Muscular soreness that occurs secondary to a session of loading is a common side effect of resistance training. Delayed onset muscle soreness (DOMS) is soreness in the muscles that typically peaks 24-48 hours following exposure to a stimulus that exceeds the individual’s baseline. The actual time frame can vary widely and this should be explained to patients. At this time mechanical and metabolic stress are the two main theories put forth for why DOMS occurs but both of these have conflicting data. An example of this is the study by Malm et al who looked at 2 groups who ran downhill (eccentric), uphill, and a control¹. They found the downhill group experienced DOMS but did not have inflammatory markers in the muscle (although they did in the epimysium). This is just one of many finding DOMS in the absence of damage. The idea that DOMS is due to microtrauma isn’t wrong in the way the belief that “lactic acid” causes it is but it isn’t complete either². On the other hand there are plenty of studies that do point to local metabolic and mechanical factors. So in summary DOMS is likely due to multiple contributing factors. Similar to most pain experiences there is an aspect of uncertainty around it.

The single best way to reduce DOMS is to have previously trained at a level that prepared the body for the current workload.

When it comes to dealing with DOMS time seems to be the only good method available. Things like exercise, massage, ice, and etc don’t appear to be that beneficial³. The single best way to reduce DOMS is to have previously trained at a level that prepared the body for the current workload.

DOMS is something that is often actively pursued in the gym. The experience of soreness is often considered to be necessary for a workout to be “good”. When the soreness doesn’t occur changes are typically implemented to feel sore again. This belief is not accurate, but in general it is relatively harmless outside of the more extreme cases. On the other hand, in an athletic population the experience of DOMS can negatively impact the player’s perception and performance.

In the clinic the experience of DOMS can be a significant issue. Trost et al performed an interesting study where they assessed pain related fear in a healthy population and then took baseline lumbar extension strength measures⁴. DOMS was created by performing eccentric lumbar extension for 25, 4 second reps, done at 75% of RM in a MedX. They found that those with higher pain related fear had no issues with performing the initial test. But after the eccentric bout, this fear emerged as a significant predictor of the impact on their outcomes. Those with the higher fear levels experienced significant decreases in post test outcomes as well as the impact of this pain on their daily activities. This was independent of the level of pain they experienced. The researchers concluded that “…pain appears to be an important contextual cue, or prime, for fear-related differences to emerge.” Their findings were similar to those of Sullivan who looked at exercise induced DOMS in the shoulders of a sedentary population and found catastrophizing to predict reduced performance ⁵. Clinically this may indicate that some populations will respond more poorly than others to DOMS but caution should be indicated in extrapolation from these populations to those in chronic pain or otherwise. In summary avoiding DOMS with our patients and athletes is likely to be a goal in majority of situations but occasionally it may be desired.

The repeated bout effect (RBE) is the name given to the idea that “performing training previously prevents DOMS later”. The exercises attenuate future experiences of DOMS by exposing the muscles to some stimulus initially. Like DOMS, the reason for this protective effect is also not established, but it appears to be due to neural, cellular, and connective tissue aspects⁶. Most of the research done on this looks at an initial bout of  exercise with measures of pain and damage taken at various time intervals post. A second bout is then performed with a comparison in the response being noted. The RBE has been investigated across a shockingly broad dosage spectrum. Higher volume approaches, such as 24 maximal effort eccentric contractions, have been shown to confer this protective effect for time periods up to 9 months⁷. It is also associated with a significant level of debilitating pain and thus has almost no clinical significance.

Clinical Approach to Minimizing Delayed Onset Muscle Soreness via the Repeated Bout Effect

Fortunately, the data indicates that it is not necessary to create this sort of stimulus to experience the benefits of the RBE. In fact, the protective effect has been seen in absence of any real markers of damage⁶. This effect is also not limited to maximal eccentric training. Submaximal eccentric exercises as well as isometrics have been found to be protective^8-10. These lower loads typically give less protection than higher loads but they also have little to no soreness associated with them. There appears to be an inverse relationship between the intensity and the duration of this protective effect. The greater the impact the longer this lasts with effects lasting up to 6-9 months after high volume maximal eccentrics vs ~4 days with low volume maximal isometrics¹¹. There also appears to be a delay in this effect with isometrics showing a protective effect only after 2 days but no more than 4.

In the clinic this allows for a practical approach to minimizing the effect of DOMS on patients. For instance, with a weaker individual who presents in a detrained state, a lower load approach utilizing isometrics or lighter Theraband can be implemented. This can occur in spite of the fact that the dosage is likely sub-threshold for driving adaptations. If the goal is to minimize the risk of DOMS via the RBE then  initiating rehab in the first session or two with a sub-threshold exercise dosage may be the most appropriate approach. The included chart gives some guidelines pulled from the literature to help with this process. Ultimately the basic principals of progressive overload should drive the process but this helps with determining a better place to start.

References:

1. Malm C, Sjödin B, Sjöberg B, et al. Leukocytes, cytokines, growth factors and hormones in human skeletal muscle and blood after uphill or downhill running. The Journal of Physiology. 2004;556(3):983-1000. doi:10.1113/jphysiol.2003.056598.
2. Robergs RA. Nothing ‘evil’ and no ‘conundrum’ about muscle lactate production. Experimental Physiology. 2011;96(10):1097-1098. doi:10.1113/expphysiol.2011.057794.
3. Torres R, Ribeiro F, Duarte JA, Cabri JM. Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: Systematic review and meta-analysis. Physical Therapy in Sport. 2012;13(2):101-114. doi:10.1016/j.ptsp.2011.07.005.
4. Trost Z, France CR, Thomas JS. Pain-related fear and avoidance of physical exertion following delayed-onset muscle soreness. Pain. 2011;152(7):1540-1547. doi:10.1016/j.pain.2011.02.038.
5. Sullivan MJL, Rodgers WM, Wilson PM, Bell GJ, Murray TC, Fraser SN. An experimental investigation of the relation between catastrophizing and activity intolerance. Pain. 2002;100(1-2):47-53.
6. McHugh MP CDEREA. Exercise-Induced Muscle Damage and Potential Mechanisms for the Repeated Bout Effect. August 2012:1-14.
7. Nosaka K, Sakamoto K, Newton M, Sacco P. How long does the protective effect on eccentric exercise-induced muscle damage last? Med Sci Sports Exerc. 2001;33(9):1490-1495.
8. Nosaka K, Aoki MS. Repeated bout effect: research update and future perspective. Brazilian Journal of Biomotricity. 2011.
9. CHEN TC-C, CHEN H-L, Pearce AJ, Nosaka K. Attenuation of Eccentric Exercise–Induced Muscle Damage by Preconditioning Exercises. Med Sci Sports Exerc. 2012;44(11):2090-2098. doi:10.1249/MSS.0b013e31825f69f3.
10. CHEN H-L, Nosaka K, Pearce AJ, Chen TC. Two maximal isometric contractions attenuate the magnitude of eccentric exercise-induced muscle damage. Appl Physiol Nutr Metab. 2012;37(4):680-689. doi:10.1139/h2012-035.
11. Lima LCR, Denadai BS. Attenuation of eccentric exercise-induced muscle damage conferred by maximal isometric contractions: a mini review. Front Physiol. 2015;6:1-7. doi:10.3389/fphys.2015.00300.