The effect of eccentric exercise with blood flow restriction on neuromuscular activation, microvascular oxygenation, and the repeated bout effect

Potential Moderators of the Effects of Blood Flow Restriction Training on Muscle Strength and Hypertrophy: A Meta-analysis Based on a Comparison with High-Load Resistance Training

BACKGROUND

While it has been examined whether there are similar magnitudes of muscle strength and hypertrophy adaptations between low-load resistance training combined with blood-flow restriction training (BFR-RT) and high-load resistance training (HL-RT), some important potential moderators (e.g., age, sex, upper and lower limbs, frequency and duration etc.) have yet to be analyzed further. Furthermore, training status, specificity of muscle strength tests (dynamic versus isometric or isokinetic) and specificity of muscle mass assessments (locations of muscle hypertrophy assessments) seem to exhibit different effects on the results of the analysis. The role of these influencing factors, therefore, remains to be elucidated.

OBJECTIVES

The aim of this meta-analysis was to compare the effects of BFR- versus HL-RT on muscle adaptations, when considering the influence of population characteristics (training status, sex and age), protocol characteristics (upper or lower limbs, duration and frequency) and test specificity.

METHODS

Studies were identified through database searches based on the following inclusion criteria: (1) pre- and post-training assessment of muscular strength; (2) pre- and post-training assessment of muscular hypertrophy; (3) comparison of BFR-RT vs. HL-RT; (4) score ≥ 4 on PEDro scale; (5) means and standard deviations (or standard errors) are reported or allow estimation from graphs. In cases where the fifth criterion was not met, the data were requested directly from the authors.

RESULTS

The main finding of the present study was that training status was an important influencing factor in the effects of BFR-RT. The trained individuals may gain greater muscle strength and hypertrophy with BFR-RT as compared to HL-RT. However, the results showed that the untrained individuals experienced similar muscle mass gains and superior muscle strength gains in with HL-RT compared to BFR-RT.

CONCLUSION

Compared to HL-RT, training status is an important factor influencing the effects of the BFR-RT, in which trained can obtain greater muscle strength and hypertrophy gains in BFR-RT, while untrained individuals can obtain greater strength gains and similar hypertrophy in HL-RT.

Physiological and perceptual responses to acute arm cranking with blood flow restriction

INTRODUCTION

Lower-body aerobic exercise with blood flow restriction (BFR) offers a unique approach for stimulating improvements in muscular function and aerobic capacity. While there are more than 40 reports documenting acute and chronic responses to lower-body aerobic exercise with BFR, responses to upper-body aerobic exercise with BFR are not clearly established.

PURPOSE

We evaluated acute physiological and perceptual responses to arm cranking with and without BFR.

METHODS

Participants (N = 10) completed 4 arm cranking (6 × 2 min exercise, 1 min recovery) conditions: low-intensity at 40%VO2peak (LI), low-intensity at 40%VO2peak with BFR at 50% of arterial occlusion pressure (BFR50), low-intensity at 40%VO2peak with BFR at 70% of arterial occlusion pressure (BFR70), and high-intensity at 80%VO2peak (HI) while tissue oxygenation, cardiorespiratory, and perceptual responses were assessed.

RESULTS

During exercise, tissue saturation for BFR50 (54 ± 6%), BFR70 (55 ± 6%), and HI (54 ± 8%) decreased compared to LI (61 ± 5%, all P < 0.01) and changes in deoxyhemoglobin for BFR50 (11 ± 4), BFR70 (15 ± 6), and HI (16 ± 10) increased compared to LI (4 ± 2, all P < 0.01). During recovery intervals, tissue saturation for BFR50 and BFR70 decreased further and deoxyhemoglobin for BFR50 and BFR70 increased further (all P < 0.04). Heart rate for BFR70 and HI increased by 9 ± 9 and 50 ± 15b/min, respectively, compared to LI (both P < 0.02). BFR50 (8 ± 2, 1.0 ± 1.0) and BFR70 (10 ± 2, 2.1 ± 1.4) elicited greater arm-specific perceived exertion (6-20 scale) and pain (0-10 scale) compared to LI (7 ± 1, 0.2 ± 0.5, all P < 0.05) and pain for BFR70 did not differ from HI (1.7 ± 1.9).

CONCLUSION

Arm cranking with BFR decreased tissue saturation and increased deoxyhemoglobin without causing excessive cardiorespiratory strain and pain.

Acute effects of static balance exercise combined with different levels of blood flow restriction on motor performance fatigue as well as physiological and perceptual responses in young healthy males and females

PURPOSE

This study investigated the acute effects of a static balance exercise combined with different blood flow restriction (BFR) pressures on motor performance fatigue development and recovery as well as physiological and perceptual responses during exercise in males and females.

METHODS

Twenty-four recreational active males (n = 13) and females (n = 11) performed static balance exercise on a BOSU ball (3 sets of 60 s with 30 s rest in-between) on three separate (> 3 days) laboratory visits with three different BFR pressures (80% arterial occlusion pressure [AOP], 40%AOP, 30 mmHg [SHAM]) in random order. During exercise, activity of various leg muscles, vastus lateralis muscle oxygenation, and ratings of effort and pain perception were recorded. Maximal squat jump height was measured before, immediately after, 1, 2, 4, and 8 min after exercise to quantify motor performance fatigue development and recovery.

RESULTS

Quadriceps muscle activity as well as ratings of effort and pain were highest, while muscle oxygenation was lowest in the 80%AOP compared to the 40%AOP and SHAM condition, with no differences in postural sway between conditions. Squat jump height declined after exercise with the highest reduction in the 80%AOP (- 16.4 ± 5.2%) followed by the 40%AOP (- 9.1 ± 3.2%), and SHAM condition (- 5.4 ± 3.3%). Motor performance fatigue was not different after 1 min and 2 min of recovery in 40% AOP and 80% AOP compared to SHAM, respectively.

CONCLUSION

Static balance exercise combined with a high BFR pressure induced the largest changes in physiological and perceptual responses, without affecting balance performance. Although motor performance fatigue was increased by BFR, it may not lead to long-term impairments in maximal performance.

The effects of blood flow restriction training on PAP and lower limb muscle activation: a meta-analysis

Objective: This study aims to systematically evaluate the effects of blood flow restriction (BFR) training on lower limb muscle activation and post-activation potentiation (PAP) in athletes through a meta-analysis and discuss methods to improve instant muscle strength so as to provide a reference for training in this field. Methods: Randomized controlled trials (RCTs) that examined the impact of BFR training on muscle activation and PAP were gathered through database searches, such as CNKI, Wanfang, Web of Science, PubMed, and others. The Cochrane risk of bias tool was used to include and exclude literature. Quality evaluation and statistical analysis were conducted using ReviewManager 5.3 software, STATA 16.0, and other software programs. The sensitivity analysis and funnel plots were employed to assess result stability and publication bias. Results: In total, 18 literature studies were included with a total of 267 subjects. The meta-analysis showed that BFR could significantly improve the RMS value of lower limb muscles [SMD = 0.98, 95% CI (0.71, 1.24), and p < 0.00001]. BFR had a significant effect on the immediate explosive power of the lower limbs [SMD = 0.28, 95% CI (0.02, 0.53), and p = 0.03], but the heterogeneity was obvious (I 2 = 51%). The subgroup analysis showed that different training methods may be influencing factors that lead to the heterogeneity between studies. The measurement indexes were the counter movement jump (CMJ) [SMD = 0.45, 95% CI (0.20, 0.69), and p = 0.0004], training mode to overcome body weight [SMD = 0.57, 95% CI (0.33, 0.82), and p < 0.00001], and compressive strength of 40%-60% arterial occlusion pressure (AOP) [SMD = 0.57, 95% CI (0.31, 0.83), and p < 0.0001], which reached the maximum effect and was statistically significant. Conclusion: BFR training can induce lower extremity muscle activation and PAP. Combining self-weight training with BFR exercises set at 40%-60% AOP appears to be particularly effective in inducing PAP, especially for enhancing CMJ. Furthermore, combining body-weight training with BFR is considered an effective warm-up method to improve CMJ. Systematic Review Registration: http://inplasy.com, identifier INPLASY2023100087.

75-repetition versus sets to failure of blood flow restriction exercise on indices of muscle damage in women

ABSTRACTThere is conflicting evidence regarding the prevalence and magnitude of exercise-induced muscle damage (EIMD) following low-load resistance exercise with blood flow restriction (LL + BFR) that may be related to exercise protocols. The purpose of this investigation was to examine the effects of 75-repetition (BFR-75) (1 × 30, 3 × 15) and 4 sets to failure (BFR-4x) protocols on indices of EIMD among untrained women. Thirteen women completed this investigation. One leg was randomly assigned to BFR-75 and the other to BFR-4x. Each leg performed isokinetic, unilateral, concentric-eccentric, leg extension muscle actions at 30% of maximal strength. Indices of EIMD (muscle soreness, range of motion [ROM], limb circumference, pain pressure threshold [PPT], and maximal voluntary isometric contraction [MVIC]) were recorded before exercise, 0-, 24-, 48-, 72-, and 96-hours post-exercise. There were no changes for ROM, circumference, or PPT. Muscle soreness increased similarly in both conditions 0-, 24-, and 48-hours post-exercise and MVIC increased 24-, 48-, 72-, and 96-hours post-exercise. These findings suggested BFR-75 and BFR-4x were not associated with EIMD and elicited similar physiological responses. The increases in muscle soreness may be due to metabolic stress associated with LL + BFR protocols apart from EIMD.

Exercise responses to heart rate clamped cycling with graded blood flow restriction

OBJECTIVES

To quantify the acute effects of graded blood flow restriction on the interaction between changes in mechanical output, muscle oxygenation trends and perceptual responses to heart rate clamped cycling.

DESIGN

Repeated measures.

METHODS

Twenty-five adults (21 men) performed six, 6-min cycling bouts (24 min of recovery) at a clamped heart rate corresponding to their first ventilatory threshold at 0 % (unrestricted), 15 %, 30 %, 45 %, 60 % and 75 % of arterial occlusion pressure with the cuffs inflated bilaterally from the fourth to the sixth minute. Power output, arterial oxygen saturation (pulse oximetry) and vastus lateralis muscle oxygenation (near-infrared spectroscopy) were monitored during the final 3 min of pedalling, whilst perceptual responses (modified Borg CR10 scales) were obtained immediately after exercise.

RESULTS

Compared to unrestricted cycling, average power output for minutes 4-6 decreased exponentially for cuff pressures ranging 45-75 % of arterial occlusion pressure (P < 0.001). Peripheral oxygen saturation averaged ∼96 % across all cuff pressures (P = 0.318). Deoxyhemoglobin changes were larger at 45-75 % versus 0 % of arterial occlusion pressure (P < 0.05), whereas higher total haemoglobin values occurred at 60-75 % of arterial occlusion pressure (P < 0.05). Sense of effort, ratings of perceived exertion, pain from cuff pressure, and limb discomfort were exaggerated at 60-75 % versus 0 % of arterial occlusion pressure (P < 0.001).

CONCLUSIONS

Blood flow restriction of at least 45 % of arterial occlusion pressure is required to reduce mechanical output during heart rate clamped cycling at the first ventilatory threshold. Whilst power decreases non-linearly above this pressure threshold, higher occlusion levels ranging 60-75 % of arterial occlusion pressure also accentuate muscle deoxygenation and exercise-related sensations.

Effect of supervised rehabilitation combined with blood flow restriction training in athletes with chronic ankle instability: a randomized placebo-controlled trial

Blood flow restriction (BFR) resistance exercise has been advocated as an alternative approach for improving muscle strength in patients undergoing musculoskeletal rehabilitation. The present study aimed to evaluate the effectiveness of a 4-week supervised rehabilitation (R) with and without BFR on muscle strength, cross-sectional area (CSA), dynamic balance, and functional performance in athletes with chronic ankle instability (CAI). A total of 16 collegiate athletes with CAI participated in this study. They were randomly assigned to the BFR+R group (n=8) or the R group (n=8). Both groups underwent supervised rehabilitation 3 times weekly for 4 consecutive weeks. Additionally, the BFR+R group was applied with a cuff around the proximal thigh at 80% arterial occlusion pressure in addition to the traditional rehabilitation program, whereas the R group received the sham BFR only. Before and after 4 weeks of intervention, isokinetic muscle strength, CSA, Y-balance test, and side hop test (SHT) were measured. Following a 4-week intervention, the BFR+R group exhibited significant improvements in muscle strength of ankle plantarflexor and evertor, CSA of fibularis longus, and SHT timed performance compared with prior training and the R group (all, P<0.05). However, no significant difference was observed on dynamic balance among the groups. The present finding indicated that a 4-week supervised rehabilitation combined with BFR is more effective in improving muscle strength and size and functional performance compared with the traditional rehabilitation alone. This information could have implications for physical therapists and clinician in developing and designing a rehabilitation program for athletes with CAI.

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 low-load blood flow restriction exercise to failure and non-failure on myoelectric activity: a meta-analysis

OBJECTIVES

To compare the short- and long-term effects of low load blood flow restriction (LL-BFR) versus low- (LL-RT) or high-load (HL-RT) resistance training with free blood flow on myoelectric activity, and investigate the differences between failure and non-failure protocols.

DATA SOURCE

We identified sources by searching the MEDLINE/PUBMED, CINAHL, WEB OF SCIENCE, CENTRAL, SCOPUS, SPORTDiscus, and PEDro electronic databases.

STUDY SELECTION

We screened titles and abstracts of 1048 articles using our inclusion criteria. A total of 39 articles were selected for further analysis.

DATA EXTRACTION

Two reviewers independently assessed the methodological quality of each study and extracted data from studies. A meta-analytic approach was used to compute standardized mean differences (SMD ± 95% confidence intervals (CI)). Subgroup analyses were conducted for both failure or non-failure protocols.

DATA SYNTHESIS

The search identified n = 39 articles that met the inclusion criteria. Regarding the short-term effects, LL-BFR increased muscle excitability compared with LL-RT during non-failure exercises (SMD 0.61, 95% CI 0.34 to 0.88), whereas HL-RT increased muscle excitability compared with LL-BFR regardless of voluntary failure (SMD -0.61, 95% CI -1.01 to 0.21) or not (SMD -1.13, CI -1.94 to -0.33). Concerning the long-term effects, LL-BFR increased muscle excitability compared with LL-RT during exercises performed to failure (SMD 1.09, CI 0.39 to 1.79).

CONCLUSIONS

Greater short-term muscle excitability levels are observed in LL-BFR than LL-RT during non-failure protocols. Conversely, greater muscle excitability is present during HL-RT compared with LL-BFR, regardless of volitional failure. Furthermore, LL-BFR performed to failure increases muscle excitability in the long-term compared with LL-RT.

Strength Training: In Search of Optimal Strategies to Maximize Neuromuscular Performance

Training with low-load exercise performed under blood flow restriction can augment muscle hypertrophy and maximal strength to a similar extent as the classical high-load strength training method. However, the blood flow restriction method elicits only minor neural adaptations. In an attempt to maximize training-related gains, we propose using other protocols that combine high voluntary activation, mechanical tension, and metabolic stress.

Metabolic Demand and Indirect Markers of Muscle Damage After Eccentric Cycling With Blood Flow Restriction

Purpose: To compare the effects of a single bout of eccentric cycling (ECC) and eccentric cycling with blood flow restriction (ECC_BFR) on the changes in cardio-metabolic demand and indirect markers of muscle damage in healthy men. Method: Twenty-one young men (24.0 ± 3.2 y) were randomly allocated in two groups to perform a 30-min eccentric cycling bout with or without blood flow restriction. Oxygen consumption, heart rate, rate of perceived exertion and mean arterial blood pressure were monitored during cycling. Blood lactate was measured before and after cycling. Maximal voluntary isometric knee extensor strength and muscle damage were measured before, immediately after and 1-4 days after each eccentric cycling bout. Results: Oxygen consumption, heart rate, rate of perceived exertion and mean arterial blood pressure were similar between bouts. Blood lactate concentrations increased in both groups (p < .01), with ECC_BFR showing 60% greater blood lactate concentration than eccentric cycling (p < .01). Maximal voluntary isometric knee extensor strength decreased 19-7% until 48 h and decreased 16-7% until 72 h after ECC and ECC_BFR, respectively. Muscle soreness and pressure pain threshold remained elevated until 72 h after ECC and until 96 h after ECC_BFR. Conclusion: These results show that ECC_BFR induces similar cardiovascular stress, greater lactate production and longer time to recover than ECC alone. Thus, BFR can be safely implemented with eccentric cycling.

Physiological responses of human skeletal muscle to acute blood flow restricted exercise assessed by multimodal MRI

Important physiological quantities for investigating muscle hypertrophy include blood oxygenation, cell swelling, and changes in blood flow. The purpose of this study was to compare the acute changes of these parameters in human skeletal muscle induced by low-load (20% 1-RM) blood flow-restricted (BFR-20) knee extensor exercise compared with free-flow work-matched (FF-20_WM) and free-flow 50% 1-RM (FF-50) knee extensor exercise using multimodal magnetic resonance imaging (MRI). Subjects (n = 11) completed acute exercise sessions for each exercise mode in an MRI scanner, where interleaved measures of muscle R₂ (indicator of edema), [Formula: see text] (indicator of deoxyhemoglobin), macrovascular blood flow, and diffusion were performed before, between sets, and after the final set for each exercise protocol. BFR-20 exercise resulted in larger acute decreases in R₂ and greater increases in cross-sectional area than FF-20_WM and FF-50 (P < 0.01). Blood oxygenation decreased between sets during BFR-20, as indicated by a 13.6% increase in [Formula: see text] values (P < 0.01)), whereas they remained unchanged for FF-20_WM and decreased during FF-50 exercise. Quadriceps blood flow between sets was highest for the heavier load (FF-50), averaging 305 mL/min, and lowest for BFR-20 at 123 ± 73 mL/min until post-exercise cuff release, where blood flow rates in BFR-20 exceeded both FF protocols (P < 0.01). Acute changes in diffusion rates were similar for all exercise protocols. This study was able to differentiate the acute exercise response of selected physiological factors associated with skeletal muscle hypertrophy. Marked differences in these parameters were found to exist between BFR and FF exercise conditions, which contribute to explain the anabolic potential of low-load blood flow restricted muscle exercise.NEW & NOTEWORTHY Acute changes in blood flow, diffusion, blood oxygenation, cross-sectional area, and the "T₂ shift" are evaluated in human skeletal muscle in response to blood flow-restricted (BFR) and conventional free-flow knee extensor exercise performed in an MRI scanner. The acute physiological response to exercise was dependent on the magnitude of load and the application of BFR. Physiological variables changed markedly and established a steady state rapidly after the first of four exercise sets.

A Systematic Review and Meta-Analysis on Neural Adaptations Following Blood Flow Restriction Training: What We Know and What We Don't Know

Objective: To summarize the existing evidence on the long-term effects of low-load (LL) blood flow restricted (BFR) exercise on neural markers including both central and peripheral adaptations. Methods: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. The literature search was performed independently by two reviewers in the following electronic databases: PubMed, Web of Science, Scopus and CENTRAL. The systematic review included long-term trials investigating the effects of LL-BFR training in healthy subjects and compared theses effects to either LL or high-load (HL) training without blood flow restriction. Results: From a total of N = 4499 studies, N = 10 studies were included in the qualitative synthesis and N = 4 studies in a meta-analysis. The findings indicated that LL-BFR resulted in enhanced levels of muscle excitation compared to LL training with pooled effect sizes of 0.87 (95% CI: 0.38-1.36). Compared to HL training, muscle excitation following LL-BFR was reported as either similar or slightly lower. Differences between central activation between LL-BFR and LL or HL are less clear. Conclusion: The summarized effects in this systematic review and meta-analysis highlight that BFR training facilitates neural adaptations following LL training, although differences to conventional HL training are less evident. Future research is urgently needed to identify neural alterations following long-term blood flow restricted exercise.

Effects of acute inspiratory loading during treadmill running on cerebral, locomotor and respiratory muscle oxygenation in women soccer players

Respiratory limitation can be a primary mechanism for exercise cessation in female athletes. This study aimed to assess the effects of inspiratory loading (IL) on intercostal muscles (IM), vastus lateralis (VL) and cerebral (Cox) muscles oxygenation in women soccer players during high-intensity dynamic exercise. Ten female soccer players were randomized to perform in order two constant-load tests on a treadmill until the exhaustion time (Tlim) (100 % of maximal oxygen uptake- V˙O₂). They breathed freely or against a fixed inspiratory loading (IL) of 41 cm H₂O (∼30 % of maximal inspiratory pressure). Oxygenated (Δ[OxyHb]), deoxygenated (Δ[DeoxyHb]), total hemoglobin (Δ[tHb]) and tissue saturation index (ΔTSI) were obtained by NIRs. Also, blood lactate [La^-] was obtained. IL significantly reduced Tlim (224 ± 54 vs 78 ± 20; P < 0.05) and increased [La^-], V˙O₂, respiratory cycles and dyspnea when corrected to Tlim (P < 0.05). IL also resulted in decrease of Δ[OxyHb] of Cox and IM during exercise compared with rest condition. In addition, decrease of Δ[OxyHb] was observed on IM during exercise when contrasted with Sham (P < 0.05). Furthermore, significant higher Δ[DeoxyHb] of IM and significant lower Δ[DeoxyHb] of Cox were observed when IL was applied during exercise in contrast with Sham (P < 0.05). These results were accompanied with significant reduction of Δ[tHb] and ΔTSI of IM and VL when IL was applied (P < 0.05). High-intensity exercise with IL decreased respiratory and peripheral muscle oxygenation with negative impact on exercise performance. However, the increase in ventilatory work did not impact cerebral oxygenation in soccer players.

The Effects of Blood Flow Restriction on Muscle Activation and Hypoxia in Individuals With Chronic Ankle Instability

CONTEXT

Muscle dysfunction is common in patients with chronic ankle instability (CAI). Blood flow restriction (BFR) may enhance muscle responses during exercise and provide an opportunity to enhance muscle adaptations to ankle rehabilitation exercises; however, there is no evidence examining the effect of BFR on muscle function in CAI patients.

OBJECTIVE

Examine the effects of BFR on muscle activation and oxygen saturation during submaximal ankle eversion and dorsiflexion exercises in individuals with CAI.

DESIGN

Cross-over study design.

SETTING

Laboratory setting. Patients (or Other Participants): Nineteen young adults with a history of CAI.

INTERVENTIONS

Participants performed 4 sets (30, 15, 15, and 15) of eversion and dorsiflexion resistance exercises at 30% of maximum voluntary isometric contraction during 2 conditions, BFR and control. For BFR, a cuff was applied above the knee at 80% of blood flow occlusion. For control, the cuff was not inflated.

MAIN OUTCOME MEASURES

Fibularis longus and tibialis anterior electromyography muscle activation, lower-leg muscle oxygen saturation, and ratings of perceived exertion were recorded during exercises.

RESULTS

Average grand mean muscle activation was 5.6% greater during eversion (P = .03) and 7.7% greater during dorsiflexion (P = .01) resistance exercises with BFR compared with control; however, the magnitudes of the effects of BFR were only clinically important during the dorsiflexion exercises. Lower-leg muscle oxygen saturation was 31% to 44% lower (P < .001) during BFR exercises. Ratings of perceived exertion were significantly higher during BFR exercises (P < .001).

CONCLUSIONS

Greater muscle activation and hypoxia were present during submaximal resistance exercise with BFR in participants with CAI. Greater muscle activation and hypoxia during BFR exercises may be important acute responses mediating the training-related muscle adaptations that have been observed with BFR. The presence of these acute responses in CAI patients supports further research examining BFR as a potential ankle rehabilitation tool.

Acute Neuromuscular and Microvascular Responses to Concentric and Eccentric Exercises With Blood Flow Restriction

Lauver, JD, Cayot, TE, Rotarius, TR, and Scheuermann, BW. Acute neuromuscular and microvascular responses to concentric and eccentric exercises with blood flow restriction. J Strength Cond Res 34(10): 2725-2733, 2020-The purpose of this study was to investigate the effects of the addition of blood flow restriction (BFR) during concentric and eccentric exercises on muscle excitation and microvascular oxygenation status. Subjects (N = 17) were randomly assigned to either a concentric (CON, CON + BFR) or eccentric (ECC, ECC + BFR) group, with one leg assigned to BFR and the other to non-BFR. Surface electromyography and near-infrared spectroscopy were used to measure muscle excitation and microvascular deoxygenation (deoxy-[Hb + Mb]) and [total hemoglobin concentration] during each condition, respectively. On separate days, subjects completed 4 sets (30, 15, 15, 15) of knee extension exercise at 30% maximal torque, and 1 minute of rest was provided between the sets. Greater excitation of the vastus medialis was observed during CON + BFR (54.4 ± 13.3% maximal voluntary isometric contraction [MVIC]) and ECC + BFR (53.0 ± 18.0% MVIC) compared with CON (42.0 ± 10.8% MVIC) and ECC (46.8 ± 9.6% MVIC). Change in deoxy-[Hb + Mb] was greater during CON + BFR (10.0 ± 10.4 μM) than during CON (4.1 ± 4.0 μM; p < 0.001). ECC + BFR (7.8 ± 6.7 μM) was significantly greater than ECC (3.5 ± 4.7 μM; p = 0.001). Total hemoglobin concentration was greater for ECC + BFR (7.9 ± 4.4 μM) compared with ECC (5.5 ± 3.5 μM). The addition of BFR to eccentric and concentric exercises resulted in a significant increase in metabolic stress and muscle excitation compared with non-BFR exercise. These findings suggest that although BFR may increase the hypertrophic stimulus during both modes of contraction, BFR during concentric contractions may result in a greater stimulus.

Separate and combined effects of local and systemic hypoxia in resistance exercise

PURPOSES

This study quantified performance, physiological, and perceptual responses during resistance exercise to task failure with blood flow restriction (BFR), in systemic hypoxia, and with these stimuli combined.

METHODS

Fourteen young men were tested for 1-repetition maximum (1RM) in the barbell biceps curl and lying triceps extension exercises. On separate visits, subjects performed exercise trials (4 sets to failure at 70% 1RM with 90 s between sets) in six separate randomized conditions, i.e., in normoxia or hypoxia (fraction of inspired oxygen = 20.9% and 12.9%, respectively) combined with three different levels of BFR (0%, 45%, or 60% of resting arterial occlusion pressure). Muscle activation and oxygenation were monitored via surface electromyography and near-infrared spectroscopy, respectively. Arterial oxygen saturation, heart rate, and perceptual responses were assessed following each set.

RESULTS

Compared to set 1, the number of repetitions before failure decreased in sets 2, 3, and 4 for both exercises (all P < 0.001), independently of the condition (P > 0.065). Arterial oxygen saturation was lower with systemic hypoxia (P < 0.001), but not BFR, while heart rate did not differ between conditions (P > 0.341). Muscle oxygenation and activation during exercise trials remained unaffected by the different conditions (all P ≥ 0.206). A significant main effect of time, but not condition, was observed for overall perceived discomfort, difficulty breathing, and limb discomfort (all P < 0.001).

CONCLUSION

Local and systemic hypoxic stimuli, or a combination of both, did not modify the fatigue-induced change in performance, trends of muscle activation or oxygenation, nor exercise-related sensations during a multi-set resistance exercise to task failure.

Low intensity blood flow restriction exercise: Rationale for a hypoalgesia effect

Exercise-induced hypoalgesia is characterised by a reduction in pain sensitivity following exercise. Recently, low intensity exercise performed with blood flow restriction has been shown to induce hypoalgesia. The purpose of this manuscript is to discuss the mechanisms of exercise-induced hypoalgesia and provide rationale as to why low intensity exercise performed with blood flow restriction may induce hypoalgesia. Research into exercise-induced hypoalgesia has identified several potential mechanisms, including opioid and endocannabinoid-mediated pain inhibition, conditioned pain modulation, recruitment of high threshold motor units, exercise-induced metabolite production and an interaction between cardiovascular and pain regulatory systems. We hypothesise that several mechanisms consistent with prolonged high intensity exercise may drive the hypoalgesia effect observed with blood flow restriction exercise. These are likely triggered by the high level of intramuscular stress in the exercising muscle generated by blood flow restriction including hypoxia, accumulation of metabolites, accelerated fatigue onset and ischemic pain. Therefore, blood flow restriction exercise may induce hypoalgesia through similar mechanisms to prolonged higher intensity exercise, but at lower intensities, by changing local tissue physiology, highlighting the importance of the blood flow restriction stimulus. The potential to use blood flow restriction exercise as a pain modulation tool has important implications following acute injury and surgery, and for several load compromised populations with chronic pain.

Changes in microvascular oxygenation and total hemoglobin concentration of the vastus lateralis during neuromuscular electrical stimulation (NMES)

Background and Introduction: Neuromuscular electrical stimulation (NMES) is predicated on eliciting muscle contractions and increasing muscle demand to promote increase in strength. Previous studies have shown differences in the magnitude of elicited force among various NMES waveforms but less is known about metabolic demand of muscle during NMES.Objective/Purpose: The purpose of this study was to compare elicited force and muscle metabolic demand during electrically elicited contractions using different NMES waveforms.Methods: A single-session repeated measures design was used. Electrically elicited force (EEF), microvascular oxygenation (SmO2), total hemoglobin concentration ([THC]) of the vastus lateralis, and subject tolerance (VAS score) were measured using three NMES waveforms; burst modulated alternating current (Russian), biphasic pulsed current (VMS®), and burst modulated biphasic pulsed current (VMS-burst®).Results: A significant main effect for waveform was noted for EEF (F = 12.693, p < .001), SmO2 (F = 8.340, p = .001), and VAS (F = 4.213, p = .025), but not [THC]. Compared to Russian current, VMS-burst and VMS resulted in significantly greater EEF (p = .001; p = .009) and local metabolic demand (i.e. decreased SmO2) (p = .005; p = .003), but not [THC]. VAS was significantly greater (p = .023) for VMS (4.2) compared to Russian (3.07) but not different between VMS-burst and Russian and VMS-burst and VMS.Conclusion: Greater muscle force and local metabolic demand were observed with VMS-burst and VMS compared to Russian current. These data provide novel evidence to guide clinical decision making when selecting an NMES waveform.

The Association Between Muscle Deoxygenation and Muscle Hypertrophy to Blood Flow Restricted Training Performed at High and Low Loads

The metabolic stress induced by blood flow restriction (BFR) during resistance training (RT) might maximize muscle growth. However, it is currently unknown whether metabolic stress are associated with muscle hypertrophy after RT protocols with high- or low load. Therefore, the aim of the study was to compare the effect of high load RT (HL-RT), high load BFR (HL-BFR), and low load BFR (LL-BFR) on deoxyhemoglobin concentration [HHb] (proxy marker of metabolic stress), muscle cross-sectional area (CSA), activation, strength, architecture and edema before (T1), after 5 (T2), and 10 weeks (T3) of training with these protocols. Additionally, we analyzed the occurrence of association between muscle deoxygenation and muscle hypertrophy. Thirty young men were selected and each of participants’ legs was allocated to one of the three experimental protocols in a randomized and balanced way according to quartiles of the baseline CSA and leg extension 1-RM values of the dominant leg. The dynamic maximum strength was measured by 1-RM test and vastus lateralis (VL) muscle cross-sectional area CSA echo intensity (CSA_echo) and pennation angle (PA) were performed through ultrasound images. The measurement of muscle activation by surface electromyography (EMG) and [HHb] through near-infrared spectroscopy (NIRS) of VL were performed during the training session with relative load obtained after the 1-RM, before (T1), after 5 (T2), and 10 weeks (T3) training. The training total volume (TTV) was greater for HL-RT and HL-BFR compared to LL-BFR. There was no difference in 1-RM, CSA, CSA_echo, CSA_echo/CSA, and PA increases between protocols. Regarding the magnitude of the EMG, the HL-RT and HL-BFR groups showed higher values than and LL-BFR. On the other hand, [HHb] was higher for HL-BFR and LL-BFR. In conclusion, our results suggest that the addition of BFR to exercise contributes to neuromuscular adaptations only when RT is performed with low-load. Furthermore, we found a significant association between the changes in [HHb] (i.e., metabolic stress) and increases in muscle CSA from T2 to T3 only for the LL-BFR, when muscle edema was attenuated.

Tissue Oxygenation in Response to Different Relative Levels of Blood-Flow Restricted Exercise

Blood flow restrictive (BFR) exercise elicits a localized hypoxic environment compatible with greater metabolic stress. We intended to compare the acute changes in muscle microvascular oxygenation following low-intensity knee extension exercise, combined with different levels of BFR. Thirteen active young men (age: 23.8 ± 5.4 years) were tested for unilateral knee extension exercise (30 + 15 + 15 + 15 reps at 20% one repetition maximum) on four different conditions: no-BFR (NOBFR), 40, 60, and 80% of arterial occlusion pressure (AOP). Deoxyhemoglobin+myoglobin concentration Deoxy[Hb+Mb], total hemoglobin [T(H+Mb)] and tissue oxygen saturation [TOI] were measured on the vastus lateralis muscle using near-infrared spectroscopy (NIMO, Nirox srl, Brescia, Italy). The magnitude of change in Deoxy[Hb+Mb]during exercise was similar between 60 and 80% AOP. Overall, compared to that seen during 60 and 80% AOP, NOBFR as well as 40% AOP resulted in a lower magnitude of change in Deoxy[Hb+Mb] (p < 0.05). While the oxygen extraction decreased during each inter-set resting interval in NOBFR and 40% AOP, this was not the case for 60 or 80% AOP. Additionally, TOI values obtained during recovery from each set of exercise were similarly affected by all conditions. Finally, our data also show that, when performed at higher restrictive values (60 and 80%), BFR exercise increases total Deoxy[Hb+Mb] extraction (p < 0.05). Taken together, we provide evidence that BFR is effective for increasing deoxygenation and reducing tissue oxygenation during low-intensity exercise. We also showed that when using low loads, a relative pressure above 40% of the AOP at rest is required to elicit changes in microvascular oxygenation compared with the same exercise with unrestricted conditions.

Skeletal Muscle Mitochondrial Protein Synthesis and Respiration Increase With Low-Load Blood Flow Restricted as Well as High-Load Resistance Training

Purpose: It is well established that high-load resistance exercise (HLRE) can stimulate myofibrillar accretion. Additionally, recent studies suggest that HLRE can also stimulate mitochondrial biogenesis and respiratory function. However, in several clinical situations, the use of resistance exercise with high loading may not constitute a viable approach. Low-load blood flow restricted resistance exercise (BFRRE) has emerged as a time-effective low-load alternative to stimulate myofibrillar accretion. It is unknown if BFRRE can also stimulate mitochondrial biogenesis and respiratory function. If so, BFRRE could provide a feasible strategy to stimulate muscle metabolic health.

Methods: To study this, 34 healthy previously untrained individuals (24 ± 3 years) participated in BFRRE, HLRE, or non-exercise control intervention (CON) 3 times per week for 6 weeks. Skeletal muscle biopsies were collected; (1) before and after the 6-week intervention period to assess mitochondrial biogenesis and respiratory function and; (2) during recovery from single-bout exercise to assess myocellular signaling events involved in transcriptional regulation of mitochondrial biogenesis. During the 6-week intervention period, deuterium oxide (D₂O) was continuously administered to the participants to label newly synthesized skeletal muscle mitochondrial proteins. Mitochondrial respiratory function was assessed in permeabilized muscle fibers with high-resolution respirometry. Mitochondrial content was assessed with a citrate synthase activity assay. Myocellular signaling was assessed with immunoblotting.

Results: Mitochondrial protein synthesis rate was higher with BFRRE (1.19%/day) and HLRE (1.15%/day) compared to CON (0.92%/day) (P < 0.05) but similar between exercise groups. Mitochondrial respiratory function increased to similar degree with both exercise regimens and did not change with CON. For instance, coupled respiration supported by convergent electron flow from complex I and II increased 38% with BFRRE and 24% with HLRE (P < 0.01). Training did not alter citrate synthase activity compared to CON. BFRRE and HLRE elicited similar myocellular signaling responses.

Conclusion: These results support recent findings that resistance exercise can stimulate mitochondrial biogenesis and respiratory function to support healthy skeletal muscle and whole-body metabolism. Intriquingly, BFRRE produces similar mitochondrial adaptations at a markedly lower load, which entail great clinical perspective for populations in whom exercise with high loading is untenable.

Blood flow in humans following low-load exercise with and without blood flow restriction

Blood flow restriction (BFR) in combination with exercise has been used to increase muscle size and strength using relatively low loads (20%–30% 1-repetition maximum (1RM)). In research, the range of applied pressures based on a percentage of arterial occlusion pressure (AOP), is wide. The purpose of the study is to measure the blood flow response before exercise, following each set of exercise, and postexercise to low-load elbow flexion combined with no restriction (NOBFR), 40% of AOP (40BFR), and 80% of AOP (80BFR). One hundred and fifty-two participants volunteered; 140 completed the protocol (women = 75, men = 65). Participants were counter-balanced into 1 of 3 conditions. Following AOP and 1RM measurement, ultrasound was used to measure standing blood flow at rest in the right brachial artery. Participants performed 4 sets of elbow flexion at 30% 1RM. Blood flow was measured between sets and at 1 and 5 min postexercise. Blood flow decreased following inflation, with no difference between conditions (p < 0.001). Men had greater blood flow than women in all conditions at all time points (p < 0.001). Resting hyperemia decreased with pressure (NOBFR > 40BFR > 80BFR, p < 0.001). Blood flow increased from rest to after set 1 regardless of condition. Following cuff deflation, blood flow increased in both the 80BFR and 40BFR conditions. The reduction in hyperemia during BFR is pressure-dependent. Contrary to previous investigations, blood flow was increased above baseline following exercise.

Impact of Resistance Training on Skeletal Muscle Mitochondrial Biogenesis, Content, and Function

Skeletal muscle metabolic and contractile properties are reliant on muscle mitochondrial and myofibrillar protein turnover. The turnover of these specific protein pools is compromised during disease, aging, and inactivity. Oppositely, exercise can accentuate muscle protein turnover, thereby counteracting decay in muscle function. According to a traditional consensus, endurance exercise is required to drive mitochondrial adaptations, while resistance exercise is required to drive myofibrillar adaptations. However, concurrent practice of traditional endurance exercise and resistance exercise regimens to achieve both types of muscle adaptations is time-consuming, motivationally demanding, and contended to entail practice at intensity levels, that may not comply with clinical settings. It is therefore of principle interest to identify effective, yet feasible, exercise strategies that may positively affect both mitochondrial and myofibrillar protein turnover. Recently, reports indicate that traditional high-load resistance exercise can stimulate muscle mitochondrial biogenesis and mitochondrial respiratory function. Moreover, fatiguing low-load resistance exercise has been shown capable of promoting muscle hypertrophy and expectedly entails greater metabolic stress to potentially enhance mitochondrial adaptations. Consequently, fatiguing low-load resistance exercise regimens may possess the ability to stimulate muscle mitochondrial adaptations without compromising muscle myofibrillar accretion. However, the exact ability of resistance exercise to drive mitochondrial adaptations is debatable, not least due to some methodological challenges. The current review therefore aims to address the evidence on the effects of resistance exercise on skeletal muscle mitochondrial biogenesis, content and function. In prolongation, a perspective is taken on the specific potential of low-load resistance exercise on promoting mitochondrial adaptations.

Do metabolites that are produced during resistance exercise enhance muscle hypertrophy?

Many reviews conclude that metabolites play an important role with respect to muscle hypertrophy during resistance exercise, but their actual physiologic contribution remains unknown. Some have suggested that metabolites may work independently of muscle contraction, while others have suggested that metabolites may play a secondary role in their ability to augment muscle activation via inducing fatigue. Interestingly, the studies used as support for an anabolic role of metabolites use protocols that are not actually designed to test the importance of metabolites independent of muscle contraction. While there is some evidence in vitro that metabolites may induce muscle hypertrophy, the only study attempting to answer this question in humans found no added benefit of pooling metabolites within the muscle post-exercise. As load-induced muscle hypertrophy is thought to work via mechanotransduction (as opposed to being metabolically driven), it seems likely that metabolites simply augment muscle activation and cause the mechanotransduction cascade in a larger proportion of muscle fibers, thereby producing greater muscle growth. A sufficient time under tension also appears necessary, as measurable muscle growth is not observed after repeated maximal testing. Based on current evidence, it is our opinion that metabolites produced during resistance exercise do not have anabolic properties per se, but may be anabolic in their ability to augment muscle activation. Future studies are needed to compare protocols which produce similar levels of muscle activation, but differ in the magnitude of metabolites produced, or duration in which the exercised muscles are exposed to metabolites.