Aerobic Training With Blood Flow Restriction for Endurance Athletes: Potential Benefits and Considerations of Implementation

Exploring immediate cardiorespiratory responses: low-intensity blood flow restricted cycling vs. moderate-intensity traditional exercise in a randomized crossover trial

PURPOSE

Blood-flow restriction (BFR) endurance training may increase endurance performance and muscle strength similar to traditional endurance training while requiring a lower training intensity. We aimed to compare acute cardiorespiratory responses to low-intensity interval exercise under BFR with moderate-intensity traditional interval exercise (TRA).

METHODS

We conducted a randomized crossover study. The protocol involved three cycling intervals interspersed with 1 min resting periods. With a 48-h washout period, individuals performed the protocol twice in random order: once as BFR-50 (i.e., 50% incremental peak power output [IPPO] and 50% limb occlusion pressure [LOP]) and once as TRA-65 (65% IPPO without occlusion). TRA-65 intervals lasted 2 min, and time-matched BFR-50 lasted 2 min and 18 s. Respiratory parameters were collected by breath-by-breath analysis. The ratings of perceived breathing and leg exertion (RPE, 0 to 10) were assessed. Linear mixed models were used for analysis.

RESULTS

Out of the 28 participants initially enrolled in the study, 24 healthy individuals (18 males and 6 females) completed both measurements. Compared with TRA-65, BFR-50 elicited lower minute ventilation (VE, primary outcome) (-3.1 l/min [-4.4 to -1.7]), oxygen consumption (-0.22 l/min [-0.28 to -0.16]), carbon dioxide production (-0.25 l/min [-0.29 to -0.20]) and RPE breathing (-0.9 [-1.2 to -0.6]). RPE leg was significantly greater in the BFR-50 group (1.3 [1.0 to 1.7]).

CONCLUSION

BFR endurance exercise at 50% IPPO and 50% LOP resulted in lower cardiorespiratory work and perceived breathing effort compared to TRA at 65% IPPO. BFR-50 could be an attractive alternative for TRA-65, eliciting less respiratory work and perceived breathing effort while augmenting perceived leg muscle effort.

TRIAL REGISTRATION

NCT05163600; December 20, 2021.

Deciphering Blood Flow Restriction Training to Aid Lipid Lowering in Obese College Students through Untargeted Metabolomics

(1) Objective: The aim of this study was to observe the lipid-lowering effects of blood flow restriction training (BFR) combined with moderate-intensity continuous training (MICT) in obese college students by observing lipid-lowering hormones and untargeted metabolomics. (2) Methods: In this study, 14 obese college students were convened into three groups-MICT, MICT+BFR, and high-intensity interval training (HIIT)-for a crossover experiment. Blood was drawn before and after exercise for the analysis of lipolytic agents and untargeted metabolomics. The study used a paired t-test and ANOVA for statistical analyses. (3) Results: The lipolytic agent results showed that MICT+BFR was superior to the other two groups in terms of two agents (p = 0.000 and p = 0.003), namely, GH and IL-6 (difference between before and after testing: 10,986.51 ± 5601.84 and 2.42 ± 2.49, respectively), and HIIT was superior to the other two groups in terms of one agent (p = 0.000), i.e., EPI (22.81 ± 16.12). No advantage was observed for MICT. The metabolomics results showed that, compared to MICT, MICT+BFR was associated with the upregulated expression of xanthine, succinate, lactate, N-lactoylphenylalanine, citrate, ureido acid, and myristic acid after exercise, with the possibility of the involvement of the citric acid cycle, alanine, aspartic acid, glutamate metabolism, butyric acid metabolism, and the histidylate metabolism pathway. (4) Conclusions: The superior lipid-lowering effect of MICT+BFR over MICT in a group of obese college students may be due to the stronger activation of GH and IL-6 agents, with the citric acid cycle and alanine, aspartate, and glutamate metabolic pathways being associated with this type of exercise.

Effects of blood flow restriction training on physical fitness among athletes: a systematic review and meta-analysis

Blood flow restriction training (BFRT) is an effective, scientific and safe training method, but its effect on the overall quality of athletes remains unclear. The aim of this systematic review with meta-analysis was to clarify the effects of BFRT on the physical fitness among athletes. Based on the PRISMA guidelines, searches were performed in PubMed, Web of Science, SPORTDiscus, and SCOUPS, the Cochrane bias risk assessment tool was used to assess methodological quality, and RevMan 5.4 and STATA 15.0 software were used to analyze the data. A meta-analysis of 28 studies with a total sample size of 542 athletes aged 14-26 years and assessed as low risk for quality was performed. Our results revealed that the BFRT intervention had small to large improvements in the athletes' strength (ES = 0.74-1.03), power (ES = 0.46), speed (ES = 0.54), endurance (ES = 1.39-1.40), body composition (ES = 0.28-1.23), while there was no significant effect on body mass (p > 0.05). Subgroup analyses revealed that moderator variables (training duration, frequency, load, cuff pressure, and pressurization time) also had varying degrees of effect on athletes' physical fitness parameters. In conclusion, BFRT had a positive effect on the physical fitness parameters of the athletes, with significantly improved strength, power, speed, endurance and body composition, but not body mass parameters. When the training frequency ≥ 3 times/week, cuff pressure ≥ 160 mmHg, and pressurization time ≥ 10 min, the BFRT group was more favorable for the improvement of physical fitness parameters.

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.

Effect of High-Intensity Interval Exercise versus Continuous Low-Intensity Aerobic Exercise with Blood Flow Restriction on Psychophysiological Responses: A Randomized Crossover Study

This study compared the effect of continuous low-intensity aerobic exercise with blood flow restriction (LI-AE-BFR) versus high-intensity interval exercise (HIIE), matching total external mechanical work between conditions, on perceptual (exertion, pain, affective and pleasure) and physiological responses (heart rate [HR], blood lactate [BL] and muscle fatigue). Ten healthy untrained men (25.6 ± 3.78 years old; 75.02 ± 12.02 kg; 172.2 ± 6.76 cm; 24.95 ± 3.16 kg/m²) completed three visits to the laboratory. In visit 1, anthropometry, blood pressure and peak running velocity on the treadmill were measured. In visits 2 and 3, participants were randomly assigned to HIIE or LI-AE-BFR, both in treadmill. HIIE consisted of 10 one-minute stimuli at 80% of peak running velocity interspersed with one-minute of passive recovery. LI-AE-BFR consisted of 20-minutes of continuous walking at 40% of peak running velocity with bilateral cuffs inflated to 50% of arterial occlusion pressure. BL and maximum isometric voluntary contraction (MIVC - fatigue measure) were measured pre- and immediately post-exercise. HR, rating of perceived exertion (RPE), and rating of perceived pain (RPP) were recorded after each stimulus in HIIE and every two minutes in LI-AE-BFR. Affective response to the session, pleasure, and future intention to exercise (FIE) were assessed 10 minutes after the intervention ended. Increases in BL concentrations were greater in HIIE (p = 0.028; r = 0.51). No effects time or condition were reported for MIVC. HR was higher in HIIE at all analyzed time points (p < 0.001; d = 3.1 to 5.2). RPE did not differ between conditions (p > 0.05), while average session RPP was higher in LI-AE-BFR (p = 0.036; r = 0.46). Affective positive response (p = 0.019; d = 0.9) and FIE (p = 0.013; d = 0.97) were significantly higher in HIIE. Therefore, HIIE elicited higher physiological stress, positive affective response, and intention to engage in future exercise bouts compared to LI-AE-BFR.

Update on Current Concepts of Blood Flow Restriction in the Perioperative Period of Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament tears or ruptures are common orthopedic injuries. Anterior cruciate ligament reconstruction (ACLR) is an orthopedic procedure allowing for earlier return to sports, improved maintenance of lifestyle demands, and restored knee stability and kinematics. A perioperative rehabilitative adjunct recently gaining interest is blood flow restriction (BFR), a method in which temporary restriction of blood flow to a chosen extremity is introduced and can be used as early as a few days postoperative. There has been increasing investigation and recent literature regarding BFR. This review synthesizes current concepts of BFR use in the ACLR perioperative period. [Orthopedics. 2023;46(6):e333-e340.].

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.

Blood-Flow Restriction Is Associated With More Even Pacing During High-Intensity Cycling

PURPOSE

This study examined the influence of blood-flow restriction (BFR) on the distribution of pace, physiological demands, and perceptual responses during self-paced cycling.

METHODS

On separate days, 12 endurance cyclists/triathletes were instructed to produce the greatest average power output during 8-minute self-paced cycling trials with BFR (60% arterial occlusion pressure) or without restriction (CON). Power output and cardiorespiratory variables were measured continuously. Perceived exertion, muscular discomfort, and cuff pain were recorded every 2 minutes.

RESULTS

Linear regression analysis of the power output slope was statistically significant (ie, deviated from the intercept) for CON (2.7 [3.2] W·30 s-1; P = .009) but not for BFR (-0.1 [3.1] W·30 s-1; P = .952). Absolute power output was ∼24% (12%) lower at all time points (P < .001) during BFR compared with CON. Oxygen consumption (18% [12%]; P < .001), heart rate (7% [9%]; P < .001), and perceived exertion (8% [21%]; P = .008) were reduced during BFR compared with CON, whereas muscular discomfort (25% [35%]; P = .003) was greater. Cuff pain was rated as "strong" (5.3 [1.8] au; 0-10 scale) for BFR.

CONCLUSION

Trained cyclists adopted a more even distribution of pace when BFR was applied compared with a negative distribution during CON. By presenting a unique combination of physiological and perceptual responses, BFR is a useful tool to understand how the distribution of pace is self-regulated.

Low-intensity swimming with blood flow restriction over 5 weeks increases VO2peak: A randomized controlled trial using Bayesian informative prior distribution

Peak oxygen uptake (VO₂peak) and speed at first (LT1, minimal lactate equivalent) and second lactate threshold (LT2 = LT1 +1.5 mmol·L^-1) are crucial swimming performance surrogates. The present randomized controlled study investigated the effects of blood flow restriction (BFR) during low-intensity swimming (LiT) on VO₂peak, LT1, and LT2. Eighteen male swimmers (22.7 ±3.0 yrs; 69.9 ±8.5 kg; 1.8 ±0.1 m) were either assigned to the BFR or control (noBFR) group. While BFR was applied during LiT, noBFR completed the identical LIT without BFR application. BFR of the upper limb was applied via customized pneumatic cuffs (75% of occlusion pressure: 135 ±10 mmHg; 8 cm cuff width). BFR training took place three times a week over 5 weeks (accumulated weekly net BFR training: 60 min·week^-1; occlusion per session: 2-times 10 min·session^-1) and was used exclusively at low intensities. VO₂peak, LT1, and LT2 diagnostics were employed. Bayesian credible intervals revealed notable VO₂peak improvements by +0.29 L·min^-1 kg^-1 (95% credible interval: -0.26 to +0.85 L·min^-1 kg^-1) when comparing BFR vs. noBFR. Speed at LT1 -0.01 m·s^-1 (-0.04 to +0.02 m·s^-1) and LT2 -0.01 m·s^-1 (-0.03 to +0.02 m·s^-1) did not change meaningfully when BFR was employed. Fifteen sessions of LIT swimming (macrocycle of 5 h over 5 weeks) with a weekly volume of 60 min with BFR application adds additional impact on VO₂peak improvement compared to noBFR LIT swimming. Occasional BFR applications should be considered as a promising means to improve relevant performance surrogates in trained swimmers. HighlightsLow-intensity swimming with blood flow restricted (BFR) induced superior peak oxygen consumption adaptations compared to non-restricted swimming training over a 5-week lasting training periodBFR and non-BFR swimming training-induced similar adaptations regarding swimming speed at first and second lactate thresholdIn conclusion, BFR served as a feasible, promising and beneficial complementary training stimuli to traditional swimming training regarding oxygen consumption adaptations.

Effect of Low-Intensity Aerobic Training Combined with Blood Flow Restriction on Body Composition, Physical Fitness, and Vascular Responses in Recreational Runners

This study investigated the effect of low-intensity aerobic training combined with blood flow restriction (LABFR) on body composition, physical fitness, and vascular functions in recreational runners. The participants were 30 healthy male recreational runners, randomized between the LABFR (n = 15) and control (n = 15) groups. The LABFR group performed five sets of a repeated pattern of 2 min running at 40% VO2max and 1 min passive rest, while wearing the occlusion cuff belts on the proximal end of the thigh. The frequency was three times a week for the period of eight weeks. The control group performed the identical running protocol without wearing the occlusion cuff belts. At the end of the training, the participants’ body composition (fat mass, body fat, muscle mass, and right and left thigh circumference), physical fitness (power and VO2max), and vascular responses (flow-mediated dilation (FMD), brachial ankle pulse wave velocity (baPWV), ankle brachial index (ABI), systolic blood pressure (SBP) and diastolic blood pressure (DBP)) were measured. The results showed a significant time × group interaction effect on muscle mass (F = 53.242, p = 0.001, ηp2 = 0.664) and right thigh circumference (F = 4.544, p = 0.042, ηp2 = 0.144), but no significant variation in any other factors, including fat mass, body fat, left thigh circumference, FMD, baPWV, ABI, SBP, and DBP (p > 0.05). Overall, our results suggested that eight-week LABFR exerted a positive effect on the body composition, especially muscle mass and thigh circumference, of recreational runners.

Self-Paced Cycling at the Highest Sustainable Intensity With Blood Flow Restriction Reduces External but Not Internal Training Loads

Purpose: This study compared training loads and internal:external load ratios from an aerobic interval session at the highest perceptually sustainable intensity with and without blood flow restriction (BFR). Methods: On separate days, 14 endurance cyclists/triathletes completed four 4-minute self-paced aerobic cycling intervals at their highest sustainable intensity, with and without BFR (60% of arterial occlusion pressure). Internal training load was quantified using 3 training impulses (TRIMP; Banister, Lucia, and Edwards) and sessional ratings of perceived exertion. External load was assessed using total work done (TWD). Training load ratios between all internal loads were calculated relative to TWD. Results: Lucia TRIMP was lower for the BFR compared with non-BFR session (49 [9] vs 53 [8] arbitrary units [au], P = .020, dz = −0.71). No between-conditions differences were observed for Banister TRIMP (P = .068), Edwards TRIMP (P = .072), and training load in sessional ratings of perceived exertion (P = .134). The TWD was lower for the BFR compared with non-BFR session (223 [52] vs 271 [58] kJ, P < .001, dz = −1.27). Ratios were greater for the BFR session compared with non-BFR for Lucia TRIMP:TWD (0.229 [0.056] vs 0.206 [0.056] au, P < .001, dz = 1.21), Edwards TRIMP:TWD (0.396 [0.105] vs 0.370 [0.088] au, P = .031, dz = 0.66), and training load in sessional ratings of perceived exertion:TWD (1.000 [0.266] vs 0.890 [0.275] au, P = .044, dz = 0.60), but not Banister TRIMP:TWD (P = .306). Conclusions: Practitioners should consider both internal and external loads when monitoring BFR exercise to ensure the demands are appropriately captured. These BFR-induced changes were reflected by the Lucia TRIMP:TWD and Edwards TRIMP:TWD ratio, which could be used to monitor aerobic BFR training loads. The Lucia TRIMP:TWD ratio likely represents BFR-induced changes more appropriately compared with ratios involving either Edwards or Banister TRIMP.