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This is the published version of a paper published in Scandinavian Journal of Medicine and
Science in Sports.

Citation for the original published paper (version of record):

Ekblom Bak, E., Börjesson, M., Bergman, F., Bergström, G., Dahlin#Almevall, A. et al.
(2022)
Accelerometer derived physical activity patterns in 27.890 middle#aged adults – the
SCAPIS cohort study
Scandinavian Journal of Medicine and Science in Sports, 32(5): 866-880
https://doi.org/10.1111/sms.14131

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N.B. When citing this work, cite the original published paper.

Open access licence CC BY-NC 4.0

Permanent link to this version:

http://urn.kb.se/resolve?urn=urn:nbn:se:gih:diva-6949
Received: 13 August 2021
| Revised: 21 December 2021
| Accepted: 22 January 2022

DOI: 10.1111/sms.14134

ORIGINAL ARTICLE

Resistance training variable manipulations are less relevant

than intrinsic biology in affecting muscle fiber hypertrophy

Vitor Angleri1 | Felipe Damas1 | Stuart M. Phillips2 |

Heloisa Sobreiro Selistre-­de-­Araujo3 | Anabelle Silva Cornachione4 |
Uliana Sbeguen Stotzer3 | Natalia Santanielo1 | Samuel Domingos Soligon1 |
Luiz Augusto Riani Costa5 | Manoel Emílio Lixandrão5 | Miguel Soares Conceição5 |
Felipe Cassaro Vechin5 | Carlos Ugrinowitsch5 | Cleiton Augusto Libardi1

1
MUSCULAB –­ Laboratory of
Neuromuscular Adaptations to We aimed to investigate whether muscle fiber cross-­sectional area (fCSA) and
Resistance Training, Department of associated molecular processes could be differently affected at the group and
Physical Education, Federal University
individual level by manipulating resistance training (RT) variables. Twenty
of São Carlos, São Carlos, Brazil
2
Department of Kinesiology, McMaster
resistance-­trained subjects had each leg randomly allocated to either a standard
University, Hamilton, Ontario, Canada RT (RT-­CON: without specific variables manipulations) or a variable RT (RT-­
3
LBBM –­ Laboratory of Biochemistry VAR: manipulation of load, volume, muscle action, and rest interval at each RT
and Molecular Biology, Department of
session). Muscle fCSA, satellite cell (SC) pool, myonuclei content, and gene ex-
Physiological Sciences, Federal University
of São Carlos, São Carlos, Brazil pression were assessed before and after training (chronic effect). Gene expression
4
Muscle Physiology and Biophysics was assessed 24 h after the last training session (acute effect). RT-­CON and RT-­
Laboratory, Department of Physiological VAR increased fCSA and myonuclei domain in type I and II fibers after train-
Sciences, Federal University of São
Carlos, São Carlos, Brazil
ing (p < 0.05). SC and myonuclei content did not change for both conditions
5
School of Physical Education and (p > 0.05). Pax-­7, MyoD, MMP-­2 and COL3A1 (chronic) and MGF, Pax-­7, and
Sport, University of São Paulo, São MMP-­9 (acute) increased similar for RT-­CON and RT-­VAR (p < 0.05). The in-
Paulo, Brazil
crease in acute MyoG expression was significantly higher for the RT-­VAR than
Correspondence RT-­CON (p < 0.05). We found significant correlation between RT-­CON and RT-­
Cleiton Augusto Libardi, VAR for the fCSA changes (r = 0.89). fCSA changes were also correlated to satel-
MUSCULAB -­ Laboratory of
lite cells (r = 0.42) and myonuclei (r = 0.50) changes. Heatmap analyses showed
Neuromuscular Adaptations to
Resistance Training / Department coupled changes in fCSA, SC, and myonuclei responses at the individual level,
of Physical Education / Federal regardless of the RT protocol. The high between and low within-­subject variabil-
University of São Carlos -­ UFSCar Rod.
Washington Luiz, km 235 –­ SP 310,
ity regardless of RT protocol suggests that the intrinsic biological factors seem to
CEP 13565-­905, São Carlos, SP, Brazil. be more important to explain the magnitude of fCSA gains in resistance-­trained
Email: c.libardi@ufscar.br subjects.
Funding information
KEYWORDS
National Council for Scientific and
Technological Development (CNPq); biological predisposition, individual responses, resistance exercise, responsiveness, satellite
The São Paulo Research Fundation cells, training variables
(FAPESP), Grant/Award Number:
2017/05331-­6, 2016/24259-­1, 2018/13064-­
0, 2013/00789-­2, 2013/07104-­6,
2016/22635-­6 and 2017/04299-­1

© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Scand J Med Sci Sports. 2022;00:1–12.  wileyonlinelibrary.com/journal/sms   | 1

2 |    ANGLERI et al.

1 | I N T RO DU CT ION the variability in the change of these intrinsic biological

factors between high and low responders.
Skeletal muscle mass plays a vital role in health, sports per- This study aimed to investigate whether intrinsic bio-
formance, and esthetics.1,2 Resistance training (RT) is the logical factors (i.e., SC response, myonuclei addition, and
most effective method to increase muscle fiber cross-­section gene expression) could be modulated by frequent manip-
area (fCSA) (i.e., muscle hypertrophy).3–­5 Frequent manip- ulations of RT variables and potentiate the gains in fCSA
ulation of RT variables (e.g., load, volume, muscle action, in resistance-­trained young men. We also investigated
and rest) is widely suggested to differently potentiate fiber whether within-­subject variability in fCSA and intrinsic
type-­specific CSA increases compared to standard progres- biological factors could be modulated by RT variables ma-
sive RT, especially for resistance-­trained individuals.5–­10 nipulations and whether these intrinsic factors could be
Theoretically, manipulating RT variables would potentiate related to the magnitude of increase in fCSA. To address
the response of intrinsic biological factors (e.g., increase in these aims, we used an unilateral RT, in which one leg
satellite cell pool, myonuclei number, and gene expression) performed a standard progressive RT (RT-­CON), and the
controlling skeletal muscle hypertrophic response.1,11–­15 contralateral leg performed a variable RT (RT-­VAR) modu-
Nevertheless, it was recently demonstrated similar vastus lating key-­exercise variables, such as load, volume, muscle
lateralis muscle hypertrophy between a RT protocol with action, and interset rest interval. We hypothesized that: (1)
frequent manipulation of several training variables as com- RT-­CON and RT-­VAR would similarly increase type I and
pared with a standard linear progressive RT one, at last, II muscle fCSA; (2) RT-­CON and RT-­VAR would induce
when both protocols are performed to (or close to) concen- similar SC response, myonuclei addition, and expression
tric muscle failure.16 However, there is a paucity of data on of the genes involved in this mechanism; (3) RT proto-
the effect of frequent manipulation of RT variables at the cols would produce a low variability at the within-­subject
fCSA level and the previously mentioned intrinsic biologi- level and large variability in the fCSA increases and the
cal factors in resistance-­trained individuals. intrinsic biological factors irrespective of RT regimen at
A large between-­subject variability has been observed the between-­subject level; and (4) the intrinsic biological
in the RT-­induced increase in fCSA, when comparing factors would better explain the individual magnitude of
distinct RT protocols.12-­14,17,18 Accordingly, we recently muscle fiber hypertrophy, regardless RT modulations.
demonstrated higher between-­ than within-­subject vari-
ability in myofibrillar protein synthesis and muscle hyper-
trophy, regardless of the RT protocol, using a within-­subject 2 | METHODS
design (i.e., one training protocol for each leg).16 These
findings suggest that intrinsic biological factors, rather 2.1 | Participants
than extrinsic ones (e.g., manipulating RT variables), are
mainly mediating the magnitude of muscle hypertrophic Healthy young resistance-­trained men (n = 20; age:
response between high and low responders. Among the 26 ± 3 year, body mass index: 25.6 ± 2.1 kg/m2 and RT ex-
hypertrophy-­related intrinsic factors, the SC has received perience: 2.5 ± 1.1 year) volunteered to participate in this
particular attention,12–­14,18 as they donate myonuclei to study. Subjects were considered as trained if they trained
muscle fibers to support the increased protein synthesis for at least 1 year uninterruptedly.5,16,23,24 Participants had
demand of an expanding cytoplasmic volume.12,14,19 This to be free from musculoskeletal disorders and stated they
process is coordinated by an increased expression of genes had not taken anabolic steroids in the previous year. All
related to the SC cycle and its niche (e.g., matrix metallo- participants signed an informed consent form. The study
proteinases [MMP-­2 and MMP-­9], mechanogrowth factor was conducted according to the Declaration of Helsinki,
[MGF], paired box protein 7 [Pax-­7], myoblast determina- and the Human Research Ethics Committee of the local
tion protein 1 [MyoD], and myogenin [MyoG]) induced by university approved the study (#2.226.596).
both a single and several RT sessions (acute and chronic
effect).12,13,20-­22 Importantly, it was demonstrated that the
magnitude of the change in the expression of some of the 2.2 | Experimental design
aforementioned genes13 and SC-­mediated myonuclei ad-
dition14 were aligned with the magnitude of increase in We used a within-­subject design in which chronic and
fCSA induced by a standard RT program, in individuals acute data were obtained (Figure 1). Briefly, each partici-
with no previous RT experience. Although these findings pant's legs were balanced and randomly assigned to (1)
suggest that between-­subject variability can explain the standard progressive control RT (RT-­CON, 10 dominant
differences in adaptive response, they do not determine if and 10 non-­dominant legs) protocol or (2) variable RT (RT-­
the frequent variation of RT-­related variables can decrease VAR, 10 dominant and 10 non-­dominant legs) protocol
ANGLERI et al.    | 3

that manipulated the RT variables (full descriptions of RT with isopentane cooled by liquid nitrogen to perform fCSA,
protocols below) on a per-­session basis. Participants re- fiber distribution, SC, and myonuclear content and myo-
frained from exercising for 72 h before the first experimen- nuclear domain per fiber type analyses. Approximately
tal session. A vastus lateralis muscle biopsy was performed 50 mg of muscle tissue was separated for gene expression
in one of the legs in a randomized fashion immediately analyses. All samples were stored at −80°C until analysis.
before the first RT session (Pre). Subjects performed two
weekly RT sessions over 8 weeks (total of 16 RT sessions),
in which both protocols were performed. Bilateral vastus 2.4 | Resistance training
lateralis biopsies were performed 96 h after the last train-
ing session (Post). Then, subjects performed an additional Both RT protocols were performed to (or near to) con-
RT session (i.e., 17th session), and vastus lateralis muscle centric muscle failure. The RT-­CON performed 8 sets
samples were harvested from each leg 24 h after it. Biopsies (4 sets of leg press followed by 4 sets of leg extension) with
Pre and Post were used to assess chronic changes in fCSA, 9–­12 maximum repetitions, dynamic muscle actions (con-
SC, myonuclei, and gene expression. Biopsies Post (for centric and eccentric), and 2-­min rest interval between
these analyses now named as 0 h) and 24 h determined the sets and exercises. The load was increased or decreased
acute effect of the 17th training session. In the acute RT to maintain the repetition range as previously described.16
session, participants performed the RT-­CON protocol with For RT-­VAR, one of the following RT manipulations was
the same leg they used in the RT-­CON program (n = 20), performed: (1) load: 4 sets of both leg press and leg ex-
and the contralateral leg was randomly assigned to one of tension of 25-­30RM with 2-­min rest interval; (2) volume:
the four RT-­VAR conditions (n = 20; n = 5 per condition). 6 sets of leg press and 6 sets of leg extension of 9-­12RM
Although subjects had previous RT experience, the acute with 2-­min rest interval; (3) muscle action: 4 sets of leg
trial was performed only at the end of training protocol press and 4 of leg extension of 10 eccentric contractions at
to mitigate any bias produced by an unaccustomed exer- 110% of the load used in the RT-­CON with 2-­min rest in-
cise stimulus. Participants consumed 30 g of isolated whey terval; and (4) rest: 4 sets of leg press and 4 of leg extension
protein provided by the researcher after each RT session, with 9-­12RM with 4-­min rest interval. As 16 RT sessions
including the acute trial (i.e., 17th RT session). were performed during the 8 weeks, this sequence of RT-­
VAR protocols was repeated 4 times by each participant in
a randomized and balanced order.
2.3 | Muscle biopsy

Vastus Lateralis muscle biopsies were performed using 2.5 | Immunohistochemical analyses
percutaneous biopsy needles with suction under local an-
esthesia (2–­3 ml of 1% Xylocaine). A portion of 20–­30 mg Frozen muscle samples were sectioned using a cryostat
was placed in optimum cutting temperature (OCT) with (Leica CM 1860) at −25°C. The slides with muscle cross-­
fibers perpendicular to the horizontal surface and frozen sections (6 µm) were left at room temperature for ~20 min

F I G U R E 1 Experimental design. Double arrows indicate bilateral muscle biopsies. The black arrow indicates biopsy utilized for the Pre
measurements of the chronic design; white arrows indicate biopsies utilized for the Post measurements in the chronic design (96 h after
the 16th RT session) and 0 h (immediately before the 17th RT session) measurements in the acute design; and gray arrows indicate biopsies
utilized for the 24 h post 17th RT session analyses in the acute design. RT: resistance training; CON: control RT (4 sets for both leg press and
leg extension, 9-­12RM/2-­min rest); VAR: variable RT; VAR-­load: 4 sets for both leg press and leg extension, 25-­30RM/2-­min rest; VAR-­sets:
6 sets for both leg press and leg extension, 9-­12RM/2-­min rest; VAR-­ecc: 4 sets for both leg press and leg extension, 10 eccentric contractions
at 110% of the load used in CON leg/2-­min rest; VAR-­rest: 4 sets for both leg press and leg extension, 9-­12RM/4-­min rest
4 |    ANGLERI et al.

to stabilize. Samples were incubated with the primary an- remove contaminants of genomic DNA. The treated RNA
tibodies at 37°C for 45 min. The samples were washed 3 (1 µg) was reverse transcribed using GoScript™ Reverse
times for 5 min in phosphate-­buffered saline (PBS) and then Transcriptase (Promega Corporation, Madison, WI, USA).
were incubated with the secondary antibodies at 37°C for The real-­time PCR (CFX 96 real-­time PCR–­Bio-­Rad, San
45 min. After 3 more 5 min washes in PBS, the sections were Francisco, USA) was performed using 20 ng of cDNA, and
mounted in FluorQuest with DAPI. The images were ob- 0.5 µM of each primer was used in 25 µl volume system mix
tained with an ImageXpress Micro XLS with a magnification containing SoFastTM Eva Green (BioRad, San Francisco,
of 20x. The analyses were performed in the ImageJ software. USA). Samples were analyzed in duplicate. Thermal
Due to a problem in the image acquisition for one sample, cycling was 95°C for 10 min, 40 cycles of 95°C for 15 s,
the subsequent procedures were conducted with 19 subjects. 54.4–­63.3°C for 30 s, and 72°C for 30 s, respectively. To en-
The fCSA was determined using computerized planimetry sure that only one PCR product was amplified per reaction,
for each fiber type. To ensure that only cross-­sectioned fib- the melting curve was completed after PCR. Gene expres-
ers were analyzed, fibers with circularity below 0.60 were sion fold changes were calculated using the delta–­delta Ct
excluded from the analysis.11,25 For type I fCSA, the number method.26 We tested 4 genes (RPLP0, RPL13A, TFRC, and
of fibers analyzed was 48 ± 6 at Pre, 44 ± 12 at Post (RT-­ GAPDH) as housekeeping and used the GAPDH to nor-
CON), and 47 ± 7 at Post (RT-­VAR). Regarding type II fCSA, malize Ct values (delta-­Cts [ΔCt]). Then, the values were
the number of fibers analyzed was 50 ± 0 at Pre, 47 ± 9 at used to normalize the ΔCt values (delta-­delta Cts [ΔΔCt]).
Post (RT-­CON), and 50 ± 1 at Post (RT-­VAR). The typical The values were transformed out of the logarithmic scale
error (TE) between two measurements performed 72 h apart the equation: fold change = 2−ΔΔCt.26
was 116.8 µm2; 219.0 µm2; and 175.9 µm2 for fCSA from type
I and II muscle fibers, and total fCSA (fCSA I + fCSA II),
respectively. The number of myonuclei for each fiber type 2.7 | Statistical analysis
was counted and normalized by the number of analyzed
fibers. The TE between two measurements performed 72 h Chronic effects of RT-­CON and RT-­VAR on fCSA, SC, and
apart was 0.15 myonuclei/fiber, 0.13 myonuclei/fiber, and myonuclei content and gene expression were analyzed
0.17 myonuclei/fiber for fiber type I, type II, and total (type through two procedures. As Pre data analyses were per-
I + type II) myonuclei number, respectively. The ratio be- formed based on the muscle tissue harvested from just one
tween fCSA and the normalized number of myonuclei was leg, we used a one-­way ANOVA to determine whether the
determined as myonuclear domain. The number of SC of dependent variables (fCSA, SC and myonuclei content and
specific fiber types was determined by co-­localization of chronic gene expression) at Post (RT-­CON and RT-­VAR)
DAPI and Pax-­7. The fiber type-­specific SC was normalized were different from Pre. A Dunnett post hoc test was per-
per number of specific fiber type. The TE between two meas- formed, in case of significant F-­values, having Pre as the
urements performed 72 h apart was 0.02 SC/fiber for SC of control condition. The same dependent variables were
fiber type I, type II, and total (type I + II). The number of type compared between RT-­CON and RT-­VAR at Post using
I fibers analyzed for SC and myonuclei count were 97 ± 49 paired t-­tests. Acute changes in gene expression were ana-
at Pre, 95 ± 55 at Post (RT-­CON), and 128 ± 88 at Post (RT-­ lyzed using several mixed models assuming time (0 and
VAR). Finally, the number of type II fibers analyzed for SC 24 h) and protocol (RT-­CON and RT-­VAR) as fixed fac-
and myonuclei count were 144 ± 85 at Pre, 136 ± 86 at Post tors and subjects as a random factor. Pearson's correlation
(RT-­CON), and 160 ± 97 at Post (RT-­VAR). estimated the association of the changes in fCSA, SC and
myonuclei between protocols and between them. We also
assessed the association of the changes in fCSA with chronic
2.6 | qRT-­PCR and acute gene expression changes between protocols and
legs. As the changes in fCSA (r = 0.89) were highly corre-
The RNA was isolated, incubating, and homogenizing lated between RT-­CON and RT-­VAR legs, we collapsed all
~15 mg of muscle tissue in the Trizol reagent (Invitrogen the data to perform the subsequent correlations (n = 38).
Corporation, California, USA) according to the manufac- Thus, we performed Pearson's correlations between total
turer's instructions. RNA concentration and purity and con- fCSA changes and (i) total satellite cells change; (ii) total
centration were determined by assessing the absorbance myonuclei changes; (iii) chronic gene expression; and (iv)
(NanoDrop 2000) of each sample at 260 and 260/280 nm, acute gene expression. Heatmaps were used to explore the
respectively. The RNA integrity of all samples was certifi- alignment between muscle fiber hypertrophy and intrinsic
cated by electrophoresis on 1% agarose gel with a pattern biological factors. To generate the heatmaps, the total fCSA
of 28S and 18S ribosomal RNA. The samples were treated (CSA of fibers type I + CSA of fibers type II) of each sub-
with DNase I (Invitrogen Corporation California, USA) to ject was ranked according to the mean change (Δ%) values
ANGLERI et al.    | 5

of both legs ([RT-­CON +RT-­VAR] ÷ 2). Then, the Δ% of 3.2 | Fiber type distribution, cross-­
the other dependent variables (i.e., total SC [number of SC sectional area, satellite cells content,
per type I + II fibers], total myonuclei number [number myonuclear content and domain
of myonuclei per type I + type II], chronic [Pre to Post],
and acute changes [0 to 24 h] gene expression) per subject There were significant increases in type I fCSA for RT-­
were ranked according to the Δ% of total fCSA. The delta CON (13.0% [p = 0.01]) and RT-­VAR (12.3% [p = 0.02])
change for each heatmap column was normalized individ- (Table 1). Type II fCSA also significantly increased
ually. For total fCSA, SC and myonuclei heatmaps baseline for RT-­CON (12.7% [p = 0.02]) and RT-­VAR (12.2%
values were set to 0. The heatmap for the chronic gene ex- [p = 0.03]) (Table 1). Myonuclear domain size for type
pression had the baseline value set as the mean value of Pre I muscle fibers significantly increased for RT-­CON
gene expression, whereas the acute gene expression had (15.4% [p = 0.0001]) and RT-­VAR (19.9% [p = 0.0013])
the baseline value set as the mean of RT-­CON and RT-­VAR (Table 1). There were significant increases in myonu-
gene expression at 0 h. Changes above and below the base- clear domain size for type II muscle fiber for RT-­CON
line values were filled with red and blue color, respectively, (23.1% [p = 0.0002]) and RT-­VAR (24.2% [p = 0.004])
intense shades of red indicating higher Δ% and more in- (Table 1). No significant changes in fiber type distri-
tense shades of blue indicating a decrease in the depend- bution, myonuclear and SC content were found for
ent variable. White shades indicate no changes. Finally, RT-­CON and RT-­VAR for both fiber types (p > 0.05)
three heatmaps were performed comparing: 1—­total fCSA (Table 1). Importantly, no significant differences were
Δ%, total SC Δ%, and total myonuclei content Δ%; 2—­total found between RT-­CON and RT-­VAR for any dependent
fCSA Δ% and chronic gene expression Δ%; and 3—­total variables at post (p > 0.05) (Table 1).
fCSA Δ% and acute gene expression Δ%. These analyses
allow us to visually explore whether the higher or lower
responders for total fCSA were aligned with higher and 3.3 | mRNA gene expression (Chronic RT
lower changes on the assessed biological factors and if the effect)
RT regimen could modulate this response.
Results demonstrated significant changes in gene expres-
sion for Pax-­7 (RT-­CON: p = 0.0151; RT-­VAR: p = 0.0032),
3 | R E S U LTS MyoD (RT-­CON: p = 0.0181; RT-­VAR: p = 0.0107),
MMP-­2 (RT-­CON: p = 0.0363; RT-­VAR: p = 0.0318), and
3.1 | Volume load COL3A1 (RT-­CON: p = 0.0030; RT-­VAR: p < 0.0002)
(Table 2). No significant changes in MGF, MyoG,
We found a higher accumulated volume load (sets × reps and MMP-­9 mRNA expression (p > 0.05) were found
× load [kg]) for RT-­VAR (217,613 ± 43,834 kg) compared (Table 2). Importantly, no significant differences were
with RT-­CON (193,259 ± 39,731 kg) (12.6% difference be- found between RT-­CON and RT-­VAR for any target gene
tween legs; p < 0.001; results not shown in figure). (p > 0.05) (Table 2).

T A B L E 1 Type I and II muscle fiber distribution, cross-­sectional area (fCSA), satellite cells, myonuclear number, and domain size at
baseline (Pre) and after 8 weeks (Post) of control resistance training (RT-­CON) and variable resistance training (RT-­VAR)

Post

Variables Fiber type Pre RT-­CON RT-­VAR

Fiber distribution (%) I 41.1 ± 11.3 42.8 ± 12.8 42.0 ± 14.1
II 58.9 ± 11.3 57.2 ± 12.8 58.0 ± 14.1
fCSA per fiber (μm2) I 5617.62 ± 1111.88 6348.71 ± 972.21* 6311.07 ± 1035.77*
II 6323.63 ± 1291.28 7124.91 ± 1367.20* 7094.78 ± 1427.28*
Satellite cells per fiber (n) I 0.077 ± 0.032 0.066 ± 0.045 0.075 ± 0.035
II 0.073 ± 0.026 0.063 ± 0.054 0.069 ± 0.037
Myonuclei number per fiber (n) I 4.78 ± 0.97 4.65 ± 0.72 4.47 ± 0.72
II 4.03 ± 0.89 3.65 ± 0.76 3.67 ± 0.90
2
Myonuclear domain size per fiber (μm ) I 1195.80 ± 214.96 1380.06 ± 206.16* 1434.22 ± 265.97*
II 1607.84 ± 341.17 1978.92 ± 325.57* 1997.51 ± 460.16*
Note: Values are expressed as mean ± SD. *Significantly different from Pre (p < 0.05).
6 |    ANGLERI et al.

3.4 | mRNA gene expression (Acute RT vs protocol interaction; p < 0.0261). MyoD, MMP-­2, and
effect) COL3A1did not change from 0 to 24 h (p > 0.05) (Table 3).

No significant differences in acute gene expression were

detected between RT-­CON and RT-­VAR at baseline (0 h) 3.5 | Correlation analysis
for all assessed genes (p > 0.05) (Table 3). Both RT-­CON
and RT-­VAR significantly increased MGF (main time ef- Significant correlations were found for changes in total
fect; p = 0.0060), Pax-­7 (main time effect, p < 0.0001), and fCSA (p < 0.0001; r = 0.89), total SC (p < 0.0001; r = 0.82)
MMP-­9 (main time effect; p = 0.0199) mRNA expression and a strong trend for total myonuclei (p < 0.07; r = 0.42)
from 0 to 24 h (i.e., acute). No significant differences were between RT-­CON and RT-­VAR legs. However, no correla-
found between RT-­CON and RT-­VAR at 24 h for MGF, tions were observed for chronic and acute gene expression
Pax-­7, and MMP-­9 (p > 0.05). For MyoG, only RT-­VAR between RT-­CON and RT-­VAR legs (p > 0.05), except for
presented significant increase from 0 to 24 h (time vs chronic MyoD expression (p < 0.0001; r = 0.87).
protocol interaction; p < 0.0001). Additionally, RT-­VAR The collapsed analysis (RT-­CON + RT-­VAR) found
was significantly different from RT-­CON at 24 h (time significant correlations between total fCSA changes with
total SC changes (p < 0.01; r = 0.42) and fCSA changes
T A B L E 2 Relative chronic gene expression at baseline (Pre) with total myonuclei changes (p < 0.001; r = 0.50) changes.
and after 8 weeks (Post) for control resistance training (RT-­CON) However, no significant correlation was observed between
and variable resistance training (RT-­VAR) total fCSA changes and gene expression (chronic and
acute) (p > 0.05), except for chronic (p < 0.001; r = 0.56)
Post
and acute (p < 0.02; r = 0.43) MyoD expression.
Gene Pre RT-­CON RT-­VAR
MGF 1.14 ± 0.65 1.23 ± 0.86 1.61 ± 1.12
Pax-­7 0.98 ± 0.50 1.65 ± 0.83* 2.17 ± 1.11* 3.6 | Heatmaps
MyoD 1.70 ± 0.78 4.13 ± 3.48* 3.86 ± 3.06*
Heatmaps show a coupled response between the magni-
MyoG 1.08 ± 0.55 0.90 ± 0.24 0.81 ± 0.37
tude of total fCSA increases with SC and myonuclei re-
MMP-­2 1.10 ± 0.59 1.57 ± 0.70* 1.88 ± 1.16*
sponses (Δ%). This is highlighted by the higher and lower
MMP-­9 1.00 ± 0.57 1.35 ± 1.52 1.37 ± 1.50 responders for total fCSA who also presented the high-
COL3A1 1.12 ± 0.56 3.42 ± 2.61* 3.82 ± 2.16* est and lowest SC and myonuclei responses, respectively
Note: Values are expressed as mean ±DP. *Significantly different from Pre (Figure 2A). Additionally, the heatmaps showed that both
(p < 0.05). legs of each subject were in similar color shades, indicating

T A B L E 3 Relative acute gene

RT-­CON RT-­VAR
expression at baseline (0 h) and after
Gene 0h 24 h 0h 24 h (24 h) training sessions for control
resistance training (RT-­CON) and variable
MGF 1.24 ± 0.88 1.96 ± 1.36* 1.23 ± 0.85 2.46 ± 1.77*
resistance training (RT-­VAR)
Pax-­7 1.17 ± 0.62 2.12 ± 1.00* 1.22 ± 0.62 1.88 ± 0.91*
MyoD 0.91 ± 0.77 1.10 ± 1.05 0.84 ± 0.67 0.96 ± 0.62
MyoG 1.03 ± 0.28 2.12 ± 1.20 1.03 ± 0.27 4.25 ± 3.03*,†
MMP-­2 1.12 ± 0.52 0.93 ± 0.33 1.01 ± 0.63 1.09 ± 1.06
MMP-­9 1.50 ± 1.68 2.24 ± 2.48* 1.30 ± 1.39 3.37 ± 3.76*
COL3A1 1.35 ± 1.04 1.43 ± 0.86 1.23 ± 0.74 1.79 ± 1.52
Note: Values are expressed as mean ± DP. *Significantly different from 0 h (p < 0.05). †Significantly
different from 24 h (p < 0. 0261).

F I G U R E 2 Heatmap of the magnitude of change (Δ%) for each dependent variable. (A) total fCSA Δ% (Pre to Post), total SC Δ% (Pre to
Post), and total myonuclei content Δ% (Pre to Post). (B) total fCSA Δ% (Pre to Post) and chronic gene expression Δ% (Pre to Post). (C) total
fCSA Δ% (Pre to Post) and acute gene expression Δ% (0 h to 24 h). The magnitude of change for each variable is indicated by the color gradient.
The most intense shades of red in the red gradient represent the greatest magnitudes of change for the dependent variable. As the color gradient
becomes whiter, it indicates no change in the dependent variable (i.e., Δ% = 0). As the color gradient flows from white to more intense shades
of blue, it indicates a decrease (i.e., negative Δ%) in the values of the dependent variable. Cells filled with “X” represent missing data
ANGLERI et al.    | 7
8 |    ANGLERI et al.

that the magnitude of individual responses for total fCSA, confirming our hypothesis. Other authors had also dem-
SC, and myonuclei was not substantially modulated by a onstrated similar increases in both fiber types regardless
specific protocol (RT-­CON or RT-­VAR) (Figure 2A). On of the RT load (low vs. high load)27 or differences in accu-
the contrary, we showed a poor alignment between the mulated load volume28,29 when both protocols were per-
individual magnitude of total fCSA increases with chronic formed to concentric muscle failure in resistance-­trained
(Figure 2B) or acute (Figure 2C) gene expression. In this subjects. Additionally, these results corroborate with our
regard, the heatmaps illustrated that some of the highest previous study that demonstrated similar increases in the
responders for total fCSA presented the lowest responses vastus lateralis cross-­sectional area for RT-­CON and RT-­
for chronic and/or acute gene expression. In contrast, some VAR in the same cohort of resistance-­trained young men.16
of the lowest responders for total fCSA showed the high- Nevertheless, we expand our previous results demonstrat-
est chronic and/or acute gene expression (Figure 2B,C). ing that frequent manipulation of RT variables (i.e., load,
Furthermore, while the gene expression was not differ- volume, muscle action, and rest) do not enhance muscle
ently affected by the RT protocols for some subjects (e.g., hypertrophy response at the fiber level, at least when RT is
subjects 4 and 19 [chronic MyoD expression]—­Figure 2B; performed to, or near to, concentric muscle failure.
subjects 3 and 16 [acute COL3A1 expression]—­Figure The SC response is an intrinsic mechanism suggested
2C), others presented higher responses for a specific pro- to involve in the RT-­induced muscle hypertrophy.12-­14,18
tocol (e.g., RT-­CON leg) and lower responses for the other It is suggested that this mechanism is important during
protocol (e.g., RT-­VAR leg) in the heatmaps (e.g., subjects fCSA increases.12,14,19,30 However, the fCSA increases re-
2 and 5 [chronic Pax-­7 expression]—­Figure 2B; subject 18 ported herein were not accompanied by chronic (i.e., basal
[acute PAX-­7 expression] Figure 2C). pre-­to-­post changes) increases in the number of SC and
myonuclei after 16 RT sessions. Despite the paucity of
studies investigating the chronic SC response in previously
4 | DI S C USSION resistance-­trained individuals, the evidence demonstrated
that for novice RT practitioners, the extensive increase in
We demonstrated that frequent manipulations of RT the fCSA in the early stages of RT induces a proliferation
variables do not enhance fCSA increase compared to a of SC pool to support the myonuclei donation to muscle
standard RT protocol using a within-­subject design in fibers, undergoing sarcoplasmic volume expansion.12,14,19
resistance-­trained subjects. Additionally, we did not find However, we did not report increases in SC or myonuclei
increases in SC and myonuclei content either for RT-­CON content herein. Importantly, our recent meta-­analysis
and RT-­VAR, with the gene expression suggesting a SC demonstrated that a substantial SC-­mediated myonuclei
self-­renewal for both protocols. The individual analyses addition is observed when fCSA increases ≥22%, whereas
demonstrated, to some extent, an aligned response be- our subjects presented ~12% of increase in fCSA.30 It is
tween fCSA, SC, and myonuclei responses (i.e., subjects possible that our resistance-­trained participants have al-
who had greater muscle fiber hypertrophy also had a ready experienced myonuclear addition; therefore, the
greater SC and myonuclei responses, and the opposite is pre-­existing number of myonuclei was able to support
true), regardless of the RT protocol. Additionally, we did the increase in sarcoplasmic volume (i.e., our subjects
not find an alignment between chronic or acute increases did not require new SC-­mediated myonuclei addition).
in gene expression and fCSA changes. Finally, our histo- This hypothesis seems to be supported by studies that
logical assays suggest that individual SC and myonuclei demonstrated ~2.5 myonuclei per fiber in novice RT prac-
responses exert a more pronounced effect on fCSA in- titioners,12,14,31 while we showed ~4.0 myonuclei per fiber
creases than extrinsic manipulations of RT variables. in resistance-­trained subjects. Although both RT protocols
did not significantly increase SC content in our resistance-­
trained subjects, they may have stimulated the SC self-­
4.1 | Effects of resistance training renewal to maintain the SC pool. This hypothesis can be
variables manipulations at group level supported by chronic increases in Pax-­7 and MyoD expres-
sion without increases in MyoG, suggesting an activation
To optimize/maximize muscle hypertrophy and/or po- and proliferation of SC pool without subsequent differenti-
tentiate the hypertrophy of specific muscle fiber types, ation.20,32–­35 Additionally, it has already been demonstrated
reputable guidelines advise frequent manipulation in that SC self-­renewal and maintenance of the pool are in-
RT variables, especially for resistance-­trained individu- fluenced on the activity of MMPs to remodel the ECM.36,37
als.2,4,5,9 However, we found similar increases in fCSA for Accordingly, we demonstrated increases in chronic MMP-­2
both type I and II fibers between protocols, regardless the and acute MMP-­9 expression, which is associated with
slight difference in accumulated volume load between legs, chronic increases in collagen expression (a proxy marker
ANGLERI et al.    | 9

of ECM remodeling). These results expand our previous responsiveness (between-­subjects) on muscle fiber hyper-
findings,38 suggesting that even subjects with years of RT trophy. Therefore, we suggest that the intrinsic individual
experience have continuous ECM remodeling. Regarding capacity to respond to a RT program can be the key deter-
acute gene expression, it is well established that a single minant of RT-­induced hypertrophy rather than the extrin-
bout of RT produces increases in MGF, Pax-­7, MyoG, and sic manipulation of RT variables.
MMP-­9.13,20,39 For most of the genes assessed acutely, both Regarding the role of SC on individual muscle adap-
protocols induced similar expression responses. These re- tations, many studies have investigated the SC-­mediated
sults suggest that manipulating RT variables stimulates myonuclei addition as a potential regulator of individ-
the genes involved in myogenesis and ECM remodeling ual RT-­induced hypertrophic response.12,14 Some studies
similarly to a constant progressive RT. Only for MyoG, the showed a relationship between the magnitude of fCSA in-
RT-­VAR protocol induced a higher gene expression than creases with the SC response and myonuclei addition,12,14
RT-­CON, suggesting a higher level of terminal myoblast while others demonstrated similar RT-­induced SC re-
differentiation for RT-­VAR.33,34 However, we did not find sponse18 and myonuclei addition,15 regardless the magni-
higher increases in SC content with subsequent myonuclei tude of the muscle hypertrophy. In those studies, it should
addition for RT-­VAR. These results support the hypothesis be noted that clusters were composed of young and older
that although acute MyoG expression is responsive to RT subjects of both sexes without previous RT experience,12,14
manipulations,40 these results are not accompanied by dif- or by young novice RT practitioners.18 Our results sug-
ferences in muscle fiber hypertrophy. gest that for a cohort of young resistance-­trained subjects,
the RT-­induced SC and myonuclei responses are aligned
with the magnitude of fCSA increases. Our heatmap
4.2 | Effects of resistance training demonstrated that the highest responders for total fCSA
variables manipulations at individual level gains presented some of the highest SC and myonuclei re-
sponses. In contrast, the subjects with lowest hypertrophic
Regarding the individual responses, we found large response showed the lowest SC and myonuclei responses.
between-­subject variability in fCSA, corroborating Furthermore, the heatmap illustrates that none of the sub-
our previous findings at the whole-­muscle level.16 jects with the highest increases of total fCSA presented the
Additionally, the wide and similar between-­subject vari- lowest responses for SC and or myonuclei responses, and
ability in the fiber hypertrophy for RT-­CON (−14.7% to the opposite is true. These results also agree with the sig-
69.4% for fCSA type I and −14.9% to 58.5% for fCSA type nificant correlation between total fCSA changes and total
II) and RT-­VAR (−18.2% to 59.5% for fCSA type I and SC (p < 0.01; r = 0.42) and total myonuclei (p < 0.001;
−15.8% to 65.5% for fCSA type II) expands our previous r = 0.50) changes. Similar to the fCSA results, the SC and
results suggesting that RT regimen (RT-­CON or RT-­VAR) myonuclei responses also seem to be little affected by the
do not impact the high between-­subject variability also at frequent manipulation of RT variables (i.e., no difference
the fiber level. In accordance, the heatmaps demonstrated within-­subject), at least when high effort RT protocols are
that the RT-­induced individual hypertrophic adaptations applied. We demonstrate a high between-­subjects variabil-
(i.e., between legs) were also not affected by the RT regi- ity with heatmaps colors gradient ranging from the most
men, that is, neither the frequent manipulation of the RT intense shades of blue to the most intense shades of red
variables (RT-­VAR) nor the standard RT program (RT-­ for both SC and myonuclei responses. Conversely, heat-
CON) were able to modulate the individual response sub- maps demonstrated a lower within-­subject (between legs)
stantially. In this regard, the heatmap demonstrated that variability, with most subjects’ legs ranging within the
no subject presented substantial differences in the color same gradient of colors and only a few subjects presenting
gradient between conditions; but, few subjects showed a a slight variation between colors gradient for both SC and
slightly variation between conditions with colors ranging myonuclei responses. These results align with the correla-
from white to blue or white to red. In other words, the tion (p < 0.0001; r = 0.82) between RT-­CON and RT-­VAR
low variability of the hypertrophic response at the within-­ for total SC changes and a strong trend for total myonuclei
subject (between legs) level illustrates that the subjects (p < 0.07; r = 0.42) changes. These results suggest that SC
did not have a greater benefit in the hypertrophic adap- and myonuclei responses to chronic RT are determinants
tations with a given protocol. This is supported by the of the individual muscle fiber hypertrophy and were not
high correlation (p < 0.0001; r = 0.89) between RT-­CON modulated by the manipulation of RT applied herein.
and RT-­VAR for total fCSA changes. Taken together, In contrast, we observed a non-­alignment between
these results suggest that the influence of RT modula- the muscle fiber hypertrophy and the expression of most
tion (RT-­VAR) at the within-­subject (between legs) level of the investigated genes in both the acute and chronic
is substantially smaller than the effects of individual stages. The significant correlation between muscle fiber
10 |    ANGLERI et al.

hypertrophy and chronic and acute gene expression only Islam et al.46 investigated the repeatability of the entire
for MyoD suggests that the expression of the vast majority RT-­PCR (from muscle biopsy to gene amplification), sub-
of hypertrophy-­related genes may not be good predictors of mitting the same subjects to two identical exercise bouts.
phenotypic adaptations.41,42 Other studies demonstrated a Despite the similar gene expression results at the group
non-­alignment between muscle adaptations and acute38,43 level and a good to excellent repeatability in each step of
and chronic18,38 changes in gene expression. However, little RT-­PCR, there was a lack of repeatability at the individual
is known about the individual RT-­induced change in acute level at the basal state and between exercise bouts. These
and chronic gene expression in resistance-­trained subjects. results suggest that although inferences based on exercise-­
Our heatmaps showed that several subjects that presented induced transcriptional responses appear to be valid at the
the highest total fCSA increases demonstrated one of the group level, they may not be a sensitive biomarker of adap-
lowest gene expression responses for several target genes, tive potential and/or an indicator of individual responsive-
while subjects with the lowest fCSA response showed ro- ness to a given exercise protocol. Thus, we suggest that
bust gene expressions. Additionally, some subjects pre- future studies should include different time points, use
sented the highest gene expression level for one leg while techniques that encompass biological processes besides
the opposite leg presented the lowest gene expression level, gene expression (e.g., multi-­omics analyses) also on an in-
which corroborates with the lack of correlation between dividual basis, and be cautious when attributing solely to
legs for acute and chronic gene expression, except for genes the role of the mechanisms involved in phenotypic
MyoD. Collectively, these results suggest a disconnection responses, mainly at the individual level.
between most of the analyzed genes and the RT-­induced Our study is not without limitation. To minimize the
phenotypic adaptation. Buccitelli and Selbach44 suggested number of muscle biopsies and reduce the burden to our
that although gene expression provides important insights subjects, we performed a unilateral biopsy only at base-
into biological systems, the differential translation, pro- line. The baseline muscle samples harvested from one leg
tein degradation, contextual confounders, and pervasive may be a limitation in our design since a variability may
protein-­level buffering, difficult the statement that pro- exist between legs, although previous studies have not
teins are actually being synthesized or phenotype changes demonstrated significant/important differences for fiber
are responding proportionally to the gene expression. In cross-­sectional area, myonuclei content, and gene expres-
this regard, gene expression should not be interpreted as sion between legs in a within-­subject design.47,48
the final output of phenotypic responses. Thus, acquiring
and integrating multi-­omics datasets provide a better un-
derstanding of the flow of information from genomic to 5 | CONC LUSION
proteomic to phenotypic level.44,45 Furthermore, one may
argue that the poor agreement between muscle fiber hy- Frequent manipulations of resistance training variables
pertrophy with acute and chronic gene expression is be- promoted similar responses on type I and II muscle fiber
cause subjects present different individual time points to hypertrophy, satellite cells and myonuclei content, and
increase the gene expression. Supporting this hypothesis, gene expression as compared a standard resistance train-
Nederveen et al.21 assigned subjects in clusters accordingly ing program in resistance-­trained subjects. Additionally,
to the capillary density (which is thought to support SC both protocols produce similar low within-­subject and
responses and hypertrophy) and demonstrated that the high between-­subjects variability. Finally, the individual
expression of myogenic genes significantly increased in analyses showed that the muscle fiber hypertrophy is
different time points (i.e., 6 vs. 24 vs. 72 vs. 96 h after a aligned with the satellite cell response and myonuclei re-
RT bout) in each cluster. Although Nederveen et al.21 had sponses, but not with chronic and acute gene expression,
assessed the expression of myogenic genes in a wide range regardless of the resistance training protocol.
of time points, the authors did not investigate the re-
sponses of these genes on an individual basis. In contrast,
Mallinson et al.43 demonstrated different levels of individ- 6 | PERSPECTIVE
ual mRNA expression throughout a RT program (i.e., 24 h
after the 1st RT session vs. 7 days vs. 28 days vs. 84 days of The present study provides novel information about the ef-
the RT program) for 93 genes involved in RT-­induced skel- fects of frequent manipulation of RT variables in the fCSA
etal muscle regulation. Therefore, it is possible that some increase and related intrinsic biological factors. This study
subjects characterized as low or high responders for gene showed that fCSA, SC, myonuclei, and gene expression
expression could present a different level of responsive- responses seem not to be modulated by RT variables ma-
ness if analyzed in another time point. Finally, the lack of nipulations. Additionally, the low within-­subject and high
alignment may be related to random biological variability. between-­subject variability suggests a higher contribution
ANGLERI et al.    | 11

2. Garber CE, Blissmer B, Deschenes MR, et al. Quantity and

of intrinsic biological factors in the RT-­induced increases
quality of exercise for developing and maintaining cardiore-
in fCSA compared with RT variables manipulations. This spiratory, musculoskeletal, and neuromotor fitness in appar-
work suggests that although frequent RT variables manip- ently healthy adults: guidance for prescribing exercise. Med Sci
ulations could be performed by practitioners that appreci- Sports Exerc. 2011;43(7):1334-­1359.
ate this strategy (e.g., making the training less monotonous 3. Kraemer WJ, Adams K, Cafarelli E, et al. American College
and/or feeling more motivated), subjects that do not toler- of Sports Medicine position stand. Progression models in re-
ate these manipulations will not have impaired responses sistance training for healthy adults. Med Sci Sports Exerc.
2002;34(2):364-­380.
performing a standard progressive RT. Future study
4. Kraemer WJ, Ratamess NA. Fundamentals of resistance train-
should investigate the effects of other training schemes
ing: progression and exercise prescription. Med Sci Sports Exerc.
(e.g., periodization models and blood flow restriction) and 2004;36(4):674-­688.
intrinsic biological factors (e.g., ribosome biogenesis, mi- 5. ACSM. American College of Sports Medicine position stand.
croRNAs, and capillary density) in the inter-­ and within-­ Progression models in resistance training for healthy adults.
subjects skeletal muscle responses. Med Sci Sports Exerc. 2009;41(3):687-­708.
6. Fry AC. The role of resistance exercise intensity on muscle fibre
ACKNOWLEDGMENTS adaptations. Sports Med. 2004;34(10):663-­679.
7. Vikne H, Refsnes PE, Ekmark M, Medbo JI, Gundersen V,
This work was supported by The São Paulo Research
Gundersen K. Muscular performance after concentric and
Foundation (#2017/05331-­6 to V. Angleri; #2016/24259-­1 eccentric exercise in trained men. Med Sci Sports Exerc.
and #2018/13064-­0 to F. Damas; #2013/00789-­2 to H. S. 2006;38(10):1770-­1781.
Selistre-­de-­Araujo; #2013/07104-­6 to A. S. Cornachione; 8. Friedmann-­Bette B, Bauer T, Kinscherf R, et al. Effects of
#2016/22635-­6 to M. E. Lixandrão and #2017/04299-­1 to strength training with eccentric overload on muscle adaptation
C. A. Libardi). C. A. Libardi and C. Ugrinowitsch also in male athletes. Eur J Appl Physiol. 2010;108(4):821-­836.
were supported by the National Council for Scientific and 9. Fleck KW. Designing Resistance Training Programs. 4th ed.
Technological Development (C. A. Libardi #302801/2018-­ Human Kinetics; 2014.
10. Ogborn D, Schoenfeld BJ. The role of fiber types in muscle hy-
9; and C. Ugrinowitsch #303085/2015-­0). The au-
pertrophy: implications for loading strategies. Strength Cond J.
thors acknowledge Supley Laboratório de Alimentos e 2014;36(2):20-­25.
Suplementos Nutricionais (Max Titanium, São Paulo, 11. Kosek DJ, Kim JS, Petrella JK, Cross JM, Bamman MM. Efficacy
Brazil) for donating whey protein. Also, we would like to of 3 days/wk resistance training on myofiber hypertrophy and
show appreciation to the subjects who participated in this myogenic mechanisms in young vs. older adults. J Appl Physiol.
study. 2006;101(2):531-­544.
12. Petrella JK, Kim JS, Cross JM, Kosek DJ, Bamman MM.
Efficacy of myonuclear addition may explain differential myofi-
CONFLICT OF INTEREST
ber growth among resistance-­trained young and older men and
Dr. Phillips reports sitting on the scientific advisory board
women. Am J Physiol Endocrinol Metab. 2006;291(5):937-­946.
for Enhanced Recovery but receives no payment outside 13. Bamman MM, Petrella JK, Kim JS, Mayhew DL, Cross JM.
the submitted work. In addition, Dr. Phillips has a pat- Cluster analysis tests the importance of myogenic gene expres-
ent Canadian 3052324 issued to Exerkine, and a patent US sion during myofiber hypertrophy in humans. J Appl Physiol.
20200230197 pending to Exerkine but reports no financial 2007;102(6):2232-­2239.
gains. No conflicts of interest, financial or otherwise, are 14. Petrella JK, Kim JS, Mayhew DL, Cross JM, Bamman MM.
also declared by other authors. Potent myofiber hypertrophy during resistance training in hu-
mans is associated with satellite cell-­mediated myonuclear ad-
dition: a cluster analysis. J Appl Physiol. 2008;104(6):1736-­1742.
DATA AVAILABILITY STATEMENT
15. Haun CT, Vann CG, Mobley CB, et al. Pre-­training skeletal
The data that support the findings of this study are avail- muscle fiber size and predominant fiber type best predict hy-
able on request from the corresponding author. pertrophic responses to 6 weeks of resistance training in previ-
ously trained young men. Front Physiol. 2019;10:10297.
ORCID 16. Damas F, Angleri V, Phillips SM, et al. Myofibrillar protein
Miguel Soares Conceição https://orcid. synthesis and muscle hypertrophy individualised responses to
org/0000-0002-9170-7890 systematically changing resistance training variables in trained
young men. J Appl Physiol. 2019;127:806-­815.
Cleiton Augusto Libardi https://orcid.
17. Churchward-­Venne TA, Tieland M, Verdijk LB, et al. There are
org/0000-0002-9003-7610 no nonresponders to resistance-­type exercise training in older
men and women. J Am Med Dir Assoc. 2015;16(5):400-­411.
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