Moving forward with backward pedaling: a review on eccentric cycling

The effects of eccentric cycling on vascular reactivity

Purpose

Eccentric cycling has gained attention as a novel exercise modality that increases muscle performance at lower metabolic demand, which could enhance cardiovascular rehabilitation. However, endothelial function response to eccentric cycling (ECC) has yielded contradictory results. Therefore, the purpose of this study was to determine the effect of 30 min of moderate-intensity cycling ECC on endothelial function.

Methods

A total of 15 (9 females, 6 males) young, apparently healthy participants were recruited for two laboratory visits. First, a maximum oxygen consumption (VO2max) and blood lactate (BLa) threshold were measured to determine moderate workload intensity, followed by a familiarization stage on an ECC ergometer. During the second visit, a 30-min of moderate ECC was performed 72 h after the first visit. Endothelial function was measured via Flow-Mediated Dilation (FMD) pre- and post-exercise bout. FMD was calculated following traditional recommendations and adjusting for exercise-induced endothelial shear stress (ESS), utilizing the same pre-exercise baseline artery diameter for post-exercise FMD calculations.

Results

There was a significant increase in endothelial function (p = 0.037) when adjusting pre-exercise baseline diameter to adjust for ESS, but when utilizing the traditional method no change in endothelial function was observed.

Conclusion

30-min of moderate ECC showed a significant improvement in endothelial function when accounting for exercise-induced ESS. These results support the use of the pre-exercise baseline diameter when calculating post-exercise FMD to avoid the exercise-induced ESS or muscle metabolites effects on post-exercise artery diameter.

Peak Eccentric Cycling Exercise and Cardiorespiratory Responses to Normobaric Hypoxia Versus Normobaric Normoxia in Healthy Adults: A Randomized, Controlled Crossover Trial

Background/Objectives: Pulmonary rehabilitation clinics are traditionally located at higher altitudes (HAs), where lower PO2 reduces exercise capacity and blood oxygenation. Eccentric cycling exercise (ECC), with its lower cardiorespiratory demand compared to concentric cycling (CON), might therefore be a potential advantageous training modality at HAs, particularly for individuals with reduced exercise capacity. This study aimed to compare the cardiorespiratory responses of ECC while breathing normoxic versus hypoxic gas in healthy participants. Methods: This randomized, controlled crossover trial involved healthy participants performing CON in normoxia (FiO2 = 0.21), followed by two incremental ECC tests until 70-100% of peak exercise, one with normoxia and one with normobaric hypoxia (FiO2 = 0.15), in a randomized order. Oxygen uptake (V'O2) and additional outcomes were measured breath-by-breath. Endpoints were defined at rest, 50%, 70%, peak exercise, and isotime. The trial is registered on clinicaltrails.gov (NCT05185895). Results: Twelve healthy participants (age: 30 ± 11 years, six females) completed the study. During both interventions, V'O2 increased linearly with exercise intensity, with no significant differences between normoxic and hypoxic conditions. At peak exercise, SpO2 and peak work rate were significantly lowered by 5% (95%CI: 3 to 8%, p < 0.001) and by 22 W (95%CI: 8 to 36 W, p = 0.009) in hypoxia compared to normoxia. Other outcomes were unchanged. When comparing CON to ECC in normoxia, the mean differences in V'O2 increased with higher loads. Conclusions: This study demonstrated that V'O2 and other cardiopulmonary parameters remain unchanged when performing ECC in hypoxia compared to normoxia. Comparing CON to ECC in normoxia, participants achieved higher workloads and greater V'O2 consumption during CON compared to ECC at comparable watts, confirming the higher metabolic cost associated with CON. We identified that the optimal submaximal ECC intensities, with the highest difference in V'O2 between CON versus ECC, are around 40% of peak V'O2.

Strength and power adaptations of the upper body following 20 training sessions on an eccentric arm-crank ergometer

PURPOSE

Eccentric strength training is an innovative and promising approach to improve exercise performance. However, most eccentric training studies in the past were performed with a focus on the lower extremities. The present study aimed to test the feasibility and effects on strength and power adaptations of a structured upper-body eccentric training program.

METHODS

Fourteen (median age (Q1-Q3) 29 years (27-32); 9 females, 5 males) healthy, regularly exercising individuals performed 20 progressive training sessions (2-3 sessions/week at 20-50% peak power for 8-14 min) on a symmetric eccentric arm-crank ergometer. Before and after the intervention, anaerobic peak power (PP) and maximal concentric aerobic power output (POmax) on an arm-crank ergometer as well as the one repetition maximum (1RM) for bench press were determined as main outcome parameters. A p-value ≤ 0.05 was considered statistically significant.

RESULTS

Significant improvements in PP (+ 4% (1-8), p = 0.007), POmax (+ 6% (0-8); p = 0.01), and 1RM (+ 12% (10-17); p < 0.001) were found. Exercise intensity was relatively low at 64% (55-70) of maximum heart rate.

CONCLUSIONS

Twenty progressive training sessions on a symmetric arm-crank ergometer are effective in inducing significant aerobic and anaerobic performance and strength improvements in the upper body. This intervention is safe and feasible, and can be performed at relatively low cardiovascular intensities. Therefore, this training method offers an interesting approach from elite sports to rehabilitation.

Submaximal, Low-Dose Eccentric vs Traditional Cycling Exercise: Reduced Oxygen Uptake and Pulmonary Artery Pressure Assessed by Echocardiography in Healthy Middle-aged Adults. A Randomized Controlled, Crossover Trial

Objective

To investigate the ventilatory and circulatory differences between eccentric (ECC) and concentric (CON) cycling exercise at submaximal, low-dose intensity from onset to end-exercise in healthy middle-aged participants.

Design

Randomized controlled crossover trial.

Setting

The participants underwent 1 ECC and 1 CON test according to stepwise incremental exercise protocols at identical, submaximal intensities. Breath-by-breath analyses of ventilatory gas exchange and echocardiography were used to assess cardiopulmonary function during exercise.

Participants

24 healthy middle-aged, untrained participants (14 women, 10 men, 50±14 years) were included.

Interventions

1 ECC and 1 CON test at submaximal intensities.

Main Outcome Measure

The main outcome was oxygen uptake (V'O2).

Results

The V'O2 increase was reduced by -422 mL/min (-52%, 95% confidence interval: -513 to -292, P<.001) during ECC, as well as the ventilatory drive. Echocardiographic parameters, heart rate (-14%), cardiac output (-21%), stroke volume (-15%), and pulmonary artery pressure by tricuspid regurgitation pressure gradient (TRPG) (-26%) were also significantly reduced during ECC compared with CON at identical intensities. Participants reported significantly less dyspnea and unchanged perceived leg fatigue in ECC.

Conclusion

ECC was well tolerated, and significant reductions were observed in V'O2, ventilation, and right ventricular load compared with CON, even at low intensity levels. This study, conducted on healthy middle-aged participants, did not raise concerns that would hinder further investigation of the effects of ECC in patients with severely limited cardiopulmonary disease, and it calls for further research on this topic.

Cardiovascular Responses to Eccentric Cycling Based on Perceived Exertion Compared to Concentric Cycling, Effect of Pedaling Rate, and Sex

Interest in eccentric exercises has increased over the last decades due to its efficiency in achieving moderate-high intensity muscular work with reduced metabolic demands. However, individualizing eccentric exercises in rehabilitation contexts remains challenging, as concentric exercises mainly rely on cardiovascular parameters. To overcome this, perceived exertion could serve as an individualization tool, but the knowledge about cardiovascular responses to eccentric cycling based on perceived exertion are still scarce. For this purpose, the cardiorespiratory parameters of 26 participants were assessed during two 5 min bouts of concentric cycling at 30 and 60 rpm and two bouts of eccentric cycling at 15 and 30 rpm matched for rating of perceived exertion. With this method, we hypothesized higher exercise efficiency during eccentric cycling for a same perceived exertion. The results revealed significantly elevated heart rate and cardiac index at higher pedalling rates during concentric (p < 0.001), but not during eccentric cycling (p ≈ 1). Exercise efficiency was higher during concentric cycling (64%), decreasing with pedalling rate, while eccentric cycling exhibited increased work rates (82%), and increased by over 100% with higher pedalling rate. Hence, eccentric cycling, with lower cardiorespiratory work for the same perceived exertion, facilitates higher work rates in deconditioned populations. However, further studies are needed for effective individualization.

Acute physiological responses to eccentric cycling: a systematic review and meta-analysis

INTRODUCTION

Eccentric cycling (ECCCYC) has attracted considerable interest due to its potential applicability for exercise treatment/training of patients with poor exercise tolerance as well as healthy and trained individuals. Conversely, little is known about the acute physiological responses to this exercise modality, thus challenging its proper prescription. This study aimed to provide precise estimates of the acute physiological responses to ECCCYC in comparison to traditional concentric cycling (CONCYC).

EVIDENCE ACQUISITION

Searches were performed until November 2021 using the PubMed, Embase, and ScienceDirect databases. Studies that examined individuals' cardiorespiratory, metabolic, and perceptual responses to ECCCYC and CONCYC sessions were included. Bayesian multilevel meta-analysis models were used to estimate the population mean difference between acute physiological responses from ECCCYC and CONCYC bouts. Twenty-one studies were included in this review.

EVIDENCE SYNTHESIS

The meta-analyses showed that ECCCYC induced lower cardiorespiratory (i.e., V̇O2, V̇E, and HR), metabolic (i.e., [BLa]), and perceptual (i.e., RPE) responses than CONCYC performed at the same absolute power output, while greater cardiovascular strain (i.e., greater increases in HR, Q, MAP, [norepinephrine], and lower SV) was detected when compared to CONCYC performed at the same V̇O2.

CONCLUSIONS

The prescription of ECCCYC based on workloads used in the CONCYC sessions may be considered safe and, therefore, feasible for the rehabilitation of individuals with poor exercise tolerance. However, the prescription of ECCCYC based on the V̇O2 obtained during CONCYC sessions should be conducted with caution, especially in clinical settings, since there is a high probability of additional cardiovascular overload in this condition.

Pedal cadence does not affect muscle damage to eccentric cycling performed at similar mechanical work

Purpose: This study aimed to investigate muscle damage when performing equal mechanical work of fast and slow pedaling speed by eccentric muscle actions (ECCs) cycling.

Methods: Nineteen young men [mean ± standard deviation (SD) age: 21.0 ± 2.2 years; height: 172.7 ± 5.9 cm; and body mass: 70.2 ± 10.5 kg] performed maximal effort of ECCs cycling exercise with fast speed (Fast) and slow speed trials (Slow). First, subjects performed the Fast for 5 min by one leg. Second, Slow performed until the total mechanical work was equal to that generated during Fast other one leg. Changes in maximal voluntary isometric contraction (MVC) torque of knee extension, isokinetic pedaling peak torque (IPT), range of motion (ROM), muscle soreness, thigh circumference, muscle echo intensity, and muscle stiffness were assessed before exercise, and immediately after exercise, and 1 and 4 days after exercise.

Results: Exercise time was observed in the Slow (1422.0 ± 330.0 s) longer than Fast (300.0 ± 0.0 s). However, a significant difference was not observed in total work (Fast:214.8 ± 42.4 J/kg, Slow: 214.3 ± 42.2 J/kg). A significant interaction effect was not observed in peak values of MVC torque (Fast:1.7 ± 0.4 Nm/kg, Slow: 1.8 ± 0.5 Nm/kg), IPT, muscle soreness (Fast:4.3 ± 1.6 cm, Slow: 4.7 ± 2.9 cm). In addition, ROM, circumference, muscle thickness, muscle echo intensity, and muscle stiffness also showed no significant interaction.

Conclusion: The magnitude of muscle damage is similar for ECCs cycling with equal work regardless of velocity.

Chronic Adaptations to Eccentric Cycling Training: A Systematic Review and Meta-Analysis

This study aimed to investigate the effects of eccentric cycling (ECCCYC) training on performance, physiological, and morphological parameters in comparison to concentric cycling (CONCYC) training. Searches were conducted using PubMed, Embase, and ScienceDirect. Studies comparing the effect of ECCCYC and CONCYC training regimens on performance, physiological, and/or morphological parameters were included. Bayesian multilevel meta-analysis models were used to estimate the population's mean difference between chronic responses from ECCCYC and CONCYC training protocols. Group levels and meta-regression were used to evaluate the specific effects of subjects and study characteristics. Fourteen studies were included in this review. The meta-analyses showed that ECCCYC training was more effective in increasing knee extensor strength, vastus lateralis fiber cross-sectional area, and six-minute walking distance compared to CONCYC. Moreover, ECCCYC was as effective as CONCYC in decreasing body fat percentage. CONCYC was more effective in increasing V˙O2max and peak power output attained during concentric incremental tests. However, group-level analyses revealed that ECCCYC was more effective than CONCYC in improving V˙O2max in patients with cardiopulmonary diseases. ECCCYC is a viable modality for exercise interventions aiming to improve parameters of muscle strength, hypertrophy, functional capacity, aerobic power, and body composition, with more advantages than CONCYC training in improving neuromuscular variables.

Fractal Correlation Properties of Heart Rate Variability as a Biomarker for Intensity Distribution and Training Prescription in Endurance Exercise: An Update

While established methods for determining physiologic exercise thresholds and intensity distribution such as gas exchange or lactate testing are appropriate for the laboratory setting, they are not easily obtainable for most participants. Data over the past two years has indicated that the short-term scaling exponent alpha1 of Detrended Fluctuation Analysis (DFA a1), a heart rate variability (HRV) index representing the degree of fractal correlation properties of the cardiac beat sequence, shows promise as an alternative for exercise load assessment. Unlike conventional HRV indexes, it possesses a dynamic range throughout all intensity zones and does not require prior calibration with an incremental exercise test. A DFA a1 value of 0.75, reflecting values midway between well correlated fractal patterns and uncorrelated behavior, has been shown to be associated with the aerobic threshold in elite, recreational and cardiac disease populations and termed the heart rate variability threshold (HRVT). Further loss of fractal correlation properties indicative of random beat patterns, signifying an autonomic state of unsustainability (DFA a1 of 0.5), may be associated with that of the anaerobic threshold. There is minimal bias in DFA a1 induced by common artifact correction methods at levels below 3% and negligible change in HRVT even at levels of 6%. DFA a1 has also shown value for exercise load management in situations where standard intensity targets can be skewed such as eccentric cycling. Currently, several web sites and smartphone apps have been developed to track DFA a1 in retrospect or in real-time, making field assessment of physiologic exercise thresholds and internal load assessment practical. Although of value when viewed in isolation, DFA a1 tracking in combination with non-autonomic markers such as power/pace, open intriguing possibilities regarding athlete durability, identification of endurance exercise fatigue and optimization of daily training guidance.

Effects of workload level on the timing of concentric-eccentric contractions during cycling

BACKGROUND

The mechanical energy required to drive the cranks during cycling depends on concentric and eccentric muscle actions. However, no study to date provided clear evidence on how workload levels affect concentric and eccentric muscle actions during cycling. Therefore, the aim of this study was to investigate the workload effects on the timing of lower limb concentric and eccentric muscle actions, and on joint power production.

METHODS

Twenty-one cyclists participated in the study. At the first session, maximal power output (POMAX) and power output at the first (POVT1) and second (POVT2) ventilatory thresholds were determined during an incremental cycling test. At the second session, cyclists performed three trials (2-min/each) in the workloads determined from their POMAX, POVT1 and POVT2, acquiring data of lower limb muscle activation, pedal forces and kinematics. Concentric and eccentric timings were computed from muscles' activations and muscle-tendon unit excursions along with hip, knee and ankle joints' power production.

RESULTS

Longer rectus femoris eccentric activation (62%), vastus medialis concentric (66%) and eccentric activation (26%) and biceps femoris concentric (29%) and eccentric (133%) activation at POMAX were observed compared to POVT1. Longer positive (12%) and shorter negative (12%) power were observed at the knee joint for POMAX compared to POVT1.

CONCLUSIONS

We conclude that, to sustain higher workload levels, cyclists improved the timing of power transmission from the hip to the knee joint via rectus femoris eccentric, vastus medialis concentric and eccentric and biceps femoris concentric and eccentric contractions.

A Semi-recumbent Eccentric Cycle Ergometer Instrumented to Isolate Lower Limb Muscle Contractions to the Appropriate Phase of the Pedal Cycle

Eccentric (ECC) cycling is used in rehabilitation and sports conditioning settings. We present the construction and mode of operation of a custom-built semi-recumbent ECC cycle designed to limit the production of lower limb muscle activity to the phase of the pedal cycle known to produce ECC contractions. A commercially available semi-recumbent frame and seat (Monarch, 837E Semi-recumbent Bike, Sweden) were used to assemble the ergometer. An electrical drive train system was constructed using individual direct drive servo motors. To avoid active muscle activation occurring during the non-ECC pedaling phase of cycling, a “trip” mechanism was integrated into the drivetrain system using a servo-driven regenerative braking mechanism based on the monitoring of the voltage produced over and above a predetermined threshold produced by the motors. The servo drive internal (DC bus) voltage is recorded and internally monitored during opposing (OPP) and non-opposing (N-OPP) phases of the pedal cycle. To demonstrate that the cycle functions as desired and stops or “trips” when it is supposed to, we present average (of 5 trials) muscle activation patterns of the principal lower limb muscles for regular ECC pedal cycles in comparison with one pedal cycle during which the muscles activated outside the desired phase of the cycle for a sample participant. This semi-recumbent ECC cycle ergometer has the capacity to limit the occurrence of muscle contraction only to the ECC phase of cycling. It can be used to target that mode of muscle contraction more precisely in rehabilitation or training studies.

Analysis of Fractal Correlation Properties of Heart Rate Variability during an Initial Session of Eccentric Cycling

Eccentric cycling (ECC) has attracted attention as a method to improve muscle strength and aerobic fitness in populations unable to tolerate conventional methods. However, agreement on exercise prescription targets have been problematic. The current report is an initial exploration of a potentially useful tool, a nonlinear heart rate (HR) variability (HRV) index based on the short-term scaling exponent alpha1 of detrended fluctuation analysis (DFA a1), which has been previously shown to correspond to exercise intensity. Eleven male volunteers performed 45 min of concentric (CON) cycling and ECC separated by 1 month. Work rates were matched for HR (~50% of the maximal HR) during the first 5 min and remained stable thereafter. HRV, HR, oxygen consumption (VO2), and cycling power were monitored and evaluated at elapsed times of 10 (T10) and 45 (T45) minutes duration. HR significantly increased between ECC T10 and ECC T45 (p = 0.003, d = 1.485), while DFA a1 significantly decreased (p = 0.004, d = 1.087). During CON, HR significantly increased (p < 0.001 d = 1.570) without significant DFA a1 change (p = 0.48, d = 0.22). Significantly higher HR was observed at T45 in ECC than in CON (p = 0.047, d = 1.059). A session of unaccustomed ECC lead to decreased values of DFA a1 at T45 in comparison to that seen with CON at similar VO2. ECC lead to altered autonomic nervous system balance as reflected by the loss of correlation properties compared to CON.

Acute and Delayed Effects of Time-Matched Very Short "All Out" Efforts in Concentric vs. Eccentric Cycling

BACKGROUND

To the authors' knowledge, there have been no studies comparing the acute responses to "all out" efforts in concentric (isoinertial) vs. eccentric (isovelocity) cycling.

METHODS

After two familiarization sessions, 12 physically active men underwent the experimental protocols consisting of a 2-min warm-up and 8 maximal efforts of 5 s, separated by 55 s of active recovery at 80 rpm, in concentric vs. eccentric cycling. Comparisons between protocols were conducted during, immediately after, and 24-h post-sessions.

RESULTS

Mechanical (Work: 82,824 ± 6350 vs. 60,602 ± 8904 J) and cardiometabolic responses (mean HR: 68.8 ± 6.6 vs. 51.3 ± 5.7% HRmax, lactate: 4.9 ± 2.1 vs. 1.8 ± 0.6 mmol/L) were larger in concentric cycling (p < 0.001). The perceptual responses to both protocols were similarly low. Immediately after concentric cycling, vertical jump was potentiated (p = 0.028). Muscle soreness (VAS; p = 0.016) and thigh circumference (p = 0.045) were slightly increased only 24-h after eccentric cycling. Serum concentrations of CK, BAG3, and MMP-13 did not change significantly post-exercise.

CONCLUSIONS

These results suggest the appropriateness of the eccentric cycling protocol used as a time-efficient (i.e., ~60 kJ in 10 min) and safe (i.e., without exercise-induced muscle damage) alternative to be used with different populations in future longitudinal interventions.

Effect of Cycling Cadence on Neuromuscular Function: A Systematic Review of Acute and Chronic Alterations

There is a wide range of cadence available to cyclists to produce power, yet they choose to pedal across a narrow one. While neuromuscular alterations during a pedaling bout at non-preferred cadences were previously reviewed, modifications subsequent to one fatiguing session or training intervention have not been focused on. We performed a systematic literature search of PubMed and Web of Science up to the end of 2020. Thirteen relevant articles were identified, among which eleven focused on fatigability and two on training intervention. Cadences were mainly defined as “low” and “high” compared with a range of freely chosen cadences for given power output. However, the heterogeneity of selected cadences, neuromuscular assessment methodology, and selected population makes the comparison between the studies complicated. Even though cycling at a high cadence and high intensity impaired more neuromuscular function and performance than low-cadence cycling, it remains unclear if cycling cadence plays a role in the onset of fatigue. Research concerning the effect of training at non-preferred cadences on neuromuscular adaptation allows us to encourage the use of various training stimuli but not to say whether a range of cadences favors subsequent neuromuscular performance.

Reliability of a Protocol to Elicit Peak Measures Generated by the Lower Limb for Semi-recumbent Eccentric Cycling

Semi-recumbent eccentric (ECC) cycling is increasingly used in studies of exercise with healthy and clinical populations. However, workloads are generally prescribed using measures obtained during regular concentric cycling. Therefore, the purpose of the study was to quantify the reliability of measures derived from a protocol that elicited peak ECC torque produced by the lower limb in a semi-recumbent position. Experiments were carried out on a dynamometer in a seated, semi-recumbent position identical to that of a custom-built ECC cycle, a modified Monark recumbent cycle. Thirty healthy participants completed two testing sessions. Each session comprised three series of six repetitions of a peak ECC torque protocol (PETP) on an isokinetic dynamometer. Absolute and relative reliability of peak torque, power, angle of peak torque, and work (recorded for each repetition) was determined using coefficient of variation (CV) and intraclass correlation coefficient (ICC), respectively. Ratings of perceived exertion (RPE), muscle soreness, and perceived effort (PE) were recorded pre-PETP, immediately post-PETP, and 1-min post each PETP. The protocol showed absolute reliability values <15% for mean peak (CV = 10.6-12.1) torque, power (CV = 10.4-12.3), angle of peak torque (CV = 1.2-1.4), and work (CV = 9.7-12.1). Moderate to high between-test relative reliability is reported for mean and highest torque (ICC = 0.84-0.95; ICC = 0.88-0.98), power (ICC = 0.84-0.94; ICC = 0.89-0.98), and work (ICC = 0.84-0.93; ICC = 0.88-0.98), respectively. Within-session peak torque, peak power, and peak work showed high relative reliability for mean (ICC = 0.92-0.95) and highest (ICC = 0.92-0.97) values. Overall, the PETP test provides a reliable way of determining peak ECC torque specific to semi-recumbent ECC cycling that may be used to prescribe workloads for this form of exercise.

Eccentric Cycling Training Improves Erythrocyte Antioxidant and Oxygen Releasing Capacity Associated with Enhanced Anaerobic Glycolysis and Intracellular Acidosis

The antioxidant capacity of erythrocytes protects individuals against the harmful effects of oxidative stress. Despite improved hemodynamic efficiency, the effect of eccentric cycling training (ECT) on erythrocyte antioxidative capacity remains unclear. This study investigates how ECT affects erythrocyte antioxidative capacity and metabolism in sedentary males. Thirty-six sedentary healthy males were randomly assigned to either concentric cycling training (CCT, n = 12) or ECT (n = 12) at 60% of the maximal workload for 30 min/day, 5 days/week for 6 weeks or to a control group (n = 12) that did not receive an exercise intervention. A graded exercise test (GXT) was performed before and after the intervention. Erythrocyte metabolic characteristics and O₂ release capacity were determined by UPLC-MS and high-resolution respirometry, respectively. An acute GXT depleted Glutathione (GSH), accumulated Glutathione disulfide (GSSG), and elevated the GSSG/GSH ratio, whereas both CCT and ECT attenuated the extent of the elevated GSSG/GSH ratio caused by a GXT. Moreover, the two exercise regimens upregulated glycolysis and increased glucose consumption and lactate production, leading to intracellular acidosis and facilitation of O₂ release from erythrocytes. Both CCT and ECT enhance antioxidative capacity against severe exercise-evoked circulatory oxidative stress. Moreover, the two exercise regimens activate erythrocyte glycolysis, resulting in lowered intracellular pH and enhanced O₂ released from erythrocytes.