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Discover the benefits of Personalized Blood Flow Restriction Rehabilitation (PBFR) certification with Owens Recovery Science. Our comprehensive program is designed for healthcare professionals seeking to enhance their skills and improve patient outcomes. Join our community of PTs, OTs, ATCs, DCs, MDs, and Strength Coaches and start your journey towards PBFR certification today.

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title	Home \| Personalized Blood Flow Restriction Certification \| Owens Recovery Science
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description	Discover the benefits of Personalized Blood Flow Restriction Rehabilitation (PBFR) certification with Owens Recovery Science. Our comprehensive program is designed for healthcare professionals seeking to enhance their skills and improve patient outcomes. Join our community of PTs, OTs, ATCs, DCs, MDs, and Strength Coaches and start your journey towards PBFR certification today.
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[H1] BLOOD FLOW RESTRICTION TRAINING
[H2] THE FUTURE OF REHABILITATION
[H3] LEADERS IN PERSONALIZED BLOOD FLOW RESTRICTION EDUCATION
[H3] What is Personalized Blood Flow Restriction?
[H3] What are the Benefits of Personalized Blood Flow Restriction?
[H3] What can be Learned by taking the Personalized Blood Flow Restriction Certification Course?
[H3] Who is the Personalized Blood Flow Restriction Certification For?
[H3] UPCOMING COURSES
[H3] Latest Blog Posts
[H4] Benefits of blood flow restricted exercise include:
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[H4] Primary Deficits and Challenges\n\nStrength Impairments\n\nPatients with CAI typically exhibit reduced strength in the peroneal muscles, which are critical for lateral stability (Donovan & Hertel, 2012). This weakness often persists despite conventional rehabilitation protocols, creating a foundational deficit that contributes to ongoing instability. Traditional rehabilitation approaches frequently fail to adequately address deep muscle weakness and force production capabilities, particularly at functional speeds and in sport-specific movements (Kaminski et al., 2013). \n\nBiomechanical Challenges in Traditional Strengthening\n\nOne of the fundamental biomechanical limitations in ankle rehabilitation relates to the short lever arm of the foot and ankle complex. Unlike larger proximal joints that can accommodate substantial external loading (such as the knee or hip), the distal nature and shorter lever length of the ankle make traditional progressive resistance training particularly challenging (Donovan & Feger, 2017). The mechanical disadvantage of this anatomical arrangement significantly limits the effective loads that can be safely applied, especially for critical lateral stabilizers like the peroneal muscles. Conventional strengthening often reaches a ceiling effect where further functional gains become difficult to achieve due to these loading limitations, creating a gap between rehabilitation exercise intensity and the demands of high-velocity, sport-specific movements (Kaminski et al., 2013). This biomechanical constraint represents a significant barrier to restoring complete functional strength and power in individuals with CAI, particularly when attempting to replicate the forces encountered during cutting, landing, and other dynamic sporting movements.\n\nBalance and Proprioceptive Deficits\n\nCAI is characterized by impaired proprioception and neuromuscular control, manifesting as poor balance and position awareness (Hertel, 2008). While balance training is commonly prescribed, conventional protocols often lack the specificity and progressive challenge needed to translate improvements to dynamic, sport-specific scenarios. Static balance improvements frequently fail to transfer to dynamic athletic movements, leaving athletes vulnerable during competition (McKeon & Hertel, 2008).\n\nReturn to Play Considerations\n\nA significant limitation in current rehabilitation approaches is the lack of standardized, evidence-based criteria for return to play decisions (Clanton et al., 2012). Clinicians often rely on subjective assessments or basic functional tests that may not adequately reflect the demands of competitive sports. This gap between rehabilitation outcomes and sport demands contributes to premature returns and subsequent reinjuries (Wikstrom et al., 2013).\n\nReinjury Rates\n\nPerhaps most concerning is the high rate of recurrence\u2014up to 70% of athletes with CAI experience reinjury upon returning to sport (Anandacoomarasamy & Barnsley, 2005). This cycle of injury-rehabilitation-reinjury suggests fundamental limitations in current treatment protocols. Traditional rehabilitation often fails to address the complex interplay of mechanical instability, functional deficits, and psychological factors that contribute to reinjury risk (Hiller et al., 2011).\n\nLimitations in Current Rehabilitation Approaches\n\nCurrent rehabilitation protocols for CAI face several key limitations:\n\nInsufficient Loading Parameters: Traditional exercises often fail to provide adequate progressive overload to restore full strength and power in sport-specific movements (Lepley et al., 2018).Limited Neuromuscular Training Specificity: Many protocols emphasize basic balance exercises without progression to sport-specific neuromuscular challenges that replicate competitive demands (McKeon et al., 2014).Inadequate Addressing of Mechanical Instability: Rehabilitation frequently focuses on functional components while undertreating the structural contributors to instability (Delahunt et al., 2010).Psychological Readiness Overlooked: Fear of reinjury and lack of confidence are rarely systematically addressed, despite their significant impact on movement patterns and reinjury risk (Houston et al., 2014).Poor Integration of Sensorimotor Training: Rehabilitation often separates strength and proprioceptive training rather than integrating them to develop functional stability during complex movements (Needle et al., 2017).Limited Long-term Approaches: Most protocols focus on short-term symptom resolution rather than long-term prevention strategies, contributing to the high recurrence rates (Donovan & Hertel, 2012).\n\nBlood Flow Restriction Training: A Novel Intervention for CAI\n\nEmerging research suggests that Blood Flow Restriction (BFR) training represents a promising novel intervention that directly addresses many of the limitations in conventional CAI rehabilitation. What began as a theoretical application has evolved into an evidence-supported tool with substantial potential for ankle rehabilitation.\n\nSeveral years ago, we hypothesized that BFR could be particularly beneficial for chronic ankle instability, but at that time there were no published papers specifically examining this application (Faltus et al., 2018). What began as a theoretical model has evolved into an evidence-supported tool with substantial potential for ankle rehabilitation.\n\n\n\n\n\nBFR training offers unique advantages in addressing the complex deficits associated with CAI. As we outlined in our previous work, BFR can help overcome the biomechanical challenge of the ankle's short lever arm by enabling greater strength and hypertrophy adaptations at lower mechanical loads (typically 20-30% of maximum), effectively circumventing the \"ceiling effect\" that conventional strengthening encounters due to the ankle's mechanical disadvantage (Faltus et al., 2018). This approach creates what we've recently described as a mismatch between \"external load\" (the physical work performed during exercise) and \"internal load\" (the physiological and perceptual responses to exercise), allowing clinicians to elicit high internal training responses despite using low external loads that respect the biomechanical constraints of the ankle (Bielitzki et al., 2024). \n\nEmerging Evidence Base\n\n Seven published studies involving 184 CAI subjects demonstrate that BFR training can lead to significant improvements in lower-leg strength, balance, neuromuscular activation, range of motion, and self-reported function. These findings suggest BFR may offer a systematic approach to addressing the complex deficits associated with CAI.\n\n Key research findings highlight BFR's multifaceted benefits:\n\nEnhanced Neuromuscular Activation: Killinger et al. (2019) demonstrated significant increases in EMG activation during ankle eversion and dorsiflexion exercises with BFR, suggesting improved motor unit recruitment\u2014a critical factor in restoring dynamic stability.\n\n\n\nKillinger et al 2019\n\nSuperior Strength Development: Nagdi et al. (2024) found 67-73% strength gains in dorsiflexors and plantarflexors with BFR combined with proprioceptive training, compared to more modest improvements with proprioception alone. Patient-reported outcomes (FAAM scores) improved 24% with BFR versus 13% in controls.Intensified Neuromuscular Challenge: Burkhardt et al. (2021) revealed that BFR during balance activities creates an \"internal perturbation,\" enhancing muscle activation in the vastus lateralis and soleus while increasing perceived exertion and instability\u2014effectively challenging the sensorimotor system in ways standard training cannot achieve.\n\n \n\n\n\nBurkhardt et al 2021\n\nFatigue Resistance Training: Clark et al. (2024) demonstrated that BFR during the Star Excursion Balance Test simulates late-game fatigue, potentially training sensorimotor adaptability under challenging conditions that better reflect competitive demands.Comprehensive Functional Improvements: Multiple studies (Werasirirat & Yimlamai, 2022; Kim et al., 2023; Liu & Wang, 2024) have shown that integrating BFR with traditional rehabilitation elements produces superior outcomes in strength, hypertrophy, dynamic balance, range of motion, and patient-reported function.\n\n \n\nAddressing Rehabilitation Gaps\n\nBFR appears to address several critical limitations in traditional CAI rehabilitation:\n\nOptimized Loading: BFR enables greater strength and hypertrophy adaptations at lower mechanical loads (typically 20-30% of maximum), directly addressing the biomechanical limitation of the ankle's short lever arm that restricts effective loading in traditional rehabilitation. By creating metabolic stress and cellular swelling with reduced mechanical load, BFR circumvents the \"ceiling effect\" that conventional strengthening encounters due to the ankle's mechanical disadvantage, allowing for continued strength development without the need for potentially harmful high external loads (Patterson et al., 2019).Enhanced Neuromuscular Training: BFR creates a unique neurophysiological challenge that naturally integrates strength and proprioceptive training through what we recently published as a mismatch between \"external load\" and \"internal load\" (Bielitzki et al., 2024). In traditional ankle rehabilitation, static balance exercises represent a relatively low external load (the physical work performed during exercise), but when combined with BFR, they generate significantly higher internal load (the physiological and perceptual responses to exercise). Our research has shown that BFR during balance activities creates an \"internal perturbation\" that substantially increases muscle activation in the vastus lateralis and soleus while simultaneously increasing perceived exertion and instability (Burkhardt et al., 2021). This neurophysiological challenge cannot be achieved with standard training, as applying BFR effectively transforms low external load balance exercises into high internal load neuromuscular training. This approach is particularly valuable for ankle rehabilitation, given the biomechanical limitation of the ankle's short lever arm, which restricts the application of progressive external loads. By focusing on manipulating internal load through BFR rather than increasing mechanically limited external loads, clinicians can more effectively challenge the sensorimotor system while maintaining safe mechanical stress on healing tissues.Integrated Sensorimotor Challenge: BFR naturally combines strength and proprioceptive training by creating what neuroscientists call \"afferent-efferent coupling.\" During BFR balance activities, the metabolite accumulation stimulates type III and IV afferent fibers, which simultaneously increases the central nervous system's activation of motor pathways (Burkhardt et al., 2021). This neurophysiological mechanism creates a dual challenge: the muscles must work harder (increased efferent output) while the brain receives altered sensory information (modified afferent input).In simpler terms, BFR balance exercises require the brain to maintain stability while receiving unusually challenging sensory signals and commanding muscles that are experiencing accelerated fatigue. This is particularly valuable because traditional balance training often separates strength from proprioception, while BFR seamlessly integrates them in a single exercise. The proprioceptive system learns to maintain stability despite growing muscle fatigue \u2013 precisely the challenge athletes face in late-game situations when ankle injuries commonly occur.This integrated sensorimotor approach addresses a fundamental limitation in traditional CAI rehabilitation, where exercises typically target either strength OR balance in isolation. Research shows that BFR during simple balance tasks produces similar neuromuscular recruitment patterns to those seen during complex, high-load functional movements (Bielitzki et al., 2023), allowing clinicians to train functional stability with less mechanical stress on healing tissues. The end result is a more efficient neuromuscular system that can maintain ankle stability even as muscles fatigue throughout athletic competition.Functional Performance Transfer: The improvements in patient-reported outcomes suggest that BFR-induced adaptations translate effectively to real-world functional performance, bridging the critical gap between clinical measures and meaningful patient experience.When examining the research, we see that patients with CAI who undergo BFR training report significantly greater improvements in self-perceived function compared to those in conventional training groups. For example, Nagdi et al. (2024) documented a 24% improvement in Foot and Ankle Ability Measure (FAAM) scores with BFR versus only 13% with standard proprioceptive training. These results are particularly meaningful because they reflect the patient's own assessment of how their ankle functions during daily activities and sport-specific movements.From a clinical perspective, these enhanced patient-reported outcomes provide several significant advantages. First, they serve as a powerful motivational tool, as patients who perceive tangible improvements in function tend to demonstrate greater adherence to rehabilitation programs. When patients can feel the difference in their ankle stability during basketball-specific movements like cutting, pivoting, and landing, they're more likely to maintain their therapeutic exercise regimen.Second, improved self-reported function correlates strongly with psychological readiness to return to sport\u2014a critical but often overlooked component of successful rehabilitation. Athletes with CAI frequently develop fear-avoidance behaviors and decreased confidence in their ankle, which can persist even after objective measures have normalized. The robust improvements in patient-perceived function with BFR training may help restore this confidence more effectively than traditional approaches.Third, these outcomes allow clinicians to better monitor rehabilitation progress from the patient's perspective. By tracking tools like the FAAM, Cumberland Ankle Instability Tool (CAIT), or Identification of Functional Ankle Instability (IdFAI), therapists can quantify subjective improvements and adjust treatment plans accordingly. This patient-centered approach ensures that rehabilitation addresses the functional limitations that matter most to the individual athlete, rather than focusing solely on clinical measures that may not translate to performance.For basketball players specifically, the transfer to functional performance often means they can return to sport with greater confidence in their ankle's stability during high-demand movements like defensive slides, rebounding, and jump landings. This functional confidence is invaluable in preventing the hesitancy and altered movement patterns that often lead to reinjury or compensatory injuries elsewhere in the kinetic chain.By generating improvements that patients can feel and measure in their daily lives and sport performance, BFR training helps close the often-frustrating gap between clinical recovery and functional return to sport that has traditionally challenged CAI rehabilitation.\n\nConclusion\n\nWhile research on long-term outcomes and re-injury rates is still developing, the current evidence base strongly suggests that BFR represents a valuable, evidence-informed tool that can be strategically integrated into comprehensive CAI rehabilitation protocols. For clinicians seeking to overcome the limitations of traditional approaches, BFR offers a systematic method to enhance strength, balance, and functional outcomes for individuals struggling with chronic ankle instability.\n\n By Johnny Owens, MPT\n\nReferences\n\nAnandacoomarasamy, A., & Barnsley, L. (2005). Long term outcomes of inversion ankle injuries. British Journal of Sports Medicine, 39(3), e14.\n\nBielitzki, R., Behrens, M., Behrendt, T., Franz, A., Centner, C., Hughes, L., Patterson, S. D., Owens, J., Behringer, M., & Schega, L. (2024). The discrepancy between external and internal load\/intensity during blood flow restriction exercise: Understanding blood flow restriction pressure as modulating factor. Sports Medicine - Open, 10(95), 1-11.\n\nBurkhardt, E., Akins, J., Valenzuela, K., McGrath, M., & Johnson, S. (2021). Effects of blood flow restriction on dynamic balance: A crossover study. Journal of Sport Rehabilitation, 30(5), 735-742.\n\nClark, B.C., Ford, K.R., Uhl, T.L., & Johnson, B.T. (2024). Blood flow restriction during the Star Excursion Balance Test affects performance and perceived stability. Physical Therapy in Sport.\n\nClanton, T. O., Matheny, L. M., Jarvis, H. C., & Jeronimus, A. B. (2012). Return to play in athletes following ankle injuries. Sports Health, 4(6), 471-474.\n\nDelahunt, E., Coughlan, G. F., Caulfield, B., Nightingale, E. J., Lin, C. W., & Hiller, C. E. (2010). Inclusion criteria when investigating insufficiencies in chronic ankle instability. Medicine and Science in Sports and Exercise, 42(11), 2106-2121.\n\nDonovan, L., & Feger, M. A. (2017). Relationship between ankle frontal plane kinematics during different functional tasks. Gait & Posture, 54, 214-220. doi: 10.1016\/j.gaitpost.2017.03.017\n\nDonovan, L., & Hertel, J. (2012). A new paradigm for rehabilitation of patients with chronic ankle instability. Physician and Sportsmedicine, 40(4), 41-51.\n\nDrakos, M. C., Domb, B., Starkey, C., Callahan, L., & Allen, A. A. (2010). Injury in the National Basketball Association: a 17-year overview. Sports Health, 2(4), 284-290.\n\nFaltus, J., Owens, J., & Hedt, C. (2018). Theoretical applications of blood flow restriction training in managing chronic ankle instability in the basketball athlete. International Journal of Sports Physical Therapy, 13(3), 552-560. doi: 10.26603\/ijspt20180552\n\nGribble, P. A., Bleakley, C. M., Caulfield, B. M., Docherty, C. L., Fourchet, F., Fong, D. T., ... & Delahunt, E. (2016). Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), 1496-1505.\n\nHertel, J. (2008). Sensorimotor deficits with ankle sprains and chronic ankle instability. Clinics in Sports Medicine, 27(3), 353-370.\n\nHiller, C. E., Kilbreath, S. L., & Refshauge, K. M. (2011). Chronic ankle instability: evolution of the model. Journal of Athletic Training, 46(2), 133-141.\n\nHouston, M. N., Van Lunen, B. L., & Hoch, M. C. (2014). Health-related quality of life in individuals with chronic ankle instability. Journal of Athletic Training, 49(6), 758-763.\n\nHughes, L., Paton, B., Rosenblatt, B., Gissane, C., & Patterson, S. D. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal of Sports Medicine, 51(13), 1003-1011.\n\nKaminski, T. W., Hertel, J., Amendola, N., Docherty, C. L., Dolan, M. G., Hopkins, J. T., ... & Richie, D. (2013). National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. Journal of Athletic Training, 48(4), 528-545.\n\nKillinger, B., Lauver, J. D., Calvert, L., & Donovan, L. (2019). Blood flow restriction increases muscle activation during submaximal exercise in individuals with chronic ankle instability. Journal of Electromyography and Kinesiology, 45, 11-17.\n\nKim, S. J., Cho, J. H., & Kim, S. H. (2023). Effects of blood flow restriction training combined with active joint mobilization on dynamic balance and muscle activation in patients with chronic ankle instability. Journal of Back and Musculoskeletal Rehabilitation, 36(1), 187-196.\n\nLepley, L. K., Davi, S. M., Burland, J. P., & Lepley, A. S. (2018). Importance of muscle strength in the management of chronic ankle instability. Foot & Ankle Specialist, 11(2), 175-181. \n\nLiu, C., & Wang, X. (2024). Effects of blood flow restriction combined with instrument-assisted soft tissue mobilization and exercise on chronic ankle instability: A randomized controlled trial. Journal of Sport Rehabilitation.\n\nMcKeon, P. O., & Hertel, J. (2008). Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? Journal of Athletic Training, 43(3), 305-315.\n\nMcKeon, P. O., Ingersoll, C. D., Kerrigan, D. C., Saliba, E., Bennett, B. C., & Hertel, J. (2014). Balance training improves function and postural control in those with chronic ankle instability. Medicine & Science in Sports & Exercise, 46(8), 1559-1567.\n\nNagdi, S. A., Gad, A. M., & Saleh, A. K. (2024). Effect of blood flow restriction on ankle proprioception in athletes with chronic ankle instability. Journal of Bodywork and Movement Therapies, 37, 101-109.\n\nNeedle, A. R., Kaminski, T. W., Baumeister, J., Higginson, J. S., Farquhar, W. B., & Swanik, C. B. (2017). The relationship between joint stiffness and muscle activity in unstable ankles and copers. Journal of Sport Rehabilitation, 26(1), 15-25.\n\nPatterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., & Owens, J. (2019). Blood flow restriction exercise: Considerations of methodology, application, and safety. Frontiers in Physiology, 10, 533.\n\nWerasirirat, P., & Yimlamai, T. (2022). Effects of blood flow restriction training on muscle strength, hypertrophy, and functional performance in patients with chronic ankle instability. Physical Therapy in Sport, 56, 204-211.\n\nWikstrom, E. A., Hubbard-Turner, T., & McKeon, P. O. (2013). Understanding and treating lateral ankle sprains and their consequences. Sports Medicine, 43(6), 385-393.\n","words":0,"datetime":"2025-05-22T14:49:42-07:00","timer":5336,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/chronic-ankle-instability-rehabilitation-challenges-and-the-promising-role-of-bfr","id":"blog\/chronic-ankle-instability-rehabilitation-challenges-and-the-promising-role-of-bfr","aria":"Read more about ","genrelink":"","authorlink":"johnny-owens-mpt"},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health\/image\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health\/image\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health-th.jpg","sq":"cms-data\/blog\/blog\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health\/image\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"BLOOD FLOW RESTRICTION TRAINING HEADS TO SPACE: HOW THE DELFI PTS IS POWERING ASTRONAUT HEALTH","permalink":"-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health","timestamp":1745262138,"summary":"Blood Flow Restriction Training Heads to Space: How the Delfi PTS is Powering Astronaut Health\n\nBy Owens Recovery ScienceApril 2025\n\n\n\nThis isn\u2019t just about space\u2014it\u2019s about pushing the edge of human performance and resilience, wherever the human body goes.\n\n\n\nFrom Rehab Rooms to the Final Frontier\n\nAs humanity prepares for deep-space missions to the Moon, Mars, and beyond, one challenge looms large: how do we preserve muscle, bone, and cardiovascular function in the weightlessness of space?\n\nEnter: Blood Flow Restriction (BFR) Training.\n\nDeveloped and clinically applied here on Earth, BFR is now going orbital\u2014thanks to the groundbreaking efforts of Delfi Medical Innovations, Owens Recovery Science, and visionary researchers like Dr. Luke Hughes of Northumbria University. What began as a tool to help ACL patients walk sooner and athletes train harder is now a legitimate part of NASA and SpaceX's astronaut countermeasure playbook.\n\n\n\nBFR in Microgravity: The Fram2 Mission\n\nThe SpaceX Fram2 mission was a landmark: for the first time, astronauts integrated active BFR training into their in-orbit routines. The Delfi Personalized Tourniquet System (PTS) played a starring role, regulating occlusion pressure in real time\u2014even in the zero-gravity environment of a spacecraft.\n\n\"The same system trusted by over 15,000 clinicians on Earth is now helping keep astronauts strong in space.\"\n\nThe BFR protocol onboard Fram2 included low-load resistance training using the Delfi PTS, which automatically adjusted pressure to match the user\u2019s physiological needs. This wasn\u2019t theoretical\u2014this was precision tourniquet science applied at 17,500 miles per hour.\n\n\n\nFig 1: The NASA \u201cCuff n Buff\u201d & \u201cBlack Freaking Magic\u201d Delfi PTS for BFR\n\n\n\nEarth-Born Science, Space-Tested Impact\n\nIf you know us, you know BFR isn't new. It's trusted in:\n\nOrthopedic Rehab: Mitigating atrophy post-ACL, TKA, and more.Geriatric Care: Promoting strength gains in the elderly\u2014safely.Athletics: Used by professional teams across the NFL, MLB, NHL, and more.\n\nBut now, it\u2019s being validated in the harshest environment known to man\u2014space.\n\n\u201cAstronauts lose up to 20% of their muscle and 2% of their bone mass in just one month in microgravity. Sound familiar to post-op rehab?\u201d\n\nJust like your patients recovering from surgery, astronauts in space face rapid degeneration. But with BFR\u2014particularly when personalized and autoregulated via Delfi's PTS\u2014they can fight back.\n\n\n\nFig 2: Early use of BFR at NASA rehab with Gen 1 Delfi PTS\u2014proof they\u2019ve been in the game for years.\n\n\n\nWhat This Means for the Future\n\nThe implications of successful BFR use in microgravity are enormous:\n\n\u2705 Mars Missions: Compact and effective\u2014ideal for long-duration flights.\u2705 Space Habitats: Daily BFR may become as routine as brushing your teeth.\u2705 Earth-Based Rehab: Insights from space can enhance protocols back home.\n\n\n\nFinal Word\n\nWe\u2019re proud to see the Delfi PTS system, the same one we use with our patients and athletes every day, helping write the next chapter of space medicine. From ORs to orbit, BFR is proving its value where it matters most.\n\nOwens Recovery Science is proud to be part of a team redefining recovery, training, and human capability\u2014on Earth and beyond.\n\n\n\nLearn More & Read the Science\n\nHughes, L., Hackney, K. J., & Patterson, S. D. Optimization of exercise countermeasures to spaceflight using blood flow restriction.Loenneke, J. P., et al. (2011). Potential exercise countermeasures to attenuate skeletal muscle deterioration in space. Journal of TrainologyHackney, K. J., et al. (2012). Blood flow-restricted exercise in space. Extreme Physiology & Medicine, 1(1), 12\n\n\n\nCheck out this cool video describing the mission\n","words":0,"datetime":"2025-04-21T12:02:18-07:00","timer":5223,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health","id":"blog\/-blood-flow-restriction-training-heads-to-space-how-the-delfi-pts-is-powering-astronaut-health","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training\/image\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training\/image\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training-th.jpg","sq":"cms-data\/blog\/blog\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training\/image\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"UPPER EXTREMITY CYCLE ERGOMETRY WITH BLOOD FLOW RESTRICTION TRAINING ","permalink":"upper-extremity-cycle-ergometry-with-blood-flow-restriction-training","timestamp":1690926674,"summary":"Tee\u2019d up for this round of the Owens Recovery Science blog we have a topic we\u2019ve never covered before: Upper extremity cycle ergometry. That\u2019s due in large part to the fact that there aren\u2019t many studies at all. I think this topic is interesting because it starts to expose some of the limitations of the existing literature on blood flow restriction training and why it\u2019s imperative that practitioners not only possess, but apply a basic understanding of exercise principles when using BFR.\n\nMethods Overview\n\nThe study titled, \u201cAcute physiological responses to steady\u2011state arm cycling ergometry with and without blood flow restriction\u201d comes out of Dr. Summer Cook\u2019s lab at University of New Hampshire, but is a collaboration with another long-time BFR researcher, Dr. Brendan Scott from Murdoch University.(Frechette et al., 2023) They utilized a randomized cross-over design with four different conditions to examine UE cycle ergometry combined with BFR. The conditions were as follows:\n\nHW - Steady state cycling at 60% of an individual\u2019s max power output LW - Steady state cycling at 30% of max power outputLW + BFR - Steady state cycling at 30% max with BFR @ 70% LOPBFR only - BFR at 70% of LOP\n\nDuring each condition they captured the following physiologic data:\n\nHeart Rate (HR)VO2 Peak (VO2)Blood Lactate (BL)Rating of Perceived Exertion (RPE)Borg 6-20 scale (during)Local UE rating q 2 minutesWhole body rating q 2 minutesRPE 1-10 scale (session)Upon completion of session\n\nUpon each visit to the lab individuals cycled and\/or had BFR applied continuously for 15 minutes at the above described workloads and pressures. I suspect many of you after seeing the study design have some thoughts in terms of what they will find. You might also have some questions regarding the choice of 70% LOP as the pressure used. Following I\u2019ll share my initial thoughts and then my thoughts after having time to ponder a bit.\n\nWhy'd they choose that pressure?\n\nThe pressure choice definitely puzzled me, and the authors did not provide much rationale for their selection. I expected they\u2019d use pressures more in-line with the methodology paper that Dr. Scott was a contributing author to, but then I recalled, that paper didn\u2019t differentiate between upper and lower extremity recommendations. (Patterson et al., 2019) It merely suggested that individualized pressures be used and a range of 40-80% of LOP be utilized. \n\nWe typically recommend 40-50% LOP for UE exercise which we base off a study out of Dr. Jeremy Loenneke\u2019s lab that indicated 40% LOP was just as effective as 90% blood-flow restriction. (Counts et al., 2016) They examined different pressures in 10% increments with 40 and 90 being the lower and upper bounds. Then of course there\u2019s the more recent paper out of Houston Methodist indicating 50% LOP is the optimal pressure for shoulder exercise. (Roehl et al., 2023) Up until this study no one had even used an individualized pressure in an upper extremity cycling task, so it seemed logical to me they\u2019d target a lower magnitude pressure much like has been used in resistance exercise trials. But, as I read the introduction to this paper it pointed me to a potential reason for their use of a higher pressure. The authors first note that \u201cphysiological responses to exercise may differ between the arms and legs.\u201d Specifically, \u201c...larger increases in blood flow can be expected in the arms\u2026due to lower oxygen extraction in the muscles of the arms.\u201d They also cite three recent studies examining blood volume responses to BFR upper and lower body cycling which \u201c...increases\u2026with the arms being more responsive than the legs\u2026\u201d The final piece here I think is the fact that it has previously been shown that higher pressures in the UE\u2019s (80% LOP) elicit greater vascular conductance than lower pressures (40% LOP). (Mouser et al., 2019) So given the ultimate goal of their study was to evaluate how submaximal upper extremity cycle ergometry may \u201caugment acute physiological and perceptual responses which underpin improvements in fitness, and how these demands compare to traditional higher-workload exercise\u201d, the choice of a higher pressure makes some sense given our existing knowledge.\n\nWhat did they find?\n\nThe authors hypothesized \u201cthat BFR alone would be insufficient to augment these physiological and perceptual measures, whilst adding BFR to low-workload arm cycling would exaggerate the demands of exercise, though not to the same level as performing high-workload exercise.\u201d Upon reading the methods that hypothesis sounded likely to be true. It\u2019s essentially what we seem to know about blood flow restricted exercise on the whole; the addition of BFR will make low load resistance training more intense and fatiguing than the low intensity exercise without BFR. Interestingly, what the authors found was that both heart rate (HR) and blood lactate (BL) responses to the 30% workload were unchanged by the addition of BFR for the duration of the exercise. A surprising finding no doubt, but made more puzzling by the fact that \u201csessional RPE\u2019s were similar between the HW and LW-BFR conditions and greater than the LW condition.\u201d Thus, the efficacy of adding BFR during low-workload UE aerobic exercise is questionable since it also \u201cmay not be well-tolerated by some participants.\u201d\n\n\n\nHW (60% max)LW (30% max)LW+BFR (70% LOP)BFR (70% LOP)Heart Rate* 91%\u2190 68% \u219215%VO2peak* 71%\u2190 41% \u21920Blood Lactate* 7.7 mmol\/L\u2190 3.5 mmol\/L \u21920RPE (q 2mins)* 14\u2190 10.4 \u21920\n\n* denotes significantly different from all other conditions\n\nBFR Training Knowledge Gaps (not a comprehensive assessment by any standard)\n\nI said earlier that I think this topic is interesting because it starts to expose some of the limitations of the existing literature on BFR. While UE cycling might be a less common task to add BFR to, this study helps us illustrate that merely adding the BFR cuff to a task doesn\u2019t mean that something positive for muscle is happening. For example, this study should cast serious doubts on the claims we hear from time to time that BFR is all systemic and the addition of UE BFR will somehow prevent LE atrophy <eye roll>. Elaborating on this notion a bit, consider if you will that the vast majority of resistance training with blood flow restriction studies have been conducted on the quadriceps or the biceps. Very few studies have even looked at the hamstrings, and I believe one has looked at the triceps. None of those studies were constructed in a way to elucidate optimal parameters for exercise with blood flow restriction in those muscle groups. This makes the hamstring study out of USC even more valuable since subjects required only 30% 1RM eccentrically with BFR at 80% LOP to achieve similar increases in force production to a heavy loaded cohort. (Jones et al., n.d.) The authors note in their discussion that there exist known differences in how UE\u2019s and LE\u2019s respond to exercise. Specifically they note, \u201cIt is possible that lower amounts of muscle mass, differences in type 2 muscle fiber distribution, diminished oxygen extraction possibly due to vascular properties, and heightened sensitivity\/responsiveness to oxygenation in the upper limbs compared to the lower limbs, could result in divergent physiological responses during upper limb BFR aerobic exercise.\u201d Collectively this highlights for me how important it is that we individualize load and pressure according to the parameters set forth by the Patterson methodology paper. Further, it illustrates that in order to ensure the effectiveness of our exercise prescription we must monitor effort and routinely re-assess our client\u2019s strength so that modifications can be made in a timely fashion.\n\nShould you use blood flow restriction training with UE cycle ergometry?\n\nOne final piece here, as you might be thinking, UE cycling with BFR lacks value given the fact it did not augment cardiorespiratory or metabolic responses. It\u2019s important to note that the perceptual demands of the LW+BFR were greater than LW. This could of course be merely a rating of the pressure as the authors note, but it could also be something different. If perceptual demands are in fact augmented, then there\u2019s potential to improve some fatigue resistance which of course could have value for overhead athletes and some clinical populations. Further, this was an acute study on healthy people, clinical populations certainly could respond differently; it\u2019s harder though to reason how repeated exposures might elicit something different physiologically. \n\nHave you tried UE cycling ergometry with BFR in your practice? What successes, or lack thereof, have you had? Let us know!!\n\n#EARNYOURDEFLATE\n\n\n\nReferences\n\nCounts, B. R., Dankel, S. J., Barnett, B. E., Kim, D., Mouser, J. G., Allen, K. M., Thiebaud, R. S., Abe, T., Bemben, M. G., & Loenneke, J. P. (2016). Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle & Nerve, 53(3), 438\u2013445.\n\nFrechette, M. L., Scott, B. R., Vallence, A.-M., & Cook, S. B. (2023). Acute physiological responses to steady-state arm cycling ergometry with and without blood flow restriction. European Journal of Applied Physiology, 123(4), 901\u2013909.\n\nJones, M. J., Dominguez, J. F., Macatugal, C., Coleman, K., Reed, B., & Schroeder, E. T. (n.d.). Low Load With BFR vs. High Load Without BFR Eccentric Hamstring Training Have Similar Outcomes on Muscle Adaptation. Journal of Strength and Conditioning Research \/ National Strength & Conditioning Association. http:\/\/journals.lww.com\/nsca-jscr\n\nMouser, J. G., Mattocks, K. T., Buckner, S. L., Dankel, S. J., Jessee, M. B., Bell, Z. W., Abe, T., Bentley, J. P., & Loenneke, J. P. (2019). High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training. Physiological Measurement. https:\/\/doi.org\/10.1088\/1361-6579\/ab0d2a\n\nPatterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., Abe, T., Nielsen, J. L., Libardi, C. A., Laurentino, G., Neto, G. R., Brandner, C., Martin-Hernandez, J., & Loenneke, J. (2019). Blood Flow Restriction Exercise Position Stand: Considerations of Methodology, Application, and Safety. Frontiers in Physiology, 10, 533.\n\nRoehl, T., Lambert, B. S., Ankersen, J., Hernandez, K., McCulloch, P. C., & Hedt, C. (2023). Optimal Blood Flow Restriction Occlusion Pressure for Shoulder Muscle Recruitment With Upper Extremity Exercise. The American Journal of Sports Medicine, 3635465231166959.\n","words":0,"datetime":"2023-08-01T14:51:14-07:00","timer":7364,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training","id":"blog\/upper-extremity-cycle-ergometry-with-blood-flow-restriction-training","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/blood-flow-restriction-how-low-can-you-go\/image\/blood-flow-restriction-how-low-can-you-go.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/blood-flow-restriction-how-low-can-you-go\/image\/blood-flow-restriction-how-low-can-you-go-th.jpg","sq":"cms-data\/blog\/blog\/blood-flow-restriction-how-low-can-you-go\/image\/blood-flow-restriction-how-low-can-you-go-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"Zac Dunkle, PT, DPT, OCS","title":"BLOOD FLOW RESTRICTION: HOW LOW CAN YOU GO?","permalink":"blood-flow-restriction-how-low-can-you-go","timestamp":1685999567,"summary":"\n\nOne of the huge advantages of Blood Flow Restriction (BFR) for rehab professionals is the ability to achieve similar muscle changes to heavy load training but with much lower loads. This has a clear benefit when working with someone who isn\u2019t able to tolerate higher intensity exercise. But one important question to ask is: Does BFR truly replace the importance of mechanical loading? \n\nThe short answer is \"No.\" While BFR is great for reducing the load needed to achieve fatigue and stimulate an anabolic effect, one must still achieve a session volume (weight x total reps performed) similar to that of heavy load training. And while the ability to lift light has inherent appeal, there is likely a floor beyond which you cannot continue to reduce load and expect equivalent outcomes. Let\u2019s examine how this might look at different percentages of an individual\u2019s one rep max (1RM). \n\n\n\n\n\n15% 1RM\n\n\n\nThe BFR evidence is quite limited when it comes to the investigation of loads that do not meet the standard of 20-40% 1RM set out by the methodology paper spearheaded by Dr. Stephen Patterson. (Patterson et al. 2019) On the whole, the exercise physiology literature is far more robust regarding very light loads such as 15% 1RM. Generally it would indicate that one\u2019s training status will interact strongly with the need for external load. Put simply, the more resistance trained the individual, the more load will matter. Regardless of training status, as loads dip below 30% 1RM, they seem to have a lesser effect on force production as an outcome than hypertrophy. (Schoenfeld et al. 2021)\n\nJessee et al used an 8 week training period to tease out the effect of 15% 1RM knee extensions with BFR at different pressures vs both a load matched free flow control or 70% 1RM. (Jessee et al. 2018) BFR was performed at either 40% LOP or 80% LOP. All groups performed 4 sets to failure to ensure equal effort across groups. Following 16 sessions, muscle thickness increased in all groups with no difference between groups. However, only the 70% 1RM group demonstrated a significant increase in 1RM strength. \n\nSimilarly, Buckner et al used the same methods to examine the effects of 16 sessions of biceps curls. (Buckner et al. 2020) Since it\u2019s generally accepted that higher relative pressures are necessary in the lower extremities, this allows for the examination of whether or not the magnitude of pressure might augment the effect of the very light load. Following the eight-week training period, each condition increased muscle thickness, however the 70% load condition produced significantly greater changes in muscle thickness. When looking at changes in strength, only the 70% condition had an increase in 1RM strength. Given the suboptimal muscle changes with very low loads the authors concluded, \"Blood flow restriction [even with high pressures] cannot be used to compensate for an insufficient external load.\"\n\nThe research tends to suggest that very low loads create minimal or at least a suboptimal muscle response and we shouldn\u2019t train with them for an extended period. However, this doesn\u2019t mean there isn\u2019t a benefit to using them in rehab. Clinically, this can be beneficial when trying to progress someone from a passive protocol into resistance exercise or when acclimating the individual to BFR. Effort (proximity to failure) is still king when it comes to muscle growth. This highlights the importance of adding exercise volume and\/or cuff pressure when mechanical loading is at its lowest. Focusing on these targets instead of an arbitrary number of reps likely gives us the best chance of ensuring progress when the load is inadequate. \n\n20% 1RM\n\nA training load set to 20% of the individuals 1RM appears to be the lower threshold to produce similar muscle adaptations to heavy load training. One of the early projects looking at the physiologic effects of low load BFR training was done by Laurentino et al. (Laurentino et al. 2012) In this project, the authors had individuals perform knee extensions for eight weeks separated into a high load condition at 80% 1RM and two low load conditions at 20% 1RM; one with BFR at 80% LOP and the other without BFR. Following sixteen sessions, the high load group and BFR group had significantly greater improvements in knee extension 1RM strength and CSA compared to the traditional low load group.\n\nMore recently Biazon et al conducted a 10 week training study comparing heavy load with and without BFR to low load with BFR. (Biazon et al. 2019) The set\/rep scheme was 80% 1RM for 3x10 for both heavy load conditions and 20% 1RM for 3x20 in the low load group. Following the 5thweek, an additional set was added to each condition. Pressure was set to 60% LOP for both BFR conditions. Following the 10 weeks of training, all groups significantly increased their 1RM compared to baseline with no difference between groups. Muscle CSA measurements also significantly increased for all conditions with no difference between groups. The results from this paper indicate a load of 20% with BFR is just as effective as training at heavy load and there seems to be no additional benefit to performing BFR with heavy load. \n\nCollectively, and in agreement with Patterson 2019, these papers indicate a load of 20% 1RM should be the targeted entry point to BFR resistance exercise with a tourniquet pressure in the lower extremity that is relatively high, between 60-80% LOP. \n\n30% 1RM\n\nA training load of 30% 1RM with BFR has generally been considered the preferred training load to produce similar muscle changes to heavy load training. For instance, in an 8 week study Kim et al separated individuals into three conditions. (Kim et al. 2017) There was a training group who completed 24 sessions and had each arm randomized to either 75% 1RM biceps curls or 30% 1RM biceps curls with BFR at 50% LOP. The training conditions were compared to a non exercising control group. Following the training period, there were significant increases in muscle thickness for both training conditions with no difference between conditions. Additionally, 1RM strength significantly increased in both training conditions. \n\nIn a more clinically relevant example, Hughes et al enrolled individuals coming off a recent ACLr into performing a structured PT program with the addition of a leg press exercise. (Hughes et al. 2019) The two training conditions for the leg press were 30% 1RM with BFR at 80% LOP or 70% 1RM to target traditional heavy load. Following the 8-week training period, both conditions had a significant increase in muscle fiber thickness and pennation angle as well as 10RM leg press strength, with no difference between groups. In another clinical example, Dr. Noyes et al looked at the effect of BFR amongst those with chronic strength loss following a variety of knee surgeries.(Noyes et al. 2021) On average, subjects had a 43% deficit in quadriceps strength at 8 months post-op and had completed 5 months of structured PT. Individuals initially performed 9 sessions of BFR resistance exercise at 25-35% 1RM with pressures ranging from 60-80% LOP. The authors noted higher pressures were used with lower loads and a lower pressure if the individual was able to perform the exercises in the higher load range. Following the initial 9 sessions, the individuals were encouraged to perform an additional 9 sessions. After 9 sessions, 69% of the patients had a 10% or greater increase in MVIC (isometric strength). Following 18 sessions, 86% of the patients had a 20% or greater increase in quadriceps MVIC. \n\n30% of an individual\u2019s 1 RM has been one of the most common target intensities for BFR studies. It appears to be an adequate training load to create a similar response to traditional heavy load training but may still require a fairly high cuff pressure like 60-80% LOP in the LE to ensure that effect. \n\n40% 1RM or more\n\nRecently Alan Kacin\u2019s group did a follow up to their initial ACL prehab paper where they took 18 individuals who were scheduled to have an ACLr and divided them into a BFR group or a sham-BFR group.(Kacin et al. 2021) Over a 3-week period, individuals performed 9 sessions of knee extensions and hamstring curls loaded to ~40% 1RM for 4 sets to failure. The BFR group used a pressure of 150mmHg with a wide tourniquet (13.5 cm). Following the prehab period, the BFR group significantly improved isokinetic strength at 60 degrees\/sec by 14% and improved quadriceps CSA by 4.9% while the sham group had no change from baseline. \n\nLixandr\u00e3o et al conducted a longer-term knee extension study looking at the effect of two different loads at two different percentages of LOP and compared those to a high load group exercising at 80% 1RM. (Lixandr\u00e3o et al. 2015) The BFR groups trained at 20% and 40% 1RM with 40% LOP and 80% LOP for each loading condition. The set\/rep scheme was 2-3 sets of 15 for the BFR conditions and 3 sets of 10 for the 80% load group (which creates significant volume differences). Following the 12-week training period, muscle CSA significantly increased in all groups except the 20% 1RM\/40% LOP group. The greatest increases came from the 40% load groups (regardless of pressure) and 80% 1RM. The results in CSA indicate when the load is low one needs to keep a high pressure, but as the load is increased towards a moderate load the pressure can be decreased. There were similar increases in strength amongst all BFR conditions, which were significantly lower than the change in 1RM strength in the 80% 1RM group. One should consider these results with caution as the volume of work was not close to being equated nor did the low load groups demonstrate a high amount of effort. \n\nModerate loads such as 40% 1RM with BFR can be utilized to progress exercise intensity when the individual would be unable to tolerate high intensity training. From the available data, when training at this intensity a lower pressure of 40-50% LOP could be utilized.\n\nManipulating the set\/rep scheme to produce a similar exercise volume as high load training is a great strategy. For example, 30\/15\/15\/15 with 30% 1RM, 25\/15\/15 at 40% 1RM, 15\/15\/15 with 50% 1RM, and 10\/10\/10 at 75% 1RM would all produce a similar training volume (weight x reps). \n\nTakeaways\n\nBFR reduces but it doesn\u2019t replace the importance of load. Very low loads can be effectively used to improve tolerance and slow down the loss of muscle during the very acute phases of rehab (check out our blog on Anabolic Resistance or our podcast on preventing muscle atrophy for more on this). However, to achieve similar results to high load resistance training while using BFR, it looks like we need a training load of 20% 1RM or above and to use a relatively high pressure (60-80% LOP in the lower extremity or 50% LOP in the upper extremity) when at that 20% intensity. As the loading increases, the cuff pressure can likely come down. The individual\u2019s strength should continuously be monitored and the training loads adjusted\/progressed to reflect their change in strength. This can be accomplished by formally determining an individual\u2019s maximal strength or multi-repetition max every 4 weeks and progressing their working weight after the individual is able to complete the prescribed sets and reps. If we can account for these within session targets of effort, load, and cuff pressure, then we should see consistent effects from our use of BFR. \n\nReferences:\n\n1. Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., Abe, T., Nielsen, J. L., Libardi, C. A., Laurentino, G., Neto, G. R., Brandner, C., Martin-Hernandez, J., & Loenneke, J. (2019). Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety. Frontiers in Physiology, 10, 533.\n\n2. Schoenfeld, B. J., Grgic, J., Van Every, D. W., & Plotkin, D. L. (2021). Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel, Switzerland), 9(2). https:\/\/doi.org\/10.3390\/sports9020032 \n\n3. Jessee MB, Buckner SL, Mouser JG, et al. Muscle Adaptations to High-Load Training and Very Low-Load Training With and Without Blood Flow Restriction. Front Physiol. 2018;9:1448.\n\n4. Buckner SL, Jessee MB, Dankel SJ, et al. Blood flow restriction does not augment low force contractions taken to or near task failure. EJSS . 2020;20(5):650-659.\n\n5. Laurentino GC, Ugrinowitsch C, Roschel H, et al. Strength training with blood flow restriction diminishes myostatin gene expression. Med Sci Sports Exerc. 2012;44(3):406-412.\n\n6. Biazon TMPC, Ugrinowitsch C, Soligon SD, et al. The Association Between Muscle Deoxygenation and Muscle Hypertrophy to Blood Flow Restricted Training Performed at High and Low Loads. Front Physiol. 2019;10:446.\n\n7. Kim D, Loenneke JP, Ye X, et al. Low-load resistance training with low relative pressure produces muscular changes similar to high-load resistance training. Muscle Nerve. 2017;56(6):E126-E133.\n\n8. Hughes L, Rosenblatt B, Haddad F, et al. Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports Med. Published online July 12, 2019. doi:10.1007\/s40279-019-01137-2\n\n9. Noyes FR, Barber-Westin S, Sipes L. Blood Flow Restriction Training Can Improve Peak Torque Strength in Chronic Atrophic Postoperative Quadriceps and Hamstrings Muscles. Arthroscopy. 2021;0(0). doi:10.1016\/j.arthro.2021.03.040\n\n10. Cook S, Cleary C. Progression of Blood Flow Restricted Resistance Training in Older Adults at Risk of Mobility Limitations. Front Physiol. 2019;10:738.\n\n11. Kacin A, Drobni\u010d M, Mar\u0161 T, et al. Functional and Molecular Adaptations of Quadriceps and Hamstring Muscles to Blood Flow Restricted Training in Patients with ACL Rupture. Scand J Med Sci Sports. Published online April 10, 2021. doi:10.1111\/sms.13968\n\n12. Lixandr\u00e3o ME, Ugrinowitsch C, Laurentino G, et al. Effects of exercise intensity and occlusion pressure after 12 weeks of resistance training with blood-flow restriction. Eur J Appl Physiol. 2015;115(12):2471-2480.\n","words":0,"datetime":"2023-06-05T14:12:47-07:00","timer":6460,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/blood-flow-restriction-how-low-can-you-go","id":"blog\/blood-flow-restriction-how-low-can-you-go","aria":"Read more about ","genrelink":"","authorlink":"zac-dunkle-pt-dpt-ocs"},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/choosing-a-blood-flow-restriction-cuff-\/image\/choosing-a-blood-flow-restriction-cuff-.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/choosing-a-blood-flow-restriction-cuff-\/image\/choosing-a-blood-flow-restriction-cuff--th.jpg","sq":"cms-data\/blog\/blog\/choosing-a-blood-flow-restriction-cuff-\/image\/choosing-a-blood-flow-restriction-cuff--sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"CHOOSING A BLOOD FLOW RESTRICTION CUFF ","permalink":"choosing-a-blood-flow-restriction-cuff-","timestamp":1676613600,"summary":"Choosing a Blood Flow Restriction Cuff\n\nBlood flow restriction training is a relatively new and innovative method of strength training that has been gaining popularity in recent years. This technique involves using bands or cuffs to restrict blood flow to the working muscle during exercise, which can lead to increased muscle growth and strength gains. However, with so many different types of devices on the market, it can be difficult to know which one is the best fit for your needs. In this blog, we'll take a look at some of the key factors to consider when choosing the best BFR cuff for your setting.\n\nSize and Fit of BFR Cuff\n\nThe first thing to consider when choosing BFR bands is the size and fit. BFR cuffs should fit snugly on a limb without gaps at the top or bottom. They should be long enough to fully encircle the limb, while not overlapping onto itself too much. These features affect the delivery of pressure to the limb and thus affect the magnitude of pressure needed to measure limb occlusion pressure and subsequently the pressure used for the session. Some devices offer a variety of cuff sizes, others do not. The Delfi PTS for Personalized Blood Flow Restriction comes standard with three different cuff sizes so that it can be used across a broad range of limb sizes.\n\nQuality and Durability of BFR Bands\n\nIf you truly seek the best blood flow restriction bands available then quality and durability are important factors to consider. You want to choose a BFR device that is made from durable materials that will last a long time and can withstand the rigors of regular use. Look for bands that are made from high-quality materials such as nylon or rubber and have reinforced stitching to ensure they will last for a long time. Delfi has been making tourniquet systems for use in hospital operating rooms for 40 years now. Their product has stood the test of time and that's one of many reasons we at Owens Recovery Science recommend it!\n\nDetermining Pressure for Blood Flow Restriction Training\n\nUnderstanding how the device you choose to use for occlusion training determines pressure is an extremely important piece in using BFR equipment in the safest manner possible and to ensure the consistency of the method. Automated devices, hand held doppler, or manufacturer recommendations are the three most common ways that occlusion cuffs determine the pressure for treatment. Automated BFR devices like the Delfi PTS for PBFR are becoming increasingly popular as they enhance the ease of use, are free of human error and in many cases are quicker than other techniques. A good question to ask regarding automated systems is, what sort of validation has been performed on the device to ensure the pressure it provides is accurate? A hand held doppler has been found to be a valid way to measure limb occlusion pressure, but can be limited by practitioner skill, time, the need for conductance gel, and clinic noise. Finally, some manufacturers provide \"recommended settings\" for their products based off characteristics of the person it is to be used upon. At present, systolic blood pressure, limb circumference and cuff width are the three chief variables with scientific merit that contribute to the pressure needed to achieve full limb occlusion, and thus determine a treatment pressure.\n\nVersatility of Blood Flow Restriction Bands\n\nFinally, consider the versatility of the device you plan to use. Whether you will be using your cuffs for blood flow restriction rehabilitation as a physical therapist or just want to take advantage of the benefits of blood flow restriction resistance training in your own exercise routine, the best device will be the one that addresses all your needs. Some lesser known features of devices can really make the difference here. Below are some potential options you may not have considered:\n\nDoes the cuff auto-regulate pressure during exercise?If the cuff auto-regulates, how responsive is that function?How long does it take the cuff to inflate to a target pressure?How long does it take to deflate?Can you manually choose a pressure?Can you adjust pressure real time if a set pressure isn't tolerated?Does the device store the pressure so multiple exercises can be performed within a training session?\n\nThe Best Blood Flow Restriction Device...\n\nIn conclusion, to choose the best BFR training device you need some basic knowledge of the features the leg cuffs or arm cuffs you're considering possess. Blood flow restriction therapy or training is certainly an innovative training method. However, with so many different types of BFR devices on the market, it can be difficult to know which one is the best fit for you. Making the best decision starts with considering who the device will be used on, and how do the individual features of the device help that person achieve their goals in the safest and most consistent manner possible.\n\n\n\nIf you want to learn more about implementing BFR in to a rehabilitation program, consider taking one of our courses!\n","words":0,"datetime":"2023-02-16T22:00:00-08:00","timer":6439,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/choosing-a-blood-flow-restriction-cuff-","id":"blog\/choosing-a-blood-flow-restriction-cuff-","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/manipulating-blood-flow-restriction-training-bfr-parameters\/image\/manipulating-blood-flow-restriction-training-bfr-parameters.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/manipulating-blood-flow-restriction-training-bfr-parameters\/image\/manipulating-blood-flow-restriction-training-bfr-parameters-th.jpg","sq":"cms-data\/blog\/blog\/manipulating-blood-flow-restriction-training-bfr-parameters\/image\/manipulating-blood-flow-restriction-training-bfr-parameters-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"MANIPULATING BLOOD FLOW RESTRICTION TRAINING (BFR) PARAMETERS","permalink":"manipulating-blood-flow-restriction-training-bfr-parameters","timestamp":1671230578,"summary":"As more and more papers come out using a variety of parameters for blood flow restriction training or occlusion training interventions we are routinely asked if we have new protocols to share. From our perspective, any and all protocols have flaws, and oftentimes those flaws are rather large and unavoidable. Thus, we generally try to avoid them, opting instead to teach principles of exercise prescription and how to adjust those in relation to physical therapy or rehabilitation and the use of BFR. In reading a recent paper written to summarize the existing literature on blood flow restriction training with endurance exercise, a line from the paper prompted me to try and map out the many variables and criteria one should have a mastery of in order to manipulate a blood flow restricted exercise intervention in a comprehensive manner. Ferguson et al wrote, \u201cIn many respects, the permutations of intensity and duration of exercise and the application of BFR are endless.\u201d (Ferguson et al., 2021) \n\nBelow is a list of most of the variables you can manipulate for a given exercise session:\n\nPROBABLE BFR EXERCISE VARIABLES:\n\nPressure: Percentage of Limb Occlusion Pressure (LOP = the minimum pressure needed to stop arterial blood flow in a limb) Pressure Application: Continuous or IntermittentLoadTaskRep \/ set schemeEffortLoad progression \/ regression\n\nAny number of factors could play into why you might adjust the aforementioned variables with the use of BFR training. For example, perceptual responses like discomfort could be addressed via pressure reduction until tolerance increases. Another strategy to alleviate discomfort would be to deflate the cuff between sets two and three or incorporate some form of intermittent blood flow restriction. Difficulty completing the rep \/ set scheme with bfr training could be the result of the load being too heavy, or perhaps the task itself was just too complex or difficult. If the load was too heavy, try reducing the weight and see if that makes it easier to complete the reps \/ sets. If the task was just too difficult or complex, try breaking it down into smaller, more manageable pieces.\n\nIn today\u2019s Instagram world, an oft perpetuated myth is that the more complex and \u201ccool\u201d an exercise is, the more effective it is. These \u201ccircus bear exercise feats\u201d are often followed by some word salad explanation that is very confident, and in effect hypnotizes the reader into thinking the author must clearly know more than the reader regarding exercise prescription. Well, the good news is that exercise does not need to be complex in order to create changes in muscle size and strength. In fact, the more complex an exercise, the more varied the adaptations or lack thereof may be and this seems to hold true when resistance exercise is combined with a BFR cuff. A nice example of that can be found in the paper we reviewed on our most recent podcast. The authors described why they favored a single joint strength assessment over a multi-joint assessment as follows, \u201c...and single joint > multiple joint strength test. This approach was chosen in order to minimize outcome variability by favouring low exercise neuromotor difficulty (e.g. knee extension > leg press).\u201d (Gr\u00f8nfeldt et al., 2020) The more complex an exercise task, the more options there are for how to complete it. This has also been detailed very nicely in two papers from researchers at USC who showed that even to the trained eye, picking up on how someone alters their strategy to complete a task as simple as a squat is virtually impossible. (Chan & Sigward, 2019, 2020) Thus, in order to force a muscle to work hard enough to elicit a change even with low load resistance training and BFR, at minimum one must consider if there\u2019s an escape for that muscle via an alteration in strategy, and control for it by constraining the movement.\n\nEffective prescription of exercise with and without blood flow restriction requires that you have a goal for the exercises you choose. Presently, some targets for exercise with blood flow restriction that have an established evidence base are pain reduction, or increases in endurance, hypertrophy, or strength. Hughes et al have indicated that higher percentages of blood flow occlusion may play a role in the magnitude of hypoalgesia. (Hughes & Patterson, 2020) They've shown this with resistance exercise combined with BFR as well as low-intensity cycle training with restricted blood flow. (Hughes et al. 2021) Guidance for endurance, hypertrophy, and strength were nicely detailed in the 2019 methodology paper spear-headed by Stephen Patterson, PhD. (Patterson et al., 2019) Additional benefits of blood flow restriction training are of course possible, but at least one of these should comprise the reason for choosing BFR.\n\nIn addition to having a treatment and \/ or parameter target based on current evidence, inherent limitations in rehab will result in the clinician inevitably encountering scenarios where BFR may be used in a strategic fashion to progress toward more optimal parameters, or progress away from the intervention altogether. This is why we\u2019d suggest having a performance as well as a progression target to help you determine when to modify the intervention. With that in mind, simple aerobic type tasks combined with blood flow restriction can serve as a bridge to more difficult resistance training with blood flow restriction as the patient gains ROM, and the ability to complete a high volume of work. Those early visits with low level activity can be used to familiarize w\/ blood flow restriction pressure as well as with engaging fatigue at a lower intensity than will ultimately be necessary to build muscle. Early phase interventions like combining BFR w\/ NMES can also contribute in this way, but could have a place later in rehab as a finisher too.\n\nSome simple adjustments to variables can help the clinician gain buy-in from his or her patient, while exposing them gradually to an intervention. If you\u2019re like me, you probably undershoot the load initially. This can work well as an introduction to BFR though. It does however require that you be mindful of effort and progress load as soon as possible. I watch rather intently how well my patient completes their last set of 15. Did I have to encourage them, did I have to assist them, or did they finish with just some minor effort? These are questions that help me determine how to adjust their next visit. If they make it through all 75 reps 2 visits in a row, load goes up. Sometimes it is obvious you have undershot and merely adding exercise volume to get more effort on the fly is certainly an option. Then make a note to progress the load the next visit. Other times a patient might really be having a tough time with the pressure. In those cases you can of course reduce the pressure, but you could also fully deflate during the rest period (to do this with a Delfi, disconnect the hose from the cuff and cover it with your thumb...pushing deflate will force a 1 minute rest). That\u2019s just a sampling of how to think through your BFR exercise. Below you will also find a sample of a chart I made to help me think through the many variables I need to be attending to and modifying!\n\n\n\nReferences:\n\nChan, M.-S., & Sigward, S. M. (2020). Center of pressure predicts Intra-limb compensatory patterns that shift demands away from knee extensors during squatting. Journal of Biomechanics, 110008.Chan, M.-S., & Sigward, S. M. (2019). Loading Behaviors Do Not Match Loading Abilities Postanterior Cruciate Ligament Reconstruction. Medicine and Science in Sports and Exercise, 51(8), 1626\u20131634.Ferguson, R. A., Mitchell, E. A., Taylor, C. W., Bishop, D. J., & Christiansen, D. (2021). Blood-flow-restricted exercise: Strategies for enhancing muscle adaptation and performance in the endurance-trained athlete. Experimental Physiology. https:\/\/doi.org\/10.1113\/EP089280Gr\u00f8nfeldt, B. M., Lindberg Nielsen, J., Mieritz, R. M., Lund, H., & Aagaard, P. (2020). Effect of blood-flow restricted vs. heavy-load strength training on muscle strength: Systematic review and meta-analysis. Scandinavian Journal of Medicine & Science in Sports. https:\/\/doi.org\/10.1111\/sms.13632Hughes, L., & Patterson, S. D. (2020). The effect of blood flow restriction exercise on exercise-induced hypoalgesia and endogenous opioid and endocannabinoid mechanisms of pain modulation. Journal of Applied Physiology. https:\/\/doi.org\/10.1152\/japplphysiol.00768.2019Hughes, L., Grant, I., & Patterson, S. D. (2021). Aerobic exercise with blood flow restriction causes local and systemic hypoalgesia and increases circulating opioid and endocannabinoid levels. Journal of Applied Physiology. https:\/\/doi.org\/10.1152\/japplphysiol.00543.2021Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., Abe, T., Nielsen, J. L., Libardi, C. A., Laurentino, G., Neto, G. R., Brandner, C., Martin-Hernandez, J., & Loenneke, J. (2019). Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety. Frontiers in Physiology, 10, 533.\n","words":0,"datetime":"2022-12-16T14:42:58-08:00","timer":5826,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/manipulating-blood-flow-restriction-training-bfr-parameters","id":"blog\/manipulating-blood-flow-restriction-training-bfr-parameters","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/bfr-after-acl-reconstructionmore-than-just-muscle\/image\/bfr-after-acl-reconstructionmore-than-just-muscle.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/bfr-after-acl-reconstructionmore-than-just-muscle\/image\/bfr-after-acl-reconstructionmore-than-just-muscle-th.jpg","sq":"cms-data\/blog\/blog\/bfr-after-acl-reconstructionmore-than-just-muscle\/image\/bfr-after-acl-reconstructionmore-than-just-muscle-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"BFR AFTER ACL RECONSTRUCTION...MORE THAN JUST MUSCLE","permalink":"bfr-after-acl-reconstructionmore-than-just-muscle","timestamp":1666894729,"summary":"It\u2019s finally here! The article you\u2019ve all been waiting for\u2026or maybe just some of you. I know we\u2019ve been waiting for and talking about this one for a while. The crew at Houston Methodist just published a study involving BFR post ACL reconstruction. This study was a little different than the other ones we\u2019ve seen previously in that they went beyond the assessment of muscle size, muscle strength, and functional outcomes. They added the assessment of bone using a DEXA scan and the long term outcome of meeting return to sport criteria. Let's take a closer look at what they did and what they found. \n\nParticipants all underwent an ACL reconstruction with BTB autograft and were randomized into a BFR (n=17) or Routine Rehab (control, n=15) group. The intervention period started within 7 days of surgery and involved 12 weeks of progressive rehab performed twice a week. The BFR condition performed \u201cselect exercises\u201d at 80% LOP and 20% 1RM for the commonly prescribed 30\/15\/15\/15. Individual\u2019s 1RM was assessed in the uninvolved limb - Brutal!. DEXA scans were done pre-surgically and at 6 and 12 weeks post-op. Assessments of lower extremity function including single leg squat, single leg step down, Y Balance, single leg leg press, and single leg hamstring curl were done at 8 and 12 weeks post op. After the 12 week intervention period, subjects were required to complete supervised PT out to at least 6 months post surgery. \n\nWhat they Found: \n\nThe BFR group had better preservation of whole limb bone mass and site specific (femur, tibia, and fibula) bone mineral density (BMD) at 6 and 12 weeks post surgeryThe BFR group had better preservation of lower extremity lean mass at 6 and 12 weeks post surgery There was a similar improvement in functional measures in both groups between week 8 and week 12The BFR group did better than the control group in the anterior Y-balance The BFR group met return to sport criteria (cleared by a physician) 1.4 months faster than the control group\n\nAs informative as these research papers are, the description of what was done can leave things to the reader's imagination. Instead of us giving you our own interpretation of the details of this study and how it adds to our understanding of BFR in post operative care, we thought it would be helpful to sit down and have a discussion with one of the clinicians\/authors on the paper. Here\u2019s how that went down:\n\nBen: As with most studies, the methods leave some things open to interpretation. Can you clarify the exercise intensity and how it was determined for the BFR and the Control group?\n\nCorbin: With the BFR group, we wanted to stick to the standard 20-30 %1RM that is used in most studies and we thought we would err on the side of 20% as the target. We decided we were going to do a 1RM on the opposite limb as long as the other limb was healthy and we did that for all of the loaded exercises other than things like quad sets and SLRs. For the control group, we didn\u2019t do the same 1RM testing on the opposite limb but we tried to make the group as effort matched as we could. We did the 30, 15, 15, 15 and progressed the intensity or loading if all of the reps could be completed. \n\nBen: How did participants tolerate BFR and the exercise intensity that early after surgery? Were there any modifications needed?\n\nCorbin: Fortunately, I don\u2019t remember any of the participants that we had to hold off on or really modify the protocol for. We were mindful of massive effusion or leaky incisions and would have held off a couple extra days for something like that, but for the most part everyone was ready to go at the one week mark. With the BFR group, we were only doing quad sets with BFR for the first couple weeks and 80% LOP was tolerated well for everyone in the study. \n\nBen: How did you guys progress loading and was it the same across both groups? \n\nCorbin: The progression of loading was left up to the treating clinician and was done session by session based on completing the prescribed volume of reps. It was set up to be similar to the load progression in routine clinical care.\n\nBen: What are your thoughts on the lack of difference between groups in functional outcomes at 8 and 12 weeks?\n\nCorbin: That was a tough one for me since I was excited about the potential difference between groups. I think it may have just been too early or too short of a timeframe to see changes. Looking at the data and especially the lean mass differences between groups at that time, it looks like it was just a matter of time to see measurable functional differences between groups.\n\nBen: What are your major takeaways from this study?\n\nCorbin: The biggest takeaway from this study was the difference in bone between groups. It\u2019s something that we thought was there from what we\u2019ve seen with BFR but it hadn\u2019t really been measured formally or shown directly in other research. The bone side of things is definitely going to be a part of how we plan research going forward.\n\nBen: If you could do the study again, would you do anything differently?\n\nCorbin: I would do more exercises to give more of a BFR stimulus to the BFR group. I would also like to see the functional outcomes taken further out and assessed at a later time point than 12 weeks. \n\nBen: Have the results of this study changed how you manage patients following ACLR?\n\nCorbin: It really just confirmed what we thought all along. BFR is a safe intervention to use early after surgery without anything adverse happening and it looks like it has the potential to improve the patient outcome especially in regards to overall lean mass. \n\nIt was great to get the additional context from Corbin and we really appreciate him offering his time. We look forward to seeing additional research come from him and the group at Methodist. \n\nLike most publications, this study doesn\u2019t answer all of the questions we have about BFR. It does show the potential for BFR to affect more than just muscle and that applying BFR early after surgery is well tolerated without causing adverse events. Check out the paper for yourself at the journal website. We\u2019re planning a future podcast with Corbin so send us any additional questions you want us to ask about this paper or their future projects. \n\n#EarnYourDeflate\n\nReferences: \n\nJack, R. A., 2nd, Lambert, B. S., Hedt, C. A., Delgado, D., Goble, H., & McCulloch, P. C. (2022). Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction. Sports Health, 19417381221101006.\n","words":0,"datetime":"2022-10-27T11:18:49-07:00","timer":5159,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-after-acl-reconstructionmore-than-just-muscle","id":"blog\/bfr-after-acl-reconstructionmore-than-just-muscle","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/its-systemic\/image\/its-systemic.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/its-systemic\/image\/its-systemic-th.jpg","sq":"cms-data\/blog\/blog\/its-systemic\/image\/its-systemic-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"IT'S SYSTEMIC!!","permalink":"its-systemic","timestamp":1662042201,"summary":"Two. Little. Words. My, how they have impacted the BFR world. What are the words?\n\nYep you guessed it\u2026\u201dIt\u2019s Systemic!!\u201d\n\nThose two words have been used, by few, to explain a lot of the effectiveness BFR \u201ccould have\u201d in rehabilitation from musculoskeletal injuries or surgeries. So let me state this very clearly from the outset, before we venture into the nuance: to date NO clinical trial using BFR as an intervention has investigated whether or not BFR elicited a systemic response of any sort. It should then go without saying that no study has been designed for the expressed purpose of determining whether or not any sort of systemic response from BFR elicited a treatment effect. Those are two very, very large holes.\n\nPresently, any claim that BFR elicits a systemic response that enhances the recovery from any condition has no support in the literature. Period. Thus, it should not be used as rationale to support the use of BFR.\n\nAlright I feel better that\u2019s out of the way, and to be fair that may be as far as many of you care to read. I have zero problem with that, but I do want to lay out some of the evidence there is on the topic of systemic effects from BFR exercise. Like with all things BFR related, we have to start with what we know about the systemic effects of exercise without BFR, as that body of literature is much larger and can help us identify relevant outcomes. This is where the problems begin for systemic effects; just check out this title, \u201cNeither load nor systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men.\u201d That study was performed by the prestigious lab of Stu Phillips, PhD at McMasters University. It had resistance trained young men perform total body exercise for 12 weeks at either a 30-50% of 1RM load or a 75-90% of 1RM load. (Morton 2016) Trained subjects were used as there was some thought that anabolic hormone responses might matter more in trained individuals since all the unsuccessful prior work in this area had used highly adaptable, untrained individuals. News flash\u2026it didn\u2019t matter.\n\nI think it\u2019s important to layer in some nuance here as \u201csystemic effects\u201d is probably too broad a phrase. Technically systemic effects would involve changes to multiple systems like the cardiovascular, endocrine and other systems which of course BFR does as described by Miller 2021. Historically those who reference the systemic effects of BFR are referring to \u201csystemic hormonal effects\u201d as they are appropriately called by Morton 2016. This would mean exercise induced increases in things like growth hormone, testosterone, and the like.\n\nPrior to the study referenced above, West et al examined the influence post exercise elevations in systemic hormones have on muscle protein synthesis (MPS) rates. (West 2009) This was done via crossover trial where subjects performed moderately loaded biceps curls to the point of failure. On one day they performed biceps curls on a randomly selected arm, ingested 25g of whey protein (to maximize the MPS response) and had blood draws and muscle biopsies to assess MPS rates, lactate, testosterone, growth hormone, IGF-1 and cortisol levels. On a different day they used the same protocol, but the subjects also performed a lower body exercise program previously shown to elicit a systemic hormonal response. The condition involving lower body exercise elicited significant increases in lactate, IGF-1, GH, cortisol and testosterone without augmenting MPS rates. At minimum this study shows us that systemic hormonal responses of exercise do not augment the acute effects of well dosed exercise. \n\nFrequently when the systemic hormonal effects of BFR exercise are referenced, the context given is that contralateral BFR exercise can be used to preserve muscle mass and strength in an immobilized limb that has had a recent surgery or injury. As mentioned earlier, this has never been studied, but the above paper by West can provide us some insight into the plausibility of this claim. Chiefly it should be noted that subjects in the West study performed bilateral lower extremity exercise as follows: 5 sets of 10 leg press, then 3 sets of 12 leg extension\/leg curl supersets at 90% of a 10RM. That\u2019s a pretty good amount of lower body exercise, which did elicit a systemic hormone response. The fact these had no effect on MPS in an arm that performed biceps exercise sufficient to create adaptation certainly raises questions around claims that a BFR bicep curl might elicit a sufficient systemic response to preserve contralateral shoulder muscle mass after shoulder surgery. \n\nThinking critically though, it could be that in the aforementioned, subjects were maxed out; there was a ceiling effect if you will on what was physiologically possible given the biceps exercise on its own was enough to elicit adaptation. In this context we need to mention a couple BFR papers that indicate systemic effects of BFR exercise might actually reduce the amount of work remote tissue must perform in order to elicit adaptation. Madarame 2008 and May 2018 showed using very similar protocols that an underdosed unilateral biceps curl (50% 1RM), if coupled with bilateral BFR leg curls and extensions, elicited unexpected increases in biceps size and force output. They did not measure any systemic hormones, but their control group did do low load LE exercise without BFR and saw no changes in the moderately loaded biceps curl arm. So it appears that the addition of BFR here did reduce the amount of work necessary to create adaptations in muscle size and force production. However, this study also showed us that whatever BFR did here, it had no effect on the biceps that did not exercise. Thus, in light of this data, claiming preservation of function in inactive, remote muscle tissue in a clinical scenario becomes a very large leap.\n\nFinally, when discussing the systemic hormonal effects of BFR exercise, some seem to simply reference this as a mechanism for adaptation that is somehow unique to BFR. This typically occurs around the conversation of how to structure exercise programs, where the proponent of systemic effects might encourage whole body exercise without specifically targeting a muscle group via individualized loading, pressure, or effort levels in favor of 20 minutes of exercise because\u2026it\u2019s all systemic. The confusion here potentially centers around the fact that we know systemic hormones are in fact anabolic during puberty or when given exogenously (via injection). But context matters, during puberty or if given exogenously, testosterone levels for example are chronically supraphysiologic. When exercise causes supraphysiologic elevations in hormones, those elevations are transient. (West 2010) As discussed earlier, these transient increases do not affect anabolism. But perhaps BFR is doing something altogether different to systemic hormones than traditional heavy lifting. Laurentino et al sought to examine this as no one had directly compared the effects of low load BFR exercise to traditional heavy lifting. (Laurentino 2022) They used an 8 week bilateral knee extensions protocol with 20% 1RM and no BFR, 20% 1RM with BFR and 80% 1RM to examine this. The 20% 1RM groups did 4 sets of 15 reps and the 80% 1RM group did 4 sets of 8 reps. The BFR group used 80% LOP. Subjects had blood draws performed at their first and last sessions 15 minutes before and after the exercise protocol. These were used to assess testosterone, growth hormone, lactate, IGF-1 and cortisol levels. This protocol allowed them not only to get an individual session comparison, but also to determine if there were any adaptations in these responses over time as well as compare outcomes of muscle cross-sectional area and force output. They found no differences acutely or chronically in the systemic hormone responses to BFR or heavy loaded exercise. Further affirming that their study accurately compared the two conditions was the fact that there were no differences in the accretion of muscle or increases in quadriceps force output. \n\nThus, it doesn\u2019t look like BFR is doing anything magical at the systemic hormonal level. Maybe, rather intense BFR exercise can sort of \u201cprime the system\u201d if you will for adaptation, but any remote tissue where you might be looking to create an effect is still going to have to do some moderate level work. And regardless, that effect can be achieved with or without BFR.\n\n#EARNYOURDEFLATE\n\n\n\nReferences:\n\nMorton, R. W., Oikawa, S. Y., Wavell, C. G., Mazara, N., McGlory, C., Quadrilatero, J., Baechler, B. L., Baker, S. K., & Phillips, S. M. (2016). Neither load nor systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men. Journal of Applied Physiology, 121(1), 129\u2013138.West DW, Kujbida GW, Moore DR, Atherton P, Burd NA, Padzik JP, De Lisio M, Tang JE, Parise G, Rennie MJ, Baker SK, Phillips SM. Resistance exercise-induced increases in putative anabolic hormones do not enhance muscle protein synthesis or intracellular signalling in young men. J Physiol 587: 5239\u20135247, 2009.West DW, Burd NA, Tang JE, Moore DR, Staples AW, Holwerda AM, Baker SK, Phillips SM. Elevations in ostensibly anabolic hormones with resistance exercise enhance neither training-induced muscle hypertrophy nor strength of the elbow flexors. J Appl Physiol (1985) 108: 60\u201367, 2010.Miller, B. C., Tirko, A. W., Shipe, J. M., Sumeriski, O. R., & Moran, K. (2021). The Systemic Effects of Blood Flow Restriction Training: A Systematic Review. International Journal of Sports Physical Therapy, 16(4), 978\u2013990.Madarame, H., Neya, M., Ochi, E., Nakazato, K., Sato, Y., & Ishii, N. (2008). Cross-transfer effects of resistance training with blood flow restriction. Medicine and Science in Sports and Exercise, 40(2), 258\u2013263.May, A. K., Russell, A. P., & Warmington, S. A. (2018). Lower body blood flow restriction training may induce remote muscle strength adaptations in an active unrestricted arm. European Journal of Applied Physiology, 118(3), 617\u2013627.West, D. W. D., Burd, N. A., Staples, A. W., & Phillips, S. M. (2010). Human exercise-mediated skeletal muscle hypertrophy is an intrinsic process. The International Journal of Biochemistry & Cell Biology, 42(9), 1371\u20131375.Laurentino, G. C., Loenneke, J. P., Ugrinowitsch, C., Aoki, M. S., Soares, A. G., Roschel, H., & Tricoli, V. (n.d.). Blood-flow-restriction-training-induced hormonal response is not associated with gains in muscle size and strength. https:\/\/doi.org\/10.2478\/hukin-2022-0095\n","words":0,"datetime":"2022-09-01T07:23:21-07:00","timer":5364,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/its-systemic","id":"blog\/its-systemic","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/bfr-and-long-covid\/image\/bfr-and-long-covid.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/bfr-and-long-covid\/image\/bfr-and-long-covid-th.jpg","sq":"cms-data\/blog\/blog\/bfr-and-long-covid\/image\/bfr-and-long-covid-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"BFR AND LONG COVID???","permalink":"bfr-and-long-covid","timestamp":1657822446,"summary":"Greetings all! This month I wanted to share some information and resources with you that will relate to your use of BFR, but is also very relevant to our current healthcare climate and has great potential to be impactful for your patients, community, friends, or family members. Should you use BFR in this population? I don\u2019t know. I\u2019ll offer up some thoughts at the end of this blog, but I hope you\u2019ll spend a bit of time learning about Long COVID and its unique challenges before you ever consider the appropriateness of BFR.A few months back I posted in our Inside Circle group on Facebook asking if anyone had any experience using BFR in patients that had Long COVID. To my surprise I got no affirmative responses. So let me define that term real quick and then I want to lay out some these resources for y\u2019all. Long COVID is very much an umbrella term with no clear clinical presentation. It broadly refers to protracted symptoms following Sars-COV-2 infection that range from mild and gradually resolving to unpredictable, severe and recalcitrant. The important thing about the term is that it\u2019s been patient driven.You also might not know that physios around the world have really been leading in this space as very early on so many were infected and noted poor recoveries. This lead to the formation of group called Long COVID Physio. Here\u2019s their website: https:\/\/longcovid.physio\/Here\u2019s a JOSPT blog that the Long COVID Physio folks wrote outlining what exactly Long COVID is: https:\/\/www.jospt.org\/do\/10.2519\/jospt.blog.20210203One of the big mis-steps that so many physios made early on was pushing too hard. The Long COVID Physio crew addressed that in a follow-up blog: https:\/\/www.jospt.org\/do\/10.2519\/jospt.blog.20210210One of the people I owe a lot of credit to for enlightening me to what was inevitable is Todd Davenport, PT, DPT. Todd has worked in the Myalgic Encephalomyelitis \/ Chronic Fatigue Syndrome (ME\/CFS) space for years and he was immediately sharing that there were going to be some predictable impacts on people\u2019s long term health from Sars-COV-2 infection. He wrote a wonderful JOSPT blog on that here: https:\/\/www.jospt.org\/do\/10.2519\/jospt.blog.20210310Todd and his colleagues at the WorkWell Foundation followed up Todd\u2019s piece with a nice set of blog\u2019s for JOSPT on how what we\u2019ve learned from ME\/CFS can be used in the management of those with Long COVID:Part One: Post Exertional Symptom ExacerbationPart Two: Physiological Characteristics of Acute ExercisePart Three: Energy System First AidPart Four: Hear Rate Monitoring to Manage\n\nTodd also has a Medbridge course available if you\u2019re interested in learning more in a different format: Medbridge Long COVID CourseAnd if you really love learning in conference format\u2026they've got you!! Long COVID Physio is hosting an international forum on September 9th and 10th! You can attend live online or you can watch at a later time!Long COVID Physio International Forum: https:\/\/longcovid.physio\/forumAnd of course, if you don\u2019t have a podcast\u2026do you even physio? :))Long COVID Physio PodcastSo after doing some learning on Long COVID, what do you think? Should we consider using BFR in this population? Well let me be more specific, because as we said earlier, Long COVID is quite broad. Should we use BFR in people who experience post exertional symptom exacerbation and dysautonomia as part of their clinical presentation of Long COVID?I\u2019d suggest we can use the same clinical reasoning strategies we use every day in clinic to determine if using BFR is feasible and how to begin. As you\u2019ve undoubtedly learned from the information above, monitoring heart rate is the best way to pace daily activity for your patient and control post-exertional symptom exacerbations. So once you\u2019ve done the foundational work of teaching your patient pacing, the next question to answer would be whether or not you can provide any additional value in clinic that would justify them returning beyond monitoring their pacing strategy. This is when I might consider grabbing my Delfi and manipulating some variables. However, it is imperative that you understand two things: 1) the following is hypothetical with the goal of demonstrating the wealth of options you have and 2) persons experiencing dysautonomia do not respond in typical ways to activity. Please keep this context as you read on and if you choose to consider using this approach clinically.You\u2019ve got a heart rate monitor and you can use your Delfi to get a personalized pressure. I\u2019d start on the upper extremity as there\u2019s less tissue and the pressures are not as high. Does just taking LOP have an effect on HR? It could. If it does, then perhaps BFR isn\u2019t the best choice. However, if HR comes down or the elevation was mild and there\u2019s no exacerbation the following day, then perhaps you could just measure LOP 2 times the following visit. If that goes well, perhaps you increase the duration of the pressure, but reduce the magnitude to say 40% LOP. You know what responses to monitor and those will help determine duration. If that goes well could you just add another inflation the next visit? Hopefully you see where I\u2019m going here. There are a lot of options you have at your disposal with the addition of a Delfi to your repertoire. I\u2019ve perhaps given an extreme example here but the purpose was to show you just how far you can regress things. Once you have a starting place you incrementally manipulate the magnitude of pressure, the lengths of inflations and deflations, and the number of both inflations and deflations. I think building a tolerance toward a typical ischemic preconditioning stimulus is a good goal. At that point I\u2019d consider further modifications, perhaps using bilaterally, or moving to the lower extremity to involve more tissue and greater pressures, maybe you add some isometric contractions or just a bit of AROM. There\u2019s no protocol. There\u2019s no data. But we know what to watch for and how to gradually progress the interventions we have at our disposal, no to mention we have a client in front of us that can help us understand the effect of our intervention.\n\nThank you Kyle Kimbrell, MPT for the write up and resources. \n","words":0,"datetime":"2022-07-14T11:14:06-07:00","timer":5934,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-and-long-covid","id":"blog\/bfr-and-long-covid","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":{"img":"cms-data\/blog\/blog\/combining-bfr-with-nmes\/image\/combining-bfr-with-nmes.jpg","alt":"Service Image","thumb":{"th":"cms-data\/blog\/blog\/combining-bfr-with-nmes\/image\/combining-bfr-with-nmes-th.jpg","sq":"cms-data\/blog\/blog\/combining-bfr-with-nmes\/image\/combining-bfr-with-nmes-sq.jpg"}},"genre":"","media":"","archived":false,"draft":false,"featured":false,"author":"","title":"COMBINING BFR WITH NMES","permalink":"combining-bfr-with-nmes","timestamp":1649874633,"summary":"Combining BFR rehabilitation with neuromuscular electrical stimulation holds quite a bit of potential in the healthcare arena. Read the findings of some studies that have been conducted to gain more insight. Neuromuscular electrical stimulation (NMES) has long been used to aid recovery and maintenance of size and strength following surgical procedures and other injuries impairing neuromuscular function. However, it\u2019s utility is limited by our physiology and tolerance to the procedure. Therefore, if personalized blood flow restriction can enhance NMES\u2019s ability to create muscle adaptation, that would equate to significant value for our clients in this evolving healthcare market. \n\n\n\nThis is a review of three studies that have examined three different questions regarding NMES\u2019s use in combination with BFR. Inagaki (2010) demonstrated the ability of NMES + BFR to increase serum GH at a low level of stimulation. They used NMES at 20% of MVC for knee extension, with and without BFR applied to the proximal thigh at 150 mmHg. Ultimately their main research goal was to examine whether or not there is a local metaboreflex vs. centrally mediated control of GH secretion. Their findings demonstrated that there does seem to be a metaboreflex, triggered by lactate build up within the exercised muscle involved in GH secretion from the pituitary. This indicates that we, as clinicians, can achieve an environment within the muscle for our clients that may play a role in their healing, and recovery of size and strength even when their exercise tasks are limited by precaution, pain, or tolerance to the NMES modality.\n\nGrowth Hormone (ng\/mL)Pre2 min15 min30 minNMES w\/ BFRNO CHANGENO CHANGEINCREASEINCREASENMES w\/o BFRNO CHANGENO CHANGENO CHANGENO CHANGE\n\nGorgey (2016) published a fascinating study using NMES + BFR on incomplete spinal cord injury patients. They sought to determine if they could improve size, strength, and function of the all important wrist extensors via NMES + BFR; thus amplifying, or reproducing without load, results that have already been demonstrated using NMES alone. After six weeks of training, the NMES + BFR group did, in fact, add more muscle size and strength, than the NMES group. The functional increases were similar between groups for \u201cgrasp and release\u201d of a soda can, block, weight, and fork, but the BFR group did improve the speed with which it was able to grasp and release a peg. The authors cite many limitations that give them pause in the interpretation of their results but, nonetheless, were confident in claiming that the combination of NMES + BFR demonstrated its potential to achieve desired results without the challenge of externally loading wrist extensors in the SCI population. Another aspect of the Gorgey study examined flow-mediated dilation of the NMES + BFR group vs. BFR alone. What they found was that the acute dilation of the upper extremity vasculature was amplified in the NMES group vs. the BFR alone group. Presumably, the accumulation of metabolites in the NMES group aided the resultant dilation upon release of the occlusion. The authors conclude that this finding may provide evidence to support a potential contribution of lactate accumulation and nitric oxide release in the role of skeletal muscle hypertrophy. \n\nNatsume (2015) sought to examine NMES + BFR\u2019s ability to increase muscle size, isometric, and isokinetic strength. Part of the problem they sought to address is the fact that NMES\u2019s ability to create muscle adaptation is directly proportionate to the intensity of the NMES used. They cite a variance in tolerance from 12-95% of maximal strength. Subjects underwent twice daily isometric knee extension exercise bouts, five days a week for two weeks, with or without BFR using NMES at a 5-10% intensity of maximal strength. In addition to examining the training period\u2019s outcomes, they assessed the groups after a 2-week detraining period. The NMES + BFR group showed significant improvement in muscle size and strength compared to NMES alone. However, these results were only partially maintained during a detraining period.\n\nsizeisom90\u00b0 \/ s180\u00b0 \/ sNMES + BFR3.9% INCREASE14.2% INCREASE7% INCREASE8.3% INCREASENMESNO CHANGENO CHANGENO CHANGENO CHANGEBFR detrain3.0% DECREASE6.8% DECREASE1.9% DECREASE0.6% DECREASE\n\nIn summary, we have evidence to indicate that combining low-intensity BFR with NMES can increase muscle size and strength in healthy and neurologically impaired populations, as well as positively affect blood flow to the exercised region. Due to the low-intensity, the intervention may need to be performed for longer bouts and\/or with higher frequency to see adaptation. There hasn\u2019t been a study yet to show the effects of BFR with NMES 2-3 days a week in an injured or post-surgical population, but the clinical results are very promising. This can be a very valuable tool for maximizing muscle activation and minimizing loss when mechanical loading is limited. \n\nThank you, Kyle Kimbrell, MPT for the article summary.\n","words":0,"datetime":"2022-04-13T11:30:33-07:00","timer":7246,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/combining-bfr-with-nmes","id":"blog\/combining-bfr-with-nmes","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content-jpg\/ORS-HamCurl-1.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"MANAGING MUSCLE STRAINS VIA PERSONALIZED BLOOD FLOW RESTRICTION (PBFR)","permalink":"managing-muscle-strains-via-personalized-blood-flow-restriction-pbfr","timestamp":1648184400,"summary":"Recently we\u2019ve had a few conversations in our Facebook group, at the NBA Combine, as well as emails regarding how best to manage muscle strains via PBFR. So, we thought we\u2019d put together a brief post centered around this topic. When it comes to this and most other subjects, our chief objective is that we convey the underlying principles driving our decision making and exercise prescription. Having a strong physiologic foundation for our clinical reasoning enables us to apply our knowledge effectively across the broadest range of circumstances. Thus, helping to continue to build this for you will always be our chief focus, because no pre-packaged protocol will ever address comprehensively the individual scenario you will encounter in the clinic. So, let\u2019s dive in further to learn how PBFR can be used for muscle strain treatment.\n\nWhen one injures a muscle, the body has two primary means of addressing this insult. It involves a delicate interplay between scar and repair. In the context of causing muscular adaptation by lifting heavy weight, our body is quite capable of repairing that damage in a manner that results in growth, or more specifically, increases in strength and hypertrophy. But when one strains a muscle, that insult is often too great to repair fully with muscle tissue, so our scar pathways jump into action to speed up this process. (J\u00e4rvinen does a beautiful job of describing this process in detail. J\u00e4rvinen et al. 2005) That can be good as it restores a large amount of function rather quickly, but the resultant reduction in quality tissue affects the muscle\u2019s capacity to perform at a high level. The good news is it looks like from animal research that we can limit that scar via activity. The bad news is that moving the injured tissue hurts, which usually affects how much or how intensely we can move. This was demonstrated elegantly by scientists in the Department of Defense that found forcing a rat to run 1-week after inflicting a large soft tissue injury on their hind limb produced muscle regeneration, the animals who were immobilized primarily produced fibrosis. We as clinicians are unable to force patients with muscle strains to sprint a week after injury and the sedentary state results in the muscle not receiving a strong enough signal to limit scar formation and prioritize muscle regeneration.\n\nThe TGF - \u03b2 superfamily, a scar pathway, is likely the chief driver of the scar response following injury. Myostatin is part of this family, and as presented in the certification course, we can use low load exercise with PBFR to downregulate the myostatin gene very similarly to how heavy lifting will. (Laurentino et al. 2012) Therefore, we would want to knock that gene\u2019s expression down as a means of limiting scar formation and mimicking the \"forced running\" type of regenerative pathway seen in the rat models. This is one mechanism by which we believe we may help the body to prioritize muscle repair over scarring. In addition to reducing myostatin\u2019s expression, we would also want to maximize our protein synthetic response, as this will optimize our ability to repair rather than scar muscle. Certainly, we know that we can achieve this via PBFR. (Fry et al. 2010; Fujita et al. 2007; Gundermann et al. 2014, for a detailed review read Dr. Bradley Lambert's paper, Lambert et al. 2018) In addition to these two primary mechanisms, there are some other processes we may be able to influence via PBFR to help stimulate the repair of muscle. A key player in the repair process would be the proliferation and differentiation of satellite cells. It looks like the inherent hypoxia created by the damage to the muscle encourages this initially (Jash et al. 2015) and may certainly be further influenced via PBFR exercise.\n\n(Nielsen et al. 2012) Lastly, increases in angiogenesis, (Hunt et al. 2013) and reductions in pain via PBFR may be helpful. (Korakakis et al. 2018; Ellingson et al. 2014; Giles et al. 2017) The latter is something I\u2019ve seen be a very powerful tool in the clinic with this subset of injuries. The pain reductions I\u2019ve seen have been immediate, substantial, and lasting. This provided me the ability to progress to heavier loaded tasks much more rapidly than I anticipated, and thus resulted in shortened courses of care. When it comes to how best to implement PBFR in the management of muscle strains, I would suggest beginning with a load the person can execute without pain or with very tolerable pain. Your goal in this first session is to use PBFR to induce a fatigued state that is surprising to the patient, as they would generally associate this with a bout of heavy lifting that their injury would not allow. Secondly, you will need to assess the person\u2019s tolerance to the cuff pressure, particularly if the injury is underneath the cuff. If it\u2019s too painful then you may need to reduce the pressure, or potentially wait a bit before beginning PBFR. If you\u2019re able to find a load, and your person can tolerate the pressure, then the standard 30\/15\/15\/15 set and rep scheme seems to work well. I\u2019ve found this sufficient to induce fatigue. In some cases, I\u2019ve had to assist the completion of the exercise volume manually, in others I\u2019ve had to increase the volume real time as I may have undershot the load a little.\n\nEither way, if you are able to fatigue the person\u2019s injured muscle, I\u2019ve found they experience an almost immediate reduction in pain. This can obviously be a very valuable thing clinically for a number of reasons. At subsequent visits be sure to re-assess the load you will use prior to the session, and progress it as much as you can with the goal of moving away from PBFR as quickly as possible toward progressively loaded tasks for the injured muscle. You may supplement with PBFR following your heavy session simply to ensure you\u2019ve achieved a large enough protein synthetic response to aid the repair via quality tissue.\n\nOh yeah and get your protein!! #leftbrisket\n\nThank you Kyle Kimbrell, MPT for the write up on PBFR for muscle strain treatment.\n\n\n\nEllingson, L. D., Koltyn, K. F., Kim, J.-S., & Cook, D. B. (2014). Does exercise induce hypoalgesia through conditioned pain modulation? Psychophysiology, 51(3), 267\u2013276. Fry, C. S., Glynn, E. L., Drummond, M. J., Timmerman, K. L., Fujita, S., Abe, T., \u2026 Rasmussen, B. B. (2010). Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men. Journal of Applied Physiology, 108(5), 1199\u20131209. Fujita, S., Abe, T., Drummond, M. J., Cadenas, J. G., Dreyer, H. C., Sato, Y., \u2026 Rasmussen, B. B. (2007). Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis. Journal of Applied Physiology, 103(3), 903\u2013910. Giles, L., Webster, K. E., McClelland, J., & Cook, J. L. (2017). Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. British Journal of Sports Medicine, 51(23), 1688\u20131694. Gundermann, D. M., Walker, D. K., Reidy, P. T., Borack, M. S., Dickinson, J. M., Volpi, E., & Rasmussen, B. B. (2014). Activation of mTORC1 signaling and protein synthesis in human muscle following blood flow restriction exercise is inhibited by rapamycin. American Journal of Physiology-Endocrinology and Metabolism, 306(10), E1198\u2013E1204. Hunt, J. E. A., Galea, D., Tufft, G., Bunce, D., Ferguson, R. A. (2013). Time course of regional vascular adaptations to low load resistance training with blood flow restriction. Journal of Applied Physiology, 115(3), 403\u2013411. J\u00e4rvinen, T. A. H., J\u00e4rvinen, T. L. N., K\u00e4\u00e4ri\u00e4inen, M., Kalimo, H., & J\u00e4rvinen, M. (2005). Muscle injuries: biology and treatment. The American Journal of Sports Medicine, 33(5), 745\u2013764. Jash, S., & Adhya, S. (2015). Effects of Transient Hypoxia versus Prolonged Hypoxia on Satellite Cell Proliferation and Differentiation In Vivo. Stem Cells International, 2015, 961307. Korakakis, V., Whiteley, R., & Epameinontidis, K. (2018). Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Physical Therapy in Sport: Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 32, 235\u2013243. Lambert, Bradley S., et al. \"Blood Flow Restriction Therapy for Stimulating Skeletal Muscle Growth: Practical Considerations for Maximizing Recovery in Clinical Rehabilitation Settings.\" Techniques in Orthopaedics 33.2 (2018): 89-97. Laurentino, G. C., Ugrinowitsch, C., Roschel, H., Aoki, M. S., Soares, A. G., Neves, M., Jr, \u2026 Tricoli, V. (2012). Strength training with blood flow restriction diminishes myostatin gene expression. Medicine and Science in Sports and Exercise, 44(3), 406\u2013412. Mason, M. J. S., Owens, J. G., & Brown, L. W. J. (2018). Blood Flow Restriction Training: Current and Future Applications for the Rehabilitation of Musculoskeletal Injuries. Techniques in Orthopaedics, 33(2), 71. Nielsen, J. L., Aagaard, P., Bech, R. D., Nygaard, T., Hvid, L. G., Wernbom, M., \u2026 Frandsen, U. (2012). Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction. The Journal of Physiology, 590(17), 4351\u20134361.\n","words":0,"datetime":"2022-03-24T22:00:00-07:00","timer":5613,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/managing-muscle-strains-via-personalized-blood-flow-restriction-pbfr","id":"blog\/managing-muscle-strains-via-personalized-blood-flow-restriction-pbfr","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-1.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"PERIPHERAL VASCULAR CHANGES WITH PBFR","permalink":"peripheral-vascular-changes-with-pbfr","timestamp":1648184400,"summary":"Understanding how BFR training affects the peripheral vascular system can be beneficial in clinical settings. Changes in vascular function have been studied sparingly in BFR research, but present as an interesting clinical target. In aging and pathological populations, decreased vascular function can be correlated with decreased muscle function. Zargi et al. demonstrated around a 30% decrease in blood flow to the quadriceps muscle 4 weeks post ACL surgery. Along with the decrease in blood flow, there was a corresponding 50% decrease in muscular endurance. Increases in post-occlusive blood flow or signs of increased capillarity have been shown in multiple BFR studies (Patterson 2011, Hunt 2013, Zargi 2018). A recently published study by Mouser et al. aimed to expand the knowledge on BFR and vascular adaptation by comparing the effectiveness of different pressures for upper and lower extremity.\n\nThe authors of this study had 40 individuals complete 16 sessions of bicep curls and knee extension over 8 weeks. There were four groups: light load control (15% of 1RM), light load with low pressure (15% of 1RM with 40% limb occlusion pressure (LOP)), light load with high pressure (15% of 1RM with 80% LOP), and heavy load (70% of 1RM). Vascular conductance for upper and lower body increased in the high pressure and heavy load groups to a significantly greater extent than the low pressure or no pressure groups. Venous compliance changed only in the upper extremity. The methods used in this study match pretty well with a clinical model. The participants performed exercises twice a week with very low load. This appears to provide additional support for 80% pressure in the lower extremity and we may need to increase pressure to 80% LOP for optimal vascular changes in the upper extremity when the loading is very low. \n\nAs always, more research is needed to tease out the best parameters across multiple pressures, loads, and populations. However, as more and more BFR research is confirming, personalization of the pressure to the individual, in this case a high personalized pressure, appears crucial to elicit changes across multiple pathways.\n\n\n\nMouser, J. Grant, et al. \u201cHigh-Pressure Blood Flow Restriction with Very Low Load Resistance Training Results in Peripheral Vascular Adaptations Similar to Heavy Resistance Training.\u201d Physiological Measurement, Mar. 2019, doi:10.1088\/1361-6579\/ab0d2a.Hunt, Julie E. A., et al. \u201cTime Course of Regional Vascular Adaptations to Low Load Resistance Training with Blood Flow Restriction.\u201d Journal of Applied Physiology, American Physiological Society Bethesda, MD, Aug. 2013, doi:10.1152\/japplphysiol.00040.2013.Patterson, Stephen D., and Richard A. Ferguson. \u201cEnhancing Strength and Postocclusive Calf Blood Flow in Older People with Training with Blood-Flow Restriction.\u201d Journal of Aging and Physical Activity, vol. 19, no. 3, July 2011, pp. 201\u201313.\u017dargi, Tina, et al. \u201cShort\u2013Term Preconditioning With Blood Flow Restricted Exercise Preserves Quadriceps Muscle Endurance in Patients After Anterior Cruciate Ligament Reconstruction.\u201d Frontiers in Physiology, vol. 9, 2018, p. 1150.\n","words":0,"datetime":"2022-03-24T22:00:00-07:00","timer":6277,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/peripheral-vascular-changes-with-pbfr","id":"blog\/peripheral-vascular-changes-with-pbfr","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-19.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"DO DIFFERENT PRESSURES CHANGE LE BLOOD FLOW? ","permalink":"do-different-pressures-change-le-blood-flow","timestamp":1648057202,"summary":"Recently a paper was published in Medicine & Science in Sports & Exercise that investigated the effects of cuff pressures on blood flow into the LE at rest and during exercise. The conclusion drawn by the paper has some a bit puzzled, so the folks at Tourniquets.org wrote a response explaining why this conclusion may have been drawn. We've provided a bulleted summary below:\n\n\n\nMeasurement of only the superficial femoral artery.The method used to measure \"blood flow\" actually measures \"blood velocity\", not volumetric blood flow into a limb.The cuff used provided non-uniform pressure.Only one pressure was studied during exercise.\n\n\n\nWant to read the full blog? Click Here Interested in reading the paper on how limb occlusion pressure impacts blood velocity? Click Here\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5647,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/do-different-pressures-change-le-blood-flow","id":"blog\/do-different-pressures-change-le-blood-flow","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-16.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"A BLOG ABOUT PROTEIN!!","permalink":"a-blog-about-protein","timestamp":1648057202,"summary":"For those of you who have taken our course or listen to our podcast, you know quite well how important we think it is to have at least a minimum understanding of protein ingestion targets. Protein ingestion is quite complex in the end, so instead of trying to shrink this down into a digestible blog, we thought it would be a nice change to provide you with some resources for you to read, listen, or watch at your own pace. \n\nShameless plug!!! check out one of our very first podcasts, \u201cStop the Muscle Dump\u201d with Kevin Tipton, PhD where we talk all things protein! \n\nA comprehensive review that is good to have on hand is a paper by Rob Morton, PhD in BJSM. You\u2019ve heard us no doubt recommend a daily ingestion of 1.6 g \/ kg of body weight for hypertrophy. This paper is where we gleaned that information. It\u2019s open access; just follow the link below. (Morton et al. 2018) A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. \n\nIf you like podcasts, Dr. Morton came on the \u201cWe Do Science\u201d podcast to discuss the paper: Episode 125: Protein Supplementation & Resistance Exer Training w\/ Rob Morton PhD \n\nSpeaking of the We Do Science podcast, they\u2019ve tackled this protein topic quite extensively. Below you\u2019ll find a few of their other offerings that we\u2019ve found quite helpful in deepening our knowledge. \n\nEpisode 5: Professors Stu Phillips and Kevin Tipton \n\nEpisode 18: Protein Nutrition and Critical Appraisal - Professor Kevin Tipton \n\nEpisode 24: Muscle Anabolic Potential of Leucine - Leigh Breen, PhD \n\nEpisode 34: Nutrient Priming & the Protein Synthetic Response - Lee Hamilton, PhD \n\nEpisode 67: Protein Ingestion & Muscle Mass - Professor Luc van Loon \n\nEpisode 98: Protein: An Update with Professors Stu Phillips & Kevin Tipton \n\nEpisode 110: Nutrition Support for Exercise Induced Injury with Professor Kevin Tipton \n\nEpisode 158: BCAA\u2019s for Muscular Strength & Hypertrophy with Professor Kevin Tipton \n\nAnother podcast we liked that has since been discontinued is The Iraki Nutrition podcast. Luckily a few of their episodes are on YouTube. \n\nEpisode 39: Jorn Trommelen: Protein Distribution \n\nEpisode 43: Prof.Stuart Phillips: Sarcopenia \n\nEpisode 67: Professor Don Layman: Protein Metabolism \n\nEpisode 68: Dr.Shawn Arent: Nutrient Timing \n\nAnd finally, if you prefer more of a lecture-style presentation with a slide deck, this presentation by Dr. Stu Phillips is quite recent and very comprehensive! All Things Protein, Protein Synthesis and Hypertrophy - Dr. Stuart Phillips & Dr. Richard Mackenzie \n\nHappy learning!! Let\u2019s continue to make exercise more stressful and make sure we eat some protein. #leftbrisket\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":7264,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/a-blog-about-protein","id":"blog\/a-blog-about-protein","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-HamCurl-2.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"ACUTE PERCEPTUAL & MUSCLE ACTIVATION RESPONSES BETWEEN DELFI, B-STRONG AND HIGH LOAD","permalink":"acute-perceptual-muscle-activation-responses-between-delfi-b-strong-and-high-load","timestamp":1648057202,"summary":"As more and more BFR devices come to market it is quite useful for independent investigators to examine the performance of these devices. This allows the consumer to make a more educated decision when seeking to determine what is the best choice for their setting and clientele. It is however very important that these trials are conducted in a manner that allows outcomes to be compared.(1)\n\nRecently, Bordessa et al examined the acute effects of low intensity BFR knee extensions with two different BFR devices against a heavy load control.(2) The BFR interventions were provided by an unregulated handheld pump device (B-Strong), and a regulated device (Delfi). The loads utilized were 30% and 80% 1RM and the outcomes measured were muscle activation (peak and mean EMG), RPE (Omni-Res), and pain via the Numeric Pain Rating Scale (NPRS). The researchers found no difference in mean or peak muscle activation between the BFR groups, but a significantly greater EMG response for the high load group. Additionally, Delfi was found to be associated with greater pain and RPE than either the B-Strong or heavy loaded groups; while the B-Strong group was associated with a significantly greater pain and RPE than the heavy load group.\n\nThe major limitation of this study is the failure of the design to ensure both BFR groups received the same or even similar levels of blood flow restriction. This limitation alone calls into question any comparison of acute responses between the two devices. The Delfi device uses a research validated measurement of occlusion pressure and accurate pressure regulation throughout an exercise.(3) This approach to applying BFR pressure is generally accepted by the medical and research communities as the gold standard.(4,5) To our knowledge there have been no trials conducted using B-Strong to validate its means of determining pressure. Given the marketing and reported design of the B-Strong device that, \u201cit will never occlude\u201d, raises the question whether or not an individualized pressure could ever be determined using that device.\n\nA number of factors are reported to be taken into account for the pressure used by the B-Strong device: age, gender, overall health, size of the strap used, limb girth and preferred intensity level. Importantly, of the variables considered, only the effect limb girth has on LOP has been studied. When used with a narrow cuff like B-Strong, limb girth only explained 15% of the variance in LOP.(6) Without controlling for the magnitude of restriction, one is unable to determine if the findings or lack thereof, are a result of a difference in the amount of restriction or because one device is regulated and the other is not. This would be synonymous with looking at the effects of two different pain relievers without being mindful of the dosage of each.\n\nWhile the EMG data is interesting, the findings of greater discomfort and RPE were predictable given the comparison of a high relative pressure (80% LOP) against an arbitrary pressure from a cuff that is less than half the width of Delfi.(7) Acutely, this appears to be closely related to the absolute pressure of the tourniquet when the same relative load is used.(8,9) However, over a training period, this response is diminished and similar to that achieved by high load resistance training.(10,11) Nevertheless, during the initial few sessions, if the pressure is not well tolerated, the clinician can employ a couple strategies to address this. When utilizing a low load (20% 1RM), initially starting with a lower pressure, such as 60% LOP and gradually progressing back towards 80% can allow individuals to acclimate to the pressure, making the 80% LOP more tolerable when reached. In addition to modifying the percentage of occlusion during the exercise, the clinician can keep the pressure high during the exercise and decrease the pressure to 40% LOP during the 30 second rest period. This approach will make the rest period more tolerable, but maintains full venous occlusion so the metabolites accumulated during the exercise are not flushed out of the muscle.\n\nSurface EMG amplitudes are commonly collected and compared between exercise techniques or loads. Based on these acute comparisons, researchers attempt to extrapolate findings into longitudinal changes in muscle mass or strength. However, the longitudinal relevance of acute EMG responses has recently been questioned.(12) It would also appear from Morton et al that the chief determinant of EMG amplitude is the relative load being lifted. The findings of Bordessa et al certainly seem to support this. Previous research indicates there are numerous parameters ranging from cuff width, relative occlusion pressure, and effort, which strongly influence muscle activation, lactate accumulation and ultimately muscle hypertrophy.(6,13\u201315) By only looking at muscle activation, one is unable to accurately assess how much effort was exerted by the muscle and if the effort exerted was sufficient to produce an anabolic effect that would subsequently lead to an increase in muscle hypertrophy throughout a training period. Recent research strongly suggesting there are comparable increases in muscle mass over a resistance training period when a similar volume (weight*total reps) is performed, regardless of the load lifted.(16) Given this, one must ultimately question the overall value of EMG data as it relates to a stimulus being sufficient to cause a desired adaptation.\n\nIn conclusion, when using low loads, the exercise must be taken close to the point of failure, to produce similar hypertrophic results to high load training. An important component to this when performing low load BFR exercises is doing the entire protocol (30\/15\/15\/15) and ensuring a proper pressure is utilized (60%-80% LOP). When looking at the effect of BFR, it is important to establish a relative pressure for each individual, this will ensure all individuals receive an objective, repeatable stimulus. Lastly, when prescribing an intervention to an individual, the clinician should always consider what the goal of the treatment is and how is this going to accomplish an overall treatment outcome. Many of the issues faced in a clinical setting are a result of muscle disuse. The primary goal to address this acutely is to perform a resistance exercise that significantly increases muscle protein synthesis, longitudinally this will increase muscle hypertrophy and contribute to an increase in strength. Both adaptations can be accomplished regardless of the load lifted, as long as the individual performs the lift close to the point of fatigue.\n\n\n\n1. Rolnick N, Cerqueira MS. Comparison of Blood Flow Restriction Devices and Their Effect on Quadriceps Muscle Activation: Letter to the Editor. Phys Ther Sport. Published online March 22, 2021. doi:10.1016\/j.ptsp.2021.03.006\n\n2. Bordessa JM, Hearn MC, Reinfeldt AE, et al. Comparison of Blood Flow Restriction Devices and Their Effect on Quadriceps Muscle Activation. Phys Ther Sport. Published online February 12, 2021. doi:10.1016\/j.ptsp.2021.02.005\n\n3. Masri BA, Day B, Younger ASE, Jeyasurya J. Technique for Measuring Limb Occlusion Pressure that Facilitates Personalized Tourniquet Systems: A Randomized Trial. J Med Biol Eng. 2016;36(5):644-650.\n\n4. Patterson SD, Hughes L, Warmington S, et al. Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety. Front Physiol. 2019;10:533.\n\n5. Day B. Personalized Blood Flow Restriction Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery? Arthroscopy. 2018;34(8):2511-2513.\n\n6. Loenneke JP, Fahs CA, Rossow LM, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903-2912.\n\n7. Rossow LM, Fahs CA, Loenneke JP, et al. Cardiovascular and perceptual responses to blood-flow-restricted resistance exercise with differing restrictive cuffs. Clin Physiol Funct Imaging. 2012;32(5):331-337.\n\n8. Mattocks KT, Mouser JG, Jessee MB, et al. Perceptual changes to progressive resistance training with and without blood flow restriction. J Sports Sci. 2019;37(16):1857-1864.\n\n9. Dankel SJ, Jessee MB, Mattocks KT, et al. Perceptual and arterial occlusion responses to very low load blood flow restricted exercise performed to volitional failure. Clin Physiol Funct Imaging. 2019;39(1):29-34.\n\n10. Teixeira EL, Painelli V de S, Schoenfeld BJ, et al. Perceptual and Neuromuscular Responses Adapt Similarly Between High-Load Resistance Training and Low-Load Resistance Training With Blood Flow Restriction. J Strength Cond Res. Published online December 9, 2020. doi:10.1519\/JSC.0000000000003879\n\n11. Mart\u00edn-Hern\u00e1ndez J, Ruiz-Aguado J, Herrero AJ, et al. Adaptation of Perceptual Responses to Low-Load Blood Flow Restriction Training. J Strength Cond Res. 2017;31(3):765-772.\n\n12. Morton RW, Sonne MW, Zuniga AF, et al. Muscle fibre activation is unaffected by load and repetition duration when resistance exercise is performed to task failure. J Physiol. Published online July 11, 2019. doi:10.1113\/JP278056\n\n13. Laurentino GC, Loenneke JP, Teixeira EL, Nakajima E, Iared W, Tricoli V. The Effect of Cuff Width on Muscle Adaptations after Blood Flow Restriction Training. Med Sci Sports Exerc. 2016;48(5):920-925.\n\n14. Stray-Gundersen S, Wooten S, Tanaka H. Walking With Leg Blood Flow Restriction: Wide-Rigid Cuffs vs. Narrow-Elastic Bands. Front Physiol. 2020;11:568.\n\n15. Ilett M, Rantalainen T, Keske M, May A, Warmington S. The Effects of Restriction Pressures on the Acute Responses to Blood Flow Restriction Exercise. Front Physiol. 2019;10:1018.\n\n16. Schoenfeld BJ, Grgic J, Ogborn D, Krieger JW. Strength and Hypertrophy Adaptations Between Low- vs. High-Load Resistance Training: A Systematic Review and Meta-analysis. J Strength Cond Res. 2017;31(12):3508-3523.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6189,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/acute-perceptual-muscle-activation-responses-between-delfi-b-strong-and-high-load","id":"blog\/acute-perceptual-muscle-activation-responses-between-delfi-b-strong-and-high-load","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-8.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"BFR AND PROXIMAL OR CONTRALATERAL EFFECTS","permalink":"bfr-and-proximal-or-contralateral-effects","timestamp":1648057202,"summary":"Studying the contralateral and proximal effects from BFR therapy is beneficial for clinical and rehabilitation settings. The question of whether or not BFR can stimulate changes proximal to the application of the cuff or in a remote limb is a hot topic of discussion.\n\n\n\nIn a bench press study by Yasuda (2010) and a squat and hamstring curl study by Abe (2005), the authors demonstrated changes in the pectoralis and gluteal muscles respectively. However, these studies were performed with a frequency that would be difficult or impossible to achieve in a clinical setting. In studies by Madarame (2008) and May (2018), they assessed if the addition of lower extremity exercises with and without BFR would have an effect on an exercising or non-exercising upper extremity. In both studies, the response of the exercising arm was significantly greater with the addition of BFR to the lower extremity exercises. This remote effect looks promising but brings up questions about whether insurance companies would reimburse for the treatment time spent on the lower extremity with an upper extremity pathology.\n\n\n\nIn a recently published article, Bowman et al. studied whether the addition of BFR to simple, rehabilitation-based exercises would have an effect on the proximal musculature or a contralateral limb. They had healthy participants perform four exercises, twice a week for six weeks. Both groups performed straight leg raises, side-lying abduction, long arc quadricep extension, and standing hamstring curls at 30% of a 1RM on both lower extremities. The BFR group had a cuff on one limb at 80% limb occlusion pressure (LOP), using the Delfi Personalized Tourniquet System. The limb that performed the exercises with BFR demonstrated a significant increase in cross sectional area, strength (knee extension, knee flexion, hip abduction, hip extension, and plantar flexion), and muscular endurance (single leg heel raises) compared to the control group. The non-BFR limb in the BFR group had significant hypertrophy of the thigh, significantly increased peak torque for knee extension, and significantly improved single leg heel raises compared to the control group.\n\n\n\nThis study is one of the first to assess proximal or remote effects for BFR with exercise in a model that reflects clinical or rehabilitation application. As you might expect, the greatest effects were found in the limb that performed the exercise with BFR. However, this study adds support to the limited evidence for changes in the muscles proximal to the application of the cuff and provides evidence for a potential cross-transfer effect to a non-BFR limb. It looks like there still needs to be an exercise stimulus in the area where the effects are desired. More research is needed to determine the most effective parameters for application. Let's continue to make rehab exercises more effective!\n\n\n\nBowman, Eric N., et al. \u201cProximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial.\u201d Sports Health, Jan. 2019, p. 1941738118821929. Madarame, Haruhiko, et al. \u201cCross-Transfer Effects of Resistance Training with Blood Flow Restriction.\u201d Medicine and Science in Sports and Exercise, vol. 40, no. 2, Feb. 2008, pp. 258\u201363. May, Anthony K., et al. \u201cLower Body Blood Flow Restriction Training May Induce Remote Muscle Strength Adaptations in an Active Unrestricted Arm.\u201d European Journal of Applied Physiology, vol. 118, no. 3, Mar. 2018, pp. 617\u201327. Abe, et al. Skeletal Muscle Size and Circulating IGF-1 Are Increased after Two Weeks of Twice Daily \u201cKAATSU\u201d Resistance Training..pdf. Yasuda, T., et al. \u201cEffects of Low\u2010intensity Bench Press Training with Restricted Arm Muscle Blood Flow on Chest Muscle Hypertrophy: A Pilot Study.\u201d And Functional Imaging, Wiley Online Library, 2010, http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/j.1475-097X.2010.00949.x\/full.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5670,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-and-proximal-or-contralateral-effects","id":"blog\/bfr-and-proximal-or-contralateral-effects","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-6.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"BFR AND TENDON","permalink":"bfr-and-tendon-2","timestamp":1648057202,"summary":"The question of what is happening to the tendon with BFR therapy has been a hot topic of discussion since the early days of military application. This is an area where there has been scarce information available. A study by Centner et al. was published at the end of this last year and it helps to add information to knowledge base on BFR therapy and tendon. \n\nThis study aimed to compare changes in Achilles tendon properties (size and stiffness) after performing BFR therapy with light load (LL-BFR) or heavy load (HL). There was also a non-exercising control group. Standing and seated heel raises were performed 3 days per week for 14 weeks and 1 RM was assessed and the loading was progressed every 4 weeks. The HL group performed exercise at 70% of 1RM for the first four weeks and progressed the load by 5% every four weeks, utilizing an 85% load for the final 2 weeks. The LL-BFR group performed exercise with 20% of 1RM for the first four weeks and progressed the load by 5% every four weeks, utilizing a 35% load for the final 2 weeks. The HL group performed 3 sets of 6-12 reps per exercise and the LL-BFR group performed the standard 30,15,15,15 for each exercise. A 60 second rest period was used between sets for both groups and the LL-BFR group used a 50% limb occlusion pressure (LOP) that was measured every session in the standing position. The main findings of the study were that the HL and LL-BFR protocols produced similar changes in muscle size and strength as well as similar changes in tendon CSA and mechanical properties (stiffness). \n\nThis article is really fascinating for many reasons. For starters, it shows similar changes in tendon adaptation when comparing BFR to heavy load. It's obviously a mistake to draw any strong conclusions from just one paper, but these findings certainly help counter the concern that BFR therapy may cause adaption in muscle that outpaces tendon. Second, the study was designed with a standardized progression of loading for both groups which can and probably should be carried over into our exercise prescription in rehab. Re-assess load every four weeks to establish a new rep max and apply a greater percentage of load. Third, the study applied 50% of LOP which is below the 60% threshold we've seen in other articles and typically teach in our courses for LE exercise. This lower percentage being effective may be related to the measurement being taken in standing. Hughes et al. demonstrated a significant difference in arterial occlusion pressure when comparing measurements taken in supine to seated and standing. The average pressure in supine was 187mmHg and the average in standing was 241mmHg. (Hughes 2018) Based on the numbers from this paper by Hughes, 50% pressure from the standing measurement (120mmHg) would be equal to 64% of the pressure measured in supine. This would bring it up into the 60-80% range we think of as being effective. \n\nThis seems to be another valuable piece to add to the BFR puzzle. The big takeaways are that BFR therapy is affecting more than just muscle and we need to progress the load! Listen to our most recent podcast episode to learn more about using low-load BFR therapy for the Achilles tendon. \n\nCentner C, Lauber B, Seynnes OR, et al. Low-load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared to high-load resistance training. J Appl Physiol. November 2019. doi:10.1152\/japplphysiol.00602.2019 Hughes L, Jeffries O, Waldron M, et al. Influence and reliability of lower-limb arterial occlusion pressure at different body positions. PeerJ. 2018;6:e4697.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5249,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-and-tendon-2","id":"blog\/bfr-and-tendon-2","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-7.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"BFR AND THROMBOPHILIA","permalink":"bfr-and-thrombophilia","timestamp":1648057202,"summary":"From the moment researchers began investigating the hypertrophic and strength adaptations achieved through blood flow restricted exercise, nearly every discussion section of every published paper included some version of, \u201cIt seems like this technique would be quite valuable to the rehab community.\u201d Well, these musings are certainly being realized today in musculoskeletal rehab. And while researchers posed these curiosities, they carried on attempting to elucidate the overall safety of the technique as a number of questions were important to answer. Two questions were of paramount concern:\n\nWill BFR cause a clot?What are the hemodynamic implications?\n\nWe\u2019ll tackle blood pressure and heart rate responses in another blog, and previously we\u2019ve tackled the VTE question more broadly. For this blog we\u2019d like to put out some thoughts on whether or not BFR exercise should be considered if your client has an inherited thrombophilia. If you recall from our podcast on VTE, Ben showed everyone up with his pronunciation of Virchow\u2019s Triad (fact check: it\u2019s actually pronounced \u201cfear-hoff\u201d not \u201cfear-chow\u201d), but also that Virchow\u2019s Triad is important foundational knowledge for understanding the risk of VTE. That knowledge will help us reason through whether or not to use BFR on a person with an inherited thrombophilia. Here\u2019s a graphic we made to illustrate Virchow\u2019s Triad:\n\n\n\n\n\n\n\nInherited thrombophilias will fall under the hypercoagulability portion of Virchow\u2019s Triad. An important point regarding hypercoagulability is that it encompasses both \u201cacquired\u201d and \u201chereditary\u201d forms. \u201cAcquired\u201d hypercoagulability refers to a circumstance that happens to a person. The easiest way to think about that is surgery; you\u2019ll get both endothelial damage from any incisions and stasis from reduced physical activity which will combine for increased acquired hypercoagulability. To better understand the inherited thrombophilias it is helpful to grasp the basic principle that at any point in time our body is cycling through the expression of coagulation or anti-coagulation factors. For illustration purposes, we could draw a parallel to how at any given point in the day the human body is either trying to make muscle via muscle protein synthesis or break it down via muscle protein breakdown. Persons with thrombophilia have elevated resting levels of coagulation factors or decreased levels of anti-coagulation factors. This, combined with endothelial damage or stasis further amplifies an already elevated level of clot formation risk since the body is not clearing these factors as easily due to stasis, or it is actively trying to clot in response to damage.\n\nOur approach to reasoning through any safety concerns related to BFR is to first identify what the potential concern is, investigate any literature on that condition \/ injury \/ etc. to flesh out more specifically what to look for, and then to assess the surgical tourniquet and exercise literature for any evidence that they influence our concern positively or negatively. We then will cull the BFR literature for anything that has specifically looked at our concern.\n\nHere\u2019s a sample of how we might think through the use of BFR in the presence of an inherited thrombophilia:\n\nWhat is our concern? Our concern is that BFR might increase one\u2019s risk of clot formation in persons with inherited thrombophilias. What do we know regarding why someone with an inherited thrombophilia forms a clot? From the Bond paper in JOSPT we know that it\u2019s very uncommon for a person with a thrombophilia to spontaneously form a clot. Clot formation is almost always tied to an acquired form of hypercoagulability. What does the literature say re: use of surgical tourniquets on persons with inherited thrombophilias? Nothing What does the exercise literature say re: risks to persons with inherited thrombophilias? Nothing What does the BFR literature say re: risks to persons with inherited thrombophilias?Absolutely nothing \n\nWell that clears things up nicely doesn\u2019t it? Obviously not, but this circumstance is pretty common when trying to make a reasoned decision with BFR as it pertains to the current literature base. We\u2019ve said time and again the literature is very limited on clinical applications, and those of you that have reached out with questions or posted in our Inside Circle know all too well that we routinely give you a \u00af\\_(\u30c4)_\/\u00af when posed a question related to an uncommon or at times common condition. We do, however, have a number of papers that have examined the use of BFR both acutely and chronically on factors that indicate endothelial damage or stasis. To date no study has pointed to BFR amplifying either of those. Combining that with the knowledge that thrombophilias have a low prevalence, Factor V Leiden is the most common at 3-7% of the US population, and clots are very rare in the absence of an acquired hypercoagulability, even in those with thrombophilia, gives us a framework from which to make a good clinically reasoned decision.\n\nOUR GUIDANCE...\n\nShared decision making is the bedrock of any intervention that a healthcare provider delivers. If your patient in fact knows they have a thrombophilia and has no history of VTE, the odds are, based upon what we\u2019ve presented you here that they will be just fine. But, you should discuss with them that there is no specific literature as it pertains to their thrombophilia and BFR exercise making it impossible to know one way or the other what the true risk is. If your patient has a history of VTE, or recently had surgery, this decision gets substantially more difficult as your client\u2019s risk for clot is exponentially increased. In this circumstance there should definitely be some consultation with the referring MD and potentially your patient\u2019s hematologist. It\u2019s our opinion that the medical team, along with the patient, must all agree that BFR is a very important piece to a successful course of care and is worth the potential risk that a clot may occur given all the factors on board.\n\nWe hope this is helpful! Stay tuned for our upcoming blog on hemodynamic responses for Ben! We\u2019ve provided some additional resources on VTE and thrombophilia below.\n\nCDC Resource on VTE\n\nBond paper from JOSPT on VTE\n\nAdditional information on thrombophilias also here\n\nAmerican Society for Hematologists CPG\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6416,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-and-thrombophilia","id":"blog\/bfr-and-thrombophilia","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-1.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"BLOOD FLOW RESTRICTION IN THE ASPETAR SPORTS MEDICINE JOURNAL","permalink":"blood-flow-restriction-in-the-aspetar-sports-medicine-journal","timestamp":1648057202,"summary":"Aspetar recently released Volume 9 of their Sports Medicine Journal. This volume is open access and covers everything from assessment through reconditioning after ACL reconstruction. Johnny Owens, Stephen Patterson, and Luke Hughes were featured to address the use of BFR training in early stage rehab from ACLR and how that might impact return to play. \n\n\n\n\n\nHere are some highlights from the article: \n\n\u201cThe low-load nature of BFR training and ability to create muscle hypertrophy and subsequent strength gains make it a powerful clinical rehabilitation tool; an alternative to heavy-load resistance training in populations that require muscle hypertrophy and strengths gains but in which heavy-loading of the musculoskeletal system is contraindicated.\u201d \n\n\u201cCumulatively, studies indicate that BFR training performed at a much lower exercise intensity improves physical function, pain and swelling to a greater extent than traditional resistance training, without any detrimental effect on muscle hypertrophy and strength adaptations.\u201d \n\n\u201cBy using BFR earlier in the rehabilitation to offset atrophy and strength loss (phase 1) and improve strength and hypertrophy (phase 2), practitioners can spend more time focussing on neuromuscular control, functional strength, rate of force development, and psychological readiness which are necessary for a successful return to competition and reducing the risk of re- injury.\u201d \n\nGet access to the full Journal edition at the Aspetar site: https:\/\/www.aspetar.com\/journal\/\n\nAdditional Featured Topics: \n\nIs it time to change how we assess functional performance following ACL reconstruction? Inter-limb asymmetry during rehabilitation Assessing vertical jump force-time asymmetries in athletes with Anterior Cruciate Ligament injury Single vs double leg countermovement jump tests Taking a step back to reconsider change of direction and its application following ACL Injury Applying the principles of motor learning to optimize rehabilitation and enhance performance after ACL injury Neuroplastic Multimodal ACL rehabilitation The future of ACL prevention and rehabilitation Reconstructing Cognitive function following ACL injury From control to chaos to competition\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6067,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/blood-flow-restriction-in-the-aspetar-sports-medicine-journal","id":"blog\/blood-flow-restriction-in-the-aspetar-sports-medicine-journal","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-5.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"HIGH INTENSITY LEG PRESS DOES NOT INCREASE LEG EXTENSION STRENGTH WITH OR WITHOUT BFR AFTER ACL","permalink":"high-intensity-leg-press-does-not-increase-leg-extension-strength-with-or-without-bfr-after-acl","timestamp":1648057202,"summary":"Anterior Cruciate Ligament (ACL) Reconstruction is one of the most commonly performed orthopedic procedures yearly in the United States, with injury estimates around 250,000 per year. (Mendias et al. 2013) A primary focus of rehabilitation post-ACLR is restoring quadriceps strength given it\u2019s strong relationship to graft protection and the fact that strength deficits frequently persist well beyond return to play timelines. Gumucio et al reported deficits of greater than 20% in knee extensor strength at 6 months post-ACLR. (Gumucio et al. 2018) Their unique study design identified an early deficit in cross-sectional area (CSA) of the quad that was unresolved at 6 months. Leading the researchers to conclude, in context of other recent works, that perhaps early phase rehab should increase its focus on hypertrophy via exercise prescription and \/ or pharmacologic intervention.\n\nRecently Hughes and colleagues demonstrated that following ACLR, low load exercise with BFR may result in similar increases in muscle size and strength when compared to a heavy load control.(Hughes et al. 2019) Of particular value was the fact that subjects in the BFR group had less pain, better ROM, and less joint swelling than their higher load counterparts. The ability to restore muscle CSA in the early phases of ACLR rehab, while facilitating a \u201cquiet knee\u201d, could be very valuable in the restoration of strength loss owing to a neuromuscular cause later. In theory, a \u201cquieter knee\u201d would reduce local neuromuscular contribution to strength deficits via arthrogenic muscular inhibition. This lines up nicely with the aforementioned Gumucio conclusions.\n\nGenerally, it is thought that the early phase use of BFR is the best target in rehab after ACLR. The data on this remains limited, but until recently no one had examined coupling higher load BFR in a later stage of this rehab process. In our featured paper here, a group from the University of Michigan investigated the application of heavy load BFR following ACLR. Their results lead them to title their paper, \u201cBlood Flow Restriction Training Applied with High-Intensity Exercise does not Improve Quadriceps Muscle Function After Anterior Cruciate Ligament Reconstruction.\u201d Beginning at 10 weeks post-op, and continuing at a visit frequency of twice weekly for 8 weeks, four groups performed high intensity leg press exercise as an addition to \u201cstandard-of-care rehabilitation\u201d. The authors found no significant differences between any groups in quadriceps muscle strength, size, or activation.\n\nHere is a quick recap of the intervention:\n\n Groups%1RM%LOPSets \/ RepsRestROMSize \u2191Strength \u2191Con HL70%N\/A4 \/ 102 min20-60\u00b0NoNoEcc HL70%N\/A4 \/ 102 min20-60\u00b0NoNoCon HL + BFR70%80%4 \/ 102 min20-60\u00b0NoNoEcc HL + BFR70%80%4 \/ 102 min20-60\u00b0NoNo\n\n* All groups performed a 20% 1RM warm-up set of 10 reps\n\nThis study provides some good insight into how BFR is best used. Only a few studies have investigated the coupling of heavy loads with BFR. This, like others, indicates it provides no added value to lifting heavy in a traditional fashion. Further, it is possible that the protocol used in this study was insufficient to cause adaptation regardless of the BFR condition. You\u2019ll note, no group achieved significant changes in muscle size and strength. There are a few potential reasons for this. One is that given the later stage in rehab, subjects may have simply needed a longer duration study to achieve increases in size and strength. Afterall, ACSM guidelines state 12-16 weeks are required for increases in size and strength in the uninjured. Other potential reasons for the lack of change could be: quad strength was tested in a different manner than trained (knee ext vs leg press), the limited ROM utilized (20-60\u00b0), only the concentric or eccentric phase of movement was trained, and the \u201cprimary aim\u201d values were compared to pre-op values vs pre-intervention. Lastly, the authors do not provide enough detail regarding their \u201cstandard-of-care rehabilitation\u201d routine, completed by both groups, to determine whether or not there is a potential session or weekly training volume limitation.\n\nOur readers will note, the application of BFR in this study does not align with the recent Position Stand guidelines. That, however, does not diminish the value of this paper in our mind. While we need work showing us how best to perform BFR, we also need more information on what does not work. Presently, with regard to BFR and its role in ACLR rehabilitation, we\u2019d say it fits best with light loads and earlier on in the rehab continuum.\n\nFor additional thoughts on this we\u2019d direct you to the previous blog post on ACLR rehab or the recent piece on BFR in ACLR rehab in the Aspetar Sports Medicine Journal written by Stephen Patterson, PhD, Luke Hughes, PhD, and Johnny Owens, PT.\n\nMendias CL, Lynch EB, Davis ME, et al. Changes in circulating biomarkers of muscle atrophy, inflammation, and cartilage turnover in patients undergoing anterior cruciate ligament reconstruction and rehabilitation. Am J Sports Med. 2013;41(8):1819-1826. Gumucio JP, Sugg KB, Enselman ERS, et al. Anterior cruciate ligament tear induces a sustained loss of muscle fiber force production. Muscle Nerve. January 2018. doi:10.1002\/mus.26075 Hughes L, Rosenblatt B, Haddad F, et al. Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports Med. July 2019. doi:10.1007\/s40279-019-01137-2 Curran MT, Bedi A, Mendias CL, Wojtys EM, Kujawa MV, Palmieri-Smith RM. Blood Flow Restriction Training Applied With High-Intensity Exercise Does Not Improve Quadriceps Muscle Function After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. Am J Sports Med. 2020;48(4):825-837.\n\n\n\n\n\n\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5774,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/high-intensity-leg-press-does-not-increase-leg-extension-strength-with-or-without-bfr-after-acl","id":"blog\/high-intensity-leg-press-does-not-increase-leg-extension-strength-with-or-without-bfr-after-acl","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-6.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"HOW NEW TECHNOLOGY IS IMPROVING PHYSICAL THERAPY","permalink":"how-new-technology-is-improving-physical-therapy","timestamp":1648057202,"summary":"Recently, Johnny was able to team up with clinicians from the University of Colorado Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation and the Sports Medicine Division, United States Olympic & Paralympic Committee, to write a paper on \"How Technology is Improving Physical Therapy\" in Current Reviews in Musculoskeletal Medicine. The paper includes sections on Blood Flow Restriction, exoskeletons for high energy lower extremity trauma, force plates, motion capture and biofeedback, musculoskeletal ultrasound, instrumented insoles, patient-centered tools, and personalized reference charts. It covers musculoskeletal injuries ranging from Sports Medicine to Total Joint Arthroplasty. Here are some interesting snippets from the paper:\n\n\n\nBlood Flow Restriction: \"Since the majority of orthopedic patients experience periods of disuse from injury or surgery, BFR appears to be a promising new technique to mitigate the loss of muscle that has historically been an accepted consequence of injury.\"\n\n\n\nExoskeletons for High Energy Lower Extremity Trauma: \"The IDEO utilizes a foot-plate with a rollover design to allow engagement from heel strike to toe-off to load posterior struts that simulate plantarflexion torque. Additionally, minimal ankle and foot range of motion is allowed in the IDEO which helps reduce pain from sources like post-traumatic osteoarthritis.\"\n\n\n\nForce Plates: \"During rehabilitation, deficits in kinetic performance are identified via a comparison of force during bilateral tasks. These deficits are targeted in rehabilitation or training plans and monitored as outcome measures.\"\n\n\n\nMotion Capture and Video Biofeedback: \"Real-time video or motion capture biofeedback increases a patient\u2019s awareness of their movement signature. Patients can interact with live motion capture displays to modify or correct their movement based on clinician cues.\"\n\n\n\nMusculoskeletal Ultrasound in Soft Tissue Injury: \"We can now visualize soft tissue healing, quantify muscle architecture, and evaluate changes in muscle stiffness and density. These innovations are changing the way we understand muscle recovery from injury\u2014an important development that will improve clinical decision making.\"\n\n\n\nInstrumented Insoles: Use of Real-time Feedback to Improve Patient Outcomes: \"Instrumented insoles provide a means of assessing movement quality during a variety of activities occurring in real life environments using varying feedback schedules for optimal motor learning.\"\n\n\n\nPatient-centered Care in Total Joint Arthroplasty: Tools for Personalized Care Before and After Surgery: \" The Arthroplasty Candidacy Help Engine (ACHE) tool utilizes regression modeling with common PROMs to determine a patient\u2019s likelihood of having a successful outcome after TJA\"\n\n\n\nPersonalized Reference Charts: a Novel Tool for Personalized Care: \"This approach matches individual patients with similar patients from historical data and utilizes the recovery data from these historical patients to create a personalized estimate of the recovery trajectory for the individual. This \u201cpeople-like-me\u201d methodology has been proposed as a useful tool for informing patient expectations and postoperative monitoring in patients recovering from orthopedic surgery.\"\n\n\n\nThe journal was nice enough to provide Johnny with a link that can be shared to access the text for a short time. Just like the toilet paper and paper towels on the store shelves, this link won't last long but you can find it here.\n\n\n\nOwens, J. G., Rauzi, M. R., Kittelson, A., Graber, J., Bade, M. J., Johnson, J., & Nabhan, D. (2020). How New Technology Is Improving Physical Therapy. Current Reviews in Musculoskeletal Medicine, 1-12.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":7462,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/how-new-technology-is-improving-physical-therapy","id":"blog\/how-new-technology-is-improving-physical-therapy","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-11.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"IS THERE A PAIN MODULATION EFFECT WITH BLOOD FLOW RESTRICTION EXERCISE?","permalink":"is-there-a-pain-modulation-effect-with-blood-flow-restriction-exercise","timestamp":1648057202,"summary":"Blood flow restriction resistance exercise (BFR-RE) has been shown to reduce pain across a training program in a range of clinical conditions (Ferraz et al., 2017; Giles et al., 2017; Hughes et al., 2019). Interestingly, the reduction in pain with low load BFR-RE appears to be greater than high load exercise (HL-RE). It is logical to assume that this may be primarily caused by the lower loads used during BFR-RE, which places less loading induced strain on a pathological joint or limb. However, recent studies suggest there may be an acute reduction in pain with BFR-RE, or \u201chypoalgesia effect\u201d (Cook and Koltyn, 2000). \n\nExercise is known to decrease sensitivity to pain, an endogenous form of pain modulation termed \u2018exercise-induced hypoalgesia\u2019 (EIH) (Koltyn, 2000). Pain desensitisation following exercise is not limited to the exercising limb, and is observed in non-exercising muscles in remote areas of the body (Hughes and Patterson, 2019). This suggests that both local manifestations and spinal \/ supraspinal nociceptive pathways drive a multi-segmental pain inhibitory effect with exercise. Similarly to other exercise-induced adaptations such as increased muscle strength, the magnitude of EIH appears to be augmented with higher intensity exercise of longer duration (Vaegter, Handberg and Graven-Nielsen, 2014). \n\nRecent evidence shows EIH occurs when low intensity exercise (e.g. \u226430% 1RM) is performed with BFR (Korakakis, Whiteley and Epameinontidis, 2018; Korakakis, Whiteley and Giakas, 2018). A single bout of low intensity knee extension exercise with BFR was found to reduce anterior knee pain immediately post-exercise in individuals with knee pain, compared to the same exercise protocol without BFR. This effect was sustained for a minimum of 45 minutes, and allowed the individuals to better tolerate exercise with greater loads during this 45 minute period (Korakakis, Whiteley and Epameinontidis, 2018; Korakakis, Whiteley and Giakas, 2018). Although only a subjective measure of pain was used in these studies, it provided the first evidence of a possible hypoalgesia effect with BFR. \n\nThe recent work by Hughes & Patterson (2019 & 2020) investigated hypoalgesia with BFR exercise in greater depth. Initially, the authors published a review paper in Medical Hypothesis, which discussed the literature regarding mechanisms of exercise-induced hypoalgesia with traditional exercise and speculated on possible mechanisms with BFR-RE (Hughes and Patterson, 2019). In this paper, they discussed the possible role of endogenous opioid and non-opioid mechanisms in pain reduction. During intense and painful exercise, opioid and non-opioid substances are released into blood circulation which bind to their target receptors and contribute to pain inhibition. \n\nTo investigate their hypotheses experimentally, 12 subjects, in a randomised crossover design, performed four experimental arms involving dominant limb unilateral leg press exercise (Hughes and Patterson, 2020). Three arms comprised low intensity resistance exercise at 30% of one repetition maximum; one arm was performed with free flow, while the other two were performed with BFR applied continuously at 40% and 80% LOP. The individuals in the low-load arms performed a rep \/ set scheme of 30 \/ 15 \/ 15 \/ 15 with 30 second interset rest periods. The fourth arm comprised HL-RE at 70% of one repetition maximum, where the individuals performed 4 x 10 repetitions with 53 second interset rest periods. This HL-RE protocol was designed to match the duration of the low-intensity portions of the trial, so that pre- and post-exercise measures of pain were conducted at the same time after completion across all arms. \n\nThe authors measured pain thresholds pre- and post-exercise using mechanical algometry; this was performed in the exercising limb and in remote non-exercising muscles around the body. Blood samples were obtained to examine blood markers of endogenous systems that may contribute to pain inhibition. The authors found that BFR-RE resulted in a greater hypoalgesia effect than free flow low intensity resistance in the exercising limb, as well as remote muscles. The HL-RE group and both BFR-RE groups elicited similar reductions of pain in remote muscles. In the exercising limb, BFR-RE at 40% LOP produced similar pain inhibition as HL-RE, while BFR-RE at 80% LOP produced the greatest hypoalgesia response. Interestingly, pain inhibition was still evident in the exercising limb at 24 hours after exercise in both of the BFR-RE arms. The authors also found increases in circulating plasma beta-endorphin concentration, which is part of the endogenous opioid system and contributed to the hypoalgesia effect. \n\nSeveral clinically relevant conclusions can be drawn from the existing literature at present (Hughes and Patterson, 2020).\n\nBFR-RE appears to cause acute hypoalgesia that may last for up to 24 hours.This has important implications for patients who may need to tolerate more load during rehab (e.g. painful tendinopathies)Clinicians may be able to have a lasting effect on their patient\u2019s pain in the day after a rehabilitation session.It appears that higher pressure BFR augments the effect on pain. This may partly be driven by endogenous opioid production in response to the muscle discomfort generated during BFR-RE.A systemic effect on pain is observed with BFR-RE, therefore it is possible that an individual can train an unaffected limb with BFR to trigger a reduction in pain in an injured limb, which would be particularly useful in the early stages following injury and surgery (Hughes and Patterson, 2020).\n\nReferences\n\nCook, D. B. and Koltyn, K. F. (2000) \u2018Pain and exercise.\u2019, International Journal of Sport Psychology, 31, pp. 256\u2013277.Ferraz, R. B. et al. (2017) Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis, Medicine and Science in Sports and Exercise. doi: 10.1249\/MSS.0000000000001530.Giles, L. et al. (2017) \u2018Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: A double-blind randomised trial\u2019, British Journal of Sports Medicine, 51(23), pp. 1688\u20131694. doi: 10.1136\/bjsports-2016-096329.Hughes, L. et al. (2019) \u2018Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial\u2019, Sports Medicine, 49(11), pp. 1787\u20131805. doi: 10.1007\/s40279-019-01137-2.Hughes, L. and Patterson, S. D. (2019) \u2018Low intensity blood flow restriction exercise: Rationale for a hypoalgesia effect\u2019, Medical Hypotheses, 132, p. 109370. doi: 10.1016\/j.mehy.2019.109370.Hughes, L. and Patterson, S. D. (2020) \u2018The effect of blood flow restriction exercise on exercise-induced hypoalgesia and endogenous opioid and endocannabinoid mechanisms of pain modulation\u2019, Journal of Applied Physiology, 128. doi: 10.1152\/japplphysiol.00768.2019.Koltyn, K. F. (2000) \u2018Analgesia following exercise: A review\u2019, Sports Medicine, 29(2), pp. 85\u201398. doi: 10.2165\/00007256-200029020-00002.Korakakis, V., Whiteley, R. and Epameinontidis, K. (2018) \u2018Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading\u2019, Physical Therapy in Sport. Elsevier Ltd, 32, pp. 235\u2013243. doi: 10.1016\/j.ptsp.2018.05.021.Korakakis, V., Whiteley, R. and Giakas, G. (2018) \u2018Low load resistance training with blood flow restriction decreases anterior knee pain more than resistance training alone. A pilot randomised controlled trial\u2019, Physical Therapy in Sport. Elsevier B.V., 34, pp. 121\u2013128. doi: 10.1016\/j.ptsp.2018.09.007.Vaegter, H. B., Handberg, G. and Graven-Nielsen, T. (2014) \u2018Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans\u2019, Pain. International Association for the Study of Pain, 155(1), pp. 158\u2013167. doi: 10.1016\/j.pain.2013.09.023.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6108,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/is-there-a-pain-modulation-effect-with-blood-flow-restriction-exercise","id":"blog\/is-there-a-pain-modulation-effect-with-blood-flow-restriction-exercise","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content-jpg\/ORS-HamCurl-3.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"IS THERE AN INCREASED RISK FOR VTE WITH BFR? ","permalink":"is-there-an-increased-risk-for-vte-with-bfr","timestamp":1648057202,"summary":"A potential risk for clotting or venous thromboembolism (VTE) has been a commonly voiced concern since the early days of BFR application. This is an understandable concern given the publications that highlight an increased incidence rate of VTE after surgery, and many common orthopedic procedures involve tourniquet use. (Sweetland et al. 2009)\n\nThis raises a few questions:\n\nWhat causes VTE? Does the application of a tourniquet for surgery increase the incidence of VTE post-surgically? Would the use of a tourniquet for BFR increase risk of VTE? \n\nThe formation of a VTE appears to be multifactorial. Bond et al recently put out a very good review in which they discuss a balance between coagulation and fibrinolysis. (Bond et al. 2019) They highlight that the formation of a VTE typically comes from a combination of more than one of the following: inherited or acquired thrombophilia (hypercoagulability), endothelial injury, and stasis. (Bond et al. 2019) These three factors are referred to as Virchow\u2019s triad and should be screened by the clinician. Endothelial injury is implied following orthopedic surgery, and will be coupled with physician imposed or self-imposed activity limitation (stasis). Clinically we should be mindful of the signs and symptoms of DVT: unexplained swelling, pain, cramping, soreness, red or discolored skin, or feeling of warmth in the affected limb. Additionally, some useful tools like this one from Caprini have been developed: https:\/\/venousdisease.com\/dvt-risk-assessment-online\/\n\nAccording to a study by Ocak et al, the incidence for VTE is around 1 to 2 per 1000 people per year. (Ocak et al. 2013) That\u2019s only a 0.1 to 0.2% incidence rate which is pretty low, albeit higher than many clinicians might have expected. This risk is significantly amplified after surgery. A large scale study by Sweetland et al followed 947,000+ middle aged women in the UK and found they were 70 times more likely to have a VTE in the 6 weeks following an inpatient surgery and 10 times more likely in the 6 weeks after an outpatient procedure.(Sweetland et al. 2009) Further, studies have sought to determine the causality of VTE following surgery with or without tourniquet use. A study by Jarrett et al found a high incidence of asymptomatic VTE intra-operatively that was not statistically different between tourniquet and non-tourniquet groups. (Jarrett et al. 2004) Fascinatingly, they reported visualized asymptomatic clots via ultrasound in 70% of the individuals. There is no question the risk for VTE is elevated during and after surgery, but it doesn\u2019t appear that the application of a tourniquet is directly related to the elevated risk. Interestingly, Jarrett et al went on to say, \u201cIt is possible that small venous emboli are a common physiological event during life and that the lungs are readily able to clear small numbers of small emboli.\u201d (Jarrett et al. 2004)\n\nThe risk for VTE with BFR has been assessed both acutely and chronically; we can also look at reported events longitudinally. Some of the common blood markers for VTE include D-Dimer, Fibrinogen, and CRP. BFR studies on young healthy individuals, individuals after bed rest or at simulated altitude, elderly individuals, or individuals with ischemic heart disease found no elevation in markers for VTE after one application. (Manini et al. 2012; Madarame et al. 2010; Nakajima et al. 2007; Fry et al. 2010; Madarame et al. 2013) Studies that assessed markers for VTE across multiple weeks of BFR application in young healthy individuals, elderly individuals, and after knee arthroscopy also found no elevation compared to a work-matched control. (Clark et al. 2011; Yasuda et al. 2014; Yasuda et al. 2014; Tennent et al. 2017) Johnny Owens and his co-authors at the Department of Defense examined bilateral duplex ultrasound evaluations on subjects using BFR or work matched free-flow controls before surgery and 4-weeks after knee arthroscopy and found no differences between groups. When looking at the totality of the research, there is one reported case of an individual performing chronic BFR and a VTE episode. (Noto et al. 2017) The case report is on a female instructor for KAATSU that had been performing bilateral UE BFR 3 days a week for 2 years with 30 minutes to an hour inflation of the cuffs per session. She reports having localized swelling and tenderness around the left collarbone for the 6 years leading up to the VTE. She was diagnosed with Thoracic Outlet and Paget-Schroetter Syndrome. Even though the application of BFR, in this case, doesn\u2019t match current guidelines, it\u2019s hard to say that BFR is what caused the VTE in light of her chronic confounding symptoms.\n\nFurther reassurance can be drawn from the fact that across millions of clinical applications there are not any reported VTE events involving BFR. Our recommendation will always be to apply BFR in a way that matches up with current best practices. If a patient doesn\u2019t exhibit any signs or symptoms of a VTE, there is a very low likelihood that BFR will increase the risk. As with everything done in a rehabilitation setting, sound reasoning and good clinical judgement are important for safe and successful implementation of BFR.\n\nBond et al described key points for best VTE practice that align 100% with the guidelines we at Owens Recovery Science have championed:\n\n\u201cSome clinicians may use rudimentary techniques to achieve occlusion, such as surgical tubing or elastic straps wrapped tightly around the proximal portion of the exercising limb. This method may or may not completely occlude all arterial and venous blood flow, and there is no way of knowing what occlusive pres\u00adsure the vessels experience. Further, the relatively thin diameter of the tubing or straps may cause highly localized stresses and an ineffective transmission of pres\u00adsure, potentially causing direct damage to the soft tissues and structures underneath the application site\u201d.\n\n\u201cA pressure specific to each individual would be the safest prescription meth\u00adod, because the same pressure may not necessarily occlude the same amount of blood flow for all individuals under the same conditions\u201d. ie...avoid unnecessary stasis\n\n\u201cThe cuffs developed for BFR are wider than those traditionally used. The most frequently used cuff width is 10 to 12 cm, although cuffs greater than 15 cm may be more desirable. Additionally, cuffs are now tapered to conform with the natural proximal-to-distal narrowing of the thigh or upper arm and are limb-circumference specific, which allows them to be fitted to various limb circumferences. Together, these advances enhance the transmis\u00adsion of pressure, and may appropriately mitigate complications caused by finely localized stresses from the cuff itself and reduce the pressure required to reach the same level of occlusion achieved with narrower cuffs\u201d.\n\n\u201cThe collective literature suggests that a proper prescription of BFR in the context of Virchow\u2019s triad would not heighten the risk of developing VTE. Nonetheless, clinicians need to thoroughly screen for VTE signs and symptoms and be cognizant of each patient\u2019s VTE risk factors before proceeding with BFR, particularly given the risk of asymptomatic DVT. Health care professionals must also make sure they have the proper training and are using the correct BFR equipment and pressure prescription techniques to ensure their patients\u2019 safety\u201d.\n\n\n\nSweetland S, Green J, Liu B, et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ. 2009;339:b4583. Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstr\u00f8m J. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost. 2007;5(4):692-699. Ocak G, Vossen CY, Verduijn M, et al. Risk of venous thrombosis in patients with major illnesses: results from the MEGA study: Major illnesses and venous thrombosis. J Thromb Haemost. 2013;11(1):116-123. Bond CW, Hackney KJ, Brown SL, Noonan BC. Blood Flow Restriction Resistance Exercise as a Rehabilitation Modality Following Orthopaedic Surgery: A Review of Venous Thromboembolism Risk. J Orthop Sports Phys Ther. 2019;49(1):17-27. Nakajima T, Takano H, Kurano M, Iida H. Effects of KAATSU training on haemostasis in healthy subjects. of KAATSU Training \u2026. 2007. https:\/\/www.jstage.jst.go.jp\/article\/ijktr\/3\/1\/3_1_11\/_article\/-char\/ja\/. Jarrett PM, Ritchie IK, Albadran L, Glen SK, Bridges AB, Ely M. Do thigh tourniquets contribute to the formation of intra-operative venous emboli? Acta Orthop Belg. 2004;70(3):253-259. Madarame H, Kurano M, Fukumura K. Haemostatic and inflammatory responses to blood flow\u2010restricted exercise in patients with ischaemic heart disease: a pilot study. Clin Physiol. 2013. http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/j.1475-097X.2012.01158.x\/full. Yasuda T, Fukumura K, Uchida Y, et al. Effects of Low-Load, Elastic Band Resistance Training Combined With Blood Flow Restriction on Muscle Size and Arterial Stiffness in Older Adults. J Gerontol A Biol Sci Med Sci. 2014. doi:10.1093\/gerona\/glu084 Yasuda T, Fukumura K, Fukuda T. Muscle size and arterial stiffness after blood flow\u2010restricted low\u2010intensity resistance training in older adults. J Med. 2014. http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/sms.12087\/full. Fry CS, Glynn EL, Drummond MJ, et al. Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men. J Appl Physiol. 2010;108(5):1199-1209. Clark BC, Manini TM, Hoffman RL, et al. Relative safety of 4 weeks of blood flow-restricted resistance exercise in young, healthy adults. Scand J Med Sci Sports. 2011;21(5):653-662. Madarame H, Kurano M, Takano H, et al. Effects of low-intensity resistance exercise with blood flow restriction on coagulation system in healthy subjects. Clin Physiol Funct Imaging. 2010;30(3):210-213. Manini TM, Yarrow JF, Buford TW, Clark BC, Conover CF, Borst SE. Growth hormone responses to acute resistance exercise with vascular restriction in young and old men. Growth Horm IGF Res. 2012;22(5):167-172. Tennent DJ, Hylden CM, Johnson AE, Burns TC, Wilken JM, Owens JG. Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. Clin J Sport Med. 2017;27(3):245-252. Noto T, Hashimoto G, Takagi T, et al. Paget-Schroetter Syndrome Resulting from Thoracic Outlet Syndrome and KAATSU Training. Intern Med. 2017;56(19):2595-2601.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5531,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/is-there-an-increased-risk-for-vte-with-bfr","id":"blog\/is-there-an-increased-risk-for-vte-with-bfr","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-13.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"ISCHEMIC PRECONDITIONING FOR IMPROVED CYCLING PERFORMANCE","permalink":"ischemic-preconditioning-for-improved-cycling-performance","timestamp":1648057202,"summary":"This paper covers a study on ischemic preconditioning to improve cycling performance. Learn more about the findings below. For those of you that are unfamiliar with Ischemic Preconditioning (IPC), it involves the use of brief bouts of ischemia and reperfusion to elicit effects on a local or remote target tissue. It has been used in studies to target improvements in performance (Patterson 2015, Griffin 2018, Jean-St-Michael 2011) and recovery from high intensity exercise bouts (Beaven 2012, Page 2017, Franz 2018).\n\nIn a recent systematic review by Incognito et al, the results of IPC on performance outcomes were found to be inconsistent. (Incognito 2016) One of the proposed ideas for inconsistent results is that there may be responders and non-responders. Another potential reason for variability in the results is lack of control across populations or research methods. \"In addition to potential differences in IPC responsiveness, it is difficult to compare results between studies as participant characteristics (e.g., sex, training status) and study methods (e.g., exercise mode, pre-study restrictions, IPC protocol) differ widely.\" Many of the early IPC studies (which seem to be pretty effective) were performed on animals and involved clamping of an artery to create the bouts of ischemia. In the studies that have been done on humans, most of the studies use 200 or 220 mmHg for the \"occlusive\" stimulus. If you've been using BFR in the clinic, you know that 200 or 220 would be full occlusion for some, but not all individuals. The use of potentially sub-occlusive pressure may help explain the responder versus non-responder phenomenon.\n\nCheung et al may have helped to address this gap in the literature by publishing the first IPC paper (that we know of) using personalized occlusion pressures. (Cheung 2019) Cheung et al used a within subject design to compare the application of IPC versus a sham and a control condition on cycling performance. IPC was applied for 4 sets of 5 minutes occlusion and reperfusion, alternating between legs. \"Inflation was controlled by a personalized tourniquet system (PTSii Delfi Medical Innovations Inc., Vancouver) set to the individualized lowest effective limb occlusion pressure (191 \u00b1 20mmHg). Limb occlusion pressure was determined by using the built-in feature of the personalized tourniquet system immediately prior to beginning IPC, with each subject in the supine position.\" For the sham treatment, they applied a sham therapeutic ultrasound which could be set up to appear as though it was running but only the timer was enabled. As the authors pointed out, it's probably easier to figure out that a cuff with no pressure is a sham treatment. Finally, the control condition involved participants laying supine for 40 minutes. An interesting addition to the study was the use of a visual analog scale for participants to rate how the treatment would affect their performance relative to the control. \"Data on participant expectations revealed that 69% (11\/16) of participants believed the IPC performance would be hindered compared to the control; whereas the SHAM ultrasound would improve performance.\" \"The major finding of the current study was that performing IPC immediately prior to incremental cycling exercise improved time-to-exhaustion (TTE) in comparison to both a traditional control and deceptive sham, despite participants\u2019 performance expectations anticipating the contrary.\"\n\nThis study supports the idea that IPC can be used prior to competition for improving performance or time to exhaustion. There are still a lot of questions about the mechanisms of IPC and what the optimal protocol would be. This was the first study to use personalized occlusion pressure and it was effective despite participant expectations, so it seems that future research needs to further explore the use of personalized pressure with IPC. Ensuring participants receive an occlusive stimulus may reduce the number of non-responders.\n\n\n\nBeaven, Christopher Martyn, et al. \u201cIntermittent Lower-Limb Occlusion Enhances Recovery after Strenuous Exercise.\u201d Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition et Metabolisme, vol. 37, no. 6, Dec. 2012, pp. 1132\u201339. Cheung, Christian P., et al. \u201cIschemic Preconditioning: Improved Cycling Performance Despite Nocebo Expectation.\u201d International Journal of Sports Physiology and Performance, Human Kinetics, June 2019, pp. 1\u201322. Franz, Alexander, et al. \u201cIschemic Preconditioning Blunts Muscle Damage Responses Induced by Eccentric Exercise.\u201d Medicine and Science in Sports and Exercise, vol. 50, no. 1, Jan. 2018, pp. 109\u201315. Griffin, Patrick J., et al. \u201cIschemic Preconditioning Enhances Critical Power during a 3 Minute All-out Cycling Test.\u201d Journal of Sports Sciences, vol. 36, no. 9, May 2018, pp. 1038\u201343. Incognito, Anthony V., et al. \u201cThe Effects of Ischemic Preconditioning on Human Exercise Performance.\u201d Sports Medicine , vol. 46, no. 4, Apr. 2016, pp. 531\u201344. Jean-St-Michel, Emilie, et al. \u201cRemote Preconditioning Improves Maximal Performance in Highly Trained Athletes.\u201d Medicine and Science in Sports and Exercise, vol. 43, no. 7, July 2011, pp. 1280\u201386. Page, Will, et al. \u201cThe Effect of Intermittent Lower Limb Occlusion on Recovery Following Exercise-Induced Muscle Damage: A Randomized Controlled Trial.\u201d Journal of Science and Medicine in Sport \/ Sports Medicine Australia, vol. 20, no. 8, Aug. 2017, pp. 729\u201333. Patterson, Stephen D., et al. \u201cThe Effect of Ischemic Preconditioning on Repeated Sprint Cycling Performance.\u201d Medicine and Science in Sports and Exercise, vol. 47, no. 8, Aug. 2015, pp. 1652\u201358.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6705,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/ischemic-preconditioning-for-improved-cycling-performance","id":"blog\/ischemic-preconditioning-for-improved-cycling-performance","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-2.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"MANAGING ACLS WITH PBFR","permalink":"managing-acls-with-pbfr","timestamp":1648057202,"summary":"ACL tears are one of the most common injuries in athletics that lead to surgical intervention. The rate at which ACL reconstructions (ACLR) are performed has risen 22% from 2002 to 2014; with the highest rates occurring in adolescents.1Unfortunately, far fewer return to their prior level of sport participation vs. anticipated (~65%2 vs ~84%3). During the immediate post-injury and post-op periods, and due to a number of factors, the quadriceps can atrophy quite rapidly. Accompanying this loss of muscle is an associated decrease in strength. Addressing this loss of size and strength is an important target for us in rehab, and one we need a deeper understanding of to help us intervene more effectively. Restoring muscle quality and quantity is our responsibility. Unfortunately, the data consistently shows we are not meeting this goal. In order to safely return to sport, and to reduce the risk of second injury, it is generally accepted that one needs to achieve a Limb Symmetry Index (LSI) of 90% in the quad and hamstring muscle groups. However, at 6 months only 34% had a LSI of 90%4, with a small increase to 43.5% at 8 months5. When strength was assessed at 9 months post ACLR, 53% met a LSI of 90%.4 Although the LSI is commonly used and recommended, it does not account for strength loss in the uninvolved limb due to disuse. To elaborate on this potential discrepancy, Wellsandt and colleagues assessed individual\u2019s strength prior to ACL reconstruction and at 6 months post-op.9 When comparing strength at 6 months post-op only, 57% achieved a LSI of 90%. When comparing this to the uninvolved side prior to surgery though, only 28% had a LSI of 90%.9 Welling\u2019s group found a similar over estimation of strength when they compared LSI to knee extensor torque normalized to bodyweight. Although 34% and 53% met a LSI index of 90% at 6 and 9 months respectively, only 27% and 40% met a peak torque of 3.0 Nm\/kg at 6 and 9 months.4 These discrepancies have even been identified in high level athletics as Herrington\u2019s group found a chronic decrement in knee extensor torque (2.76 Nm\/kg) amongst professional soccer players at 8 months following an ACLR.10 Collectively, these findings indicate a disuse effect of strength on the contralateral side, and that LSI may overestimate knee extensor strength. Thus, using established normalized values may be more representative of whether or not an athlete has achieved the necessary quadriceps strength for RTP.11\u201314 The silver lining from these papers is, the longer we rehab, the better quad strength becomes. Nevertheless, the majority of athletes return to sport prior to 9 months,5,6 resulting in a loss of self-reported function and an inability to return to their previous level of sport participation, out to 2 years.7,15\u201317 What causes these strength deficits?Too often, management of the acute post-injury is somewhat of an afterthought. The default is to manage pain and edema via RICE; gradually increasing ROM and weight bearing activity as the joint tolerates. Recent evidence, however, indicates this is a critical time point for muscle. For example, 14 days of knee immobilization lead to vastus lateralis atrophy of >3% at 5 days, progressing to 8.4% after 14 days. This corresponded to 6.8 and 18kg decreases in quad strength respectively.18 To help explain these rapid muscle changes, the authors also showed a 68% increase in the gene expression of myostatin at 5 days.18 Myostatin is a theoretical light switch that controls muscle function by inhibiting differentiating muscle stem cells,19,20 while down regulating muscle protein synthesis and upregulating muscle protein breakdown.21,22 Along with negatively impacting the muscle\u2019s ability to grow and repair, myostatin also contributes to an increase in fibrosis\/scar tissue development following an injury.25 In accordance with this, it has been shown that myostatin gene and protein expression is upregulated 2-fold in the involved quadriceps following an ACL injury.23 This has been shown to extend into the acute postop phase.24 Prior to surgery, increased myostatin levels contributed to a 51% reduction in muscle stem cells per fiber, a 30% decrease in quad muscle volume, and a 46% increase in fibrotic area compared to the contralateral quad.26 Importantly, six months of rehab failed to improve any of these variables. In fact, quad size decreased an additional 18%; contributing to a 49% deficit in LSI.26 What can be done to address this?Initially, performing a period of preoperative rehabilitation focused on normalizing quadriceps size and strength needs to be required prior to surgery. Preoperative atrophy has been shown to explain 46% of the decrement in quadriceps strength;27 with preoperative strength explaining 15% of the deficit.28 The Delaware-Oslo cohort showed that just 10 visits of pre-op physical therapy over 5 weeks significantly increased quadriceps strength and peak knee extensor torque.29 The use of BFR during this period is indispensable. Not only are BFR exercises well tolerated, low intensity BFR exercises have been shown to significantly reduce knee pain when compared to traditional low-intensity30, and moderate-intensity quadriceps strengthening exercises.31 In addition to addressing pain, 8 sessions of knee extensor training led to a 290% increase in muscle stem cells, which lead to a 30% increase in muscle fiber area in 3 weeks.32 BFR training for 8 weeks, decreased myostatin by 46% which may explain the aforementioned changes in muscle.33 Additionally, Kacin\u2019s lab showed 5 prehab sessions consisting of unilateral knee extensions with or without BFR in the week leading up to an ACLR led to a 50% increase in quadriceps blood flow in the BFR group, which corresponded to a 5% increase isometric knee extensor endurance.34 Kacin had previously identified quad muscle endurance was more protective of atrophy than strength.27 In the immediate post-op period, passive use of BFR has been shown to significantly attenuate knee extensor atrophy by over 60%.35 When combined with low intensity NMES, passive BFR led to a 3.9% increase in muscle thickness and a 7-8% increase in isokinetic strength.36 As soon as the individual is able to tolerate resistance exercise, BFR at low loads is initiated. A recent paper by Luke Hughes showed similar changes in muscle thickness between traditional post-op rehab combined with either low intensity BFR leg press exercise biweekly or moderate-high intensity leg press.37 In addition to changes in muscle thickness, both groups demonstrated a significant increase in vastus lateralis pennation angle compared (BFR: 4.1%; HIT: 3.1%).37 Of equal importance, these findings indicate that two months of traditional PT plus one BFR exercise can produce greater muscle changes compared to six months of traditional PT.26 The significance of these results extend beyond changes in muscle; the BFR group also achieved greater improvements in joint ROM, greater reductions in joint swelling, and greater self-reported functional improvements compared to the moderate-high intensity leg press group.38Muscle HypertrophyPennation AngleTraditional ACLR rehab for 6 months 26-18.4%-1.26%Traditional ACL rehab + BFR leg press for 8 weeks 375.8%4.1%Muscle changes following an injury occur extremely fast and continue to fester late into the post-op period. The typical strategy to reduce pain and increase ROM during this critical period is not enough and emphasis must be placed on addressing the disuse state of muscle that ensues. Current evidence indicates low intensity BFR exercises can suppress myostatin levels to a similar extent as performing high load lifting, helping to combat post injury \/ surgery loss of quad muscle size and strength. Additionally BFR following ACLR may produce significantly greater improvements in pain, joint ROM, and joint swelling making it a clinically viable alternative to high load training. Thank you Zac Dunkle, DPT for the write up on ACL management with PBFR. Herzog MM, Marshall SW, Lund JL, Pate V, Mack CD, Spang JT. Trends in Incidence of ACL Reconstruction and Concomitant Procedures Among Commercially Insured Individuals in the United States, 2002-2014. Sports Health. 2018;10(6):523-531. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-1552. Webster KE, Feller JA. Expectations for Return to Preinjury Sport Before and After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2019;47(3):578-583. Welling W, Benjaminse A, Seil R, Lemmink K, Zaffagnini S, Gokeler A. Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc. 2018;26(12):3636-3644. Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, Schmitt LC. Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs? J Orthop Sports Phys Ther. 2017;47(11):825-833. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804-808. Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC. Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):426-433. Beischer S, Hamrin Senorski E, Thome\u00e9 C, Samuelsson K, Thome\u00e9 R. Young athletes return too early to knee-strenuous sport, without acceptable knee function after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(7):1966-1974. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther. 2017;47(5):334-338.Herrington L, Ghulam H, Comfort P. Quadriceps Strength and Functional Performance After Anterior Cruciate Ligament Reconstruction in Professional Soccer players at Time of Return to Sport. J Strength Cond Res. August 2018. doi:10.1519\/JSC.0000000000002749 Zvijac JE, Toriscelli TA, Merrick WS, Papp DF, Kiebzak GM. Isokinetic concentric quadriceps and hamstring normative data for elite collegiate American football players participating in the NFL Scouting Combine. J Strength Cond Res. 2014;28(4):875-883. Whiteley R, Jacobsen P, Prior S, Skazalski C, Otten R, Johnson A. Correlation of isokinetic and novel hand-held dynamometry measures of knee flexion and extension strength testing. J Sci Med Sport. 2012;15(5):444-450. Bogdanis GC, Kalapotharakos VI. Knee Extension Strength and Hamstrings-to-Quadriceps Imbalances in Elite Soccer Players. Int J Sports Med. 2015;37(02):119-124. Ploutz-Snyder LL, Manini T, Ploutz-Snyder RJ, Wolf DA. Functionally relevant thresholds of quadriceps femoris strength. J Gerontol A Biol Sci Med Sci. 2002;57(4):B144-B152. Paterno MV, Ford KR, Myer GD, Heyl R, Hewett TE. Limb asymmetries in landing and jumping 2 years following anterior cruciate ligament reconstruction. Clin J Sport Med. 2007;17(4):258-262. Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV. The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2015;43(9):2242-2249. Ithurburn MP, Paterno MV, Thomas S, et al. Clinical measures associated with knee function over two years in young athletes after ACL reconstruction. Knee. 2019;26(2):355-363. Wall BT, Dirks ML, Snijders T, Senden JMG, Dolmans J, van Loon LJC. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol . 2014;210(3):600-611. McFarlane C, Hennebry A, Thomas M, et al. Myostatin signals through Pax7 to regulate satellite cell self-renewal. Exp Cell Res. 2008;314(2):317-329. Langley B, Thomas M, Bishop A, Sharma M, Gilmour S, Kambadur R. Myostatin inhibits myoblast differentiation by down-regulating MyoD expression. J Biol Chem. 2002;277(51):49831-49840. Han HQ, Mitch WE. Targeting the myostatin signaling pathway to treat muscle wasting diseases. Curr Opin Support Palliat Care. 2011;5(4):334-341. Christian Rommel, Bart Vanhaesebroeck, Peter K. Vogt, ed. Phosphoinositide 3-Kinase in Health and Disease. Vol 1. Springer; 2011:267-278. Peck BD, Brightwell CR, Johnson DL, Ireland ML, Noehren B, Fry CS. Anterior Cruciate Ligament Tear Promotes Skeletal Muscle Myostatin Expression, Fibrogenic Cell Expansion, and a Decline in Muscle Quality. Am J Sports Med. April 2019:363546519832864. Mendias CL, Lynch EB, Davis ME, et al. Changes in circulating biomarkers of muscle atrophy, inflammation, and cartilage turnover in patients undergoing anterior cruciate ligament reconstruction and rehabilitation. Am J Sports Med. 2013;41(8):1819-1826. Li ZB, Kollias HD, Wagner KR. Myostatin directly regulates skeletal muscle fibrosis. J Biol Chem. 2008;283(28):19371-19378. Noehren B, Andersen A, Hardy P, et al. Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction. J Bone Joint Surg Am. 2016;98(18):1541-1547. Grapar \u017dargi T, Drobni\u010d M, Vauhnik R, Koder J, Kacin A. Factors predicting quadriceps femoris muscle atrophy during the first 12weeks following anterior cruciate ligament reconstruction. Knee. 2017;24(2):319-328. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med. 2009;43(5):371-376. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010;40(11):705-721. Korakakis V, Whiteley R, Giakas Y. Low Load Resistance Training with Blood Flow Restriction decreases anterior knee pain more than resistance training alone. A pilot Randomised Controlled Trial. Phys Ther Sport. 2018;0(0). doi:10.1016\/j.ptsp.2018.09.007 Giles L, Webster KE, McClelland J, Cook JL. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017;51(23):1688-1694. Nielsen JL, Aagaard P, Bech RD, et al. Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction. J Physiol. 2012;590(17):4351-4361. Laurentino GC, Ugrinowitsch C, Roschel H, et al. Strength training with blood flow restriction diminishes myostatin gene expression. Med Sci Sports Exerc. 2012;44(3):406-412. \u017dargi T, Drobni\u010d M, Stra\u017ear K, Kacin A. Short\u2013Term Preconditioning With Blood Flow Restricted Exercise Preserves Quadriceps Muscle Endurance in Patients After Anterior Cruciate Ligament Reconstruction. Front Physiol. 2018;9:1150.Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc. 2000;32(12):2035-2039. Natsume T, Ozaki H, Saito AI, Abe T, Naito H. Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength. Med Sci Sports Exerc. 2015;47(12):2621-2627. Hughes L, Rosenblatt B, Haddad F, et al. Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports Med. July 2019. doi:10.1007\/s40279-019-01137-2Hughes L, Patterson SD, Haddad F, et al. Examination of the comfort and pain experienced with blood flow restriction training during post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service trial. Phys Ther Sport. 2019;39:90-98.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":7069,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/managing-acls-with-pbfr","id":"blog\/managing-acls-with-pbfr","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-5.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"PERFORMANCE ENHANCEMENT WITH BFR \/ IPC - PART 2: IPC IN THE ELITE ATHLETE","permalink":"performance-enhancement-with-bfr-ipc-part-2-ipc-in-the-elite-athlete","timestamp":1648057202,"summary":"Recently, the use of brief bouts of ischemia and reperfusion, often called Ischemic PreConditioning (IPC), has garnered a lot of interest amongst sports medicine practitioners and researchers alike as a method to augment performance. Briefly, IPC offers two distinct benefits across two separate time frames. The first window offers the potential for performance enhancement and occurs immediately following the application of IPC and lasts approximately four hours. The second window occurs approximately 24 hours following the intervention and extends through 72hrs post intervention. This window has mostly been shown to impact recovery following an intense bout of exercise. \n\nWindows of Action for IPC\n\n0 - 4 hours: increased performance measured via VO2max, fatiguing exercise, etc24 - 72 hours: improved recovery from exercise via attenuation of muscle damage\n\nThe majority of the research exploring the first window, or the ergogenic benefits of IPC, has focused on various performance measures immediately after the intervention out to approximately forty-five minutes post. The main drivers producing an ergogenic aid during this period consist of increased tissue perfusion and maintaining aerobic respiration for a prolonged period of time. Collectively, these help to reduce muscle fatigue allowing for an acute spike in workload. Considering these mechanisms, IPC has had varying degrees of effectiveness depending on the energy system utilized during the task. For instance, when moderately trained runners performed IPC approximately forty-five minutes prior to a 5K time trial, they completed the time trial 34 seconds faster compared to the sham condition.(1) Interestingly, the authors also showed a significantly lower level of lactate when IPC was performed; an indication of improved aerobic respiration. Ischemic PreConditioning has also been shown to have a positive impact during anaerobic activities. Paradis-Deschenes and colleagues had resistance trained individuals perform five sets of five reps of maximal isokinetic knee extensions at 20 degrees\/second preceded by IPC or sham IPC.(2) When the knee extensions were preceded by IPC, there was approximately a 12% greater increase in knee extensor strength compared to the sham condition. Despite the exercise task being anaerobic, mechanistically the increase in strength noted could also have been due to improvements in the delivery of nutrients via blood flow as the authors noted a 46% increase in perfusion of the quads at baseline; that increase remained 25% greater than the control following the fifth set. The effects of the first window of IPC on sprinting or other power activities have yielded trivial results, potentially due to those activities relying on the phosphocreatine system for energy. \n\nThe most common method of application amongst professional athletes targets the second window for recovery. Recently, Franz and colleagues showed that when IPC preceded a bout of eccentric exercise, there was a significant attenuation in creatine kinase release by approximately 95% compared to doing the same volume of eccentric exercise without IPC . Additionally, the IPC group had approximately 80% less pain compared to the group who only performed eccentrics.(3) Providing further support for IPC as a recovery modality, Page and colleagues showed when three cycles of IPC were performed following 100 depth jumps from a .5 meter box, knee extensor MVC returned to baseline at 72hrs post training while the sham group still had a 10% deficit.(4) \n\nAlthough the above results are impressive, it should not go without mentioning the mixed results and limitations with IPC. For instance, when Jean St Michel and colleagues had elite swimmers perform four bouts of IPC prior to a 100m sprint, the average swim time decreased by 0.7 seconds. This appears to be largely impacted by three swimmers improving by 2.5-3.5 seconds. However, not everyone demonstrated an improvement. Three of the swimmers actually swam slower.(5) These results tell us a couple important things about IPC. First, on average, it looks like IPC can have a significant albeit small improvement in performance (effect size: .43). (6) When looking at the highest level athletes, this small improvement could separate first from second, or being on the medal stage versus not. \n\nA second potential explanation for the mixed results includes the lack of use of an individualized pressure. This makes it particularly difficult to know how to optimize the application and why the dosage looks effective for some and not others. To our knowledge only one paper has used a personalized pressure with IPC.(7) They utilized 100% limb occlusion pressure (LOP) and it elicited a significant improvement in performance on the bike compared with a sham or control condition. Josh Slysz, PhD also highlighted the non-responder phenomena in his thesis and went on to state \u201c...an amplified metabolic stimulus may be beneficial for those who do not respond to traditional IPC.\u201d(8) This may further support the need for personalized pressures with IPC and also suggests the possibility that a number of enhancements observed with IPC are accomplished with the application of BFR and exercise. \n\nPractical application: \n\nAlthough the majority of IPC research on improving performance has focused on the effects occurring in the first window, there are a couple points to consider. The benefits during this window are time sensitive, with the bulk of research initiating the sport task immediately after the intervention. Although the benefit lasts approximately four hours post intervention, we do not know if there is a sustained ergogenic effect over the duration of the four hours or if the potential benefit gradually returns to baseline. Considering this, it could be challenging to implement this intervention in the context of a team sport since the window of benefits would likely exceed the duration of a team sport scenario. Therefore, use of IPC prior to performance might make the most sense in the context of track and field, swimming, and cycling. \n\nHowever, when looking at this from a performance perspective, the responder \/ non-responder phenomenon must be factored into the decision to use IPC or not. We need to know how the individual athlete we are working with will respond. It appears some athletes will be extreme responders while a small percentage will either be a non responder or IPC could negatively affect them. These responses are best teased out prior to use for competition. For example, IPC could be implemented a week or two ahead of time as part of a training spike and then the response to the stimuli would be known. \n\nDue to previously mentioned limitations with team sport events, IPC could be targeted for the potential benefit to improve recovery. When used in this manner, IPC is most commonly applied for three cycles of five minutes of ischemia\/reperfusion either prior to the event or shortly after. If the athlete is able to implement IPC within four hours of the event, there may be potential to improve the subsequent performance along with improving their recovery following the event. For more on the mechanisms and the application of IPC check out our previous blog and podcast. \n\nBailey TG, Jones H, Gregson W, Atkinson G, Cable NT, Thijssen DHJ. Effect of ischemic preconditioning on lactate accumulation and running performance. Med Sci Sports Exerc. 2012;44(11):2084-2089. Paradis-Desch\u00eanes P, Joanisse DR, Billaut F. Ischemic preconditioning increases muscle perfusion, oxygen uptake, and force in strength-trained athletes. Appl Physiol Nutr Metab. 2016;41(9):938-944. Franz A, Behringer M, Harmsen J-F, et al. Ischemic Preconditioning Blunts Muscle Damage Responses Induced by Eccentric Exercise. Med Sci Sports Exerc. 2018;50(1):109-115. Page W, Swan R, Patterson SD. The effect of intermittent lower limb occlusion on recovery following exercise-induced muscle damage: A randomized controlled trial. J Sci Med Sport. 2017;20(8):729-733. Jean-St-Michel E, Manlhiot C, Li J, et al. Remote preconditioning improves maximal performance in highly trained athletes. Med Sci Sports Exerc. 2011;43(7):1280-1286. Salvador AF, De Aguiar RA, Lisb\u00f4a FD, Pereira KL, Cruz RS, Caputo F. Ischemic Preconditioning and Exercise Performance: A Systematic Review and Meta-Analysis. Int J Sports Physiol Perform. 2016;11(1):4-14. Cheung CP, Slysz JT, Burr JF. Ischemic Preconditioning: Improved Cycling Performance Despite Nocebo Expectation. Int J Sports Physiol Perform. Published online June 12, 2019:1-22. Slysz J. Optimizing the Ergogenic Use of Ischemic Preconditioning. Published online 2019.https:\/\/atrium2.lib.uoguelph.ca\/xmlui\/bitstream\/handle\/10214\/17397\/Slysz_Joshua_201909_PhD.pdf?sequence=3&isAllowed=y\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5487,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/performance-enhancement-with-bfr-ipc-part-2-ipc-in-the-elite-athlete","id":"blog\/performance-enhancement-with-bfr-ipc-part-2-ipc-in-the-elite-athlete","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-18.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"PERFORMANCE ENHANCEMENT WITH BFR \/ IPC","permalink":"performance-enhancement-with-bfr-ipc","timestamp":1648057202,"summary":"This blog ended up growing on us so we\u2019re splitting it into two parts. In the first part we\u2019ll lay out some foundational thoughts as to what performance enhancement even means and then discuss what\u2019s been shown in elite level performers and BFR exercise as well as provide some thought as to how we think using it makes sense. And as is usual for us to recommend, following the recent guidelines from Patterson et al is advisable.(Patterson et al. 2019) Part 1: Performance Enhancement and Blood Flow RestrictionIt seems that ever since researchers began experimenting with Blood Flow Restriction exercise (BFR) that a translation to the rehab clinic setting was inevitable. Certainly the rehab world is benefiting from the increasingly widespread adoption of this technique to restore muscle quality and quantity in load compromised individuals. And while there\u2019s been a recent increase in clinical publications utilizing BFR, there is much left to study. On the other side of the spectrum from the injured or ill, lie individuals that routinely perform at a high level in sports or elite tactical units. The bulk of the BFR literature lies squarely in between these two populations. \u201cYoung, healthy, recreationally active individuals\u201d are probably the most commonly written words in any exercise physiology paper, and this is certainly true of the BFR literature. Neither of those apply to the injured, ill, or elite, and thus translating what we know about BFR exercise to those populations must be done with care and acknowledgement that responses might vary or even be non-existent. At elite levels of human performance, the slightest improvement can mean the difference between winning or losing; within the tactical realm, it could mean life or death. Thus, a technique that can achieve increases in muscle size and strength with less overall tissue stress likely has some utility. A strict interpretation of \u201cperformance enhancement\u201d involves the assessment of one's execution of a task requiring strength, speed, power, endurance, or agility, and uses an intervention either acutely or over the course of several weeks to create improvement in that task. In order to translate any findings from such a study to high level athletes or tactical athletes, these studies would need to be conducted on similar subjects. However, in application, \u201cperformance enhancement\u201d likely covers a much broader area. This could extend to how quickly an athlete is able to return to their prior level of performance, or perhaps keeping an aging tactical athlete performing at their best despite nagging aches and pains accumulated from a life of exposure to austere environments and scenarios. Studying \u201cperformance enhancement\u201d in this sense has unique limitations as well. In short, the evidence for BFR, or its quickly growing counterpart Ischemic Pre-Conditioning (IPC), on performance enhancement is very limited. We would not make strong recommendations for how best to use either in the achievement of performance enhancement, regardless of one\u2019s intent with the phrase. As we always suggest on the clinical side of the house, broadening and enhancing one\u2019s exercise physiology knowledge will greatly improve practitioners\u2019 ability to design and reason through exercise plans with the purpose of performance enhancement as they\u2019ll better understand specific physiologic targets for their exercise interventions and how to manipulate them to create adaptation. BFR in the Elite AthleteStudies seeking to measurably enhance performance in elite athletes via increased strength are sparse; there\u2019s a total of four papers, all with rather significant methodological flaws that likely influenced the results. Perhaps two of the best papers are a study by Luebbers, and one by Yamanaka that incorporated BFR exercise into resistance training programs for collegiate level football players (NCAA D1 & D2) and saw increases in size and strength that a work matched light load control group did not.(Luebbers et al. 2014; Yamanaka et al. 2012) In both cases BFR exercises at 20% 1RM were used in addition to heavy load exercises to increase the amount of exercise volume performed. The major limitation here is that both studies used elastic wraps for BFR, all but ensuring that the restriction stimulus was not consistent across subjects.(McEwen et al. 2018) So while it\u2019s reasonable to conclude that had they personalized pressure the results may have been even better, we learn very little from these studies about what is optimal. We only learn that it can work. Four papers have examined using BFR to improve VO2max in highly trained persons, the most notable of which is Park et al who used BFR walking, within season, via 3 minute intervals for a total of 15 minutes work, twice a day, over two weeks to increase collegiate level basketball players VO2max by a 11.6%.(Park et al. 2010) Two studies from Ferguson\u2019s lab were conducted in trained cyclists \/ triathletes utilizing 7 cycle sprint intervals of 30 seconds; BFR was used for a portion of the rest period. A 5.9% VO2max increase was noted by Mitchell and 4.5% increase in VO2max was achieved by Taylor et al.(Mitchell et al. 2018; Taylor et al. 2016) Lastly, Ursprung and Smith demonstrated that 20 minutes of walking with BFR, 5 days a week for 3 weeks improved VO2max in pararescuemen. (Ursprung and Smith 2017) One paper has investigated using BFR exercise to enhance sprint performance and showed positive results. Abe and colleagues randomized 15 collegiate track and field sprinters and jumpers into performing squats and leg curls at 20% 1RM for 3x15 or continuing with their traditional resistance training workouts under freeflow conditions.(Abe et al. 2005) Each group continued their planned sprinting and jumping workouts. The BFR training was performed for 8 consecutive days, twice daily. The BFR group enhanced their acceleration by a tenth of a second. Below is a short form breakdown of ways in which we think BFR could be incorporated into an elite team or special forces group. These are designed to utilize the light load nature of BFR to enhance an existing training program.\n\nBFR resistance exercise could be used to replace some exercises as a means of reducing joint and soft-tissue loads. This \u201creplacement\u201d should be temporary. It likely makes the most sense within the season or immediately after the season for 6-8 weeks. It also might be done within session, comprise in entire session, or as done by Hansen et al by alternating weekHansen SK, Ratzer J, Nielsen JL, Suetta C, Karlsen A, Kvorning T, Frandsen U, Aagaard P. (2020). Effects of alternating blood-flow restricted training and heavy-load resistance training on myofiber morphology and mechanical muscle function.pdf. Journal of Applied Physiology. https:\/\/doi.org\/10.1152\/japplphysiol.00015.2020BFR resistance exercise could be used to add training volume w\/o increasing joint and soft-tissue loads. This is basically what Leubbers and Yamanaka did above. This strategy might have utility in helping push through sticking points in training or performance.BFR resistance exercise could be used to \"train around\" existing musculoskeletal aches \/ pains.This is how Dwight Howard and many others in elite sport currently use it. Check out the story here!BFR exercise at a lower than usual intensity and effort level as a warm-up prior to training \/ performance.This is one way the LA Rams use BFR. They get great reports from their players on how fresh and warmed up they feel prior to practices or training sessions. You can listen to our podcast with their ATC and PT here!BFR endurance exercise could be used to improve fatigue resistance or get over training plateaus which are chiefly due to fatigue.BFR exercise with high pressure prior to competition or heavy load training to reduce pain of irritable tissues. Might have particular value in helping to manage tendinopathy.\n\nThank you for reading! This concludes part 1, stay tuned for part 2 where we\u2019ll cover Ischemic Preconditioning. We hope to get that out next week.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6497,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/performance-enhancement-with-bfr-ipc","id":"blog\/performance-enhancement-with-bfr-ipc","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-14.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"SHOULD I MEASURE LOP IN THE POSITION I AM EXERCISING?","permalink":"should-i-measure-lop-in-the-position-i-am-exercising","timestamp":1648057202,"summary":"The measurement of Limb Occlusion Pressure (LOP) takes into account variables related to the tourniquet as well as variables specific to the individual. Individual variables such as limb circumference, tissue characteristics under the cuff, and systolic blood pressure all influence LOP. Blood pressure is influenced by body position, and of course rises when transitioning from supine to sitting or standing. The increase in blood pressure is a result of mechanical deformation of the vessel and stimulation of group III\/IV afferents. This has led many to ask, \u201cshould LOP be assessed in the position the patient is exercising to more accurately determine LOP and subsequently the relative occlusion pressure used during the exercise?\u201d \n\nRecently, Sieljacks and colleagues looked at the difference in LOP between supine and sitting.(Sieljacks et al. 2018) When using a wide tourniquet, the authors found a 29 mmHg increase in LOP when measuring LOP in sitting compared to supine. Using this data in a subsequent knee extension study(Sieljacks et al. 2018), Sieljacks measured LOP in sitting, which was the position individuals were going to exercise. Although the authors measured LOP in sitting, they decided to use a relative occlusion pressure of 40% that produced a similar amount of occlusion as 50% LOP measured in supine, which was used in their previous projects. \n\nHughes et al expanded on this by comparing LOP measurements in supine, sitting and standing.(Hughes et al. 2018) When compared to supine, measuring LOP in sitting resulted in a 17 mmHg increase ; whereas in standing LOP was 54.5 mmHg higher. Applying this in a clinical context, Centner et al had individuals perform seated and standing heel raises using either high loads or low loads with BFR.(Centner et al. 2019) The BFR group performed each exercise with a relative pressure of 50% occlusion, which was assessed in standing. When measuring LOP in standing, a relative pressure of 50% occlusion roughly translates to a relative occlusion of 65% LOP measured in supine. This is important clinically because many times individuals are performing multiple exercises in different positions (sitting, lying, standing). If we set the relative pressure at 80% measured in standing, but also have them perform a supine exercise such as a SLR or leg press, the 80% LOP taken in standing will likely place that individual at full occlusion in supine. Conversely, if LOP is measured in supine, and the clinician then has a patient perform squats using a low pressure (60% LOP),the relative pressure would be much lower, approximately 45% LOP. A relative pressure this low has been shown to significantly limit the effectiveness of BFR, however, studies showing this low a pressure as ineffective were performed in a seated position rather than standing. \n\nCollectively these papers suggest, if performing a single exercise, one can assess LOP in the position the exercise will be performed. However, an important limitation to the available evidence is the two referenced papers have only assessed an acute change in LOP. We do not know if there is a significant difference in muscle activation acutely, nor do we know how this impacts adaptation in the form of strength and hypertrophy. We would emphasize that when determining the appropriate pressure to use, we want to select the lowest pressure known to have an effect. Not only will using the lowest relative arterial occlusion pressure possible make the exercise more tolerable, but the lower pressure will also minimize the risk of an adverse event. To this end, if you plan to have your patient perform multiple exercises in varied positions, we would suggest a simple strategy that we teach in our courses of measuring in supine and following the guideline of using a 60-80% LOP. If performing a single exercise, you may perform LOP in the position of the exercise. To do that just follow the table below: \n\n\n\n(for loads < \/ = 30% 1RM use highest pressure) \n\nA big thanks to Zac Dunkle, PTfor this write up!! \n\nSieljacks, P., Knudsen, L., Wernbom, M., & Vissing, K. (2018). Body position influences arterial occlusion pressure: implications for the standardization of pressure during blood flow restricted exercise. European Journal of Applied Physiology, 118(2), 303\u2013312. Hughes, L., Jeffries, O., Waldron, M., Rosenblatt, B., Gissane, C., Paton, B., & Patterson, S. D. (2018). Influence and reliability of lower-limb arterial occlusion pressure at different body positions. PeerJ, 6, e4697. Centner, C., Lauber, B., Seynnes, O. R., Jerger, S., Sohnius, T., Gollhofer, A., & K\u00f6nig, D. (2019). Low-load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared to high-load resistance training. Journal of Applied Physiology. https:\/\/doi.org\/10.1152\/japplphysiol.00602.2019\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6213,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/should-i-measure-lop-in-the-position-i-am-exercising","id":"blog\/should-i-measure-lop-in-the-position-i-am-exercising","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-HamCurl-3.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"THE EFFECT OF CUFF WIDTH FOR DETERMINING OCCLUSION PRESSURE","permalink":"the-effect-of-cuff-width-for-determining-occlusion-pressure","timestamp":1648057202,"summary":"The pursuit of improved safety and objectivity is a recurring theme in BFR research and a primary target for BFR clinical practice. The use of minimal effective pressure is considered to be the safest for tourniquet applications. An article that was published this month in the International Journal of Exercise Science took aim at that concept. Weatherholt et al compared Limb Occlusion Pressure (LOP) between the Delfi and Kaatsu tourniquet systems.Full occlusion or LOP isn't the target for BFR training with exercise, but it provides a means to individualize the pressure used on a limb. The authors measured LOP using ultrasound with a Doppler probe on the popliteal artery while participants were in the standing position. Not only was the pressure with the wider (Delfi) cuff lower, but the narrow (Kaatsu) cuff wasn't able to reduce arterial blood flow even at its max pressure. \"We observed arterial occlusion in all subjects with the wide cuff. However, we were unable to alter arterial blood flow velocity with the narrow cuff. Each subject reached the Kaatsu's maximum pressure with the narrow cuff which is 500 KTU.\"These results mirror those of other studies that demonstrate narrow cuffs need more pressure to create the same effect as wider cuffs at lower pressure. Another potential problem for the narrow cuff used in the study is a non-standardized unit of pressure. \"Kaatsu uses standard Kaatsu units (SKU) to measure pressure applied to the cuff; therefore, a pressure gauge was used to establish a conversion from SKU to mmHg. It was found that 1 SKU is equal to 1 mmHg.\" The max pressure for the Kaatsu system is equivalent to 500 mmHg and it didn't significantly alter arterial blood flow. This would indicate that LOP for the participants in this study is > 500mmHg and high pressure across a narrow surface increases the risk for nerve-related injury (Noordin 2009).In order to practice in a safe and objective fashion, we need to be able to individualize the pressure we use with BFR (Hughes 2018, McEwen 2018).\n\nNoordin, Shahryar, et al. \u201cSurgical Tourniquets in Orthopaedics.\u201d The Journal of Bone and Joint Surgery. American Volume, vol. 91, no. 12, Dec. 2009, pp. 2958\u201367. Hughes, Luke, Benjamin Rosenblatt, et al. \u201cInterface Pressure, Perceptual and Mean Arterial Pressure Responses to Different Blood Flow Restriction Systems.\u201d Scandinavian Journal of Medicine & Science in Sports, Apr. 2018, doi:10.1111\/sms.13092. McEwen, James A., et al. \u201cWhy Is It Crucial to Use Personalized Occlusion Pressures in Blood Flow Restriction (BFR) Rehabilitation?\u201d Journal of Medical and Biological Engineering, Apr. 2018, doi:10.1007\/s40846-018-0397-7. Weatherholt, Alyssa, et al. \u201cThe Effect of Cuff Width for Determining Limb Occlusion Pressure: A Comparison of Blood Flow Restriction Devices.\u201d International Journal of Exercise Science, vol. 12, no. 3, 2019, pp. 136\u201343. (Open Access at Journal Site)\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6546,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/the-effect-of-cuff-width-for-determining-occlusion-pressure","id":"blog\/the-effect-of-cuff-width-for-determining-occlusion-pressure","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-2.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"THE HALLMARK OF AGING","permalink":"the-hallmark-of-aging","timestamp":1648057202,"summary":"Sarcopenia is the hallmark of aging responsible for significant muscle mass loss seen with advancing chronological age. It is associated with decreases in functional ability due to its impact on strength; most notable are losses in mobility and increases in fall risk. This loss of muscle can begin as early as the 3rd decade of life, and results in the loss of 5-10% of one\u2019s vastus lateralis mass by the 5th decade.1 Upon reaching age 50, the sarcopenic rate accelerates causing the loss of as much as 30-40% of the vastus lateralis by age 80.1Collectively, these factors contribute to a decreased quality of life, frailty, and increased mortality. A recent meta-analysis of studies comprised of approximately 2 million men and women demonstrated that strength loss was a strong predictor of mortality across the life span, regardless of comorbidities.2 When broken down by body region, increased grip strength had a 31% reduction in all-cause mortality risk compared to those with decreased strength.2 In the lower extremity, increased knee extensor strength had a 14% reduction in all-cause mortality.2 In addition to the physical and medical burden imposed upon aged persons, the financial burden of sarcopenia in the United States is substantial as well. Annually, treatment of ailments associated with the condition amount to $40.4 billion.10 To combat sarcopenia, the American College of Sports Medicine recommends older adults perform a combination of resistance training at 70-80% 1RM at least two times per week, and participate in 150-300 minutes of moderate intensity aerobic training weekly.3 However, less than 10% of those >65 years old met both guidelines and only 14% met the resistance training guideline.4 More recently, resistance training has taken on an increasingly important target given its superior ability to impact physical functioning via strength translation.11 Why do we see sarcopenia? It\u2019s not fully understood why older adults lose muscle mass simply due to increasing age. A couple potential causes may provide reasons why BFR could provide a potential solution. It seems sarcopenia, though not as a rapid, may follow a similar mechanistic behavior to the disuse atrophy observed in a number of studies. Dubbed, anabolic resistance, these studies revealed protein ingestion that would typically impart an anabolic stimulus, no longer does so, regardless of age.5 To counter this, it seems young persons must prime the system via resistance exercise, while also getting a full complement of essential amino acids. This is tougher for the aged person, because there is a decreased anabolic response to a meal and a workout in the older adult compared to the younger adult. For example, young adults require approximately 20g of protein to fully activate muscle protein synthesis whereas the elderly require 40g to reach the same level of activation.14 Similar disparities are observed with resistance training. Muscle protein synthesis in young adults will continue to respond favorably as the individual approaches their 1RM. The elderly, however, have no increase in muscle protein synthesis beyond 60% of their 1RM (Fig. 1).15 A second potential cause, and thus a target for combatting sarcopenia with BFR could be the fact that older persons have a decrease in capillary density compared to their younger counterparts.16 The resultant change in perfusion limits the delivery of oxygen, nutrients, and growth factors, helping to explain the blunted anabolic response to a bolus of protein. BFR has been shown to elicit an angiogenic response via the release of vascular endothelial growth factor that occurs following a bout of BFR exercise.17Additionally, a few other studies have demonstrated local vascular responses that may be desired in targeting this potential cause of sarcopenia.18,19 The light load nature of BFR exercise can be friendly to aged joints and soft-tissues, thus making it less threatening and potentially better tolerated than heavier loads. A few studies have demonstrated both the efficacy and effectiveness of this intervention in aged persons. In fact, a recent review paper by Centner that pulled from 11 studies and 238 participants, indicated that the addition of BFR to a resistance or aerobic exercise program was almost certain to elicit an anabolic response in the exercised muscle(s).12Exercise at low intensities performed with BFR has been shown to increase muscle protein synthesis (MPS) post exercise by over 55%; this is similar to that observed in young adults.20 Over a 12-week training program, older adults (>60 years old) who performed BFR resistance exercises combined with moderate-vigorous intensity walking demonstrated similar changes in muscle hypertrophy and strength compared to those who performed HIT resistance training (70-80% 1RM) and moderate-vigorous intensity walking; albeit with 37% less volume.6 The reduced volume, along with the light weight nature of the intervention translates to significantly less mechanical stress on arthritic or painful joints.the release of vascular endothelial growth factor that occurs following a bout of BFR exercise.17 Additionally, a few other studies have demonstrated local vascular responses that may be desired in targeting this potential cause of sarcopenia.18,19 In addition to resistance training with low loads, BFR has the unique ability to increase muscle CSA and strength when coupled with low intensity, short duration aerobic activities. Following 6 weeks of low intensity treadmill training, Abe and colleagues observed 7 and 16% increases in knee extensor and flexor isokinetic strength respectively.8 This was followed by a similar study by Clarkson and colleagues who found a three-fold greater improvement in the 30 second sit-to-stand test, and a 2-fold improvement in the TUG compared to a work matched control.9 Findings from both studies confirm that BFR during low intensity aerobic activities is not only able to add muscle and strength, but these changes directly translate into functional activities.\"In summary, as the United States society ages and as the incidence of musculoskeletal procedures correspondingly increases, improved rehabilitative interventions focused on minimizing sarcopenia, dynapenia, improving mobility, and preventing falls is required. Initial BFR exercise studies in older adults show promise as a potential clinically relevant intervention. BFR exercise can be combined with walking, body weight exercise, elastic band resistance exercise, and traditional resistance exercise. Furthermore, as the clinical adoption of this intervention continues, additional objective measures of its utility, limitations, and contraindications will become more readily apparent for the patient.\u201d13Lexell J. Human aging, muscle mass, and fiber type composition. J Gerontol A Biol Sci Med Sci. 1995;50 Spec No:11-16.Garc\u00eda-Hermoso A, Cavero-Redondo I, Ram\u00edrez-V\u00e9lez R, et al. Muscular strength as a predictor of all-cause mortality in apparently healthy population: a systematic review and meta-analysis of data from approximately 2 million men and women. Arch Phys Med Rehabil. February 2018. doi:1016\/j.apmr.2018.01.008Chodzko-Zajko Wojtek, Proctor David, Fiatarone Singh Maria, Minson Christopher, Nigg Claudio, Salem George, and Skinner James. Exercise and Physical Activity for Older Adults. Med Sci Sports Exerc. 7\/2009;41(7):1510-1530.Carlson SA, Fulton JE, Schoenborn CA, Loustalot F. Trend and prevalence estimates based on the 2008 Physical Activity Guidelines for Americans. Am J Prev Med. 2010;39(4):305-313.Breen L, Stokes KA, Churchward-Venne TA, et al. Two Weeks of Reduced Activity Decreases Leg Lean Mass and Induces \u201cAnabolic Resistance\u201d of Myofibrillar Protein Synthesis in Healthy Elderly. J Clin Endocrinol Metab. 2013;98(6):2604-2612.Libardi CA, Chacon-Mikahil MPT, Cavaglieri CR, et al. Effect of concurrent training with blood flow restriction in the elderly. Int J Sports Med. 2015;36(5):395-399.Kim J, Lang JA, Pilania N, Franke WD. Effects of blood flow restricted exercise training on muscular strength and blood flow in older adults. Exp Gerontol. 2017;99:127-132.Abe T, Sakamaki M, Fujita S, et al. Effects of low-intensity walk training with restricted leg blood flow on muscle strength and aerobic capacity in older adults. J Geriatr Phys Ther. 2010;33(1):34-40.Clarkson MJ, Conway L, Warmington SA. Blood flow restriction walking and physical function in older adults: A randomized control trial. JSci Med Sport. 2017;20(12):1041-1046.Goates, S., Du, K., Arensberg, M. B., Gaillard, T., Guralnik, J., & Pereira, S. L. (2019). Economic Impact of Hospitalizations in US Adults with Sarcopenia. The Journal of Frailty & Aging, 8(2), 93\u201399.Mcleod, J. C., Stokes, T., & Phillips, S. M. (2019). Resistance Exercise Training as a Primary Countermeasure to Age-Related Chronic Disease. Frontiers in Physiology, 10, 645.Centner, C., Wiegel, P., Gollhofer, A., & K\u00f6nig, D. (2018). Effects of Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older Individuals: A Systematic Review and Meta-Analysis. Sports Medicine . https:\/\/doi.org\/10.1007\/s40279-018-0994-1Hackney, Kyle J., et al. \"The role of blood flow restriction training to mitigate sarcopenia, dynapenia, and enhance clinical recovery.\" Techniques in Orthopaedics2 (2018): 98-105.Breen, L., & Phillips, S. M. (2011). Skeletal muscle protein metabolism in the elderly: Interventions to counteract the \u201canabolic resistance\u201d of ageing. Nutrition & Metabolism, 8, 68.Kumar, V., Selby, A., Rankin, D., Patel, R., Atherton, P., Hildebrandt, W., \u2026 Rennie, M. J. (2009). Age-related differences in the dose-response relationship of muscle protein synthesis to resistance exercise in young and old men. The Journal of Physiology, 587(1), 211\u2013217.Hendrickse, P., & Degens, H. (2019). The role of the microcirculation in muscle function and plasticity. Journal of Muscle Research and Cell Motility. https:\/\/doi.org\/10.1007\/s10974-019-09520-2Takano, H., Morita, T., Iida, H., Asada, K.-I., Kato, M., Uno, K., \u2026 Nakajima, T. (2005). Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. European Journal of Applied Physiology, 95(1), 65\u201373.Patterson, S. D., & Ferguson, R. A. (2011). Enhancing strength and postocclusive calf blood flow in older people with training with blood-flow restriction. Journal of Aging and Physical Activity, 19(3), 201\u2013213.Shimizu, R., Hotta, K., Yamamoto, S., Matsumoto, T., Kamiya, K., Kato, M., \u2026 Masuda, T. (2016). Low-intensity resistance training with blood flow restriction improves vascular endothelial function and peripheral blood circulation in healthy elderly people. European Journal of Applied Physiology, 116(4), 749\u2013757.Fry, C. S., Glynn, E. L., Drummond, M. J., Timmerman, K. L., Fujita, S., Abe, T., \u2026 Rasmussen, B. B. (2010). Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men. Journal of Applied Physiology, 108(5), 1199\u20131209.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6084,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/the-hallmark-of-aging","id":"blog\/the-hallmark-of-aging","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/THE-PACER-PROJECT-2.png","archived":false,"draft":false,"featured":false,"author":"","title":"THE PACER PROJECT","permalink":"the-pacer-project","timestamp":1648057202,"summary":"The Post Acute COVID-19 Exercise and Rehabilitation (PACER) Project is an initiative formed by multiple APTA sections & academies as a resource for administrators, and to increase practitioner proficiency in cardiovascular and pulmonary (CVP) physical therapy, including critical illness sequelae. Subject matter experts are organizing educational resources to guide the rehab professional through the challenges seen in patients with and following the COVID-19 virus. These learning modules will be released through the APTA's Learning Center. These videos are also available for free on the Cardiovascular & Pulmonary Section's YouTube Channel.\n\nBFR'S ROLE IN PACER?Johnny Owens, PT It is currently unknown if this patient population will tolerate moderate to high-intensity exercise, potentially creating long-term disability and re-hospitalizations. Blood Flow Restriction (BFR) rehabilitation may provide a low load alternative to restore muscle quantity and quality. Additionally, our most recent Systematic Review and Meta-Analysis conducted with leadership in the APTA Cardiovascular and Pulmonary Section revealed that aerobic capacity is improved to a greater extent when low-level aerobic exercise is performed with BFR vs low-level exercise alone. This may afford an opportunity to address the significant loss in pulmonary function utilizing low intensities.\n\nPACER Project Topics\/Courses: \n\nCovid-19 Specific Physical Therapist Considerations - Heidi Engel Cardiovascular & Pulmonary Anatomy & Physiology - Steve Tepper Cardiovascular & Pulmonary Examination - Morgan Johanson Cardiovascular & Pulmonary Medications - Michael Tevald & John Lowman Vital Signs, Exercise Prescription, Oxygen devices - Ellen Hillegass Post-Intensive Care Syndrome (PICS) - Patricia Ohtake & Jim Smith Chest PT & Other Airway Clearance Techniques - Annie Downs Posture, Breathing, Ventilation - Mary Massery Inspiratory Muscle Training - Larry Cahalin Blood-Flow Restriction Training - Johnny Owens & Larry Cahalin Outpatient Pulmonary Therapy - Pam Bartlo & Naomi Bauer Cardiopulmonary Outcome Measures - Kristin Lefebvre Pediatric Considerations - Ashley Parish Geriatric Considerations - Suzanne Greenwalt Home Health Considerations - Melissa Bednarek & Ken Miller Music Therapy - Donna Frownfelter\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6991,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/the-pacer-project","id":"blog\/the-pacer-project","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-2.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"USE IT OR LOSE IT... UNDERSTANDING ANABOLIC RESISTANCE","permalink":"use-it-or-lose-it","timestamp":1648057202,"summary":"If you\u2019ve read our previous blogs on the use of Personalized Blood Flow Restriction (PBFR) for post-surgical conditions, the aging individual or listened to our podcast on \u201cthe muscle dump\u201d, you\u2019ve heard us talk about anabolic resistance. We firmly believe you need to define and understand the problem to work toward a solution. Anabolic resistance is one of those \u201cproblems\u201d clinicians should understand because it affects every patient that is in a period of disuse (ie...almost all of our patients), happens very quickly after injury or surgery and until now clinicians have had almost no tools to combat it.\n\nWhat is Anabolic Resistance?\n\nThe simple answer is that anabolic resistance is an alternative term (maybe a better one) for disuse atrophy. Elaborating, anabolic resistance is the result of periods of disuse that signal skeletal muscle to waste away. This wasting is thought to be the result of both the amplification of catabolic signaling and reduced anabolic signaling. \n\nThis includes but may not be limited to:\n\nDecreased muscle protein synthesis (MPS)Decreased muscle protein synthesis (MPS) refers to a decrease in the rate at which new proteins are created within muscle cells. Decreased MPS may be caused by a variety of factors, including aging muscle, inactivity, and certain medical conditions. Increased catabolic markers (signs for muscle protein breakdown): Myostatin, MuRF1, and MAFBxIncreased catabolic markers, such as myostatin, MuRF1, and MAFBx, have been associated with muscle loss and weakness. Additionally, these markers have been linked to other conditions that lead to muscle wasting, such as cancer and chronic inflammation. While more research is needed to fully understand the role of these markers in muscle loss, it is clear that they are involved in the process.\n\nWith the end result of:\n\nDecreased muscle cross sectional area (CSA)Decreased muscle strength\n\nThe term anabolic resistance was coined due to the fact that individuals under conditions of limb immobilization displayed a reduced rate of muscle protein synthesis in response to the ingestion of protein. Wall et al examined healthy individuals who were immobilized and forced into non-weight bearing (NWB) on one leg for 2 weeks. This resulted in close to a 30% reduction in the muscle protein synthetic response to protein ingestion. (Wall et al. 2013) The effect of this on the quad was an 8.4% decrease in CSA and a 23% decrease in strength. While it is widely accepted that this reduction in protein synthesis plays a major role in the effects of disuse on muscle, the expression of the catabolic pathways Myostatin, MuRF1, and MAFBx have also been noted in response to disuse in healthy subjects. (Wall et al. 2014) Difficulties with measurement make it more challenging to quantify their impact, and pathology may further amplify it.\n\nUnfortunately, it\u2019s not just complete disuse or immobilization that leads to this blunted muscle protein synthetic response. Reductions in activity can lead to similar changes. Allowing healthy young men to ambulate, but significantly reducing their daily step count by 90% for one week led to a 27% decrease in muscle protein synthesis rate and a 3-fold increase in myostatin. (Shad et al. 2019) Similarly, in healthy elderly individuals, a two week reduction in daily steps resulted in a 26% decrease in protein synthesis and a 4% loss of fat-free leg mass or muscle mass. (Breen et al. 2013)\n\nThe prevalence of persistent weakness following injury or surgery is evidence that too often rehab exercise isn't stressful enough to restore a person's skeletal muscle mass and potentially due to inadequate stimulation of muscle protein synthesis. This may be the most apparent in the post ACL reconstruction population. Gumucio et al demonstrated that knee extensor strength after ACL surgery had decreased by 68% in one month and deficits of greater than 20% are still present 6 months after surgery. (Gumucio et al. 2018) This potentially has larger implications for the health of the joint and is potentially a contributor to sarcopenia. (Keays et al. 2010; Lepley 2015)\n\nHow Quickly does Anabolic Resistance Happen?\n\nThe good news is you\u2019ve got a day! Dirks et al has shown that strength, insulin sensitivity, protein synthesis and catabolic markers are unchanged over a 24 hour period of disuse. (Dirks et al. 2018) The bad news...you might start to lose muscle by day 2. Kilroe et al found that changes in quadriceps and hamstring CSA (1.7 and 1.4% respectively) were evident on MRI at day 2 of immobilization. (Kilroe et al. 2019) The same laboratory found that protein synthesis was reduced by up to 30% with 3 days of immobilization, despite individuals consuming adequate amounts of ingested protein (1.6g\/kg\/day). (Kilroe et al. 2020) By day 5, there is greater loss of quad muscle size (3.5%) and significant loss of knee extensor strength (9.0%). Additionally, Myostatin, MuRF1, and MAFBx, the catabolic pathways, are significantly elevated. (Wall et al. 2014) In cases of whole body disuse, such as bedrest, as much as 3.1 pounds of muscle can be lost within 1 week. (Dirks et al. 2016) That would equate to six, 8 ounce ribeye steaks worth of muscle!\n\nNow what? How do we combat the problem?\n\nThe first step is understanding the problem. As mentioned above, anabolic resistance happens quickly. Significant changes in the response of muscle to nutrient ingestion and markers for catabolism are present within the first 2-5 days. Thus, interventions to reduce these effects and stimulate muscle protein synthesis need to begin as early as possible. The second step involves developing intervention strategies that are effective in slowing catabolic pathways. Applications like passive PBFR, while not ideal, may be our only option at this phase and it may be able to help stave off some of the loss early in the rehab process. A recent paper from Kakehi et al showed that just the application of a tourniquet alone was effective in reducing catabolism. Five rounds of 5 minutes applied twice daily without exercise reduced muscle loss in the thigh and reduced the elevation of MuRF1 during 2 weeks of disuse. The control group who were immobilized and did not receive passive BFR lost significant amounts of muscle and were not able to downregulate MuRF1 (Kakehi et al. 2020) But if the disuse period extends beyond 5-7 days, the need for anabolic stimuli to promote muscle protein accretion becomes more pressing due to the reduced activation of muscle protein synthesis previous studies have identified. In order to do so, we need to add exercise to the tourniquet condition. (Nyakayiru et al. 2019) The addition of neuromuscular electrical stimulation to BFR can be an effective strategy to help bridge the gap back to active exercise. Natsume et al showed that a very low intensity, high frequency application of NMES and BFR increased the size and strength of the quad. (Natsume et al. 2015) Progressing toward multiple, active exercises with BFR in a session is an even better target for making positive muscle changes. Bowman et al showed that 4 exercises per session (SLR, Hip Abduction, Knee Extension, and Knee Flexion), performed twice a week, for 6 weeks significantly increased LE muscle size and strength. (Bowman et al. 2019) Below is a very simple table for how this might progress.\n\n\n\n0-5 days5-10 days10-21 daysPassive (5 x 5)\u2713NMES + BFR\u2713\u2713Active Exercise\u2713\u2713\n\nGoal: Slow catabolism via repeated tourniquet inflations \n\nGoal: Need to get some form of muscle activity to try and increase MPS rates\n\nGoal: Moving toward appropriately loaded exercise w\/ high effort to restore lost mass\n\nIn the first five days, we\u2019re trying to initiate BFR to slow down the loss of muscle. This may be a time when we can only apply passive tourniquet inflation and 5 rounds of 5 minutes has been shown to be effective. As early as possible, we want to start adding muscle contraction to the equation. A tool like NMES can help bridge the gap if active exercise can\u2019t be achieved or tolerated. For both the passive and NMES applications, a higher frequency of daily or twice a day would be best. As exercises can be added, the frequency can come down to 2 or 3 days per week and multiple exercises per session, such as the 4 in the Bowman study, would be a good target. Ongoing studies with ACL reconstruction, tendon repairs, femur fractures, and total joint replacement should add valuable information on the effectiveness of BFR compared to a work-matched intervention. As usual, we need more research to be completed and published to provide more definitive guidance. For now, make exercise more stressful and don\u2019t forget to eat your brisket or target other forms of high quality protein and leucine.\n\nAdditional related podcasts:\n\nPreventing Muscle AtrophyAin\u2019t it SwellBFR Acute Responses and Use in ACL RehabProgressions for BFR\n\nKilroe SP, Fulford J, Jackman S, et al. Dietary protein intake does not modulate daily myofibrillar protein synthesis rates or loss of muscle mass and function during short-term immobilization in young men: a randomized controlled trial. Am J Clin Nutr. Published online May 29, 2020. doi:10.1093\/ajcn\/nqaa136 Kilroe S, Fulford J, Jackman S, van Loon L, Wall B. Temporal Muscle-Specific Disuse Atrophy during One Week of Leg Immobilization. Medicine . 2019;Publish Ahead of Print. doi:10.1249\/MSS.0000000000002200 Shad BJ, Thompson JL, Holwerda AM, et al. One Week of Step Reduction Lowers Myofibrillar Protein Synthesis Rates in Young Men. Med Sci Sports Exerc. 2019;51(10):2125-2134. Wall BT, Dirks ML, Snijders T, Senden JMG, Dolmans J, van Loon LJC. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol . 2014;210(3):600-611. Dirks ML, Wall BT, van de Valk B, et al. One Week of Bed Rest Leads to Substantial Muscle Atrophy and Induces Whole-Body Insulin Resistance in the Absence of Skeletal Muscle Lipid Accumulation. Diabetes. 2016;65(10):2862-2875. Dirks ML, Stephens FB, Jackman SR, et al. A single day of bed rest, irrespective of energy balance, does not affect skeletal muscle gene expression or insulin sensitivity. Exp Physiol. Published online April 15, 2018. doi:10.1113\/EP086961 Breen L, Stokes KA, Churchward-Venne TA, et al. Two weeks of reduced activity decreases leg lean mass and induces \u201canabolic resistance\u201d of myofibrillar protein synthesis in healthy elderly. J Clin Endocrinol Metab. 2013;98(6):2604-2612. Wall BT, Snijders T, Senden JMG, et al. Disuse impairs the muscle protein synthetic response to protein ingestion in healthy men. J Clin Endocrinol Metab. 2013;98(12):4872-4881. Hughes L, Rosenblatt B, Haddad F, et al. Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports Med. Published online July 12, 2019. doi:10.1007\/s40279-019-01137-2 Natsume T, Ozaki H, Saito AI, Abe T, Naito H. Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength. Med Sci Sports Exerc. 2015;47(12):2621-2627. Bowman EN, Elshaar R, Milligan H, et al. Proximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial. Sports Health. Published online January 14, 2019:1941738118821929. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med. 2010;38(3):455-463. Lepley LK. Deficits in Quadriceps Strength and Patient-Oriented Outcomes at Return to Activity After ACL Reconstruction: A Review of the Current Literature. Sports Health. 2015;7(3):231-238.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5729,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/use-it-or-lose-it","id":"blog\/use-it-or-lose-it","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-6.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"VASCULAR ENDOTHELIAL GROWTH FACTOR","permalink":"vascular-endothelial-growth-factor","timestamp":1648057202,"summary":"Although lesser known and even less frequently considered as an important growth factor for the musculoskeletal system, Vascular Endothelial Growth Factor (VEGF) plays an essential role in muscle adaptations and bone health. Characteristically VEGF is known as a potent angiogenic growth factor and appears to be upregulated during hypoxic conditions. Below, we\u2019ll discuss VEGF\u2019s role in muscle and bone, how that relates to injury, and the potential benefits of upregulating an angiogenic hormone with our BFR prescription in rehab. \n\nMuscle \n\nBlood vessels in and around the muscle play a key role in a muscle\u2019s ability to heal and adapt to stress. The density and availability of blood supply to the muscle helps to regulate the response of muscle stem cells (MuSC). MuSC, also known as satellite cells, are muscle specific progenitor cells capable of differentiating and incorporating into muscle tissue for healing following mechanical breakdown or to aid the growth response. Verma et al, found upwards of 80% of MuSC are in direct contact with capillaries while Christov et al found 63% of MuSC were surrounded by five or more capillaries, regardless of fiber type.(1,2) Interestingly, over a 24 week progressive resistance training program, muscle fibers with a lower capillary density showed no change in muscle mass, while muscle fibers with a higher capillary density demonstrated a significant increase in size.(3) The authors also found a significant increase in MuSC following 12 and 24 weeks of resistance training among individuals having a higher capillary density.(3) To put this in a clinical perspective, early clinical data following an ACL injury shows a 30% reduction in vastus lateralis perfusion with a proportional reduction in MuSC.(4,5) Impressively, Zargi and colleagues showed five BFR training sessions in the eight days leading up to a ACLR resulted in a 52% increase in quadriceps blood flow and the ability to maintain an isometric contraction at 4 weeks postoperatively.(6) The control group, performing the same number of sessions without BFR demonstrated no change in blood flow to the quad contributing to a significant decrease in the ability to maintain an isometric contraction.(6) The increased vascular supply to the vastus lateralis, explained 71% of the variance in the ability to maintain a quadriceps isometric contraction at 4 weeks postoperatively.(6) \n\nBone \n\nAs mentioned previously, one of the major drivers contributing to the upregulation of VEGF is hypoxia. During fracture healing, the area within the hematoma is very hypoxic and induces a VEGF response from adjacent osteoblast and inflammatory cells that is approximately 15 fold greater than observed in circulating plasma.(7) As the fracture continues to heal, VEGF acts through its receptors in endothelial tissue, further increasing vascularity to enhance the delivery of nutrients required for osteogenesis. These nutrients include bone morphogenic protein (BMP) and mesenchymal stem cells, which ultimately differentiate into osteoblasts.(8) In a recent presentation ahead of publication, Brad Lambert presented data from his randomized 12 week ACL post op trial conducted at Houston Methodist. Within the presentation, Lambert showed BFR rehab was able to prevent a loss of bone mineral density (BMD) in the distal femur and proximal tibia, while the group performing traditional rehab experienced significantly greater BMD loss at each location. \n\nBFR and VEGF \n\nIn addition to the overall changes in muscle and bone referenced above, the direct relationship of BFR on VEGF has been looked at as well. Recently, Ferguson and colleagues showed VEGF levels increased 5.2 fold two hours following a single bout of BFR knee extensions and continued to increase to 6.8 fold at 4 hours post. Free flow knee extensions failed to increase VEGF levels.(9) More impressively, the upregulation of VEGF following an acute bout of low intensity BFR exercise is greater than the changes observed following a session of moderate to high intensity (60-80% 1RM) knee extensions.(10) These acute changes translated to a 14% increase in capillary density over a 6 week period in the BFR limb.(11) The increase in peripheral perfusion can also reduce the strain on the cardiovascular system as well. For instance, Kambi\u010d and colleagues found 8 weeks of BFR resistance exercise significantly lowered resting systolic blood pressure.(12) The ability to upregulate VEGF can be crucial when the muscle or bone capillary network is disrupted, such as after an acute injury or prior to and following a surgery. Blood flow restriction exercise provides a way to target and manipulate VEGF within the constraints of low level exercise; hopefully resulting in better healing and restoration of function. When looking to upregulate VEGF and increase capillarity, the most important point to remember is to maintain a hypoxic environment. Previous research has shown a relative pressure between 60-80% LOP is needed to maintain an anaerobic environment.(9,13,14) It appears a similar set\/rep scheme of BFR resistance exercise (30\/15\/15\/failure) used to increase muscle mass and strength is able to provide a sufficient enough of a stimulus to maximize the response of VEGF. While a training frequency of 2-3 sessions\/week for 4-6 weeks will likely maximize angiogenesis. \n\nCheck out a previous podcast we put out on hypoxia, HIF1A, and VEGF.References \n\nVerma M, Asakura Y, Murakonda BSR, et al. Muscle Satellite Cell Cross-Talk with a Vascular Niche Maintains Quiescence via VEGF and Notch Signaling. Cell Stem Cell. 2018;23(4):530-543.e9. Christov C, Chr\u00e9tien F, Abou-Khalil R, et al. Muscle satellite cells and endothelial cells: close neighbors and privileged partners. Mol Biol Cell. 2007;18(4):1397-1409. Snijders T, Nederveen JP, Joanisse S, et al. Muscle fibre capillarization is a critical factor in muscle fibre hypertrophy during resistance exercise training in older men. J Cachexia Sarcopenia Muscle. 2017;8(2):267-276. Grapar Zargi T, Drobnic M, Jkoder J, Strazar K, Kacin A. The effects of preconditioning with ischemic exercise on quadriceps femoris muscle atrophy following anterior cruciate ligament reconstruction: a quasi-randomized controlled trial. Eur J Phys Rehabil Med. 2016;52(3):310-320. Noehren B, Andersen A, Hardy P, et al. Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction. J Bone Joint Surg Am. 2016;98(18):1541-1547. \u017dargi T, Drobni\u010d M, Stra\u017ear K, Kacin A. Short\u2013Term Preconditioning With Blood Flow Restricted Exercise Preserves Quadriceps Muscle Endurance in Patients After Anterior Cruciate Ligament Reconstruction. Front Physiol. 2018;9:1150. Street J, Winter D, Wang JH, Wakai A, McGuinness A, Redmond HP. Is human fracture hematoma inherently angiogenic? Clin Orthop Relat Res. 2000;(378):224-237. Mishima Y, Lotz M. Chemotaxis of human articular chondrocytes and mesenchymal stem cells. J Orthop Res. 2008;26(10):1407-1412. Ferguson RA, Hunt JEA, Lewis MP, et al. The acute angiogenic signalling response to low-load resistance exercise with blood flow restriction. EJSS . 2018;18(3):397-406. Gavin TP, Drew JL, Kubik CJ, Pofahl WE, Hickner RC. Acute resistance exercise increases skeletal muscle angiogenic growth factor expression. Acta Physiol . 2007;191(2):139-146. Hunt JEA, Galea D, Tufft G, Bunce D, Ferguson RA. Time course of regional vascular adaptations to low load resistance training with blood flow restriction. J Appl Physiol. 2013;115(3):403-411. Kambi\u010d T, Novakovi\u0107 M, Toma\u017ein K, Strojnik V, Jug B. Blood Flow Restriction Resistance Exercise Improves Muscle Strength and Hemodynamics, but Not Vascular Function in Coronary Artery Disease Patients: A Pilot Randomized Controlled Trial. Front Physiol. 2019;10:656. Hunt JEA, Stodart C, Ferguson RA. The influence of participant characteristics on the relationship between cuff pressure and level of blood flow restriction. Eur J Appl Physiol. 2016;116(7):1421-1432. Ilett M, Rantalainen T, Keske M, May A, Warmington S. The Effects of Restriction Pressures on the Acute Responses to Blood Flow Restriction Exercise. Front Physiol. 2019;10:1018.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5849,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/vascular-endothelial-growth-factor","id":"blog\/vascular-endothelial-growth-factor","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-HamCurl-4.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"WHY IS IT CRUCIAL TO USE PERSONALIZED PRESSURE?","permalink":"why-is-it-crucial-to-use-personalized-pressure","timestamp":1648057202,"summary":"Blood Flow restriction rehabilitation is continuing to gain popularity among medical practitioners looking to provide the best outcomes for their patients. There is a significant amount of inconsistency in the BFR literature as far as parameters of application and devices being used. These inconsistencies in application have spilled over into the application of personalized blood flow restriction in a clinical setting.\n\nIn a recent article published in the Journal of Medical and Biological Engineering, James McEwen, Johnny Owens, and Jeswin Jeyasurya addressed the primary reasons to use personalized pressure and a device that can maintain consistent pressures for BFR in a clinical or rehabilitation setting. \"An analysis of previous studies using an arbitrary fixed pressure of 200 mmHg or using a percentage of brachial systolic blood pressure (e.g. 130% of SBP) and cuffs of differing widths showed these methodologies of setting pressure may result in a significant number of subjects having cuff pressures above LOP (limb occlusion pressure). Complete arterial occlusion reduces the effectiveness of the BFR intervention... and higher pressures place a greater demand on the cardiovascular system compared to lower pressures during BFR rehabilitation.\"\n\nWith the available information, using personalized pressure and a device that can consistently target and maintain\/or adjust to changes in pressure is our safest way to perform BFR rehabilitation and standardize it in clinical settings and research trials. Consistently using a percentage of LOP will also serve as a way to control for variability in outcomes and facilitate improved protocol development moving forward.\n\nMcEwen, J. A., Owens, J. G., & Jeyasurya, J. (2018). Why is it Crucial to Use Personalized Occlusion Pressures in Blood Flow Restriction (BFR) Rehabilitation? Journal of Medical and Biological Engineering. https:\/\/doi.org\/10.1007\/s40846-018-0397-7\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":6570,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/why-is-it-crucial-to-use-personalized-pressure","id":"blog\/why-is-it-crucial-to-use-personalized-pressure","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-17.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"WIDE-RIGID VS NARROW-ELASTIC","permalink":"wide-rigid-vs-narrow-elastic","timestamp":1648057202,"summary":"The scientific and clinical communities have embarked on a never ending quest to determine the optimal prescription of exercise in healthy and pathological populations. That search carries over into the application of Blood Flow Restriction (BFR). It seems to be well accepted now that BFR can amplify the effects of low intensity exercise.(1\u20133) While the recent position stand paper provided important guidance for BFR exercise prescription in healthy persons, questions abound as to how best to apply BFR in clinical scenarios.(4) Key topics warranting continued investigation include, but are not limited to risks \/ contraindications, pressure selection, size and type of cuff, as well as typical exercise parameters of intensity, duration and frequency.\n\nA recent publication out of the University of Texas attempted to contribute to this discussion by examining exercise responses to walking with wide-rigid cuffs (WR), narrow-elastic cuffs (NE), or a no restriction control group.(5) \n\nDetailsWR Cuffs (18cm)NE Cuffs (5cm)No BFR ControlDeviceHokanson deviceB-StrongNoneMean Systolic BP116mmHg (standing)116mmHg (standing)115mmHg (standing)Pressure UsedBFR - 160mmHGBFR - 300mmHgN\/AReal-time PressureUnableUnableN\/AWalking Intervals2 min2 min2 minRest Intervals1 min1 min1 minPace0.9 m\/s0.9 m\/s0.9 m\/sReps555Total work time10 min10 min10 min\n\nThe authors used 160 mmHg for the wide cuff condition and 300 mmHg for the narrow cuff condition. Regarding their choice of pressures they state, \u201cThese same standard pressures were used for all individuals for comparative purposes.\u201d This assertion contrasts rather strongly with papers that have demonstrated clearly that cuff width, in addition to a subject's individual characteristics, provide for variances in both acute and chronic study results.(6\u20138) Additionally, their subject pool included both men and women. Men are known to have higher limb occlusion pressures than women, thus providing yet another reason why in order to compare conditions they would need to individualize the pressures used.(9) \n\nThe results of the study were generally not surprising when considering all the variables either accounted for or not by the design. They found that the wide cuff condition significantly elevated HR, SBP, DBP, MAP, lactate, RPE, and double product (a surrogate for the amount of work the heart is doing) compared to the other conditions. Within their discussion they raise concern regarding these findings, suggesting that if a WR cuff is used in a clinical setting it could present a safety concern. In so doing, they ignore some rather important pieces to that puzzle. For one, they did not look at any other pressures with the WR cuff they used; either individualized or not. This means they can only draw a conclusion based on the singular cuff pressure condition that they examined with the WR cuff. A blanket statement regarding cuff design based on these findings is at minimum short-sighted.\n\nConsidering the width of the WR cuff, and the pressure used in relation to the mean resting systolic pressure (116mmHg) of that group, it is highly likely that at 160 mmHg more than one of the subjects was exercising at full occlusion. Exercise at full occlusion in at risk populations is not something we\u2019ve seen anyone advocate for in the BFR space, nor is it something anyone has studied or advocated for in healthy persons. While they do report significant hemodynamic differences between the WR group and the other two groups, they fail to discuss the magnitude of these responses. Systolic BP was ~35 mmHg greater than control, DBP was ~20 mmHg greater, HR was at most 5 bpm greater and lactate increased 2 fold. The magnitude of these differences is not particularly concerning, especially when one considers the extremely well established fact that in order to elicit any sort of adaptation in human skeletal muscle, or cardiovascular function, increases such as these are likely at the low end of that threshold.(10)\n\nUnfortunately, this article doesn\u2019t contribute valuable information toward the continued pursuit of optimal BFR exercise prescription in healthy persons, much less in clinical settings. By applying BFR in an arbitrary fashion, the authors neglected years of research and guidance on current best practices for BFR. (4) They suggest that the findings of this study indicate there may be safety concerns with the application of wide rigid cuffs, and that narrow-elastic cuffs would be the safer alternative, but their study wasn\u2019t designed to draw such a conclusion. The only conclusion that can be drawn from this study is that the application of 160 mmHg with 18 cm wide cuffs did something different than walking under the other two conditions. However, it does reinforce the need for researchers and clinicians in the BFR space to consider and control for as many variables as they can when prescribing BFR exercise. This certainly includes consideration of the characteristics of the individual and the exercise parameters needed to provide adequate stress for the desired adaptation.\n\n\n\n1. Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. J Sci Med Sport. 2016;19(8):669-675.\n\n2. Loenneke JP, Wilson JM, Mar\u00edn PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol. 2012;112(5):1849-1859.\n\n3. Centner C, Wiegel P, Gollhofer A, K\u00f6nig D. Effects of Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older Individuals: A Systematic Review and Meta-Analysis. Sports Med. October 2018. doi:10.1007\/s40279-018-0994-1\n\n4. Patterson SD, Hughes L, Warmington S, et al. Blood Flow Restriction Exercise Position Stand: Considerations of Methodology, Application, and Safety. Front Physiol. 2019;10:533.\n\n5. Stray-Gundersen S, Wooten S, Tanaka H. Walking With Leg Blood Flow Restriction: Wide-Rigid Cuffs vs. Narrow-Elastic Bands. Front Physiol. 2020;11:568.\n\n6. Loenneke JP, Fahs CA, Rossow LM, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903-2912.\n\n7. Loenneke JP, Fahs CA, Rossow LM, et al. Blood flow restriction pressure recommendations: a tale of two cuffs. Front Physiol. 2013;4:249.\n\n8. Mouser JG, Mattocks KT, Buckner SL, et al. High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training. Physiol Meas. March 2019. doi:10.1088\/1361-6579\/ab0d2a\n\n9. Jessee MB, Buckner SL, Dankel SJ, Counts BR, Abe T, Loenneke JP. The Influence of Cuff Width, Sex, and Race on Arterial Occlusion: Implications for Blood Flow Restriction Research. Sports Med. 2016;46(6):913-921.\n\n10. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359.\n","words":0,"datetime":"2022-03-23T10:40:02-07:00","timer":5604,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/wide-rigid-vs-narrow-elastic","id":"blog\/wide-rigid-vs-narrow-elastic","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-13.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"BFR MAY PROTECT AGAINST BONE LOSS FOLLOWING ACL","permalink":"bfr-may-protect-against-bone-loss-following-acl","timestamp":1648011600,"summary":"The potential effects of BFR on bone are not well established in the available research. Based on the physiological effects of BFR, it seems there are positive changes that would promote bone healing or increases in bone density. \n\nKarabulut et al. demonstrated a similar increase in Bone-Specific Alkaline Phosphatase (marker for osteoblast activity) with a BFR group at 20% 1RM compared to a heavy lifting group at 80% 1RM. Mouser (2019), Hunt (2013), and Patterson (2011) all demonstrated increases in capillarity with BFR which would increase the transport of osteoblast to the bone. Hewitt et al. (2005) demonstrated, in an animal model, that cyclical inflation and deflation of a cuff proximal to a fracture could promote bone healing. \n\nTo date, none of the BFR studies looking directly at bone have been done on injured humans... until now. Last week, Dr Bradley Lambert, PhD and his colleagues from Houston Methodist presented their most recent and very intriguing work at American Academy of Orthopedic Surgeons in Las Vegas. They had individuals post ACL reconstruction perform exercises with Personalized Blood Flow Restriction or work-matched, standard of care exercise. As part of their trial, they assessed bone mineral density, bone mass, and lean muscle mass via DEXA scan. The BFR group performed all of their exercises with 80% Limb Occlusion Pressure using a Delfi Personalized Tourniquet System starting 10 days after surgery 2x week up to 12 weeks. \n\n\"The addition of BFR therapy to standard rehab exercises was found to prevent muscle mass loss in the whole leg and thigh in the post-operative limb compared to rehab alone. Intriguingly, the addition of BFR was also observed to minimize losses in bone mineral content and preserve bone density in the limb compared to standard rehab alone.\" \n\nWhat was equally fascinating was the large bone loss the control group suffered at 6 and 12 weeks after ACL surgery. This has not been well documented, that bone almost becomes osteopenic after surgery, and begs the question of the role this \"bone dump\" may play not only in graft incorporation but also in the cross-talk that is required between bone and muscle. Many important pathways to support muscle such as progenitor cells and HIF-1A to promote angiogenesis arise from the bone. Given that the bone is in a catabolic state up to 12-weeks after ACL surgery, and probably longer, may give insight into the difficulty for the muscle to fully recover and the slow incorporation of grafts. \n\nThis is very impactful not only for young healthy patients undergoing surgery, but perhaps even more for the elderly total joint patient that may suffer even more bone attrition. It goes without saying that the application of PBFR after fractures may be supported even more after this study. In fact, we have the largest PBFR trial in the world currently enrolling patients after femur fractures. Link: https:\/\/clinicaltrials.gov\/ct2\/show\/NCT02746458?te... Dr Lambert and his colleagues are already planning multiple follow-up studies and we are excited to be collaborating with the Methodist team. \n\nThe study will be submitted for publication soon. You can find more information on this presentation in the press release from AOSSM: https:\/\/www.sportsmed.org\/aossmimis\/Members\/About\/... \n\nHewitt, John D., et al. \u201cThe Effect of Intermittent Pneumatic Compression on Fracture Healing.\u201d Journal of Orthopaedic Trauma, vol. 19, no. 6, July 2005, pp. 371\u201376. Hunt, Julie E. A., et al. \u201cTime Course of Regional Vascular Adaptations to Low Load Resistance Training with Blood Flow Restriction.\u201d Journal of Applied Physiology, American Physiological Society Bethesda, MD, Aug. 2013, doi:10.1152\/japplphysiol.00040.2013. Karabulut, Murat, et al. \u201cEffects of High-Intensity Resistance Training and Low-Intensity Resistance Training with Vascular Restriction on Bone Markers in Older Men.\u201d European Journal of Applied Physiology, vol. 111, no. 8, Aug. 2011, pp. 1659\u201367. Patterson, Stephen D., and Richard A. Ferguson. \u201cEnhancing Strength and Postocclusive Calf Blood Flow in Older People with Training with Blood-Flow Restriction.\u201d Journal of Aging and Physical Activity, vol. 19, no. 3, July 2011, pp. 201\u201313.\n","words":0,"datetime":"2022-03-22T22:00:00-07:00","timer":6505,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/bfr-may-protect-against-bone-loss-following-acl","id":"blog\/bfr-may-protect-against-bone-loss-following-acl","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-18.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"NEURAL ADAPTATIONS FROM BFR","permalink":"neural-adaptations-from-bfr","timestamp":1648011600,"summary":"Whether or not blood flow restriction exercise (BFR) elicits neural adaptation is an important component in determining its overall utility for the rehab or exercise professional. One might consider neural adaptation is implied given we say rather confidently that BFR performed repeatedly in combination with a low load resistance exercise increases strength. Others might attribute an increase in force production following a BFR training block to be a result of the biomechanical adaptation hypertrophy. Although, the association between strength and muscle size seems to be loosening (Jessee et al., 2021). A better understanding of the neural adaptations elicited via BFR could provide valuable information regarding the mechanisms which lead to improvements in skeletal muscle strength, as well as provide support for BFR\u2019s use and refining how it is deployed. \n\nA recent review paper by Christoph Centner and Benedikt Lauber tackled the complex task of assessing the existing literature to determine how neural adaptations from BFR exercise compared to those achieved via light (LL) or heavy load (HL) resistance exercise without blood flow restriction.(Centner & Lauber, 2020) They performed their review in accordance with PRISMA guidelines, have made their data available, and only included studies that passed their risk of bias and quality assessments. While examining the acute neural responses to exercise of any sort provides insight into mechanisms or the potential for adaptation, the main objective of this review was to \u201csummarize the long-term (\u22654 weeks) effects of LL-BFR exercise on neural markers (peripheral vs. central) compared to HL and LL training without BFR\u201d. The authors were able to include 10 studies in their qualitative synthesis and 4 studies into a meta-analysis. Based on the data available, the authors were able to draw much stronger conclusions regarding peripheral adaptations than central adaptations. What data there is on central nervous system adaptations does not look to be negative in any way. It\u2019s merely questionable whether or not low-load BFR exercise elicits similar responses centrally to heavy load resistance exercise when used chronically. \n\nLL-BFR vs LL (Muscle Excitation and Central Activation)\n\nThis review was able to conclude via meta-analysis that LL-BFR does in fact lead to greater excitation in muscle than LL. However, because there\u2019s always a \u201chowever\u201d, despite this conclusion aligning with many of the studies assessing acute EMG, differences between the two appear to be attenuated when the LL cohort exercises to volitional failure. Thus, highlighting both a key concept in BFR and an imperative for muscle size increase; that BFR accelerates fatigue and exercise must elicit high levels of fatigue respectively. The authors took extra care to highlight that while important, using an elevation in EMG as a surrogate for motor unit (MU) recruitment is problematic. They directed the reader to works by Fatela that have taken steps to estimate MU recruitment and firing rates, while Krustrup in 2009 used biopsies to assess creatine phosphate levels.(Fatela et al., 2019; Krustrup et al., 2009) Taken together these findings point to early recruitment of higher threshold motor units as a result of the addition of BFR to low load resistance exercise. Evaluating central responses between LL-BFR and LL resistance exercise is much more difficult given the paucity of work in this area. There are only 2 studies looking at long-term changes in response to LL exercise with or without BFR. Those studies looked at entirely different outcomes so they were unable to compare them in any way. Briefly, Colomer showed no changes in V-wave or H-reflex following 4-weeks of LL-BFR or LL resistance exercise.(Colomer-Poveda et al., 2017) While Moore 2004 noted depressed resting twitch torque resulting in an increased post-activation potentiation finding.(Moore et al., 2004) The authors note the finding by Moore potentially helps explain the adaptation of strength increase in response to LL-BFR training, but state clearly that no one has in fact examined this in a long-term trial. \n\nLL-BFR vs HL (Muscle Excitation and Central Activation)\n\nSorting out whether or not there is a difference in muscle excitation between LL-BFR and HL is much more elusive. There are only two long-term studies to consider. An eight-week trial by Ramis 2020 found no difference in muscle excitation between their HL and their LL-BFR group while a six-week trial by Sousa 2017 actually found a 20% greater excitation in their LL-BFR group compared to their HL group.(Ramis et al., 2018; Sousa et al., 2017) The authors note a number of potential reasons for this unusual finding in light of the fact that it also contradicts the vast majority of acute EMG studies examining differences between LL-BFR and HL. Ultimately they conclude \u201ca more strict and standardized normalization of the data (e.g., to maximal M-wave amplitude or maximal EMG activity of the post-test) in future studies is therefore warranted for an adequate interpretation of these variables.\u201d Much like in the comparison between LL-BFR and LL on central activation, there are only two papers but they did assess the same outcome; electrically evoked super-imposed twitches. A 6-week trial by Cook found no significant changes in either a HL or LL-BFR cohort while Kubo noted significant increases in a HL group that were not realized in a LL-BFR group. (Cook et al., 2018; Kubo et al., 2006) \n\nSumming things up:\n\nWhile there are a large number of papers examining how BFR influences the neuromuscular system. Its influence has not been examined in a systematic way so that strong conclusions can be drawn regarding mechanisms of adaptation or how best to facilitate desired adaptations in the nervous system. \u201cFrom a practical standpoint, the findings from this systematic review and meta-analysis indicate that neural adaptations, especially on the EMG level, can be augmented when applying BFR to LL exercise. These results seem to support the notion that besides structural, also neural changes might contribute to the observed strength increases following LL-BFR training.\u201d \n\nCentner, C., & Lauber, B. (2020). A Systematic Review and Meta-Analysis on Neural Adaptations Following Blood Flow Restriction Training: What We Know and What We Don\u2019t Know. Frontiers in Physiology, 11, 887.Colomer-Poveda, D., Romero-Arenas, S., Vera-Ib\u00e1\u00f1ez, A., Vi\u00f1uela-Garc\u00eda, M., & M\u00e1rquez, G. (2017). Effects of 4 weeks of low-load unilateral resistance training, with and without blood flow restriction, on strength, thickness, V wave, and H reflex of the soleus muscle in men. European Journal of Applied Physiology, 117(7), 1339\u20131347.Cook, S. B., Scott, B. R., Hayes, K. L., & Murphy, B. G. (2018). Neuromuscular Adaptations to Low-Load Blood Flow Restricted Resistance Training. Journal of Sports Science & Medicine, 17(1), 66\u201373.Fatela, P., Mendonca, G. V., Veloso, A. P., Avela, J., & Mil-Homens, P. (2019). Blood Flow Restriction Alters Motor Unit Behavior During Resistance Exercise. International Journal of Sports Medicine. https:\/\/doi.org\/10.1055\/a-0888-8816Jessee, M. B., Dankel, S. J., Bentley, J. P., & Loenneke, J. P. (2021). A Retrospective Analysis to Determine Whether Training-Induced Changes in Muscle Thickness Mediate Changes in Muscle Strength. Sports Medicine . https:\/\/doi.org\/10.1007\/s40279-021-01470-5Krustrup, P., S\u00f6derlund, K., Relu, M. U., Ferguson, R. A., & Bangsbo, J. (2009). Heterogeneous recruitment of quadriceps muscle portions and fibre types during moderate intensity knee-extensor exercise: effect of thigh occlusion. Scandinavian Journal of Medicine & Science in Sports, 19(4), 576\u2013584.Kubo, K., Komuro, T., Ishiguro, N., Tsunoda, N., Sato, Y., Ishii, N., Kanehisa, H., & Fukunaga, T. (2006). Effects of low-load resistance training with vascular occlusion on the mechanical properties of muscle and tendon. Journal of Applied Biomechanics, 22(2), 112\u2013119.Moore, D. R., Burgomaster, K. A., Schofield, L. M., Gibala, M. J., Sale, D. G., & Phillips, S. M. (2004). Neuromuscular adaptations in human muscle following low intensity resistance training with vascular occlusion. European Journal of Applied Physiology, 92(4-5), 399\u2013406.Ramis, T. R., Muller, C. H. de L., Boeno, F. P., Teixeira, B. C., Rech, A., Pompermayer, M. G., Medeiros, N. da S., Oliveira, \u00c1. R. de, Pinto, R. S., & Ribeiro, J. L. (2018). Effects of Traditional and Vascular Restricted Strength Training Program With Equalized Volume on Isometric and Dynamic Strength, Muscle Thickness, Electromyographic Activity, and Endothelial Function Adaptations in Young Adults. Journal of Strength and Conditioning Research \/ National Strength & Conditioning Association. https:\/\/doi.org\/10.1519\/JSC.0000000000002717Sousa, J., Neto, G. R., Santos, H. H., Ara\u00fajo, J. P., Silva, H. G., & Cirilo-Sousa, M. S. (2017). Effects of strength training with blood flow restriction on torque, muscle activation and local muscular endurance in healthy subjects. Biology of Sport \/ Institute of Sport, 34(1), 83\u201390.\n","words":0,"datetime":"2022-03-22T22:00:00-07:00","timer":5936,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/neural-adaptations-from-bfr","id":"blog\/neural-adaptations-from-bfr","aria":"Read more about ","genrelink":"","authorlink":""},{"categories":[],"labels":[],"tags":[],"gallery":[],"image":null,"genre":"","media":"https:\/\/owensrecoveryscience.com\/wp-content\/uploads\/2020\/04\/ORS-Frames-9.jpg","archived":false,"draft":false,"featured":false,"author":"","title":"UNDER PRESSURE ... BFR AND HEMODYNAMICS","permalink":"under-pressure-bfr-and-hemodynamics","timestamp":1648011600,"summary":"The application of Blood Flow Restriction (BFR) is nearly a century old. Some of the earliest papers date back to the late 1930s. Much of the research on this intervention, and a large portion of the questions we receive center around safety. In previous blogs we addressed concerns around clots and dove more specifically into the implications for individuals with thrombophilia. In this installment, and as Kyle alluded to in the previous blog, we\u2019re going to continue the safety discussion by addressing the effects of BFR on hemodynamics. The primary questions have been:\n\nHow does the addition of BFR alter the hemodynamic responses of low load resistance exercise?How does this information influence the way we perform BFR?\n\nBP \/ HR RESPONSES TO RESISTANCE EXERCISE\n\nChanges in blood pressure and heart rate with exercise are well documented and are known to occur at relatively low intensity (20-50% MVC). (Lind and McNicol 1967) MacDougall et al showed that the increases in blood pressure and heart rate can be extreme when performing exercise at high intensities. When individuals performed bilateral leg press at 80-100% of their 1 rep max, blood pressure was measured as high as 480\/350 mmHg and heart rate was as high as 170 beats per minute. (MacDougall et al. 1985) Even with a small muscle group in a single arm bicep curl, they measured BP as high as 255\/190 mmHg. The authors postulated that the significant increases in pressure and heart rate occurred as a result of mechanical compression of the vasculature, valsalva or increased intraabdominal pressure, and a pressor response to maintain cardiac output. (MacDougall et al. 1985) The changes tended to be greatest with exercise that required multiple reps to achieve failure as opposed to a single max effort lift. Thus, the load, duration, and amount of muscle involved (Legs > Arms) all have an influence on the cardiovascular response.\n\nDURATION OF PRESSURE\n\nAs it pertains to BFR exercise, the work of Alam and Smirk in the late 1930s provides a seminal understanding of how mechanical pressure applied to a limb\u2019s vasculature influences the hemodynamic response (Alam and Smirk 1937) . Alam and Smirk designed a series of experiments to investigate the exercise pressor reflex. In one of their experiments they applied blood pressure cuffs to the thighs and inflated to \u201cwell above systolic blood pressure\u201d while performing a soleus exercise. They noted that systolic and diastolic blood pressure increased while performing the exercise. This was demonstrated in the UE as well via similar methods and the use of a gripping task. Attempting to apply mechanical pressure to the vasculature in a different manner they actually had individuals plunge their arms into a vat of mercury to induce vasoconstriction while doing a forearm exercise (good luck getting this through IRB). The variables in these experiments were then manipulated in such a way that they discovered BP did not return to baseline until the mechanical pressure was released despite the cessation of exercise. Additionally, after 3-4 minutes of sustained pressure and no exercise, they identified a gradual rise in blood pressure. These findings lead them to suggest that the method of vascular compression doesn\u2019t seem to matter, merely the restriction of blood flow into the limb would cause an increase in blood pressure. \n\nAs we move forward in the BFR literature, Takano in 2005 and Ozaki in 2010 added support for the work of Alam and Smirk showing that the addition of BFR increased HR and BP more than low intensity work matched exercise. (Takano et al. 2005; Ozaki et al. 2010) The increases in HR and BP in these studies were statistically significant compared to the control group, but modest in comparison to the numbers seen in the MacDougall paper. One potential reason for these findings is that when BFR is added to resistance exercise the time needed to achieve high levels of fatigue is substantially reduced. This reduces the duration pressure would be applied to the exercising limb, thus giving further support to Alam and Smirk\u2019s work. Providing further support to the influence duration of pressure application has can be found in Neto's work from 2016. They showed that deflating during the rest period (intermittent BFR) limited the increase in double product (a measure of heart rate times systolic pressure). (Neto et al. 2016)\n\nAMOUNT OF PRESSURE\n\nOne of the primary reasons we recommend using the lowest pressure possible with BFR exercise is the pressure applied with BFR really seems to matter when it comes to the hemodynamic response. Brandner et al compared 130% of systolic pressure (intermittently) to 80% of systolic pressure (continuously) while performing a bicep curl exercise with 20% of a 1 rep max. They showed that the changes in blood pressure, heart rate, and mean arterial pressure are greater even when BFR is applied intermittently at a higher pressure. (Brandner et al. 2015) The high pressure group pretty closely resembled high intensity exercise. Eliciting that kind of a response may not be a concern for a young, healthy individual, but it would at minimum be cause for concern for those with comorbidities.\n\nREGULATION OF PRESSURE\n\nAdditionally, Hughes et al showed that regulation of pressure throughout the exercise influences the hemodynamic response. In a study comparing the pressure actually being applied to the limb across multiple different tourniquet systems, they found that the two cuffs in their study which lacked the ability to rapidly adjust pressure during exercise significantly augmented mean arterial pressure. (Hughes et al. 2018) Conversely, the automatic personalized tourniquet was able to maintain consistent pressure to the limb throughout the exercise and did not cause a significant elevation in mean arterial pressure.\n\nPUTTING THIS INTO PRACTICE...\n\nFrom the information provided above, we understand that exercise with or without blood flow restriction will cause some changes in BP and HR. This may not matter for the average gym goer, but in a patient care setting, minimization of risk while applying adequate stimulus is crucial . There are a number of variables which influence the hemodynamic response while performing blood flow restriction that we can control for such as exercise intensity , pressure used, the time under pressure, and the exercise effort or exertion. \n\nGreat recommendations for load and pressure can be found in the article formerly known as the Position Stand. (Patterson et al. 2019) For patients who have hypertension or other cardiovascular concerns, we recommend you explore exercise without BFR first to understand their tolerance and establish a baseline. If you decide to incorporate BFR, it may be prudent to initiate BFR with a lower percentage of their 1RM and a lower pressure than you might use otherwise. Work from Hughes, and some unpublished work from Kacin, indicates that the ability to rapidly adjust pressure changes created by the contracting muscle may also be important (Hughes et al. 2018; Kacin et al. ). The spikes in pressure that occur from this potentially influence the exercise pressor reflex via the intensity of pressure applied to the vasculature. Lastly, deflating during the rest period can be another strategy you deploy to limit the hemodynamic response. This reduces the amount of time that pressure is applied to the vasculature and potentially reduces the overall hemodynamic response. \n\nBFR is a safe and effective intervention when applied in an objective way. Patients, however, often present with comorbidities. This requires the clinician have a deeper understanding of how the intervention they choose will, and can be manipulated to, influence factors that are relevant to their comorbidities. So take an extra moment to consider all the variables you can control and apply them in a strategic fashion. Your patient deserves that!\n\nLind AR, McNicol GW. Circulatory responses to sustained hand-grip contractions performed during other exercise, both rhythmic and static. J Physiol. 1967;192(3):595-607. MacDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR. Arterial blood pressure response to heavy resistance exercise. J Appl Physiol. 1985;58(3):785-790. Alam M, Smirk FH. Observations in man upon a blood pressure raising reflex arising from the voluntary muscles. J Physiol. 1937;89(4):372-383. Takano H, Morita T, Iida H, et al. Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. Eur J Appl Physiol. 2005;95(1):65-73. Ozaki H, Brechue WF, Sakamaki M, et al. Metabolic and cardiovascular responses to upright cycle exercise with leg blood flow reduction. J Sports Sci Med. 2010;9(2):224-230. Neto GR, Novaes JS, Dias I, Brown A, Vianna J, Cirilo-Sousa MS. Effects of resistance training with blood flow restriction on haemodynamics: a systematic review. Clin Physiol Funct Imaging. 2017;37(6):567-574. Brandner CR, Kidgell DJ, Warmington SA. Unilateral bicep curl hemodynamics: Low-pressure continuous vs high-pressure intermittent blood flow restriction. Scand J Med Sci Sports. 2015;25(6):770-777. Hughes L, Rosenblatt B, Gissane C, Paton B, Patterson SD. Interface pressure, perceptual and mean arterial pressure responses to different blood flow restriction systems. Scand J Med Sci Sports. Published online April 6, 2018. doi:10.1111\/sms.13092 Counts BR, Dankel SJ, Barnett BE, et al. Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle Nerve. 2016;53(3):438-445. Ilett M, Rantalainen T, Keske M, May A, Warmington S. The Effects of Restriction Pressures on the Acute Responses to Blood Flow Restriction Exercise. Front Physiol. 2019;10:1018. Kacin, A., Rosenblatt, B., \u017dargi, T. G., & Biswas, A. (n.d.). SAFETY CONSIDERATIONS WITH BLOOD FLOW RESTRICTED RESISTANCE TRAINING. Neto GR, Novaes JS, Salerno VP, et al. Acute Effects of Resistance Exercise With Continuous and Intermittent Blood Flow Restriction on Hemodynamic Measurements and Perceived Exertion. Percept Mot Skills. Published online November 11, 2016. doi:10.1177\/0031512516677900 Neto GR, da Silva JCG, Freitas L, et al. Effects of strength training with continuous or intermittent blood flow restriction on the hypertrophy, muscular strength and endurance of men. Acta Scientiarum Health Sciences. 2019;41:e42273.\n","words":0,"datetime":"2022-03-22T22:00:00-07:00","timer":6428,"url":"https:\/\/owensrecoveryscience.com\/blog-view\/under-pressure-bfr-and-hemodynamics","id":"blog\/under-pressure-bfr-and-hemodynamics","aria":"Read more about ","genrelink":"","authorlink":""}] { "@context" : "https://schema.org", "@type" : "BlogPosting", "headline" : "{{title}}", "description" : "", "image" : "https://owensrecoveryscience.com/{{#image}}{{img}}{{/image}}", "datePublished" : "{{datetime}}", "dateModified" : "", "url" : "https://owensrecoveryscience.com/blog-view/{{permalink}}", "mainEntityOfPage" : { "@type" : "WebPage", "@id" : "https://owensrecoveryscience.com/blog-view/{{permalink}}" }, "author" : { "@type" : "Person", "name" : "{{author}}" }, "publisher" : { "@type" : "Organization", "name" : "Owens Recovery Science", "logo" : { "@type" : "ImageObject", "url" : "https://owensrecoveryscience.com//cms-data/image/settings_logo.png" } }, "keywords" : "Blood Flow Restriction", "wordcount" : "{{words}}", "articleBody" : "{{summary}}" } {{^image}} {{/image}} {{#image}} {{#image}} {{/image}} {{/image}} {{title}}
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Keyword	Contenuto	Title	Keywords	Description	Headings
home	1
personalized	1
blood	1
flow	1
restriction	1

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