Impact of blood flow restriction intensity on pain perception and muscle recovery post-eccentric exercise

BACKGROUND

Delayed onset muscle soreness (DOMS) is a well-established phenomenon characterized by ultrastructural muscle damage that typically develops following unfamiliar or high-intensity exercise. DOMS manifests with a constellation of symptoms, including muscle tenderness, stiffness, edema, mechanical hyperalgesia, and a reduced range of joint motion. In recent years, the application of blood flow restriction (BFR) has garnered attention for its potential impact on DOMS.

OBJECTIVE

This study aimed to investigate the effects of different BFR intensities on biomechanical alterations induced by DOMS in healthy individuals.

DESIGN AND METHODS

Thirty participants were split into two groups receiving either 80% or 20% BFR applied during low-intensity resistance exercise following DOMS induction. Pain perception, pressure pain threshold, muscle biometric characteristics, and strength were assessed before DOMS, after DOMS, and following BFR application at 24, 48, and 72 h.

RESULTS

The 80% BFR group experienced faster reductions in pain perception compared to the 20% BFR group. Muscle strength recovery was also statistically faster in the 80% BFR group. No significant differences were observed between groups in muscle stiffness, flexibility, or other mechanical properties.

CONCLUSIONS

These findings suggest that BFR, particularly at higher intensities, may alleviate DOMS symptoms and accelerate muscle strength recovery. However, the lack of a control group and limitations in muscle property assessment warrant further research to definitively determine BFR's efficacy in managing DOMS.

Acute effects of blood flow restricted aerobic exercise in type 2 diabetes mellitus

BACKGROUND

This study aimed to compare the acute effects of aerobic exercise performed with blood flow restriction (BFR), a novel method to increase exercise gains, with blood free flow (BFF) conditions in type 2 diabetes mellitus (T2DM).

METHODS

Fifteen individuals with T2DM performed BFF and BFR (40% of arterial occlusion pressure) cycling exercises 48 hours apart, at equal intensity (45% heart rate reserve) and duration (38 minutes). Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), blood glucose, heart rate, and muscle oxygen saturation (SmO2) were assessed before-after and during exercise sessions.

RESULTS

SBP, DBP, and MAP in the overload phase were higher in the BFR group than in the BFF group (P = .009, 0.031, and 0.013, respectively). Changes in blood pressure (∆SBP and ∆DBP) were similar between the BFF and BFR groups (P > .05), whereas ∆MAP differed (P = .016). Changes in blood glucose levels and heart rates were not significantly different between the groups. Although SmO2baseline was lower in the BFR group (P = .049), SmO2min and SmO2max did not differ significantly between the BFF and BFR groups.

CONCLUSION

The similar decrease in blood glucose levels between the groups suggests that BFR exercise is favorable in terms of hypoglycemia. The higher blood pressure observed during the BFR exercise remained within safe limits. These results suggest that people with T2DM can safely perform BFR aerobic exercises; however, further studies are required.

An examination of acute physiological and perceptual responses following blood flow restriction exercise using a traditional research device or novel, automated system

Objective. To compare the acute physiological and perceptual responses to blood flow restriction (BFR) exercise using a traditional research device or novel, automated system.Methods. Forty-four resistance trained individuals performed four sets of unilateral elbow flexion exercise (30% one-repetition maximum) to volitional failure using two distinct restrictive devices [SmartCuffs PRO BFR Model (SMARTCUFF), Hokanson E20 Rapid Inflation device (HOKANSON)] and with two levels of BFR [40% limb occlusion pressure (LOP), 80% LOP]. Blood pressure (BP), muscle thickness (MT), and isometric strength (ISO) were assessed prior to and following exercise. Perceptual responses [ratings of perceived exertion (RPE), discomfort] were assessed prior to exercise and following each exercise set.Main results. Data are displayed as means (SD). Immediately following exercise with 40% LOP, there were no statistical differences between devices for BP, MT, and ISO. However, only following Set 1 of exercise, RPE was greater with SMARTCUFF compared to HOKANSON (p< 0.05). In addition, only following Set 2 of exercise, discomfort was greater with HOKANSON compared to SMARTCUFF (p< 0.001). Immediately following exercise with 80% LOP, there were no statistical differences between devices for BP, MT, and ISO. However, only following Set 4 of exercise, RPE was greater with HOKANSON compared to SMARTCUFF (p< 0.05). In addition, following all exercise sets, discomfort was greater with HOKANSON compared to SMARTCUFF (p< 0.001). For repetitions completed with 40% LOP there were no statistical differences between SMARTCUFF and HOKANSON across any exercise sets. For repetitions completed with 80% LOP there were no statistical differences between SMARTCUFF and HOKANSON across Set 1 of exercise (p= 0.34), however, for Sets 2-4 of exercise, significantly greater number of repetitions were completed during SMARTCUFF than HOKANSON.Significance. The present study provides valuable insight into the efficacy of a novel, automated BFR system (SMARTCUFF) eliciting comparable acute physiological responses to BFR exercise and in some cases favorable perceptual responses when compared to a traditional research device (HOKANSON).

The effects of low-intensity resistance training with blood flow restriction versus traditional resistance exercise on lower extremity muscle strength and motor functionin ischemic stroke survivors: a randomized controlled trial

BACKGROUND

Blood flow restriction (BFR) training can temporarily reduce cortical GABA concentrations and increase the size of motor volleys to deafferented muscles, which can promote motor recovery in stroke survivors.

OBJECTIVE

To determine the effect of low-intensity resistance training with BFR (LIRT-BFR) on lower extremity muscle strength, balance, functional mobility, walking capacity, gait speed, anxiety, and depression in stroke survivors and to compare the results with high-intensity resistance training (HIRT).

METHOD

It was a two-arm, single-blinded, randomized controlled trial in which 32 ischemic stroke participants were randomly allocated to LIRT-BFR or HIRT group. The LIRT-BFR group received low load resistance training (40% of 1-Repetition Maximum (1-RM)) with BFR, whereas HIRT group   received high load resistance training (80% of 1-RM). The 6-Minute Walk Test (6-MWT), five-time sit-to-stand test (5TSTST), Timed Up and Go (TUG) test, and Barthel index were the primary outcome measures. The secondary outcome measures included gait speed (m/s), stride length (cm), cadence (steps/min), and Hospital Anxiety and Depression.

RESULTS

All the primary and secondary outcome measures were significantly improved in both groups (p < 0.05). The LIRT-BFR group showed a slightly greater, but non-significant, improvement as compared to the HIRT group in terms of mean change observed in 6-MWT (81 m vs 62 m), 5TSTST (-5.27 vs -4.81), gait speed (0.19 vs 0.12), stride length (18 vs 13), and cadence (8 vs 6). No adverse event was reported.

CONCLUSION

LIRT-BFR produced a significant improvement in muscle strength, balance, walking capacity, and anxiety and depression in ischemic stroke patients, and the improvement are comparable to HIRT.

CLINICAL TRIAL REGISTRATION

NCT05281679.

Effects of High-Load Bench Press Training with Different Blood Flow Restriction Pressurization Strategies on the Degree of Muscle Activation in the Upper Limbs of Bodybuilders

Background: The aim of this study was to investigate the effects of different pressurization modes during high-load bench press training on muscle activation and subjective fatigue in bodybuilders. Methods: Ten bodybuilders participated in a randomized, self-controlled crossover experimental design, performing bench press training under three different pressurization modes: T1 (low pressure, high resistance), T2 (high pressure, high resistance), and C (non-pressurized conventional). Surface EMG signals were recorded from the pectoralis major, deltoid, and triceps muscles using a Delsys Trigno wireless surface EMG during bench presses. Subjective fatigue was assessed immediately after the training session. Results: (1) Pectoralis major muscle: The muscle activation degree of the T1 group was significantly higher than that of the blank control group during the bench press (p < 0.05). The muscle activation degree of the T2 group was significantly higher than that of the C group during the bench press (p < 0.05). In addition, the muscle activation degree of the T2 group was significantly higher than that of the T1 group during the first group bench press (p < 0.05). (2) Deltoid muscle: The muscle activation degree of the T2 group during the third group bench press was significantly lower than the index values of the first two groups (p < 0.05). The muscle activation degree in the experimental group was significantly higher than that in the C group (p < 0.05). The degree of muscle activation in the T2 group was significantly higher than that in the T1 group during the first bench press (p < 0.05). (3) Triceps: The muscle activation degree of the T1 group was significantly higher than the index value of the third group during the second group bench press (p < 0.05), while the muscle activation degree of the T2 group was significantly lower than the index value of the first two groups during the third group bench press (p < 0.05). The degree of muscle activation in all experimental groups was significantly higher than that in group C (p < 0.05). (5) RPE index values in all groups were significantly increased (p < 0.05). The RPE value of the T1 group was significantly higher than that of the C group after bench press (p < 0.05). The RPE value of the T1 group was significantly higher than that of the C group after bench press (p < 0.05). In the third group, the RPE value of the T1 group was significantly higher than that of the C and T2 groups (p = 0.002) (p < 0.05). Conclusions: The activation of the pectoralis major, triceps brachii, and deltoid muscles is significantly increased by high-intensity bench press training with either continuous or intermittent pressurization. However, continuous pressurization results in a higher level of perceived fatigue. The training mode involving high pressure and high resistance without pressurization during sets but with 180 mmHg occlusion pressure and pressurization during rest intervals yields the most pronounced overall effect on muscle activation.

Effectiveness of blood flow restriction versus traditional weight-bearing training in rehabilitation of knee osteoarthritis patients with MASLD: a multicenter randomized controlled trial

To compare the reliability and effectiveness of blood blow restriction resistance training (BFR) versus traditional weight-bearing training (WB) in knee osteoarthritis (KOA) patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

This multicenter randomized controlled trial was conducted from January 2021 to June 2022 at Shanghai Jiao Tong University affiliated Sixth People's Hospital and The People's Hospital of Mengla County. A total of 120 outpatients were recruited and randomized to perform WB (n=60) or BFR (n=60) resistance training protocols in accordance with standard recommended protocols for 12 weeks. Demographic data and Kellgren and Lawrence grading system scores were collected. Pain, range of motion (ROM), scaled maximal isotonic strength (10RM), self-reported function (KOOS), and 30-s chair sit-to-stand test results were assessed at weeks 1, 4, and 12.

RESULTS

112 patients (57 in the WB group, 55 in the BFR group) completed the training programs and assessments. No significant intergroup demographic differences were noted. ROM and scaled 10RM significantly increased at the 4- and 12-week assessments and differed significantly between groups. The pain, ability of daily living and quality of life subscale in KOOS increased significantly at the 12-week assessment and differed significantly between groups, adjusted for baseline value. Significant and comparable increases in 30-s chair sit-to-stand test results were observed within and between study groups.

CONCLUSION

BFR training enhanced muscle strength, reduced pain, and improved daily living and sports activities in patients with KOA, compared to WB training alone. BFR should be recommended for rehabilitation in KOA individuals with MASLD.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2100042872.

Skeletal Muscle Adaptations to High-Load Resistance Training With Pre-Exercise Blood Flow Restriction

ABSTRACT

Hammert, WB, Moreno, EN, Martin, CC, Jessee, MB, and Buckner, SL. Skeletal muscle adaptations to high-load resistance training with pre-exercise blood flow restriction. J Strength Cond Res 37(12): 2381-2388, 2023-This study aimed to determine if blood flow restriction (BFR) could augment adaptations to a high-load training protocol that was inadequate for muscle growth. Forty nontrained individuals had each arm assigned to 1 of 3 elbow flexion protocols: (a) high-load resistance training [TRAD; 4 sets to muscular failure at 70% 1 repetition maximum (1RM)], (b) low repetition high-load resistance training with pre-exercise BFR (PreBFR; 4 sets of 3 repetitions at 70% 1RM + 3 min of pre-exercise BFR), and (c) low repetition high-load resistance training (LRTRAD); 4 sets of 3 repetitions at 70% 1RM). Muscle thickness (MT), 1RM strength, and local muscular endurance (LME) of the elbow flexors were measured before and after 8 weeks. An alpha level of 0.05 was used for all comparisons. For the 50% site, MT increased for TRAD (0.211 cm, 95% confidence interval [95% CI]: 0.143-0.280), PreBFR (0.105 cm, 95% CI: 0.034-0.175), and LRTRAD (0.073 cm, 95% CI: 0.000-0.146). The change for TRAD was greater than PreBFR and LRTRAD. For the 60% site, MT increased for TRAD (0.235 cm, 95% CI: 0.153-0.317), PreBFR (0.097 cm, 95% CI: 0.014-0.180), and LRTRAD (0.082 cm, 95% CI: 0.000-0.164). The change for TRAD was greater than PreBFR and LRTRAD. For the 70% site MT increased for TRAD (0.308 cm, 95% CI: 0.247-0.369), PreBFR (0.103 cm, 95% CI: 0.041-0.166), and LRTRAD (0.070 cm, 95% CI: 0.004-0.137). The change for TRAD was greater than PreBFR and LRTRAD. One repetition maximum and LME significantly increased for each condition, with no differences between conditions. Collapsed across conditions 1RM strength increased 2.094 kg (95% CI: 1.771-2.416) and LME increased 7.0 repetitions (95% CI: 5.7-8.3). In conclusion, the application of BFR to low-repetition, high-load training did not enhance the adaptative response.

Blood flow restriction accelerates aerobic training-induced adaptation of [Formula: see text] kinetics at the onset of moderate-intensity exercise

It is unclear whether blood flow restriction (BFR) accelerates the adaptation of the time constant (τ) of phase II oxygen uptake ([Formula: see text]) kinetics in the moderate-intensity exercise domain via moderate-intensity aerobic training. Therefore, healthy participants underwent moderate-intensity [45-60% [Formula: see text] Reserve] aerobic cycle training with or without BFR (BFR group, n = 9; CON group, n = 9) for 8 weeks to evaluate [Formula: see text] kinetics during moderate-intensity cycle exercise before (Pre) and after 4 (Mid) and 8 (Post) weeks of training. Both groups trained for 30 min, 3 days weekly. BFR was performed for 5 min every 10 min by applying cuffs to the upper thighs. The τ significantly decreased by Mid in the BFR group (23.7 ± 2.9 s [Pre], 15.3 ± 1.8 s [Mid], 15.5 ± 1.4 s [Post], P < 0.01) and by Post in the CON group (27.5 ± 2.0 s [Pre], 22.1 ± 0.7 s [Mid], 18.5 ± 1.9 s [Post], P < 0.01). Notably, the BFR group's τ was significantly lower than that of the CON group at Mid (P < 0.01) but not at Post. In conclusion, BFR accelerates the adaptation of the [Formula: see text] kinetics of phase II by moderate-intensity aerobic training.

Effect of Leg Half-Squat Training With Blood Flow Restriction Under Different External Loads on Strength and Vertical Jumping Performance in Well-Trained Volleyball Players

Purpose

To examine the effect of blood flow restriction resistance training under different external loads on the muscle strength and vertical jumping performance in volleyball players.

Methods

18 well-trained collegiate male volleyball players were randomly divided into 3 groups: high-load resistance training group (HL-RT, 70% 1RM, n = 6), low-load blood flow restriction resistance training group (LL-BFR-RT, 30% 1RM, 50% arterial occlusion, n = 6), and high-load blood flow restriction resistance training group (HL-BFR-RT, 70% 1RM, 50% arterial occlusion, n = 6). Participants performed leg half-squat exercise 3 times per week for 8 weeks. Measurements of Isokinetic peak torque of knee extension and flexion, 1RM leg half-squat, squat jump, and 3 footed take-off were obtained before and after training. A two-way repeated-measures analysis of variance was used to examine differences among the 3 groups and between the 2 testing time (pre-test vs post-test).

Results

(1) The HL-RT group was significantly greater in muscle strength than that in the LL-BFR-RT group (P < .05), but no improvement in vertical jumping performance (P >.05). (2) Improvement in muscle strength and vertical jumping performance was significantly greater in the HL-BFR-RT group than that in the LL-BFR-RT group (P <.05). (3) The HL-BFR-RT group had greater but not significant improvement in muscle strength and vertical jumping performance than that in the HL-RT group.

Conclusions

Although increases in muscle strength were observed between training groups, HL-BFR-RT increased not only muscle strength but vertical jumping performance to a greater extent compared to LL-BFR-RT and HL-RT.

Neuromuscular Impact of Acute Hypertrophic Resistance Loading With and Without Blood-Flow Restriction

Exploring acute neuromuscular fatigue induced by different modalities of resistance exercise would help understand the adaptation subsequent to specific training programs. Therefore, we investigated the acute impact of high-intensity and low-intensity blood flow-restricted resistance exercise on the development of explosive torque throughout the torque-time curve. Seventeen healthy, young participants were included in a randomized, counterbalanced within-subjects design study, in which participants underwent two experimental conditions, separated by a 1-wk period. Low-intensity blood-flow restricted exercise and high-intensity resistance exercise were performed using dynamic elbow flexion at 20 and 75% of 1 repetition maximum, respectively. Maximal voluntary contraction (MVC) and the sequential rate of torque development (absolute and relative) were measured before and after exercise. Both protocols elicited a similar decrement in MVC (~ 25%) and in the peak rate of torque development after exercise (~ 45%). The absolute rate of torque development (0-50 and 50-100 ms) was also reduced (p<0.05) similarly between conditions. After normalizing torque values to MVC, this was only sustained for the rate of torque development 0-50ms (p<0.05). We found that both exercise protocols induced similar acute attenuation of the absolute rate of torque development up to the first 100 ms of MVC. We also demonstrated that the reduction in the rate of torque development between 50-100ms (in both protocols) was largely explained by an acute deficit in muscle strength post-exercise. Conversely, the impact of each protocol on the first 50ms of muscle torque did not depend on lower levels of muscle strength after exercise.

The blood flow restriction training effect in knee osteoarthritis people: a systematic review and meta-analysis

Objective:

To synthesize evidence on the effects of blood flow restriction (BFR) comparing with high (HLT) and low load (LLT), and on the influence of different forms of application in individuals with knee osteoarthritis.

Data sources:

The CENTRAL, PEDro, PubMed and BVS, which include Lilacs, Medline and SciELO, until April 2020.

Review methods:

A systematic review and meta-analysis of randomized trials used the PRISMA guidelines, whose main keywords were: Therapeutic Occlusion, Resistance Training, and Knee Osteoarthritie, blood flow restriction and Kaatsu training. Method quality was evaluated with the PEDro scale. When studies demonstrated homogeneity on outcome measures, the mean differences or standardized mean differences with 95% confidence interval were calculated and pooled in a meta-analysis for pooled synthesis.

Results:

Five articles were eligible in this review with moderate to low risk bias. Our results, showed no difference between BFR and HLT in knee strength (SMD = 0.00, 95% CI, –0.54 to 0.54, P = 1.00), function (SMD = −0.20, 95% CI, –0.45 to 0.06, P = 0.13), pain and volume. But, when compared BFR and LLT, the descriptive analysis demonstrated significant results in favor BFR to muscle strength (71.4% of measurement) and volume (MD = 1.66, 95% CI, 0.93 to 2.38, P < 0.00001), but not in pain or function.

Conclusion:

BFR can be used as a strategy in the rehabilitation of osteoarthritis due to gains in strength and volume with low mechanical stress. However, its application must be safe and individualized, since they can attenuate the stimuli offered by BFR.

Is there rationale for the cuff pressures prescribed for blood flow restriction exercise? A systematic review

BACKGROUND

Blood flow restriction exercise has increasingly broad applications among healthy and clinical populations. Ensuring the technique is applied in a safe, controlled, and beneficial way for target populations is essential. Individualized cuff pressures are a favored method for achieving this. However, there remains marked inconsistency in how individualized cuff pressures are applied.

OBJECTIVES

To quantify the cuff pressures used in the broader blood flow restriction exercise literature, and determine whether there is clear justification for the choice of pressure prescribed.

METHODS

Studies were included in this review from database searches if they employed an experimental design using original data, involved either acute or chronic exercise using blood flow restriction, and they assessed limb or arterial occlusion pressure to determine an individualized cuff pressure. Methodologies of the studies were evaluated using a bespoke quality assessment tool.

RESULTS

Fifty-one studies met the inclusion criteria. Individualized cuff pressures ranged from 30% to 100% arterial occlusion pressure. Only 7 out of 52 studies attempted to justify the individualized cuff pressure applied during exercise. The mean quality rating for all studies was 11.1 ± 1.2 out of 13.

CONCLUSIONS

The broader blood flow restriction exercise literature uses markedly heterogeneous prescription variables despite using individualized cuff pressures. This is problematic in the absence of any clear justification for the individualized cuff pressures selected. Systematically measuring and reporting all relevant acute responses and training adaptations to the full spectrum of BFR pressures alongside increased clarity around the methodology used during blood flow restriction exercise is paramount.

Perioperative Blood Flow Restriction Rehabilitation in Patients Undergoing ACL Reconstruction: A Systematic Review

Background:

Low-load blood flow restriction (BFR) training has attracted attention as a potentially effective method of perioperative clinical rehabilitation for patients undergoing orthopaedic procedures.

Purpose:

To (1) compare the effectiveness of low-load BFR training in conjunction with a standard rehabilitation protocol, pre- and postoperatively, and non-BFR interventions in patients undergoing anterior cruciate ligament reconstruction (ACLR) and (2) evaluate protocols for implementing BFR perioperatively for patients undergoing ACLR.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review of the 3 medical literature databases was conducted to identify all level 1 and 2 clinical trials published since 1990 on BFR in patients undergoing ACLR. Patient demographics from included studies were pooled. Outcome data were documented, including muscle strength and size, and perceived pain and exertion. A descriptive analysis of outcomes from BFR and non-BFR interventions was performed.

Results:

A total of 6 studies (154 patients; 66.2% male; mean ± SD age, 24.2 ± 3.68 years) were included. Of these, 2 studies examined low-load BFR as a preoperative intervention, 1 of which observed a significant increase in muscle isometric endurance (P = .014), surface electromyography of the vastus medialis (P < .001), and muscle blood flow to the vastus lateralis at final follow-up (P < .001) as compared with patients undergoing sham BFR. Four studies investigated low-load BFR as a postoperative intervention, and they observed significant benefits in muscle hypertrophy, as measured by cross-sectional area; strength, as measured by extensor torque; and subjective outcomes, as measured by subjective knee pain during session, over traditional low-load resistance training (all P < .05). BFR occlusion periods ranged from 3 to 5 minutes, with rest periods ranging from 45 seconds to 3 minutes.

Conclusion:

This systematic review found evidence on the topic of BFR rehabilitation after ACLR to be sparse and heterogeneous likely because of the relatively recent onset of its popularity. While a few authors have demonstrated the potential strength and hypertrophy benefits of perioperative BFR, future investigations with standardized outcomes, long-term follow-up, and more robust sample sizes are required to draw more definitive conclusions.

Hemodynamic and perceptual responses to blood flow-restricted exercise among patients undergoing dialysis

End-stage kidney disease is associated with reduced exercise capacity, muscle atrophy, and impaired muscle function. While these may be improved with exercise, single modalities of exercise do not traditionally elicit improvements across all required physiological domains. Blood flow-restricted exercise may improve all of these physiological domains with low intensities traditionally considered insufficient for these adaptions. Investigation of this technique appeals, but is yet to be evaluated, in patients undergoing dialysis. With the use of a progressive crossover design, 10 satellite patients undergoing hemodialysis underwent three exercise conditions over 2 wk: two bouts (10 min) of unrestricted cycling during two consecutive hemodialysis sessions (condition 1), two bouts of cycling with blood flow restriction while off hemodialysis on 2 separate days (condition 2), and two bouts of cycling with blood flow restriction during two hemodialysis sessions (condition 3). Outcomes included hemodynamic responses (heart rate and blood pressure) throughout all sessions, participant-perceived exertion and discomfort on a Borg scale, and evaluation of ultrafiltration rates and dialysis adequacy (Kt/V) obtained post hoc. Hemodynamic responses were consistent regardless of condition. Significant increases in heart rate, systolic blood pressure, and mean arterial blood pressure (P < 0.05) were observed postexercise followed by a reduction in blood pressures during the 60-min recovery (12, 5, and 11 mmHg for systolic, diastolic, and mean arterial pressures, respectively). Blood pressures returned to predialysis ranges following the recovery period. Blood flow restriction did not affect ultrafiltration achieved or Kt/V. Hemodynamic safety and tolerability of blood flow restriction during aerobic exercise on hemodialysis is comparable to standard aerobic exercise.

Acute Muscular Responses to Practical Low-Load Blood Flow Restriction Exercise Versus Traditional Low-Load Blood Flow Restriction and High-/Low-Load Exercise

CONTEXT

Blood flow restriction (BFR) increases muscle size and strength when combined with low loads, but various methods are used to produce this stimulus. It is unclear how using elastic knee wraps can impact acute muscular responses compared with using nylon cuffs, where the pressure can be standardized.

OBJECTIVE

Investigate how elastic knee wraps compare with nylon cuffs and high-load (HL)/low-load (LL) resistance exercise.

DESIGN

A randomized cross-over experimental design using 6 conditions combined with unilateral knee extension.

SETTING

Human Performance Laboratory.

PARTICIPANTS

A total of 9 healthy participants (males = 7 and females = 2) and had an average age of 22 (4) years.

INTERVENTION

LL (30% of 1-repetition maximum [1-RM]), HL (70% 1-RM), BFR at 40% of arterial occlusion pressure (BFR-LOW), BFR at 80% of arterial occlusion pressure (BFR-HIGH), elastic knee wraps stretched by 2 in (PRACTICAL-LOW), and elastic knee wraps stretched to a new length equivalent to 85% of thigh circumference (PRACTICAL-HIGH). BFR and practical conditions used 30% 1-RM.

MAIN OUTCOME MEASURES

Muscle thickness, maximum voluntary isometric contraction, and electromyography amplitude. Bayesian statistics evaluated differences in changes between conditions using the Bayes factor (BF10), and median and 95% credible intervals were reported from the posterior distribution.

RESULTS

Total repetitions completed were greater for BFR-LOW versus PRACTICAL-HIGH (BF10 = 3.2, 48.6 vs 44 repetitions) and greater for PRACTICAL-LOW versus BFR-HIGH (BF10 = 717, 51.8 vs 36.3 repetitions). Greater decreases in changes in maximum voluntary isometric contraction were found in PRACTICAL-HIGH versus HL (BF10 = 1035, ∼103 N) and LL (BF10 = 45, ∼66 N). No differences in changes in muscle thickness were found between LL versus PRACTICAL-LOW/PRACTICAL-HIGH conditions (BF10 = 0.32). Greater changes in electromyography amplitude were also found for BFR-LOW versus PRACTICAL-HIGH condition (BF10 = 6.13, ∼12%), but no differences were noted between the other BFR conditions.

CONCLUSIONS

Overall, elastic knee wraps produce a more fatiguing stimulus than LL or HL conditions and might be used as an alternative to pneumatic cuffs that are traditionally used for BFR exercise.

Chronic Blood Flow Restriction Exercise Improves Objective Physical Function: A Systematic Review

Background: Blood flow restriction or KAATSU exercise training is associated with greater muscle mass and strength increases than non-blood flow restriction equivalent exercise. Blood flow restriction exercise has been proposed as a possible alternative to more physically demanding exercise prescriptions (such as high-load/high-intensity resistance training) in a range of clinical and chronic disease populations. While the maintenance of muscle mass and size with reduced musculoskeletal tissue loading appeals in many of these physically impaired populations, there remains a disconnect between some of the desired clinical measures for chronic disease populations and those commonly measured in the literature examining blood flow restriction exercise. While strength does play a vital role in physical function, task-specific objective measures of physical function indicative of activities of daily living are often more clinically relevant and applicable for evaluating the success of medical and surgical interventions or monitoring age- and disease-related physical decline.

Objective: To determine whether exercise interventions utilizing blood flow restriction are able to improve objective measures of physical function indicative of activities of daily living.

Methods: A systematic search of Medline, Embase, CINAHL, SPORTDiscus, and Springer identified 13 randomized control trials utilizing an exercise intervention combined with blood flow restriction, while measuring at least one objective measure of physical function. Participants were ≥18 years of age. Systematic review of the literature and quality assessment of the included studies used the Cochrane Collaboration's tool for assessing risk bias.

Results: Data from 13 studies with a total of 332 participants showed blood flow restriction exercise, regardless of modality, most notably increased performance on the 30 s sit-to-stand and timed up and go tests, and generally improved physical function on other tests including walking tests, variations of sit-to-stand tests, and balance, jumping, and stepping tests.

Conclusions: From the evidence available, blood flow restriction exercise of multiple modalities improved objective measures of physical function indicative of activities of daily living.

Technical and Training Related Aspects of Resistance Training Using Blood Flow Restriction in Competitive Sport - A Review

Blood flow restriction (BFR) combined with resistance training (RT-BFR) shows significant benefits in terms of muscle strength and hypertrophy. Such effects have been observed in clinical populations, in groups of physically active people, and among competitive athletes. These effects are comparable or, in some cases, even more efficient compared to conventional resistance training (CRT). RT-BFR stimulates muscle hypertrophy and improves muscle strength even at low external loads. Since no extensive scientific research has been done in relation to groups of athletes, the aim of the present study was to identify technical, physiological and methodological aspects related to the use of RT-BFR in competitive athletes from various sport disciplines. RT-BFR in groups of athletes has an effect not only on the improvement of muscle strength or muscle hypertrophy, but also on specific motor abilities related to a particular sport discipline. The literature review reveals that most experts do not recommend the use RT-BFR as the only training method, but rather as a complementary method to CRT. It is likely that optimal muscle adaptive changes can be induced by a combination of CRT and RT-BFR. Some research has confirmed benefits of using CRT followed by RT-BFR during a training session. The use of BFR in training also requires adequate progression or modifications in the duration of occlusion in a training session, the ratio of exercises performed with BFR to conventional exercises, the value of pressure or the cuff width.

A method to standardize the blood flow restriction pressure by an elastic cuff

Blood flow restriction training using a practical (non-pneumatic) elastic cuff has recently increased in popularity. However, a criticism of this method is that the pressure applied and the amount of blood flow restriction induced is unknown. The aim was to quantify blood flow following the application of an elastic cuff and compare that to what is observed using a more traditional pressurized nylon cuff. Thirty-five young participants (16 men and 19 women) visited the laboratory once for testing. In a randomized order (one condition per arm), an elastic cuff (5 cm wide) was applied to one arm and blood flow was measured following the cuff being pulled to two distinct lengths; 10% and 20% of the resting length based on arm circumference. The other arm would follow a similar protocol but use a pressurized nylon cuff (5 cm wide) and be inflated to 40% and 80% of the individuals resting arterial occlusion pressure. There was a main effect of pressure for blood flow with it decreasing in a pressure-dependent manner (High < Low, P < 0.001). The mean difference (95% CI) in blood flow between cuffs was -5.9 (-18.9, 7.0) % for the lower pressure and -4.0 (-13.2, 5.1) % for the higher pressure. When the relative changes for each cuff were separated by sex, there were no differences in the changes from Pre (P ≥ 0.509). The application of a pressure relative to the initial belt length, which is largely dependent upon arm circumference, appears to provide one method to standardize the practical blood flow restriction pressure for future research.

Strengthening the Brain-Is Resistance Training with Blood Flow Restriction an Effective Strategy for Cognitive Improvement?

Aging is accompanied by a decrease in physical capabilities (e.g., strength loss) and cognitive decline. The observed bidirectional relationship between physical activity and brain health suggests that physical activities could be beneficial to maintain and improve brain functioning (e.g., cognitive performance). However, the exercise type (e.g., resistance training, endurance training) and their exercise variables (e.g., load, duration, frequency) for an effective physical activity that optimally enhance cognitive performance are still unknown. There is growing evidence that resistance training induces substantial brain changes which contribute to improved cognitive functions. A relative new method in the field of resistance training is blood flow restriction training (BFR). While resistance training with BFR is widely studied in the context of muscular performance, this training strategy also induces an activation of signaling pathways associated with neuroplasticity and cognitive functions. Based on this, it seems reasonable to hypothesize that resistance training with BFR is a promising new strategy to boost the effectiveness of resistance training interventions regarding cognitive performance. To support our hypothesis, we provide rationales of possible adaptation processes induced by resistance training with BFR. Furthermore, we outline recommendations for future studies planning to investigate the effects of resistance training with BFR on cognition.

OXYGEN UPTAKE AND RESISTANCE EXERCISE METHODS: THE USE OF BLOOD FLOW RESTRICTION

ABSTRACT Introduction: The literature has shown that a gap is identified regarding the acute effects of blood flow restriction training on aerobic variables. Objective: to analyze oxygen consumption (VO2) during and after two resistance training sessions: traditional high intensity and low intensity with blood flow restriction. Methods: After one-repetition maximum tests, eight male participants (25.7±3 years) completed the two experimental protocols, separated by 72 hours, in a randomized order: a) high intensity training at 80% of 1RM (HIRE) and b) low intensity training at 20% of 1RM combined with blood flow restriction (LIRE + BFR). Three sets of four exercises (bench press, squat, barbell bent-over row and deadlift) were performed. Oxygen consumption and excess post-exercise oxygen consumption were measured. Results: the data showed statistically significant differences between the traditional high intensity training and low intensity training with blood flow restriction, with higher values for traditional training sessions, except for the last five minutes of the excess post-exercise oxygen consumption. Oxygen consumption measured during training was higher (p = 0.001) for the HIRE (20.32 ± 1.46 mL·kg-1·min-1) compared to the LIRE + BFR (15.65 ± 1.14 mL·kg-1·min-1). Conclusion: Oxygen uptakes rates during and after the exercise sessions were higher for the high intensity training methodology. However, when taking into account the volume of training provided by both methods, these differences were attenuated. Level of Evidence III - Non-consecutive studies, or studies without consistently applied reference stand.

Muscle fatigue in response to low-load blood flow-restricted elbow-flexion exercise: are there any sex differences?

PURPOSE

This study aimed to determine whether men and women display a different magnitude of muscle fatigue in response to high-load (HL) and low-load blood flow-restricted (LLBFR) elbow-flexion exercise. We also explored to which extent both exercise protocols induce similar levels of muscle fatigue (i.e., torque decrement).

METHODS

Sixty-two young participants (31 men and 31 women) performed dynamic elbow flexions at 20 and 75% of one-repetition maximum for LLBFR and HL exercise, respectively. Maximum voluntary isometric contractions were performed before and after exercise to quantify muscle fatigue.

RESULTS

Men and women exhibited similar magnitude of relative torque decrement after both exercise protocols (p > 0.05). HL was more fatiguing (∆ torque output: 11.9 and 23 N.m in women and men, respectively) than LLBFR resistance exercise (∆ torque output: 8.3 and 15.4 N.m in women and men, respectively) in both sexes, but this was largely attenuated after controlling for the differences in volume load between protocols (p > 0.05).

CONCLUSIONS

These data show that torque decrement in response to LLBFR and HL dynamic elbow-flexion exercise does not follow a sexually dimorphic pattern. Our data also indicate that, if performed in a multiple-set fashion and prescribed for a given volume load, elbow-flexion LLBFR exercise induces similar levels of fatigue as HL acute training. Importantly, this occurs similarly in both sexes.

Effect of one bout of local vibration exercise with blood flow restriction on neuromuscular and hormonal responses

This study aimed to investigate the effects of single local vibration (LV) with and without blood flow restriction (BFR) on muscle activity and hormonal responses. A total of 12 physically inactive males were exposed to 10 sets of intermittent LV (35-40 Hz) on unilateral mid-quadriceps in the supine lying position and LV + BFR (inflated to 140 mmHg) sessions in a repeated-measures randomized crossover design, with a 1-week interval separating the sessions. The results indicated that the electromyography values from the rectus femoris during LV + BFR were greater than those during LV (p < 0.05). LV + BFR caused a minor increase in the lactate (LA) response (p < 0.05); LV with or without BFR failed to elicit change in growth hormone (GH) and testosterone (T) levels (p > 0.05). Cortisol (C) levels were decreased postexercise in both the sessions (p < 0.05). In conclusion, BFR elicited higher increase in muscle activity and metabolic response, but it did not induce hormonal responses. The exposure of LV and LV + BFR may only have a relief effect as detected by the reduction in C levels, probably because the LV did not elicit sufficient stimulus to the muscles.

Influence and reliability of lower-limb arterial occlusion pressure at different body positions

Background

Total arterial occlusive pressure (AOP) is used to prescribe pressures for surgery, blood flow restriction exercise (BFRE) and ischemic preconditioning (IPC). AOP is often measured in a supine position; however, the influence of body position on AOP measurement is unknown and may influence level of occlusion in different positions during BFR and IPC. The aim of this study was therefore to investigate the influence of body position on AOP.

Methods

Fifty healthy individuals (age = 29 ± 6 y) underwent AOP measurements on the dominant lower-limb in supine, seated and standing positions in a randomised order. AOP was measured automatically using the Delfi Personalised Tourniquet System device, with each measurement separated by 5 min of rest.

Results

Arterial occlusive pressure was significantly lower in the supine position compared to the seated position (187.00 ± 32.5 vs 204.00 ± 28.5 mmHg, p < 0.001) and standing position (187.00 ± 32.5 vs 241.50 ± 49.3 mmHg, p < 0.001). AOP was significantly higher in the standing position compared to the seated position (241.50 ± 49.3 vs 204.00 ± 28.5 mmHg, p < 0.001).

Discussion

Arterial occlusive pressure measurement is body position dependent, thus for accurate prescription of occlusion pressure during surgery, BFR and IPC, AOP should be measured in the position intended for subsequent application of occlusion.

Delayed Onset Muscle Soreness and Perceived Exertion After Blood Flow Restriction Exercise

Brandner, CR, and Warmington, SA. Delayed onset muscle soreness and perceived exertion after blood flow restriction exercise. J Strength Cond Res 31(11): 3101-3108, 2017-The purpose of this study was to determine the perceptual responses to resistance exercise with heavy loads (80% 1 repetition maximum [1RM]), light loads (20% 1RM), or light loads in combination with blood flow restriction (BFR). Despite the use of light loads, it has been suggested that the adoption of BFR resistance exercise may be limited because of increases in delayed onset muscle soreness (DOMS) and perceived exertion. Seventeen healthy untrained males participated in this balanced, randomized cross-over study. After 4 sets of elbow-flexion exercise, participants reported ratings of perceived exertion (RPE), with DOMS also recorded for 7 days after each trial. Delayed onset muscle soreness was significantly greater for low-pressure continuous BFR (until 48 hours postexercise) and high-pressure intermittent BFR (until 72 hours postexercise) than for traditional heavy-load resistance exercise and light-load resistance exercise. In addition, RPE was higher for heavy-load resistance exercise and high-pressure intermittent BFR than for low-pressure continuous BFR, with all trials greater than light-load resistance exercise. For practitioners working with untrained participants, this study provides evidence to suggest that to minimize the perception of effort and postexercise muscle soreness associated with BFR resistance exercise, continuous low-pressure application may be more preferential than intermittent high-pressure application. Importantly, these perceptual responses are relatively short-lived (∼2 days) and have previously been shown to subside after a few exercise sessions. Combined with smaller initial training volumes (set × repetitions), this may limit RPE and DOMS to strengthen uptake and adherence and assist in program progression for muscle hypertrophy and gains in strength.

Mild aerobic training with blood flow restriction increases the hypertrophy index and MuSK in both slow and fast muscles of old rats: Role of PGC-1α

AIMS

Existing evidence emphasize the role of mitochondrial dysfunction in sarcopenia which is revealed as loss of skeletal muscle mass and neuromuscular junction remodeling. We assessed the effect of low-intensity aerobic training along with blood flow restriction on muscle hypertrophy index, muscle-specific kinase (MuSK), a pivotal protein of the neuromuscular junction and Peroxisome proliferator-activated receptor gamma co-activator 1-alpha (PGC-1α) in aged male rats.

MAIN METHODS

Animals groups were control (CTL), sham (Sh), leg blood flow restriction (BFR), exercise (Ex), sham + exercise (Sh + Ex), and BFR plus exercise (BFR + Ex) groups. The exercise groups were trained with low intensity exercise for 10 weeks. 48 h after the last training session, animals were sacrificed under anesthesia. Soleus and EDL muscles were isolated, hypertrophy index was estimated and MuSK and PGC-1α were measured by western blot method.

KEY FINDINGS

Hypertrophy index enhanced in soleus and Extensor digitorum longus (EDL) muscles of BFR + Ex group (P < 0.01 versus CTL and Sh groups, and P < 0.001 versus other groups). The MuSK protein of soleus and EDL muscles increased in BFR + Ex group (P < 0.01 and P < 0.001, respectively) in comparison with CTL and Sh groups. In BFR + Ex group, the PGC-1α protein increased in both soleus and EDL (P < 0.001 compared to other groups). Also the PGC-1α of soleus muscle was higher in Ex and Sh + Ex groups versus CTL and Sh groups (P < 0.05).

SIGNIFICANCE

Findings suggest that low endurance exercise plus BFR improves the MuSK and hypertrophy index of both slow and fast muscles of elderly rats probably through the rise of PGC-1α expression.

Effects of Practical Blood Flow Restriction Training on Adolescent Lower-Body Strength

Luebbers, PE, Witte, EV, and Oshel, JQ. Effects of practical blood flow restriction training on adolescent lower-body strength. J Strength Cond Res 33(10): 2674-2683, 2019-The purpose of this study was to examine the effects of a practical blood flow restriction (BFR) training program on lower-body strength of high school weightlifters. Twenty-five students were divided into 3 groups. For 6 weeks, each group completed the same resistance training program with the exception of the parallel back squat exercise (2 d·wk), which was different for each group. One group (HI) completed a traditional high-load (≥65% 1 repetition maximum [1RM]) back squat protocol with 3 sets of low repetitions (≤10). The LO group completed the squat exercise using a relatively light load (≤30% 1RM) for 1 set of 30 repetitions and 3 sets of 15 with 30 seconds of rest between sets. The LO + BFR group followed the same protocol as LO, but did so with blood flow restricted. One repetition maximum back squat tests were conducted before the start of the program and again on conclusion, the values of which were used as the dependent measure. A 3 × 2 (group × time) repeated-measures analysis of variance revealed a significant interaction (p = 0.043). Follow-up tests were conducted to explore the interaction. Paired-sample t-tests for each group indicated a significant increase in leg strength for the LO + BFR group (p = 0.005) but not for the HI (p = 0.142) or LO groups (p = 1.00). This suggests that a practical BFR training program may be effective in increasing 1RM squat performance of high school students.

Adaptation of Perceptual Responses to Low-Load Blood Flow Restriction Training

Martín-Hernández, J, Ruiz-Aguado, J, Herrero, AJ, Loenneke, JP, Aagaard, P, Cristi-Montero, C, Menéndez, H, and Marín, PJ. Adaptation of perceptual responses to low-load blood flow restriction training. J Strength Cond Res 31(3): 765-772, 2017-The purpose of this study was to determine the adaptive response of ratings of perceived exertion (RPE) and pain over 6 consecutive training sessions. Thirty subjects were assigned to either a blood flow restriction training (BFRT) group or a high-intensity resistance training (HIT) group. Blood flow-restricted training group performed 4 sets (30 + 15 + 15 + 15, respectively) of unilateral leg extension at an intensity of 20% one repetition maximum (1RM) while a restrictive cuff was applied to the most proximal part of the leg. The HIT group performed 3 sets of 8 repetitions with 85% 1RM. Ratings of perceived exertion and pain were assessed immediately after each exercise set along the 6 training sessions and were then averaged to obtain the overall RPE and pain per session. Statistical analyses showed significant main effects for group (p ≤ 0.05) and time (p < 0.001). Ratings of perceived exertion values dropped from session 1 to session 6 in both BFRT (8.12 ± 1.3 to 5.7 ± 1.1, p < 0.001) and HIT (8.5 ± 1.2 to 6.40 ± 1.2, p < 0.001). Similar results were observed regarding pain ratings (BFRT: 8.12 ± 1.3 to 5.90 ± 1.55, p < 0.001; HIT: 6.22 ± 1.7 to 5.14 ± 1.42, p < 0.01). Our results indicate that RPE was higher after HIT, whereas differences did not reach significance regarding pain. These perceptual responses were attenuated over time, and the time course of this adaptive response was similar between BFRT and HIT. In summary, BFRT induces a marked perceptual response to training, comparable with that observed with HIT. However, this response becomes attenuated with continuous practice, leading to moderate values of RPE and pain. Perceptual responses may not limit the application of BFRT to highly motivated individuals.

Low-load resistance training with low relative pressure produces muscular changes similar to high-load resistance training

INTRODUCTION

This study compares the acute and chronic response of high-load resistance training (HL) to low-load resistance training with low blood flow restriction (LL-BFR) pressure.

METHODS

Participants completed elbow flexion with either HL or LL-BFR or nonexercise. In the chronic study, participants in the HL and LL-BFR groups were trained for 8 weeks to determine differences in muscle size and strength. The acute study examined the changes in pretesting/posttesting (Pre/Post) torque, muscle swelling, and blood lactate.

RESULTS

In the chronic study, similar changes in muscle size and strength were observed for both HL and LL-BFR. In the acute study, Pre/Post changes in the torque, muscle swelling, and blood lactate were similar between HL and LL-BFR.

DISCUSSION

Our findings indicate that pressure as low as 50% arterial occlusion can produce similar changes in muscle mass and strength compared with traditional HL. Muscle Nerve 56: E126-E133, 2017.

The influence of participant characteristics on the relationship between cuff pressure and level of blood flow restriction

Purpose

Previous investigations to establish factors influencing the blood flow restriction (BFR) stimulus have determined cuff pressures required for complete arterial occlusion, which does not reflect the partial restriction prescribed for this training technique. This study aimed to establish characteristics that should be accounted for when prescribing cuff pressures required for partial BFR.

Methods

Fifty participants were subjected to incremental blood flow restriction of the upper and lower limbs by proximal pneumatic cuff inflation. Popliteal and brachial artery diameter, blood velocity and blood flow was assessed with Doppler ultrasound. Height, body mass, limb circumference, muscle–bone cross-sectional area, adipose thickness (AT) and arterial blood pressure were measured and used in different models of hierarchical linear regression to predict the pressure at which 60 % BFR (partial occlusion) occurred.

Results

Combined analysis revealed a difference in cuff pressures required to elicit 60 % BFR in the popliteal (111 ± 12 mmHg) and brachial arteries (101 ± 12 mmHg). MAP (r = 0.58) and AT (r = −0.45) were the largest independent determinants of lower and upper body partial occlusion pressures. However, greater variance was explained by upper and lower limb regression models composed of DBP and BMI (48 %), and arm AT and DBP (30 %), respectively.

Conclusion

Limb circumference has limited impact on the cuff pressure required for partial blood flow restriction which is in contrast to its recognised relationship with complete arterial occlusion. The majority of the variance in partial occlusion pressure remains unexplained by the predictor variables assessed in the present study.

Corticomotor Excitability is Increased Following an Acute Bout of Blood Flow Restriction Resistance Exercise

We used transcranial magnetic stimulation (TMS) to investigate whether an acute bout of resistance exercise with blood flow restriction (BFR) stimulated changes in corticomotor excitability (motor evoked potential, MEP) and short-interval intracortical inhibition (SICI), and compared the responses to two traditional resistance exercise methods. Ten males completed four unilateral elbow flexion exercise trials in a balanced, randomized crossover design: (1) heavy-load (HL: 80% one-repetition maximum [1-RM]); (2) light-load (LL; 20% 1-RM) and two other light-load trials with BFR applied; (3) continuously at 80% resting systolic blood pressure (BFR-C); or (4) intermittently at 130% resting systolic blood pressure (BFR-I). MEP amplitude and SICI were measured using TMS at baseline, and at four time-points over a 60 min post-exercise period. MEP amplitude increased rapidly (within 5 min post-exercise) for BFR-C and remained elevated for 60 min post-exercise compared with all other trials. MEP amplitudes increased for up to 20 and 40 min for LL and BFR-I, respectively. These findings provide evidence that BFR resistance exercise can modulate corticomotor excitability, possibly due to altered sensory feedback via group III and IV afferents. This response may be an acute indication of neuromuscular adaptations that underpin changes in muscle strength following a BFR resistance training programme.