior side of the humerus, proximal two-thirds of the lateral
brachial intermuscular septum, and the medial head on the posterior side of the humerus on the medial brachial
intermuscular septum (Putz & Pabst, 2000). The long head of the TB originates from the infraglenoid tubercle of
the scapula, whereas the three heads are inserted into the olecranon. However, the fibers of the long head run
longitudinally, whereas those of the medial and lateral heads run obliquely (Soubeyrand et al., 2017). The
difference in origin affects functionality; while the three heads act as elbow extensors, the long head additionally
acts on the scapula, bringing the shoulder closer (Boeckh-Behrens & Buskies, 2005). Moreover, the shoulder
acts as a third-class lever, with the strength applied between the joint axis and the load (Salmons, 1995).
Current research on TB focuses on muscle length, shoulder position, and the degree of elbow flexion to
provide more targeted work on specific portions of the muscle. The position of the elbows and shoulders can
affect the activation of the long head owing to its origin, whereas the medial and lateral heads would only be
influenced by the degree of elbow angulation (Davidson & Rice, 2010). The origin of the long head affects
shoulder flexion, with the maximum point of flexion resulting in the greatest head length (Landin & Thompson,
2011). Alves et al. proposed that long headwork is preferred at the highest point of elongation (Alves, Matta, &
Oliveira, 2018). Vogt and Hoppeler suggested that training strength from different fascicle lengths would
strengthen the muscles to work in various areas of the length-tension relationship (Vogt & Hoppeler, 2014).
Recently, it has been suggested that 180-degree glenohumeral flexion achieved with overhead elbow
extension exercise leads to greater hypertrophy than the neutral version (0º °shoulder flexion), indicating that the
greater the length of the muscle separating the two involved joints, the more hypertrophy is obtained (Maeo et
al., 2023). However, Kholinne et al. found that at 0º shoulder flexion the long head generated more strength and
sEMG, with no differences between the lateral and medial head, contradicting previous proposals (Kholinne et
al., 2018). At 90º °shoulder elevation, the medial head generated more strength and sEMG without differences
between the other two, and at 180º, the lateral head provided more strength and sEMG. All the heads of the TB
generated more strength and sEMG when the elbow was flexed at 90º, and the TB was more effective when the
elbow was flexed between 20° and 30°.
Regarding the position of the elbow, Murray et al. found activation throughout the extension range of
motion in the long and lateral heads (Murray, Buchanan, & Delp, 2000), whereas the medial head has been
shown to be more activated when the elbow is flexed (Madsen et al., 2006). TB is more effective when the elbow
is flexed between 20 and 30º, as the TB tendon wraps around the upper surface of the olecranon and acts as a
pulley (Nigel, Roger, & Field, 2000).

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Functional anatomy and joint health
In addition to its effect on performance, it is worth noting that supination or pronation can also impact
joints. Prono-supination refers to the movement of the forearm around its longitudinal axis and requires the
intervention of two joints: the proximal radius-ulnar joint and ulnar-distal radius joint (Perotto, 2011). When
performing supination or pronation, there is a lack of geometric agreement between the articular surfaces in the
radial ulnar-distal joint, resulting in relative incongruence. This means that the head of the ulna does not fully fit
the sigmoid cavity of the radius, leading to reduced joint stability. At maximum pronation, the ulnar head may
even partially dislocate posteriorly, with only the posterior radioulnar ligament providing support (Soubeyrand et
al., 2017). Additionally, in both maximum pronation and supination, the triangular ligament is partially
distended, and the anterior and posterior ligaments of the distal radioulnar joint do not stabilize the joint or limit
movement.
The rotation range of the forearm is approximately 90º in pronation and supination, with neutral rotation
(thumb parallel to the humerus) considered as 0º (Soubeyrand et al., 2017). Soft tissues, such as the interosseous
membrane anterior bundle and squared ligament, limit supination, whereas the radioulnar abutment restricts
pronation in extreme cases (Soubeyrand et al., 2017). Repetitive work with high loads in pronation or maximum
supination can compromise these structures (Bonilla et al., 2022).
It is important to note that the distal and proximal radioulnar joints function as a single mechanism,
known as coaxial joints (Roman-Liu & Bartuzi, 2018). This means that the axis of one joint must be a
continuation of the other, and the maximum degree of stability for both joints is achieved in the neutral position.
This position is called the close-packed position, or maximum congruency, where the joint is most comfortable
and the ligaments work optimally (Kapandji, 2006) (see Fig. 1).

Figure 1
Maximum congruency and relative congruency. Adapted from (Srinath et al., 2015)

In mechanics, the concepts of balance and stability are closely related (Vera-García, Barbado, Moreno-
Pérez, Hernández-Sánchez, & Juan-Recio, 2015). Pollock et al. defined balance as “the state of an object when
the resultant force acting upon it is zero,” while stability refers to “the inherent ability of an object to remain in
or return to a specific state of balance and not to fail, with the inherent ability referring to the physical properties
of that object” (Pollock, Durward, Rowe, & Paul, 2000), . A body is said to be in equilibrium when the sum of
all the forces and moments of the forces acting on it is equal to zero (Bergmark, 1989). Thus, stability is the
ability of an object to maintain its state of equilibrium in the face of both internal and external forces to which it
is subjected (Elvira, 2008). Greater joint stability can compromise passive structures to a lesser extent and
prevent unwanted movements, thereby reducing the risk of injury (Cardozo et al., 2021). Therefore, greater
stability leads to better performance and a lower risk of injury (Bonilla et al., 2022).

Material and Methods

A narrative review was conducted using a convenience search due to the lack of studies evaluating hand
position in triceps exercises. Only one recently published study has addressed this issue (Villalba et al., 2024).
This narrative review allows for the inclusion of diverse views and theories in order facility a more complete
view that would not be achieved by quantifiable, or comparable means.
Exercises for triceps brachii strengthening
It has recently been concluded that exercises involving TB should be performed with full ROM to
optimize muscle hypertrophy (Kassiano et al., 2023). However, a poor technical execution performing high-load
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activities could involve an elbow extension and valgus, such as throwing or repetitive forces, the elements of
stability may not be sufficient, leading to pathologies and structural failures (Zouzias, Byram, Shillingford, &
Levine, 2012). Traditional TB exercises generally do not generate valgus, which can test the medial collateral
ligament and lead to predictable injury patterns, as seen in tennis serve, baseball hit, and javelin throw (Zouzias
et al., 2012). However, varus is more commonly caused by technical deficiencies in some TB exercises, and the
lateral ulnar collateral ligament provides varus stability. Supination, axial compression, and a varus moment can
cause posterolateral rotatory instability, which is observed in break dancers or gymnasts when they exert high
forces on their elbows to support the entire body weight (Zouzias et al., 2012).

Lying triceps extensions

When performing resistance-training exercises, practitioners should be particularly mindful of exercises
that place a high axial load on a joint, such as lying triceps extensions (also known as skullcrushers). In this
exercise, it is common for the elbow to open and create a pronounced varus, which puts extra strain on the soft
and bone tissues required for stability, especially when using high loads or experiencing fatigue. The addition of
pronation to exercise would increase the demand for soft tissues to provide stability. Pronation moves the radius
in front of the ulna, causing relative incongruity in the joint (Gordon et al., 2004). Although prono-supination is
a natural movement for eating and other tasks (hygiene and climbing), it can cause excessive stress on joints and
passive structures during analytical exercises for body building (Kapandji, 2006).
The triceps is a muscle that can generate high-power metrics (Hussain, Sundaraj, Subramaniam, et al.,
2020), and it is common a fast load progression in this exercise that in many cases these loads will alter the
correct exercise technique and therefore increase the risk of injury. Lying triceps extensions offers optimal
performance results, leading to increased muscle cross-sectional area (Goto et al., 2017). However, there are no
data on which hand position is the most favorable for working on a particular triceps head. For optimal joint
stability and risk-to-benefit ratio, it is advisable to perform the exercise in a neutral position. This maximizes the
joint congruence and minimizes the muscle expenditure. To achieve this, it is best to use a triceps bar or
dumbbell in a neutral position. When using the traditional bar, it is important to note that the functional position
for pronosupination is between the neutral position and semi-pronosupination (30-45º °pronation). This natural
balance between antagonist muscle groups can be achieved using an e-z curl bar (Gordon et al., 2004).
Performing elbow extensions over the head in pronation it is possible that this movement may increase tensile
forces on the connective tissue that could pose a risk to these structures, making it more advisable to use a
neutral position (Bonilla et al., 2022).

Cable resistance-training
There are various types of handles available to work on pulleys, such as triceps rope, short handles with
rope, bar triceps v-ergo, and straight bars that favor supine and prone grips. The triceps rope and triceps v-ergo
provide a more comfortable and ergonomic position, which is more functional between 30-45º of pronation.
However, excessive stress can be generated by abusing the grip during supination or pronation with the straight
grip. In a study by Rendos et al (Rendos et al., 2016), the influence of three different handle conditions was
examined: standard handle, ball handle with a cable between the index and middle fingers, and ball handle with a
cable between the middle and ring fingers. The assessment were performed with the hand in pronation,
unfortunately there are no data available for the scope of this review (Rendos et al., 2016).

Triceps bench dips (bench dips)

The bench dip exercise is another movement that requires attention as it places the hand in a pronated
position, adding stress to the distal radioulnar joint, while the elbow opens up. In contrast, triceps dips are a
favorable option for TB because problems with elbow positioning are not usually encountered when the hands
are positioned neutrally. Advanced participants could use an additional load as a ballast vest. However, it is
important not to confuse the full range of movements with the exercise, as it could increase the risk of shoulder
(glenohumeral) joint injury by closing the subacromial space. It is important to note that the bench press puts the
hand in pronation, in addition, with axial load, but not all the weight falls on the elbow joint, since much of the
work is carried by the shoulder girdle. On the other hand, parallel bottoms keep the upper limb in neutral
position, so it can favor the load increase, as there is a maximum congruence. But, let's not confuse the articular
health of the elbow with "lowering" too much in the bottoms, since it can close the sub-acromial space and
increase the risk of injury. Moreover, no extra benefits have been observed in electrical activity when performed
at 90º shoulder flexion or at full range (Boeckh-Behrens & Buskies, 2005).

Final considerations
There is little literature that addresses the analysis of sEMG during the different variants for triceps
brachii strengthening, and the few that exist present a high degree of heterogeneity (table 1). The available data
suggest that the degree of glenohumeral angulation may influence the degree of activation of the different TB

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heads, but in general the levels of activation are similar. In the case of the degree of pronosupination, the studies
carried out have been performed with isometric actions, so it is difficult to transfer it to dynamic actions.
However, considering some muscle adaptation data such as those provided by the muscle adaptations are similar
regardless of the exercise to be performed for TB, in women new to strength training who underwent a 6-week
program (2 sessions/week) with unilateral cable push-downs and cable overhead extensions with the
contralateral arm and cable overhead extensions with the contralateral arm.
In addition, although sEMG is considered the gold standard for non-invasively evaluating electrical
activity at the muscle level, it is essential to note that obtaining entirely reliable data for evaluating the sEMG of
the medial head using this technique is difficult. This is because the medial head was located beneath the other
two heads, which can create noise. In this regard, SENIAM (Hermens, Freriks, Disselhorst-Klug, & Rau, 2000)
does not provide recommendations for sensor location in the medial head. Consequently, sEMG investigations in
TB have evaluated the lateral, long head, or both simultaneously, because of the ease of locating and placing the
electrodes (Akagi, Shikiba, Tanaka, & Takahashi, 2016; Alves et al., 2018; Rendos et al., 2016; Roman-Liu &
Bartuzi, 2018), with some exceptions where the methodological information is confusing (A. Ali et al., 2015;
Kholinne et al., 2018; Serrau et al., 2012) or nonexistent (M. A. Ali et al., 2014; Landin & Thompson, 2011)
without specifying electrode placement. Conversely, some authors (Hussain, Sundaraj, & Subramaniam, 2020;
Hussain, Sundaraj, Subramaniam, et al., 2020) identified and placed electrodes in the presence of a physician, as
described by (Perotto, 2011) and following SENIAM. Therefore, sEMG does not appear reliable for evaluating
the middle head of the TB.
The main findings of the included studies for this review can be found in Table 1.

Table 1
Summary of the studies included in this review using SEMG for triceps brachii analysis in strengthening
exercises

Author Sample Exercise Variations sEMG location Main results

Alves et 21 males Elbow a) seated Triceps brachii long Variations b and c obtained
al 2018 25.57±5.57 extension position with the and lateral heads similar results
years, 1 repetition right arm leaning according to
At least 12 40% MVIC against the SENIAM
months of chair’s backrest, recommendations
resistance the elbow at 90°
training and forearm at
experience neutral position
b) seated
position and
right shoulder
flexed at 180°
c) lying on
supine position
and right
shoulder flexed
at 90°
Ali et al., Thirteen Handgrip in Handgrip in Lateral, long, and Electromyographic activity
2014 sportsmen neutral position neutral position medial heads of the changes are observed to be
healthy male of the upper of the upper limb TB of the dominant more significant at the long
university limb with full with full arm head as compared to the
students extension of the extension of the lateral and medial heads.
= 24.3 ± 4.1 forearm forearm between
years between abduction and
abduction and adduction
adduction
Hussaein 25 young, Triceps push- Fatigue without The three heads of Under all circumstances,
et al., healthy, down machine and with triceps brachii three heads operated
2020 recreationally Cognitive stress according to independently, and when
active 23.8±3.6 SENIAM tired, the non-synergist and
years recommendations synergist head pairs
behaved similarly.
Davidson Ten healthy Non-dominant Shoulder flexed three heads of the Measures taken from a
et al., recreationally elbow isokinetic at 0 or 90ª triceps brachii and single elbow extensor
2010 active young extension anconeus by means muscle segment do not
men (23.5±6 1.7 of intramuscular accurately reflect the group
years) electrodes as a whole, and during a
fatigue task, the relative
activity of the two-joint

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long head varied depending
on shoulder angle.
Kholinne 10 young, Elbow Five different triceps brachii long Every TB head has a
et al., healthy, 29.2 extension angles of and lateral heads distinct function for
2018 years shoulder according to extending the elbow at a
elevation; 0°, SENIAM different elevation of the
45°, 90°, 135°, recommendations shoulder. When the elbow
and 180° was stretched past 90°, all
TB heads displayed
increased muscular force
and activation.
Naito et 9 healthy From prone to Lateral head of TB No different activations for
al., 1998 subjects supine position TB
22-34 years of the forearm
while
maintinaing the
elbow position
flexed in 30, 60
and 90º
Rendos et 19-35 years Elbow (A), standard Lateral and long Similar activity levels for
al., 2016 At least 2 years extension on s handle condition head of TB the triceps
of resistance on a (B), index-
training selectorized middle fingers
experience cable machine. ball handle
condition (C),
and middle-ring
fingers ball
handle condition
(D).
Román- 15 healthy young Isometric 90º Lateral head TB When acting as stabilizers
Liu et al., adult 22.9 ±2.14 Elbow during handgrip force, BB
2018 extension and TB differ

Serrau et 18 active Isometric 90º Lateral head of TB Submaximal levels of

al., 2012 physical Elbow activation.
education extension (self- Greater for TB
students resistance
24.1±2.2 years exercise)

Therefore, further research is required to determine the degrees of muscle activation during the different
exercises as well as variants for the strengthening of the triceps brachii and thus be able to make a grouping with
scientific evidence and not with empirical data in which an exercise presumably affects more on one head of the
TB than on another. For the purpose of choosing the TB single-joint exercises, we suggest three groups of
exercises based on joint safety and effectiveness, ranging from those with the lowest mechanical load to those
with the highest.
It is worth noting that during multi-joint pushing exercises, such as the bench press, although the hand is
in pronation and works against gravity, the effort is not mainly focused on the elbow joints. Instead, a significant
portion of the work was performed using the shoulder girdle. Therefore, the elbow joint, which has a limited
range of motion (especially in lateral movements), does not bear the brunt of effort. Lehman studied the effects
of pronation and supination during bench pressing. Although the electrodes were placed on the pectoralis and
biceps brachii, and only on the lateral head of the TB, the electrical activity was not comparable across all three
heads, even in a multi-joint elbow extension exercise (Lehman, 2005).
Less information is available on exercise safety; however, based on kinesiology, hand placement may have a
greater or lesser impact on tensile forces in passive structures.

Conclusion
There is evidence to determine whether the supine or prone hand position creates extra work on one
head or the other in the TB muscle. While each head can work independently through elbow and shoulder
positions and lengths, the neutral hand position appears to be the most favorable for generating force (lower risk-
to-benefit ratio), with maximum stability, congruence, and high coaxiality between proximal and distal joints.
When working with high loads and volumes for prolonged periods, managing the stress generated in the passive
structures of the elbow is crucial, particularly for certain exercises.
Thus, spending more time in the neutral position may be advantageous. The use of pronation or
supination in some exercises may be limited to a smaller number of sets and specific contexts, such as
bodybuilding or rehabilitation, while considering the exercise and context.
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Practical applications
Weight RT focused on TB involves mechanical stress on the elbow and wrist joints that should be
considered when designing an exercise program. In this regard, we propose three groups of exercises based on
joint safety and effectiveness, starting from those with the lowest mechanical load to those with the highest, for
the selection of different single-joint exercises (Figure 2).
Figure 2
Proposal in the frequent use of different exercises of TB

Note. Based on the available evidence, the authors extracted recommendations to limit the risk of injury without
compromising the effectiveness of TB strengthening. These include:
- The position of the hand in supination, pronation, or semi-pronosupination does not ensure isolated work of the
triceps head. However, adjusting the shoulder and elbow positions (e.g., increasing the TB length) can promote a
higher level of electrical activity.
- Prioritize semi-prone supination or exercises at level 1, depending on the context (e.g., advanced athletes who
require load progression, sedentary individuals, or those with elbow or wrist problems).
- The use of Level 1 exercises does not eliminate the need for Level 2 and 3 exercises. It is important to tailor the
exercise program to the individual needs of each subject; in any case, “no pain, no gain” should not be a training
maximum.
- Levels 2 and 3 exercises are effective and can provide variation and gains in muscular strength and
hypertrophy. However, it is recommended to prioritize Level 1 exercises and gradually incorporate higher-level
exercises as appropriate to minimize joint stress.

Author Contributions:
S. V. M. served as the study coordinator and designed the experiments. S. V. M., D. A. B., I. C. M. and
M. G. S. collaborated in the analysis and revision of the manuscript. S.V.M., and I.C.M wrote the draft. All
authors have read and approved the final manuscript.
Conflicts of Interest and Source of Funding: The authors report no conflicts of interest or sources of funding.

References
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