Acute and Chronic Effects of Blood Flow Restricted High-Intensity Interval Training: A Systematic Review

Background

The implementation of blood flow restriction (BFR) during exercise is becoming an increasingly useful adjunct method in both athletic and rehabilitative settings. Advantages in pairing BFR with training can be observed in two scenarios: (1) training at lower absolute intensities (e.g. walking) elicits adaptations akin to high-intensity sessions (e.g. running intervals); (2) when performing exercise at moderate to high intensities, higher physiological stimulus may be attained, leading to larger improvements in aerobic, anaerobic, and muscular parameters. The former has been well documented in recent systematic reviews, but consensus on BFR (concomitant or post-exercise) combined with high-intensity interval training (HIIT) protocols is not well established. Therefore, this systematic review evaluates the acute and chronic effects of BFR + HIIT.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify relevant studies. A systematic search on 1 February 2022, was conducted on four key databases: ScienceDirect, PubMed, Scopus and SPORTDiscus. Quality of each individual study was assessed using the Physiotherapy Evidence Database (PEDro) scale. Extraction of data from included studies was conducted using an adapted version of the 'Population, Intervention, Comparison, Outcome' (PICO) framework.

Results

A total of 208 articles were identified, 18 of which met inclusion criteria. Of the 18 BFR + HIIT studies (244 subjects), 1 reported both acute and chronic effects, 5 examined acute responses and 12 investigated chronic effects. Acutely, BFR challenges the metabolic processes (vascular and oxygenation responses) during high-intensity repeated sprint exercise—which accelerates central and peripheral neuromuscular fatigue mechanisms resulting in performance impairments. Analysis of the literature exploring the chronic effects of BFR + HIIT suggests that BFR does provide an additive physiological training stimulus to HIIT protocols, especially for measured aerobic, muscular, and, to some extent, anaerobic parameters.

Conclusion

Presently, it appears that the addition of BFR into HIIT enhances physiological improvements in aerobic, muscular, and, to some extent, anaerobic performance. However due to large variability in permutations of BFR + HIIT methodologies, it is necessary for future research to explore and recommend standardised BFR guidelines for each HIIT exercise type.

Effects of an experimental short-time high-intensity warm-up on explosive muscle strength performance in soccer players: A pilot study

Objective: This study aimed to evaluate the effects of an experimental short-time warm-up consisting of a small number of intermittent high-intensity sprints on explosive muscle strength performance in soccer players and to identify recovery times after performing the sprints. Furthermore, we evaluated the reliability of a smartphone app in jumping performance.

Methods: Twenty male soccer players were given the following tests: 1) the counter-movement jump (CMJ) test with the Microgate system, 2) the counter-movement jump (CMJ) test with the MyJump smartphone app, and 3) the handgrip strength test. The experimental short-time high-intensity warm-up was carried out 1 week after test administration. The warm-up consisted of three maximum sprints over 60 m with 120 s of recovery between sprints. Then, the tests were administered again: the vertical jump height (VJH) performances (five trials) were measured 90 s after the last sprint; the handgrip strength performances (three trials) were measured 120 s after the last vertical jump test.

Results: The maximum VJH was found in the third trial of the CMJ test, 330 s after the last sprint (p < 0.01), the result closest to the baseline. The lowest VJH was found in the first trial of the CMJ test, 90 s after the last sprint (p < 0.05). Pearson’s analysis between the CMJ test with the Microgate system and the CMJ test with MyJump showed a strong correlation (R = 0.96). Lin’s concordance correlation coefficient showed a substantial concordance (ρc = 0.959) between measures.

Conclusion: This experimental short-time warm-up of high-intensity intermittent sprints appears to be a simple, quick, and efficient activity to accelerate soccer players’ optimal performance.

Neuromuscular responses to fatiguing locomotor exercise

Over the last two decades, an abundance of research has explored the impact of fatiguing locomotor exercise on the neuromuscular system. Neurostimulation techniques have been implemented prior to and following locomotor exercise tasks of a wide variety of intensities, durations, and modes. These techniques have allowed for the assessment of alterations occurring within the central nervous system and the muscle, while techniques such as transcranial magnetic stimulation and spinal electrical stimulation have permitted further segmentalization of locomotor exercise-induced changes along the motor pathway. To this end, the present review provides a comprehensive synopsis of the literature pertaining to neuromuscular responses to locomotor exercise. Sections of the review were divided to discuss neuromuscular responses to maximal, severe, heavy and moderate intensity, high-intensity intermittent exercise, and differences in neuromuscular responses between exercise modalities. During maximal and severe intensity exercise, alterations in neuromuscular function reside primarily within the muscle. Although post-exercise reductions in voluntary activation following maximal and severe intensity exercise are generally modest, several studies have observed alterations occurring at the cortical and/or spinal level. During prolonged heavy and moderate intensity exercise, impairments in contractile function are attenuated with respect to severe intensity exercise, but are still widely observed. While reductions in voluntary activation are greater during heavy and moderate intensity exercise, the specific alterations occurring within the central nervous system remain unclear. Further work utilizing stimulation techniques during exercise and integrating new and emerging techniques such as high-density electromyography is warranted to provide further insight into neuromuscular responses to locomotor exercise.

Neuromuscular fatigue of the elbow flexors during repeated maximal arm cycling sprints: the effects of forearm position

Repeated sprint exercise (RSE) is often used to induce neuromuscular fatigue (NMF). It is currently not known whether NMF is influenced by different forearm positions during arm cycling RSE. The purpose of this study was to investigate the effects of a pronated versus supinated forearm position on elbow flexor NMF during arm cycling RSE. Participants (n = 12) completed ten 10-s maximal arm cycling sprints interspersed by 60 s of rest on 2 separate days using either a pronated or supinated forearm position. All sprints were performed on an arm cycle ergometer in a reverse direction. Prior to and following RSE, NMF measurements (i.e., maximal voluntary contraction (MVC), potentiated twitch (PT), electromyography median frequencies) were recorded. Sprint performance measures, ratings of perceived exertion (RPE) and pain were also recorded. Irrespective of forearm position, sprint performance decreased as sprint number increased. These decreases were accompanied by significant increases in RPE (p < 0.001, ηp² = 0.869) and pain (p < 0.001, ηp² = 0.745). Participants produced greater power output during pronated compared with supinated sprinting (p < 0.001, ηp² = 0.728). At post-sprinting, the percentage decrease in elbow flexor MVC and PT force from pre-sprinting was significantly greater following supinated than pronated sprinting (p < 0.001), suggesting greater peripheral fatigue occurred in this position. The data suggest that supinated arm cycling RSE results in inferior performance and greater NMF compared with pronated arm cycling RSE. Novelty: NMF of the elbow flexors is influenced by forearm position during arm cycling RSE. Supinated arm cycling sprints resulted in worse repeated sprint performance and also greater NMF than pronated RSE.

Effect of fatigue-related group III/IV afferent firing on intracortical inhibition and facilitation in hand muscles

Fatiguing exercise causes a reduction in motor drive to the muscle. Group III/IV muscle afferent firing is thought to contribute to this process; however, the effect on corticospinal and intracortical networks is poorly understood. In two experiments, participants performed sustained maximal isometric finger abductions of the first dorsal interosseous (FDI) muscle, with postexercise blood flow occlusion (OCC) to maintain the firing of group III/IV afferents or without occlusion (control; CON). Before and after exercise, single- and paired-pulse transcranial magnetic stimulation (TMS) tested motor evoked potentials (MEPs), intracortical facilitation [ICF (12 ms)], and short-interval intracortical inhibition [SICI₂ (2 ms), SICI₃ (3 ms)]. Ulnar nerve stimulation elicited maximal M waves (M_MAX). For experiment 1 (n = 16 participants), TMS intensities were 70% and 120% of resting motor threshold (RMT) for the conditioning and MEP stimuli, respectively. For experiment 2 (n = 16 participants), the MEP was maintained at 1 mV before and after exercise and the conditioning stimulus individualized. In experiment 1, MEP/M_MAX was reduced after exercise (~48%, P = 0.007) but was not different between conditions. No changes occurred in ICF or SICI. In experiment 2, MEP/M_MAX increased (~27%, P = 0.027) and less inhibition (SICI₂: ~21%, P = 0.021) occurred after exercise for both conditions, whereas ICF decreased for CON only (~28%, P = 0.006). MEPs and SICI₂ were modulated by fatiguing contractions but not by group III/IV afferent firing, whereas sustained afferent firing appeared to counteract postexercise reductions in ICF in FDI. The findings do not support the idea that actions of group III/IV afferents on motor cortical networks contribute to the reduction in voluntary activation observed in other studies.NEW & NOTEWORTHY This is the first study to investigate, in human hand muscles, the action of fatigue-related group III/IV muscle afferent firing on intracortical facilitation and inhibition. In fatigued and nonexercised hand muscles, intracortical inhibition is reduced after exercise but is not modulated differently by the firing of group III/IV afferents. However, facilitation is maintained for the fatigued muscle when group III/IV afferents fire, but these results are unlikely to explain the reduction in voluntary activation observed in other studies.

Understanding exercise-dependent plasticity of motoneurons using intracellular and intramuscular approaches

Spinal motoneurons (MN) exhibit exercise-dependent adaptations to increased activity, such as exercise and locomotion, as well as decreased activity associated with disuse, spinal cord injury, and aging. The development of several experimental approaches, in both human and animal models, has contributed significantly to our understanding of this plasticity. The purpose of this review is to summarize how intracellular recordings in an animal model and motor unit recordings in a human model have, together, contributed to our current understanding of exercise-dependent MN plasticity. These approaches and techniques will allow neuroscientists to continue to advance our understanding of MN physiology and the plasticity of the "final common path" of the motor system, and to design experiments to answer the critical questions that are emerging in this field.

Neuromuscular evaluation of arm-cycling repeated sprints under hypoxia and/or blood flow restriction

PURPOSE

This study aimed to determine the effects of hypoxia and/or blood flow restriction (BFR) on an arm-cycling repeated sprint ability test (aRSA) and its impact on elbow flexor neuromuscular function.

METHODS

Fourteen volunteers performed an aRSA (10 s sprint/20 s recovery) to exhaustion in four randomized conditions: normoxia (NOR), normoxia plus BFR (N_BFR), hypoxia (FiO₂ = 0.13, HYP) and hypoxia plus BFR (H_BFR). Maximal voluntary contraction (MVC), resting twitch force (Db10), and electromyographic responses from the elbow flexors [biceps brachii (BB)] to electrical and transcranial magnetic stimulation were obtained to assess neuromuscular function. Main effects of hypoxia, BFR, and interaction were analyzed on delta values from pre- to post-exercise.

RESULTS

BFR and hypoxia decreased the number of sprints during aRSA with no significant cumulative effect (NOR 16 ± 8; N_BFR 12 ± 4; HYP 10 ± 3 and H_BFR 8 ± 3; P < 0.01). MVC decrease from pre- to post-exercise was comparable whatever the condition. M-wave amplitude (- 9.4 ± 1.9% vs. + 0.8 ± 2.0%, P < 0.01) and Db10 force (- 41.8 ± 4.7% vs. - 27.9 ± 4.5%, P < 0.01) were more altered after aRSA with BFR compared to without BFR. The exercise-induced increase in corticospinal excitability was significantly lower in hypoxic vs. normoxic conditions (e.g., BB motor evoked potential at 75% of MVC: - 2.4 ± 4.2% vs. + 16.0 ± 5.9%, respectively, P = 0.03).

CONCLUSION

BFR and hypoxia led to comparable aRSA performance impairments but with distinct fatigue etiology. BFR impaired the muscle excitation-contraction coupling whereas hypoxia predominantly affected corticospinal excitability indicating incapacity of the corticospinal pathway to adapt to fatigue as in normoxia.

Neuromuscular fatigue during repeated sprint exercise: underlying physiology and methodological considerations

Neuromuscular fatigue occurs when an individual’s capacity to produce force or power is impaired. Repeated sprint exercise requires an individual to physically exert themselves at near-maximal to maximal capacity for multiple short-duration bouts, is extremely taxing on the neuromuscular system, and consequently leads to the rapid development of neuromuscular fatigue. During repeated sprint exercise the development of neuromuscular fatigue is underlined by a combination of central and peripheral fatigue. However, there are a number of methodological considerations that complicate the quantification of the development of neuromuscular fatigue. The main goal of this review is to synthesize the results from recent investigations on the development of neuromuscular fatigue during repeated sprint exercise. Hence, we summarize the overall development of neuromuscular fatigue, explain how recovery time may alter the development of neuromuscular fatigue, outline the contributions of peripheral and central fatigue to neuromuscular fatigue, and provide some methodological considerations for quantifying neuromuscular fatigue during repeated sprint exercise.

Corticospinal excitability during fatiguing whole body exercise

The corticospinal pathway is considered the primary conduit for voluntary motor control in humans. The efficacy of the corticospinal pathway to relay neural signals from higher brain areas to the locomotor muscle, i.e., corticospinal excitability, is subject to alterations during exercise. While the integrity of this motor pathway has historically been examined during single-joint contractions, a small number of investigations have recently focused on whole body exercise, such as cycling or rowing. Although differences in methodologies employed between these studies complicate the interpretation of the existing literature, it appears that the net excitability of the corticospinal pathway remains unaltered during fatiguing whole body exercise. Importantly, this lack of an apparent effect does not designate the absence of change, but a counterbalance of excitatory and inhibitory influences on the two components of the corticospinal pathway, namely the motor cortex and the spinal motoneurons. Specific emphasis is put on group III/IV afferent feedback from locomotor muscle which has been suggested to play a significant role in mediating these changes. Overall, this review aims at summarizing our limited understanding of how fatiguing whole body exercise influences the corticospinal pathway.

Spinal Cord Excitability and Sprint Performance Are Enhanced by Sensory Stimulation During Cycling

Spinal cord excitability, as assessed by modulation of Hoffmann (H-) reflexes, is reduced with fatiguing isometric contractions. Furthermore, spinal cord excitability is reduced during non-fatiguing arm and leg cycling. Presynaptic inhibition of Ia terminals is believed to contribute to this suppression of spinal cord excitability. Electrical stimulation to cutaneous nerves reduces Ia presynaptic inhibition, which facilitates spinal cord excitability, and this facilitation is present during arm cycling. Although it has been suggested that reducing presynaptic inhibition may prolong fatiguing contractions, it is unknown whether sensory stimulation can alter the effects of fatiguing exercise on performance or spinal cord excitability. Thus, the aim of this experiment was to determine if sensory stimulation can interfere with fatigue-related suppression of spinal cord excitability, and alter fatigue rates during cycling sprints. Thirteen participants randomly performed three experimental sessions that included: unloaded cycling with sensory stimulation (CONTROL + STIM), sprints with sensory stimulation (SPRINT + STIM) and sprints without stimulation (SPRINT). Seven participants also performed a fourth session (CONTROL), which consisted of unloaded cycling. During SPRINT and SPRINT + STIM, participants performed seven, 10 s cycling sprints interleaved with 3 min rest. For CONTROL and CONTROL + STIM, participants performed unloaded cycling for ~30 min. During SPRINT + STIM and CONTROL + STIM, participants received patterned sensory stimulation to nerves of the right foot. H-reflexes and M-waves of the right soleus were evoked by stimulation of the tibial nerve at multiple time points throughout exercise. Sensory stimulation facilitated soleus H-reflexes during unloaded cycling, whereas sprints suppressed soleus H-reflexes. While receiving sensory stimulation, there was less suppression of soleus H-reflexes and slowed reduction in average power output, compared to sprints without stimulation. These results demonstrate that sensory stimulation can substantially mitigate the fatiguing effects of sprints.

Corticospinal excitability of the biceps brachii is shoulder position dependent

The purpose of this study was to examine the effect of shoulder position on corticospinal excitability (CSE) of the biceps brachii during rest and a 10% maximal voluntary contraction (MVC). Participants ( n = 9) completed two experimental sessions with four conditions: 1) rest, 0° shoulder flexion; 2) 10% MVC, 0° shoulder flexion; 3) rest, 90° shoulder flexion; and 4) 10% MVC, 90° shoulder flexion. Transcranial magnetic, transmastoid electrical, and Erb’s point stimulation were used to induce motor-evoked potentials (MEPs), cervicomedullary MEPs (CMEPs), and maximal muscle compound potentials (Mmax), respectively, in the biceps brachii in each condition. At rest, MEP, CMEP, and Mmax amplitudes increased ( P < 0.01) by 509.7 ± 118.3%, 113.3 ± 28.3%, and 155.1 ± 47.9%, respectively, at 90° compared with 0°. At 10% MVC, MEP amplitudes did not differ ( P = 0.08), but CMEP and Mmax amplitudes increased ( P < 0.05) by 32.3 ± 10.5% and 127.9 ± 26.1%, respectively, at 90° compared with 0°. MEP/Mmax increased ( P < 0.01) by 224.0 ± 99.1% at rest and decreased ( P < 0.05) by 51.3 ± 6.7% at 10% MVC at 90° compared with 0°. CMEP/Mmax was not different ( P = 0.22) at rest but decreased ( P < 0.01) at 10% MVC by 33.6 ± 6.1% at 90° compared with 0°. EMG increased ( P < 0.001) by 8.3 ± 2.0% at rest and decreased ( P < 0.001) by 21.4 ± 4.4% at 10% MVC at 90° compared with 0°. In conclusion, CSE of the biceps brachii was dependent on shoulder position, and the pattern of change was altered within the state in which it was measured. The position-dependent changes in Mmax amplitude, EMG, and CSE itself all contribute to the overall change in CSE of the biceps brachii.

NEW & NOTEWORTHY We demonstrate that when the shoulder is placed into two common positions for determining elbow flexor force and activation, corticospinal excitability (CSE) of the biceps brachii is both shoulder position and state dependent. At rest, when the shoulder is flexed from 0° to 90°, supraspinal factors predominantly alter CSE, whereas during a slight contraction, spinal factors predominantly alter CSE. Finally, the normalization techniques frequently used by researchers to investigate CSE may under- and overestimate CSE when shoulder position is changed.

Maximal Voluntary Activation of the Elbow Flexors Is under Predicted by Transcranial Magnetic Stimulation Compared to Motor Point Stimulation Prior to and Following Muscle Fatigue

Transcranial magnetic (TMS) and motor point stimulation have been used to determine voluntary activation (VA). However, very few studies have directly compared the two stimulation techniques for assessing VA of the elbow flexors. The purpose of this study was to compare TMS and motor point stimulation for assessing VA in non-fatigued and fatigued elbow flexors. Participants performed a fatigue protocol that included twelve, 15 s isometric elbow flexor contractions. Participants completed a set of isometric elbow flexion contractions at 100, 75, 50, and 25% of maximum voluntary contraction (MVC) prior to and following fatigue contractions 3, 6, 9, and 12 and 5 and 10 min post-fatigue. Force and EMG of the bicep and triceps brachii were measured for each contraction. Force responses to TMS and motor point stimulation and EMG responses to TMS (motor evoked potentials, MEPs) and Erb's point stimulation (maximal M-waves, M_max) were also recorded. VA was estimated using the equation: VA% = (1−SITforce/PTforce) × 100. The resting twitch was measured directly for motor point stimulation and estimated for both motor point stimulation and TMS by extrapolation of the linear regression between the superimposed twitch force and voluntary force. MVC force, potentiated twitch force and VA significantly (p < 0.05) decreased throughout the elbow flexor fatigue protocol and partially recovered 10 min post fatigue. VA was significantly (p < 0.05) underestimated when using TMS compared to motor point stimulation in non-fatigued and fatigued elbow flexors. Motor point stimulation compared to TMS superimposed twitch forces were significantly (p < 0.05) higher at 50% MVC but similar at 75 and 100% MVC. The linear relationship between TMS superimposed twitch force and voluntary force significantly (p < 0.05) decreased with fatigue. There was no change in triceps/biceps electromyography, biceps/triceps MEP amplitudes, or bicep MEP amplitudes throughout the fatigue protocol at 100% MVC. In conclusion, motor point stimulation as opposed to TMS led to a higher estimation of VA in non-fatigued and fatigued elbow flexors. The decreased linear relationship between TMS superimposed twitch force and voluntary force led to an underestimation of the estimated resting twitch force and thus, a reduced VA.

Corticospinal excitability to the biceps brachii and its relationship to postactivation potentiation of the elbow flexors

We examined the effects of a submaximal voluntary elbow flexor contraction protocol on measures of corticospinal excitability and postactivation potentiation of evoked muscle forces and if these measures were state‐dependent (rest vs. voluntary muscle contraction). Participants completed four experimental sessions where they rested or performed a 5% maximum voluntary contraction (MVC) of the elbow flexors prior to, immediately, and 5 min following a submaximal contraction protocol. During rest or 5% MVC, transcranial magnetic stimulation, transmastoid electrical stimulation, electrical stimulation of biceps brachii motor point and Erb's point were elicited to induce motor‐evoked potentials (MEPs), cervicomedullary MEPs (CMEPs), potentiated twitch (PT) force, and maximal muscle compound action potential (M_max), respectively prior to, immediately, and 5 min postcontraction protocol. MEP amplitudes increased (215 and 165%M_max, P ≤ 0.03) only at 1 and 6s postcontraction protocol, respectively during rest but not 5% MVC. CMEP amplitudes decreased during rest and 5% MVC (range:21–58%M_max, P ≤ 0.04) for up to 81 sec postcontraction protocol. Peak twitch force increased immediately postcontraction protocol and remained elevated for 90 sec (range:122–147% increase, P < 0.05). There was a significant positive correlation between MEP and PT force during rest (r = 0.88, P = 0.01) and a negative correlation between CMEP and PT force during rest (r = −0.85, P < 0.02 and 5% MVC (r = −0.96, P < 0.01) immediately postcontraction protocol. In conclusion, the change in corticospinal and spinal excitability was state‐ and time‐dependent whereas spinal excitability and postactivation potentiation were time‐dependent following the contraction protocol. Changes in corticospinal excitability and postactivation potentiation correlated and were also state‐dependent.

Repeated sprint ability but not neuromuscular fatigue is dependent on short versus long duration recovery time between sprints in healthy males

OBJECTIVES

During maximal intensity leg cycling sprints, previous research has shown that central and peripheral fatigue development occurs with various (<30s) short-duration recovery periods between sprints. The aim of the current study was to compare the development of neuromuscular fatigue during maximal intensity lower-body sprints interspersed with short and longer duration recovery periods.

DESIGN

Crossover study.

METHODS

Ten participants completed 10, 10s sprints interspersed with either 30 or 180s of recovery. Peak power outputs were measured for each sprint. Maximal force, voluntary activation (VA) and evoked contractile properties of the knee extensors were measured at pre-sprint 1, post-sprint 5 and post-sprint 10. Perceived pain was also measured immediately following each sprint.

RESULTS

Peak power output was significantly lower by 16.1±4.2% (p<0.001) during sprint 10 with 30 compared to 180s of recovery. Irrespective of recovery time, maximal force, VA and potentiated twitch force decreased by 26.7±7.2% (p<0.005), 5.8±1.2% (p=0.025), 38.7±6.1% (p=0.003) respectively, from pre-sprint 1 to post-sprint 10. MVC and PT decreased by 17±4% (p<0.003) and 23±9% (p<0.002) respectively, from pre-sprint 1 to post-sprint 5.

CONCLUSIONS

Although decreases in peak power and increases in perceived pain were greater when sprints were interspersed with 30 compared to 180s of recovery, the development of neuromuscular fatigue of the knee extensors was similar. The results illustrate that peripheral fatigue developed early whereas central fatigue developed later in the sprint protocol, however the effect of recovery time on neuromuscular fatigue could be task specific.