Effects of ischaemic training on local aerobic muscle performance in man

Distinct adaptations of muscle endurance but not strength or hypertrophy to low-load resistance training with and without blood flow restriction

Low-load resistance training promotes muscle strength and hypertrophic adaptations when combined with blood flow restriction (BFR). However, the effect of BFR on muscle endurance remains unclear. The aim of this study was to clarify the effects of BFR on muscle performance and adaptation, with special reference to local muscle endurance. In experiment 1, eight healthy men performed unilateral elbow flexion exercise to failure at 30% of one-repetition maximum with BFR (at 40% of estimated arterial occlusion pressure) and free blood flow (FBF). During the exercise, muscle activity and tissue oxygenation were measured from the biceps brachii. In experiment 2, another eight healthy men completed 6 weeks of elbow flexion training with BFR and FBF. The number of repetitions to failure at submaximal load (Rmax), the estimated time for peak torque output to decay by 50% during repetitive maximum voluntary contractions (half-time), one-repetition maximum, isometric strength and muscle thickness of elbow flexors were measured pre- and post-training. Blood flow restriction resulted in fewer repetitions and lower muscle tissue oxygenation at the end of exercise than FBF, while the muscle activity increased similarly to repetition failure. Blood flow restriction also resulted in a smaller post-training Rmax, which was strongly correlated with the total exercise volume over the 6 week period. Despite the smaller exercise volume, BFR resulted in similar improvements in half-time, muscle strength and thickness compared with FBF. These results suggest that the application of BFR can attenuate muscle endurance adaptations to low-load resistance training by decreasing the number of repetitions during exercise, both acutely and chronically.

Blood Flow Restriction Therapy and Its Use for Rehabilitation and Return to Sport: Physiology, Application, and Guidelines for Implementation

Blood flow restriction (BFR) is an expanding rehabilitation modality that uses a tourniquet to reduce arterial inflow and occlude venous outflow in the setting of resistance training or exercise. Initially, this technique was seen as a way to stimulate muscular development, but improved understanding of its physiologic benefits and mechanism of action has allowed for innovative clinical applications. BFR represents a way to decrease stress placed on the joints without compromising improvements in strength, whereas for postoperative, injured, or load-compromised individuals BFR represents a way to accelerate recovery and prevent atrophy. There is also growing evidence to suggest that it augments cardiovascular fitness and attenuates pain. The purpose of this review is to highlight the physiology and evidence behind the various applications of BFR, with a focus on postoperative rehabilitation. While much remains to be learned, it is clear that blood flow restriction therapy stimulates muscle hypertrophy via a synergistic response to metabolic stress and mechanical tension, with supplemental benefits on cardiovascular fitness and pain. New forms of BFR and expanding applications in postoperative patients and athletes hold promise for expedited recovery. Continued adherence to rehabilitation guidelines and exploration of BFRs physiology and various applications will help optimize its effect and prescription.

Level of Evidence

V, expert opinion.

Blood-flow-restricted exercise: Strategies for enhancing muscle adaptation and performance in the endurance-trained athlete

NEW FINDINGS

What is the topic of this review? Blood-flow-restricted (BFR) exercise represents a potential approach to augment the adaptive response to training and improve performance in endurance-trained individuals. What advances does it highlight? When combined with low-load resistance exercise, low- and moderate-intensity endurance exercise and sprint interval exercise, BFR can provide an augmented acute stimulus for angiogenesis and mitochondrial biogenesis. These augmented acute responses can translate into enhanced capillary supply and mitochondrial function, and subsequent endurance-type performance, although this might depend on the nature of the exercise stimulus. There is a requirement to clarify whether BFR training interventions can be used by high-performance endurance athletes within their structured training programme.

ABSTRACT

A key objective of the training programme for an endurance athlete is to optimize the underlying physiological determinants of performance. Training-induced adaptations are governed by physiological and metabolic stressors, which initiate transcriptional and translational signalling cascades to increase the abundance and/or function of proteins to improve physiological function. One important consideration is that training adaptations are reduced as training status increases, which is reflected at the molecular level as a blunting of the acute signalling response to exercise. This review examines blood-flow-restricted (BFR) exercise as a strategy for augmenting exercise-induced stressors and subsequent molecular signalling responses to enhance the physiological characteristics of the endurance athlete. Focus is placed on the processes of capillary growth and mitochondrial biogenesis. Recent evidence supports that BFR exercise presents an intensified training stimulus beyond that of performing the same exercise alone. We suggest that this has the potential to induce enhanced physiological adaptations, including increases in capillary supply and mitochondrial function, which can contribute to an improvement in performance of endurance exercise. There is, however, a lack of consensus regarding the potency of BFR training, which is invariably attributable to the different modes, intensities and durations of exercise and BFR methods. Further studies are needed to confirm its potential in the endurance-trained athlete.

Approaches to determining occlusion pressure for blood flow restricted exercise training: Systematic review

Low-intensity exercise with blood flow restriction (BFR) is an increasingly common method of improving muscular strength and hypertrophy, and improving aerobic fitness, in clinical and athletic populations. The aim of this systematic review was to describe common approaches to determining occlusion pressures for BFR exercise. A comprehensive literature search yielded 1389 results, of which 129 were included. Studies were predominantly randomised control trials (86.7%) with modest sample sizes (average number of 11.4 ± 6.2 participants per BFR group/s) of young adults (average age of 34.6 ± 17.9). Five different approaches for determining occlusion pressure were identified: arbitrary pressures (56.6%), percentage of limb occlusion pressure (25.6%), brachial systolic blood pressure (10.9%), perceived tightness (3.9%) and other (3%). From 2016 to 2018, the number of published papers using a percentage of limb occlusion pressure increased yearly, paralleling a decrease use of arbitrary pressures. Of the studies included in this review, the most common approach to determining occlusion pressure was using a non-individualised, arbitrary pressure. Given the safety concerns associated with arbitrary pressures, continual dissemination regarding the optimal applications of BFR for safety and efficacy is required.

Muscle oxygenation, endocrine and metabolic regulation during low-intensity endurance exercise with blood flow restriction

PURPOSE

The present study investigated the effect of endurance exercise with blood flow restriction (BFR) performed at either 25% maximal oxygen uptake (V˙O2 max) or 40% V˙O2 max) on muscle oxygenation, energy metabolism, and endocrine responses.

METHODS

Ten males were recruited in the present study. The subjects performed three trials: (1) endurance exercise at 40% V˙O2 max without BFR (NBFR40), (2) endurance exercise at 25% V˙O2 max with BFR (BFR25), and (3) endurance exercise at 40% V˙O2 max with BFR (BFR40). The exercises were performed for 15 min during which the pedaling frequency was set at 70 rpm. In BFR25 and BFR40, 2 min of pressure phase (equivalent to 160 mmHg) followed by 1 min of release phase were repeated five times (5 × 3 min) throughout 15 minutes of exercise. During exercise, muscle oxygenation and concentration of respiratory gases were measured. The blood samples were collected before exercise, immediately after 15 min of exercise, and at 15, 30, and 60 minutes after completion of exercise.

RESULTS

Deoxygenated hemoglobin (deoxy-Hb) level during exercise was significantly higher with BFR25 and BFR40 than that with NBFR40. BFR40 showed significantly higher total-hemoglobin (total-Hb) than NBFR40 during 2 min of pressure phase. Moreover, exercise-induced lactate elevation and pH reduction were significantly augmented in BFR40, with concomitant increase in serum cortisol concentration after exercise. Carbohydrate (CHO) oxidation was significantly higher with BFR40 than that with NBFR40 and BFR25, whereas fat oxidation was lower with BFR40.

CONCLUSION

Deoxy-Hb and total Hb levels were significantly increased during 15 min of pedaling exercise in BFR25 and BFR40, indicating augmented local hypoxia and blood volume (blood perfusion) in the muscle. Moreover, low-and moderate-intensity exercise with BFR facilitated CHO oxidation.

Training with blood flow restriction increases femoral artery diameter and thigh oxygen delivery during knee-extensor exercise in recreationally trained men

KEY POINTS

Endurance-type training with blood flow restriction (BFR) increases maximum oxygen uptake ( V ̇ O 2 max ) and exercise endurance of humans. However, the physiological mechanisms behind this phenomenon remain uncertain. In the present study, we show that BFR-interval training reduces the peripheral resistance to oxygen transport during dynamic, submaximal exercise in recreationally-trained men, mainly by increasing convective oxygen delivery to contracting muscles. Accordingly, BFR-training increased oxygen uptake by, and concomitantly reduced net lactate release from, the contracting muscles during relative-intensity-matched exercise, at the same time as invoking a similar increase in diffusional oxygen conductance compared to the training control. Only BFR-training increased resting femoral artery diameter, whereas increases in oxygen transport and uptake were dissociated from changes in the skeletal muscle content of mitochondrial electron-transport proteins. Thus, physically trained men benefit from BFR-interval training by increasing leg convective oxygen transport and reducing lactate release, thereby improving the potential for increasing the percentage of V ̇ O 2 max that can be sustained throughout exercise.

ABSTRACT

In the present study, we investigated the effect of training with blood flow restriction (BFR) on thigh oxygen transport and uptake, and lactate release, during exercise. Ten recreationally-trained men (50 ± 5 mL kg^-1  min^-1 ) completed 6 weeks of interval cycling with one leg under BFR (BFR-leg; pressure: ∼180 mmHg) and the other leg without BFR (CON-leg). Before and after the training intervention (INT), thigh oxygen delivery, extraction, uptake, diffusion capacity and lactate release were determined during knee-extensor exercise at 25% incremental peak power output (iPPO) (Ex1), followed by exercise to exhaustion at 90% pre-training iPPO (Ex2), by measurement of femoral-artery blood flow and femoral-arterial and -venous blood sampling. A muscle biopsy was obtained from legs before and after INT to determine mitochondrial electron-transport protein content. Femoral-artery diameter was also measured. In the BFR-leg, after INT, oxygen delivery and uptake were higher, and net lactate release was lower, during Ex1 (vs. CON-leg; P < 0.05), with an 11% larger increase in workload (vs. CON-leg; P < 0.05). During Ex2, after INT, oxygen delivery was higher, and oxygen extraction was lower, in the BFR-leg compared to the CON-leg (P < 0.05), resulting in an unaltered oxygen uptake (vs. CON-leg; P > 0.05). In the CON-leg, at both intensities, oxygen delivery, extraction, uptake and lactate release remained unchanged (P > 0.05). Resting femoral artery diameter increased with INT only in the BFR-leg (∼4%; P < 0.05). Oxygen diffusion capacity was similarly raised in legs (P < 0.05). Mitochondrial protein content remained unchanged in legs (P > 0.05). Thus, BFR-interval training enhances oxygen utilization by, and lowers lactate release from, submaximally-exercising muscles of recreationally-trained men mainly by increasing leg convective oxygen transport.

Blood Flow-restricted Exercise Does Not Induce a Cross-Transfer of Effect: A Randomized Controlled Trial

Supplemental digital content is available in the text.

Purpose

The goal of this trial was to determine whether low-load blood flow–restricted (BFR) exercise of appendicular muscles induces a cross-transfer of effect to the trunk extensor (TE) muscles, such that low-load TE exercise would enhance TE size and function to a greater extent than standard low-load exercise in people with recurrent low back pain (LBP). We also investigated the direct effects of BFR exercise in the appendicular muscles.

Methods

Thirty-two adults with recurrent, nonspecific LBP were randomized into two groups: Appendicular BFR exercise (BFR exercise) or control exercise (CON exercise). All participants trained (two times per week) for 10 wk, with a 12-wk follow-up. Participants performed three sets of leg extension (LE), plantar flexion (PF), and elbow flexion (EF) exercises followed by low-load TE exercise without BFR. Outcome measures included magnetic resonance imaging–derived muscle size (quadriceps and TE), strength (LE, PF, EF, and TE), and endurance (LE and TE).

Results

There was no evidence for a cross-transfer of effect to the TE. There was also no statistically significant enhancement of limb skeletal muscle size or function of BFR relative to CON exercise at any time point; though, moderate effect sizes for BFR exercise were observed for enhanced muscle size and strength in the leg extensors.

Conclusions

Low-load BFR exercise of the appendicular muscles did not result in a cross-transfer of effect to the TE musculature. There was also no significant benefit of low-load BFR exercise on the appendicular muscle size and function, suggesting no benefit from low-load BFR exercise in adults with recurrent, nonspecific LBP.

Cycling with blood flow restriction improves performance and muscle K+ regulation and alters the effect of anti-oxidant infusion in humans

KEY POINTS

Training with blood flow restriction (BFR) is a well-recognized strategy for promoting muscle hypertrophy and strength. However, its potential to enhance muscle function during sustained, intense exercise remains largely unexplored. In the present study, we report that interval training with BFR augments improvements in performance and reduces net K⁺ release from contracting muscles during high-intensity exercise in active men. A better K⁺ regulation after BFR-training is associated with an elevated blood flow to exercising muscles and altered muscle anti-oxidant function, as indicated by a higher reduced to oxidized glutathione (GSH:GSSG) ratio, compared to control, as well as an increased thigh net K⁺ release during intense exercise with concomitant anti-oxidant infusion. Training with BFR also invoked fibre type-specific adaptations in the abundance of Na⁺ ,K⁺ -ATPase isoforms (α₁ , β₁ , phospholemman/FXYD1). Thus, BFR-training enhances performance and K⁺ regulation during intense exercise, which may be a result of adaptations in anti-oxidant function, blood flow and Na⁺ ,K⁺ -ATPase-isoform abundance at the fibre-type level.

ABSTRACT

We examined whether blood flow restriction (BFR) augments training-induced improvements in K⁺ regulation and performance during intense exercise in men, and also whether these adaptations are associated with an altered muscle anti-oxidant function, blood flow and/or with fibre type-dependent changes in Na⁺ ,K⁺ -ATPase-isoform abundance. Ten recreationally-active men (25 ± 4 years, 49.7 ± 5.3 mL kg^-1  min^-1 ) performed 6 weeks of interval cycling, where one leg trained without BFR (control; CON-leg) and the other trained with BFR (BFR-leg, pressure: ∼180 mmHg). Before and after training, femoral arterial and venous K⁺ concentrations and artery blood flow were measured during single-leg knee-extensor exercise at 25% (Ex1) and 90% of thigh incremental peak power (Ex2) with i.v. infusion of N-acetylcysteine (NAC) or placebo (saline) and a resting muscle biopsy was collected. After training, performance increased more in BFR-leg (23%) than in CON-leg (12%, P < 0.05), whereas K⁺ release during Ex2 was attenuated only from BFR-leg (P < 0.05). The muscle GSH:GSSG ratio at rest and blood flow during exercise was higher in BFR-leg than in CON-leg after training (P < 0.05). After training, NAC increased resting muscle GSH concentration and thigh net K⁺ release during Ex2 only in BFR-leg (P < 0.05), whereas the abundance of Na⁺ ,K⁺ -ATPase-isoform α₁ in type II (51%), β₁ in type I (33%), and FXYD1 in type I (108%) and type II (60%) fibres was higher in BFR-leg than in CON-leg (P < 0.05). Thus, training with BFR elicited greater improvements in performance and reduced thigh K⁺ release during intense exercise, which were associated with adaptations in muscle anti-oxidant function, blood flow and Na⁺ ,K⁺ -ATPase-isoform abundance at the fibre-type level.

Effectiveness of blood flow restricted exercise compared with standard exercise in patients with recurrent low back pain: study protocol for a randomized controlled trial

BACKGROUND

Low back pain is a highly prevalent condition in the United States and has a staggeringly negative impact on society in terms of expenses and disability. It has previously been suggested that rehabilitation strategies for persons with recurrent low back pain should be directed to the medial back muscles as these muscles provide functional support of the lumbar region. However, many individuals with low back pain cannot safely and effectively induce trunk muscle adaptation using traditional high-load resistance exercise, and no viable low-load protocols to induce trunk extensor muscle adaptation exist. Herein, we present the study protocol for a randomized controlled trial that will investigate the "cross-transfer" of effects of a novel exercise modality, blood flow restricted exercise, on cross-sectional area (primary outcome), strength and endurance (secondary outcomes) of trunk extensor muscles, as well as the pain, disability, and rate of recurrence of low back pain (tertiary outcomes).

METHODS AND STUDY DESIGN

This is a single-blinded, single-site, randomized controlled trial. A minimum of 32 (and up to 40) subjects aged 18 to 50 years with recurrent low back pain and poor trunk extensor muscle endurance will be recruited, enrolled and randomized. After completion of baseline assessments, participants will be randomized in a 1:1 ratio to receive a 10-week resistance exercise training program with blood flow restriction (BFR exercise group) or without blood flow restriction (control exercise group). Repeat assessments will be taken immediately post intervention and at 12 weeks after the completion of the exercise program. Furthermore, once every 4 weeks during a 36-week follow-up period, participants will be asked to rate their perceived disability and back pain over the past 14 days.

DISCUSSION

This study will examine the potential for blood flow restricted exercise applied to appendicular muscles to result in a "cross-transfer" of therapeutic effect to the lumbar musculature in individuals with low back pain. The results of this study will provide important insights into the effectiveness of this novel exercise modality, which could potentially provide the foundation for a cost-effective and easy-to-implement rehabilitation strategy to induce muscle adaptation in the absence of high mechanical and compressive loading on the spine.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov (registration number: NCT02308189, date of registration: 2 December 2014).

Acute and chronic effect of sprint interval training combined with postexercise blood-flow restriction in trained individuals

This investigation assessed the efficacy of sprint interval training (SIT) combined with postexercise blood-flow restriction as a novel approach to enhance maximal aerobic physiology and performance. In study 1, a between-groups design was used to determine whether 4 weeks (2 days per week) of SIT (repeated 30 s maximal sprint cycling) combined with postexercise blood-flow restriction (BFR) enhanced maximal oxygen uptake (V̇(O2max)) and 15 km cycling time-trial performance (15 km TT) compared with SIT alone (CON) in trained individuals. The V̇(O2max) increased after BFR by 4.5% (P = 0.01) but was unchanged after CON. There was no difference in 15 km TT performance after CON or BFR. In study 2, using a repeated-measures design, participants performed an acute bout of either BFR or CON. Muscle biopsies were taken before and after exercise to examine the activation of signalling pathways regulating angiogenesis and mitochondrial biogenesis. Phosphorylation of p38MAPK(Thr180/Tyr182) increased by a similar extent after CON and BFR. There was no difference in the magnitude of increase in PGC-1α, VEGF and VEGFR-2 mRNA expression between protocols; however, HIF-1α mRNA expression increased (P = 0.04) at 3 h only after BFR. We have demonstrated the potency of combining BFR with SIT in increasing V̇(O2max) in trained individuals, but this did not translate to an enhanced exercise performance. Sprint interval training alone did not induce any observable adaptation. Although the mechanisms are not fully understood, we present preliminary evidence that BFR leads to enhanced HIF-1α-mediated cell signalling.

Effects of Cycling vs. Running Training on Endurance Performance in Preparation for Inline Speed Skating

Winter weather conditions restrict regular sport-specific endurance training in inline speed skating. As a result, this study was designed to compare the effects of cycling and running training programs on inline speed skaters' endurance performance. Sixteen (8 men, 8 women) high-level athletes (mean ± SD 24 ± 8 years) were randomly assigned to 1 of 2 groups (running and cycling). Both groups trained twice a week for 8 weeks, one group on a treadmill and the other on a cycle ergometer. Training intensity and duration was individually calculated (maximal fat oxidation: ∼52% of V[Combining Dot Above]O2peak: 500 kcal per session). Before and after the training intervention, all athletes performed an incremental specific (inline speed skating) and 1 nonspecific (cycling or running) step test according to the group affiliation. In addition to blood lactate concentration, oxygen uptake (V[Combining Dot Above]O2), ventilatory equivalent (VE/V[Combining Dot Above]O2), respiratory exchange ratio (RER), and heart rate were measured. The specific posttest revealed significantly increased absolute V[Combining Dot Above]O2peak values (2.9 ± 0.4, 3.4 ± 0.7, p = 0.01) and submaximal V[Combining Dot Above]O2 values (p ≤ 0.01). VE/V[Combining Dot Above]O2 and RER significantly decreased at maximal (46.6 ± 6.6, 38.5 ± 3.4, p = 0.005; 1.1 ± 0.03, 1.0 ± 0.04, p = 0.001) and submaximal intensities (p ≤ 0.04). None of the analysis revealed a significant group effect (p ≥ 0.15). The results indicate that both cycling vs. running exercise at ∼52% of V[Combining Dot Above]O2peak had a positive effect on the athletes' endurance performance. The increased submaximal V[Combining Dot Above]O2 values indicate a reduction in athletes' inline speed skating technique. Therefore, athletes would benefit from a focus on technique training in the subsequent period.

The effect of interval training combined with thigh cuffs pressure on maximal and submaximal exercise performance

The purpose of the study was to investigate the effect of interval training combined with a thigh cuffs pressure of +90 mmHg on maximal and submaximal cycling performance. Twenty untrained individuals were assigned either to a control (CON) or to an experimental (CUFF) training group. Both groups trained 3 days per week for 6 weeks at the same relative intensity; each training session consisted of 2-min work bout at 90% of VO(2max): 2-min active recovery bout at 50% of VO(2max). An incremental exercise test to exhaustion, a 6-min constant-power test at 80% of VO(2max) (Sub(80)) and a maximal constant-power test to exhaustion (TF(150)) were performed pre- and post-training. Despite the unchanged VO(2max), both groups significantly increased peak power output (CON: ∼12%, CUFF: ∼20%) that was accompanied by higher deoxygenation (ΔStO(2)) measured with near-infrared muscle spectroscopy. These changes were more pronounced in the CUFF group. Moreover, both groups reduced VO(2) during the Sub(80) test without concomitant changes in ΔStO(2). TF(150) was enhanced in both groups. Thus, an interval exercise training protocol under moderate restricted blood flow conditions does not provide any additive effect on maximal and submaximal cycling performance. However, it seems to induce peripheral muscular adaptations, despite the lower absolute training intensity.

Low intensity blood flow restriction training: a meta-analysis

The primary objective of this investigation was to quantitatively identify which training variables result in the greatest strength and hypertrophy outcomes with lower body low intensity training with blood flow restriction (LI-BFR). Searches were performed for published studies with certain criteria. First, the primary focus of the study must have compared the effects of low intensity endurance or resistance training alone to low intensity exercise with some form of blood flow restriction. Second, subject populations had to have similar baseline characteristics so that valid outcome measures could be made. Finally, outcome measures had to include at least one measure of muscle hypertrophy. All studies included in the analysis utilized MRI except for two which reported changes via ultrasound. The mean overall effect size (ES) for muscle strength for LI-BFR was 0.58 [95% CI: 0.40, 0.76], and 0.00 [95% CI: -0.18, 0.17] for low intensity training. The mean overall ES for muscle hypertrophy for LI-BFR training was 0.39 [95% CI: 0.35, 0.43], and -0.01 [95% CI: -0.05, 0.03] for low intensity training. Blood flow restriction resulted in significantly greater gains in strength and hypertrophy when performed with resistance training than with walking. In addition, performing LI-BFR 2-3 days per week resulted in the greatest ES compared to 4-5 days per week. Significant correlations were found between ES for strength development and weeks of duration, but not for muscle hypertrophy. This meta-analysis provides insight into the impact of different variables on muscular strength and hypertrophy to LI-BFR training.

Oxygen therapy during exercise training in chronic obstructive pulmonary disease

BACKGROUND

Exercise training within the context of pulmonary rehabilitation improves outcomes of exercise capacity, dyspnea and health-related quality of life in individuals with chronic obstructive pulmonary disease (COPD). Supplemental oxygen in comparison to placebo increases exercise capacity in patients performing single-assessment exercise tests. The addition of supplemental oxygen during exercise training may enable individuals with COPD to tolerate higher levels of activity with less exertional symptoms, ultimately improving quality of life.

OBJECTIVES

To determine how supplemental oxygen in comparison to control (compressed air or room air) during the exercise-training component of a pulmonary rehabilitation program affects exercise capacity, dyspnea and health-related quality of life in individuals with COPD.

SEARCH STRATEGY

All records in the Cochrane Airways Group Specialized Register of trials coded as 'COPD' were searched using the following terms: (oxygen* or O2*) AND (exercis* or train* or rehabilitat* or fitness* or physical* or activ* or endur* or exert* or walk* or cycle*). Searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE and CINAHL databases identified studies. The last search was carried out in June 2006.

SELECTION CRITERIA

Only randomized controlled trials (RCTs) comparing oxygen-supplemented exercise training to non-supplemented exercise training (control group) were considered for inclusion. Participants were 18 years or older, diagnosed with COPD and did not meet criteria for long-term oxygen therapy. No studies with mixed populations (pulmonary fibrosis, cystic fibrosis, etc) were included. Exercise training was greater than or equal to three weeks in duration and included a minimum of two sessions a week.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion in the review and extracted data. Weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated using a random-effects model. Missing data were requested from authors of primary studies.

MAIN RESULTS

Five RCTs met the inclusion criteria. The maximum number of studies compared in the meta-analysis was three (31 on oxygen versus 32 control participants), because all included studies did not measure the same outcomes. When two studies were pooled, statistically significant improvements of oxygen-supplemented exercise training were found in constant power exercise time, WMD 2.68 minutes (95% CI 0.07 to 5.28 minutes). Supplemental oxygen increased the average exercise time from 6 to 14 minutes; the control intervention increased average exercise time from 6 to 12 minutes. Constant power exercise end-of-test Borg score (on a scale from 1 to 10) also showed statistically significant improvements with oxygen-supplemented exercise training, WMD -1.22 units (95% CI -2.39 to -0.06). One study showed a significant improvement in the change of Borg score after the shuttle walk test, by -1.46 units (95% CI -2.72 to -0.19). There were no significant differences in maximal exercise outcomes, functional exercise outcomes (six-minute walk test), shuttle walk distance, health-related quality of life or oxygenation status. According to the GRADE system most outcomes were rated as low quality because they were limited by study quality.

AUTHORS' CONCLUSIONS

This review provides little support for oxygen supplementation during exercise training for individuals with COPD, but the evidence is very limited. Studies with larger number of participants and strong design are required to permit strong conclusions, especially for functional outcomes such as symptom alleviation, health-related quality of life and ambulation.

Human temperature regulation during cycling with moderate leg ischaemia

The effect of graded ischaemia in the legs on the regulation of body temperature during steady-state exercise was investigated in seven healthy males. It was hypothesised that graded ischaemia in the working muscles increases heat storage within the muscles, which in turn potentiates sweat secretion during exercise. Blood perfusion in the working muscles was reduced by applying a supra-atmospheric pressure (+6.6 kPa) around the legs, which reduced maximal working capacity by 29%. Each subject conducted three separate test trials comprising 30 min of steady-state cycling in a supine position. Exercise with unrestricted blood flow (Control trial) was compared to ischaemic exercise conducted at an identical relative work rate (Relative trial), as well as at an identical absolute work rate (Absolute trial); the latter corresponding to a 20% increase in relative workload. The average (SD) increases in both the rectal and oesophageal temperatures during steady-state cycling was 0.3 (0.2) degrees C and did not significantly differ between the three trials. The increase in muscle temperature was similar in the Control (2.7 (0.3) degrees C) and Absolute (2.4 (0.7) degrees C) trials, but was substantially lower (P < 0.01) in the Relative trial (1.4 (0.8) degrees C). Ischaemia potentiated (P < 0.01) sweating on the forehead in the Absolute trial (24.2 (7.3) g m(-2) min(-1)) compared to the Control trial (13.4 (6.2) g m(-2) min(-1)), concomitant with an attenuated (P < 0.05) vasodilatation in the skin during exercise. It is concluded that graded ischaemia in working muscles potentiates the exercise sweating response and attenuates vasodilatation in the skin initiated by increased core temperature, effects which may be attributed to an augmented muscle metaboreflex.

Supplemental oxygen during pulmonary rehabilitation in patients with COPD with exercise hypoxaemia

BACKGROUND

Supplemental oxygen in patients with chronic obstructive pulmonary disease (COPD) and exercise hypoxaemia improves exercise capacity and dyspnoea. However, the benefit of oxygen during pulmonary rehabilitation in these patients is still unknown.

METHODS

Twenty five patients with stable COPD (mean (SD) forced expiratory volume in one second (FEV(1)) 0.76 (0.29) l and 30.0 (9.89)% predicted, arterial oxygen tension (PaO(2)) 8.46 (1.22) kPa, arterial carbon dioxide tension (PaCO(2)) 6.32 (1.01) kPa) and significant arterial desaturation on exercise (82.0 (10.4)%) were entered onto a pulmonary rehabilitation programme. Patients were randomised to train whilst breathing oxygen (OT) (n = 13) or air (AT) (n = 12), both at 4 l/min. Assessments included exercise tolerance and associated dyspnoea using the shuttle walk test (SWT) and Borg dyspnoea score, health status, mood state, and performance during daily activities.

RESULTS

The OT group showed a significant reduction in dyspnoea after rehabilitation compared with the AT group (Borg mean difference -1.46 (95% CI -2.72 to -0.19)) but there were no differences in other outcome measures: SWT difference -23.6 m (95% CI -70.7 to 23.5), Chronic Respiratory Disease Questionnaire 3.67 (95% CI -7.70 to 15.1), Hospital Anxiety and Depression Scale 1. 73 (95% CI -2.32 to 5.78), and London Chest Activity of Daily Living Scale -2.18 (95% CI -7.15 to 2.79). At baseline oxygen significantly improved SWT (mean difference 27.3 m (95% CI 14.7 to 39.8) and dyspnoea (-0.68 (95% CI -1.05 to -0.31)) compared with placebo air.

CONCLUSIONS

This study suggests that supplemental oxygen during training does little to enhance exercise tolerance although there is a small benefit in terms of dyspnoea. Patients with severe disabling dyspnoea may find symptomatic relief with supplemental oxygen.

Hemoglobin/myoglobin desaturation during speed skating

The characteristic low "sitting" position of competitive speed skating has been shown to result in a right shifted heart rate-VO2 curve and elevated submaximal blood lactate values compared with running or cycling. This is thought to be a consequence of reduced blood flow and subsequent oxygen delivery to the exercising muscle while speed skating. Duel wavelength spectrophotometry was used to measure oxygenated and deoxygenated hemoglobin/myoglobin (OD) in the capillary bed of five muscle groups during in-line skating in upright (US) and low (LS) positions. Eight U.S. speed skaters (4 category 1) performed US and LS at 2.68 and 3.13 m.s-1 (4% grade) on a wide (2.44 m) treadmill (4 trials, 5 min each, 20 min recovery between trials). Expired gas parameters and blood lactate (LA) concentrations were determined for each trial. Hip and knee angles were measured (PEAK Motion Analysis) and were significantly different in US and LS. For similar oxygen uptake during US and LS (44.9 +/- 2.79, 45.6 +/- 3.52), heart rate and LA were significantly higher during LS (172 +/- 11 vs 179 +/- 10, 4.35 +/- 2.19 vs 8.70 +/- 3.60). Deoxygenation was significantly greater during LS than during US at both speeds and was greater at 3.13 m.s-1 (P < 0.05). OD was highly related to LA (r > 0.95) but not to whole body VO2. Blood volume change was less for LS than for US (P < 0.05). Increased deoxygenation in the capillary bed of the exercising quadriceps during LS versus US is consistent with the hypothesis that blood flow and subsequent O2 delivery is compromised in the low speed skating position.

Compromised oxygen uptake in speed skaters during treadmill in-line skating

The "sitting" posture of speed skating may result in compromised blood flow to the working muscles, thus limiting oxygen uptake. To examine this metabolic problem, male (N = 7) short track speed skaters performed running (TR), in-line skating upright (US), and in-line skating in the "sitting" position (LS) on a motor driven treadmill on randomized days. Each test consisted of four 4-min stages at 2.24, 2.68, 3.13, and 3.58 m.s-1 (5, 6, 7, and 8 mph) at 5% incline. After a brief rest, athletes performed at 4.03 m.s-1 (9 mph) with elevation increasing 1% each minute to exhaustion. Two on-ice 1000-m time trials (TT) were performed to assess the relationship between performance and laboratory measurements. Peak VO2 was lower during LS (57.2 +/- 2.7, 62.3 +/- 4.0, and 64.3 +/- 1.6; for LS, US, and TR, respectively; P < 0.05). At equivalent speeds, submaximal O2 uptake was lower for LS and blood lactate was higher (P < 0.05). LS peak VO2 (ml.kg-1.min-1) was strongly related to TT (P < 0.05). The depressed VO2 and higher blood lactate during LS may be related to decreased knee or trunk angle. Peak VO2 values during skating did not approach values during running. Evaluation of speed skaters in a sports-specific test is congruent with performance and demonstrates potential in addressing the unique physiological demands of the sport.