Blood Flow Restriction Improves Executive Function after Walking

Twenty-five years of blood flow restriction training: What we know, what we don't, and where to next?

Blood flow restriction is a technique that involves inflating a cuff at the proximal portion of the limb with the goal of reducing arterial inflow into the muscle and venous outflow from the muscle. Low-load or low-intensity exercise in combination with blood flow restriction has been consistently shown to augment adaptations over the same/similar exercise without restriction, with changes in muscle size and strength being two of the most commonly measured adaptations. The purpose of this manuscript is to provide an updated narrative review on blood flow restriction. Blood flow restriction's history, methodology, safety, and efficacy are highlighted. We discuss the effects of blood flow restriction on changes in muscle size and strength, and also review work completed on other variables (e.g. bone, resting blood flow, tendon, pain sensitivity, cognition, orthostatic intolerance). We finish by highlighting six possible areas for future research: 1) identifying mechanisms for growth and strength; 2) sex differences in the effects of blood flow restriction; 3) individual responses to blood flow restriction; 4) influence of pressure versus amount of blood flow restricted; 5) application of blood flow restriction with higher-loads; and 6) what considerations should be made to test the effects of blood flow restriction.

Affective, perceptual and physiologic responses to isokinetic contractions under blood flow restriction

BACKGROUND

Blood flow restriction (BFR) has been shown to enhance the effectiveness of low load resistance exercise, but less research has examined its utility in conjunction with maximal isokinetic contractions, which may depend on the restrictive pressure and speed of contraction.

METHODS

Individuals reported to the laboratory for three visits to complete three sets of 20 maximal elbow flexion exercises at 60°/s and 300°/s under 0%, 40% and 80% of their arterial occlusion pressure. Muscle thickness was measured before and after exercise, and ratings of discomfort, perceived activation, and exercise-induced feelings were obtained at the completion of each exercise. Fatigue was assessed as the decline in average peak torque across the three sets.

RESULTS

A total of 27 individuals (11 females, 16 males) completed the study. There was a significant interaction for torque at both 60°/s and 300°/s (P<0.001), with each increasing pressure resulting in greater fatigue. Muscle swelling was present across all conditions but was lowest in the 40% BFR condition applied during the 300°/s speed. At both 60°/s and 300°/s speeds, the 80% BFR pressure was associated with lower enjoyment, greater discomfort, and greater perceived activation (all P<0.05).

CONCLUSIONS

The combined effects of BFR to maximal isokinetic contractions increased fatigue with less of an impact on muscle swelling. These results indicate that BFR may enhance the effectiveness of long-term isokinetic training, but it is also important to consider the addition of BFR was associated with lower levels of enjoyment and greater discomfort which may decrease adherence.

A Review of the Efficacy and Mechanisms of Blood Flow Restriction Training in Enhancing Somatic Function and Preventing Falls in Older Adults

Falls have become an important public health problem that seriously affects the quality of survival of older adults and are a major cause of fractures, death, and reduced quality of life. With the advent of an aging society, the social, economic, and medical burdens of falls in older adults are increasing. Currently, there is a lack of effective means to prevent falls in older adults, and traditional health education and clinical interventions are not effective. It is urgent to find a safe and effective training method that can improve balance function and is suitable for the elderly. Low-intensity blood flow restriction training (BFRT) is an emerging training modality that, by restricting blood flow to the limbs and combining it with low-intensity exercise, can effectively improve muscle mass, aerobic capacity, and bone density, and has been shown to enhance somatic function in older adults. However, the effectiveness and specific mechanisms of BFRT in preventing falls in older adults are unclear. Based on recent research progress, this paper explores the possibility of BFRT in preventing falls in older adults by analyzing its positive effects on muscle mass, balance function, and cognitive function, the risk factors of falling in the elderly are summarized, as well as its potential role in reducing fall risk factors. It aims to provide new thinking for academia and clinical practice and to provide a scientific basis for reducing the risk of falls in the elderly.

Dual-task improvement of older adults after treadmill walking combined with blood flow restriction of low occlusion pressure: the effect on the heart-brain axis

OBJECTIVE

This study explored the impact of one session of low-pressure leg blood flow restriction (BFR) during treadmill walking on dual-task performance in older adults using the neurovisceral integration model framework.

METHODS

Twenty-seven older adults participated in 20-min treadmill sessions, either with BFR (100 mmHg cuff pressure on both thighs) or without it (NBFR). Dual-task performance, measured through light-pod tapping while standing on foam, and heart rate variability during treadmill walking were compared.

RESULTS

Following BFR treadmill walking, the reaction time (p = 0.002) and sway area (p = 0.012) of the posture dual-task were significantly reduced. Participants exhibited a lower mean heart rate (p < 0.001) and higher heart rate variability (p = 0.038) during BFR treadmill walking. Notably, BFR also led to band-specific reductions in regional brain activities (theta, alpha, and beta bands, p < 0.05). The topology of the EEG network in the theta and alpha bands became more star-like in the post-test after BFR treadmill walking (p < 0.005).

CONCLUSION

BFR treadmill walking improves dual-task performance in older adults via vagally-mediated network integration with superior neural economy. This approach has the potential to prevent age-related falls by promoting cognitive reserves.

Cerebral cortex activation and functional connectivity during low-load resistance training with blood flow restriction: An fNIRS study

Despite accumulating evidence that blood flow restriction (BFR) training promotes muscle hypertrophy and strength gain, the underlying neurophysiological mechanisms have rarely been explored. The primary goal of this study is to investigate characteristics of cerebral cortex activity during BFR training under different pressure intensities. 24 males participated in 30% 1RM squat exercise, changes in oxygenated hemoglobin concentration (HbO) in the primary motor cortex (M1), pre-motor cortex (PMC), supplementary motor area (SMA), and dorsolateral prefrontal cortex (DLPFC), were measured by fNIRS. The results showed that HbO increased from 0 mmHg (non-BFR) to 250 mmHg but dropped sharply under 350 mmHg pressure intensity. In addition, HbO and functional connectivity were higher in M1 and PMC-SMA than in DLPFC. Moreover, the significant interaction effect between pressure intensity and ROI for HbO revealed that the regulation of cerebral cortex during BFR training was more pronounced in M1 and PMC-SMA than in DLPFC. In conclusion, low-load resistance training with BFR triggers acute responses in the cerebral cortex, and moderate pressure intensity achieves optimal neural benefits in enhancing cortical activation. M1 and PMC-SMA play crucial roles during BFR training through activation and functional connectivity regulation.

An Updated Panorama of Blood-Flow-Restriction Methods

BACKGROUND

Exercise with blood-flow restriction (BFR) is being increasingly used by practitioners working with athletic and clinical populations alike. Most early research combined BFR with low-load resistance training and consistently reported increased muscle size and strength without requiring the heavier loads that are traditionally used for unrestricted resistance training. However, this field has evolved with several different active and passive BFR methods emerging in recent research.

PURPOSE

This commentary aims to synthesize the evolving BFR methods for cohorts ranging from healthy athletes to clinical or load-compromised populations. In addition, real-world considerations for practitioners are highlighted, along with areas requiring further research.

CONCLUSIONS

The BFR literature now incorporates several active and passive methods, reflecting a growing implementation of BFR in sport and allied health fields. In addition to low-load resistance training, BFR is being combined with high-load resistance exercise, aerobic and anaerobic energy systems training of varying intensities, and sport-specific activities. BFR is also being applied passively in the absence of physical activity during periods of muscle disuse or rehabilitation or prior to exercise as a preconditioning or performance-enhancement technique. These various methods have been reported to improve muscular development; cardiorespiratory fitness; functional capacities; tendon, bone, and vascular adaptations; and physical and sport-specific performance and to reduce pain sensations. However, in emerging BFR fields, many unanswered questions remain to refine best practice.

Improved interference control after exercise with blood flow restriction and cooling is associated with but not mediated by increased lactate

BACKGROUND

To evaluate the effects of recumbent sprint interval exercise with and without blood flow restriction and body cooling on interference control and whether the changes in interference control can be explained by the changes in blood lactate.

METHODS

85 participants (22 SD 3 years old) completed 1 familiarization visit and then 5 experimental visits in a randomized order: exercise only (Ex), exercise with blood flow restriction (ExB), exercise with cooling (ExC), and exercise with blood flow restriction and cooling (ExBC), and non-exercise control (Con). Measurements of blood lactate and the Stroop Color Word Test were performed before and after exercise. Each bout began with a 15-minute low-moderate intensity warm-up, followed by five 20-second "all out" sprints separated by 40 s of active recovery. Bayes Factors (BF10) quantified evidence for or against the null hypothesis. Within-subject mediation analysis quantified the indirect effect of changes in blood lactate (mediator) on the change in interference control (each exercise condition vs. Con).

RESULTS

Bayesian pairwise comparisons found that only ExC [σ: -0.37 (-0.59, -0.15)] and ExBC [σ: -0.3 (-0.53, -0.09)] produced changes in incongruent reaction time different from that of Con. There was also evidence that all exercise conditions increased blood lactate (BF10 = 8.65e+29 - 1.9e+32) and improved congruent reaction time (BF10 = 4.01 - 15.371) compared to that of Con. There was no evidence to show that changes in lactate mediated the change in incongruent reaction time.

CONCLUSIONS

Both exercise with body cooling and when body cooling was combined with blood flow restriction presented favorable changes in incongruent reaction time (a marker of interference control), which might not be explained by the changes in systemic blood lactate concentration.

Processing of attentional and emotional stimuli depends on retrospective response of foot pressure: Conceptualizing neuron-cognitive distribution in human brain

Cognitive function of human brain requires temporal execution of emotional or attentional tasks, or their inter-dependence influences. Smooth execution of such tasks requires spontaneous distribution of cognitive load at specific regions of brain based on its classification. A strong connectivity between peripheral sensors and central nervous system is thought to assist the cognitive load distribution effectively. Novelty of current study evaluates the modulation of foot pressure and its mapping with distributed cognitive load while executing attentional biased emotional tasks. Emotional stimulus in form of happy and sad faces with attentional paradigm drawn on them were used in the study. Behavioral results were measured with respect to the analysis of response time (RT) and response accuracy (%). Neurological signals were acquired using 10-channel EEG data acquisition system, whereas, another 6 channels were used to measure foot pressure in the left and right feet at three different locations of foot. Acquired signals were further analyzed in time and frequency domains to interpret the cognitive load distribution, and the influence of foot pressure on distribution of cognitive loads. We found that the foot pressure accelerated the response accuracy rate in attending the local scope of attention, which was not in the case of global scope of attention. This means that the global attention does not require any pressure from peripheral sensory neurons. Our event related potential (ERP) results revealed that the early sensory negative N100 characterized the processing of global scope of attention coupled with high-foot pressure. However, the late positive peak of P300 and P600 associated with local scope of attention along with high-foot pressure. The global scope of attention with low-foot pressure modulates delta and theta oscillations. These results largely contribute to the literature on cognitive neuroscience of attention and it corelation with the peripheral sensory foot pressure.

Remote ischemic preconditioning improves cognitive control in healthy adults: Evidence from an event-related potential study

It is suggested that remote ischemic preconditioning (RIPC) may be a promising treatment for improving healthy adults’ cognitive control. However, direct empirical evidence was absent. Therefore, this study aims to provide evidence for the impact of RIPC on cognitive control. Sixty healthy young male volunteers were recruited, and 30 of them received 1-week RIPC treatment (RIPC group), while the rest did not receive RIPC (control group). Their cognitive control before and after RIPC treatment was evaluated using the classic Stroop task, and the scalp electricity activity was recorded by event-related potentials (ERPs). The behavioral results showed a conventional Stroop interference effect of both reaction times (RTs) and the accuracy rate (ACC), but the Stroop interference effect of RTs significantly decreased in the posttest compared to the pretest. Furthermore, at the electrophysiological level, ERP data showed that N450 and SP for incongruent trials were larger than that for congruent trials. Importantly, the SP differential amplitude increased after RIPC treatment, whereas there was no significant change in the control group. These results implied that RIPC treatment could improve cognitive control, especially conflict resolving in the Stroop task.

Impact of Inter-Set Short Rest Interval Length on Inhibitory Control Improvements Following Low-Intensity Resistance Exercise in Healthy Young Males

The length of rest interval between sets (i.e., inter-set rest interval) is an important variable for resistance exercise program. However, the impact of the inter-set rest interval on improvements in cognitive function following resistance exercise remains unknown. In this study, we compared the effect of short rest interval (SRI) vs. long rest interval (LRI) protocols on post-exercise cognitive inhibitory control (IC) improvements induced by low-intensity resistance exercise. Twenty healthy, young males completed both SRI and LRI sessions in a crossover design. The bilateral knee extensor low-intensity resistance exercise was programed for six sets with 10 repetitions per set using 40% of one-repetition maximum. The inter-set rest interval lengths for SRI and LRI protocols were set for 1 and 3min, respectively. The color-word Stroop task (CWST) was administrated at six time points: baseline, pre-exercise, immediate post-exercise, and every 10min during the 30-min post-exercise recovery period. The levels of blood lactate, which may be an important determinant for improving IC, throughout the 30-min post-exercise recovery period were significantly higher following SRI protocol than following LRI protocol (p=0.002 for interaction effect). In line with this result, large-sized decreases in the reverse-Stroop interference score, which represent improved IC, were observed immediately after SRI protocol (d=0.94 and 0.82, respectively, vs. baseline and pre-exercise) as opposed to the moderate-sized decreases immediately after LRI protocol (d=0.62 and 0.66, respectively, vs. baseline and pre-exercise). Moreover, significant decreases in the reverse-Stroop interference score were observed from 10 to 30min after SRI protocol (all ps<0.05 vs. baseline and/or pre-exercise), whereas no such decrease was observed after LRI protocol. Furthermore, the degree of decreases in the reverse-Stroop interference score throughout the 30-min post-exercise recovery period was significantly greater in SRI protocol than in LRI protocol (p=0.046 for interaction effect). We suggest that the SRI protocol is more useful in improving post-exercise IC, potentially via greater circulating lactate levels, compared to the LRI protocol. Therefore, the inter-set rest interval length may be an important variable for determining the degree of cognitive function improvements following resistance exercise in healthy young males.

Current Techniques Used for Practical Blood Flow Restriction Training: A Systematic Review

ABSTRACT

Bielitzki, R, Behrendt, T, Behrens, M, and Schega, L. Current techniques used for practical blood flow restriction training: a systematic review. J Strength Cond Res 35(10): 2936-2951, 2021-The purpose of this article was to systematically review the available scientific evidence on current methods used for practical blood flow restriction (pBFR) training together with application characteristics as well as advantages and disadvantages of each technique. A literature search was conducted in different databases (PubMed, Web of Science, Scopus, and Cochrane Library) for the period from January 2000 to December 2020. Inclusion criteria for this review were (a) original research involving humans, (b) the use of elastic wraps or nonpneumatic cuffs, and (c) articles written in English. Of 26 studies included and reviewed, 15 were conducted using an acute intervention (11 in the lower body and 4 in the upper body), and 11 were performed with a chronic intervention (8 in the lower body, 1 in the upper body, and 2 in both the upper and the lower body). Three pBFR techniques could be identified: (a) based on the perceptual response (perceived pressure technique), (b) based on the overlap of the cuff (absolute and relative overlap technique), and (c) based on the cuffs' maximal tensile strength (maximal cuff elasticity technique). In conclusion, the perceived pressure technique is simple, valid for the first application, and can be used independently of the cuffs' material properties, but is less reliable within a person over time. The absolute and relative overlap technique as well as the maximal cuff elasticity technique might be applied more reliably due to markings, but require a cuff with constant material properties over time.

Effects of isometric handgrip exercise with or without blood flow restriction on interference control and feelings

The purpose of this study was to investigate whether isometric handgrip exercise, with or without blood flow restriction, would alter interference control and feelings. 60 healthy young adults completed three experimental visits, consisting of four sets of 2 min isometric handgrip exercise, at 30% of maximal strength with or without blood flow restriction (50% of arterial occlusion pressure), or a non-exercise/time-matched control. Exercise-induced feeling inventory and Stroop Color Word Test were performed at pre- and ~10-min post-exercise, respectively. Bayes factors (BF₁₀ ) quantified the evidence for or against the null. There were no changes or differences between conditions for interference control following exercise with or without blood flow restriction (Incongruent BF₁₀ : 0.155; Stroop Interference BF₁₀ : 0.082). There were also no differences in the error rate as well as no differences between conditions for changes in 'positivity' or 'revitalization'. Feelings of 'tranquility' were reduced relative to a control following exercise with (median δ [95% credible interval]: -0.74 (-1.05, -0.45), BF₁₀ : 5515.7) and without (median δ: -0.72 [-1.02, -0.41], BF₁₀ : 571.3) blood flow restriction. These changes were not different between exercise conditions. Feelings of 'physical exhaustion' were increased relative to a control following exercise without blood flow restriction (median δ: 0.35[0.09, 0.61], BF₁₀ : 5.84). However, this increase was not different from the same exercise with blood flow restriction. These results suggest that 1) isometric handgrip exercise could be performed without impairing interference control, even when blood flow restriction is added, and that 2) changes in feelings occur independent of changes in interference control.

Similar improvements in cognitive inhibitory control following low-intensity resistance exercise with slow movement and tonic force generation and high-intensity resistance exercise in healthy young adults: a preliminary study

This study compared the effects of low-intensity resistance exercise with slow movement and tonic force generation (ST-LRE) and high-intensity resistance exercise (HRE) on post-exercise improvements in cognitive inhibitory control (IC). Sixteen young males completed ST-LRE and HRE sessions in a crossover design. Bilateral knee extensor ST-LRE and HRE (8 repetitions/set, 6 sets) were performed with 50% of one-repetition maximum with slow contractile speed and 80% of one-repetition maximum with normal contractile speed, respectively. The IC was assessed using the color-word Stroop task at six time points: baseline, pre-exercise, immediate post-exercise, and every 10 min during the 30-min post-exercise recovery period. The blood lactate response throughout the experimental session did not differ between ST-LRE and HRE (condition × time interaction P = 0.396: e.g., mean ± standard error of the mean; 8.1 ± 0.5 vs. 8.1 ± 0.5 mM, respectively, immediately after exercise, P = 0.983, d = 0.00). Large-sized decreases in the reverse-Stroop interference scores, which represent improved IC, compared to those before exercise (i.e., baseline and pre-exercise) were observed throughout the 30 min post-exercise recovery period for both ST-LRE and HRE (decreasing rate ≥ 38.8 and 41.4%, respectively, all ds ≥ 0.95). The degree of post-exercise IC improvements was similar between the two protocols (condition × time interaction P = 0.998). These findings suggest that despite the application of a lower exercise load, ST-LRE improves post-exercise IC similarly to HRE, which may be due to the equivalent blood lactate response between the two protocols, in healthy young adults.

Effects of dual-task training with blood flow restriction on cognitive functions, muscle quality, and circulatory biomarkers in elderly women

This study investigated the effects of an eight-week dual-task training with and without blood flow restriction (BFR) on muscle quality (MQ) biomarkers, physical and cognitive functions in older women. Twenty-four healthy volunteers (62.9 ± 3.1years) were randomly assigned into either dual-task (DT), DT with blood flow restriction (DTBFR), or control (C) group. The experimental groups performed cognitive tasks while walked on a treadmill at 45% of heart rate reserve (HRR), 20 min per session, three sessions per week for eight weeks. The cuff pressure for the DTBFR group was 50% of the calculated arterial blood occlusion and was increased by 10% every 2 weeks. Pre and post-training intervention, biomarkers of MQ and cognitive functions, body composition, maximal strength, and psychological status were measured. There was a significant interaction effect on BDNF, CAF, P3NP, body mass, BMI, fat percentage, visceral fat mass, and total fat mass (p<0.05). Furthermore, a significant interaction effect on knee extension, 30-s stand-up test, 6-min walk test, timed up&go test, and QOL was observed. There was a significant effect of time on MMSE, sleep quality, and mood score. These findings suggested that including BFR to DT training result in greater physiological and psychological responses and should be considered a training method to combat undesired changes associated with increasing age.

Effect of very low-intensity resistance exercise with slow movement and tonic force generation on post-exercise inhibitory control

Background

The extremely low loads (e.g., <30% of one-repetition maximum) involved in performing resistance exercise are effective in preventing musculoskeletal injury and enhancing exercise adherence in various populations, especially older individuals and patients with chronic diseases. Nevertheless, long-term intervention using this type of protocol is known to have little effects on muscle size and strength adaptations. Despite this knowledge, very low-intensity resistance exercise (VLRE) with slow movement and tonic force generation (ST) significantly increases muscle size and strength. To further explore efficacy of ST-VLRE in the clinical setting, this study examined the effect of ST-VLRE on post-exercise inhibitory control (IC).

Methods

Twenty healthy, young males (age: 21 ± 0 years, body height: 173.4 ± 1.2 cm, body weight: 67.4 ± 2.2 kg) performed both ST-VLRE and normal VLRE in a crossover design. The load for both protocols was set at 30% of one-repetition maximum. Both protocols were programmed with bilateral knee extension for six sets with ten repetitions per set. The ST-VLRE and VLRE were performed with slow (3-sec concentric, 3-sec eccentric, and 1-sec isometric actions with no rest between each repetition) and normal contractile speeds (1-sec concentric and 1-sec eccentric actions and 1-sec rests between each repetition), respectively. IC was assessed using the color-word Stroop task at six time points: baseline, pre-exercise, immediate post-exercise, and every 10 min during the 30-min post-exercise recovery period.

Results

The reverse-Stroop interference score, a parameter of IC, significantly decreased immediately after both ST-VLRE and VLRE compared to that before each exercise (decreasing rate >32 and 25%, respectively, vs. baseline and/or pre-exercise for both protocols; all Ps < 0.05). The improved IC following ST-VLRE, but not following VLRE, remained significant until the 20-min post-exercise recovery period (decreasing rate >48% vs. baseline and pre-exercise; both Ps < 0.001). The degree of post-exercise IC improvements was significantly higher for ST-VLRE than for VLRE (P = 0.010 for condition × time interaction effect).

Conclusions

These findings suggest that ST-VLRE can improve post-exercise IC effectively. Therefore, ST-VLRE may be an effective resistance exercise protocol for improving cognitive function.