Disuse Atrophy. Seiza 2/6/19. Blood Flow Restriction Training: Expanding your toolkit for the season

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1 Blood Flow Restriction Training: Expanding your toolkit for the season Seiza Tyler Nelson DC, MS, CSCS Camp4 Human Disuse Atrophy 2 weeks of microgravity results in 20% reduction in skeletal muscle mass. 2 weeks of bedrest results in substantial atrophy. While alpine skiing in 1973, Yoshiaki Sato fell and suffered an ankle fracture and damaged his knee. He was treated with full length cast. 2 weeks of immobilization in a brace or cast results in substantial atrophy. Hakone Ski Resort Mt. Fuji in background Full Leg Cast 1

2 Decade of 70 s Sato experimented on himself and personal training partners with various belts and bands. Bicycle inner tube Ace Wrap At one point, he started coughing up blood. Evidence of a pulmonary embolism. In retrospect, he had occluded arterial inflow in his legs sufficiently to cause DVT s and pulmonary emboli to 2010 Increasing widespread use in KAATSU Kiosks develop in and around Tokyo, building a group of ~5,000 KAATSU Masters or practioners. Awareness of BFR Training Techniques in Europe and the Americas. Because Sato s equipment was unavailable, many Westerners employed many kinds of devices from wraps, straps, belts, BP cuffs, surgical tourniquets, attempting to reproduce Sato s results. Many systems were not safe, nor effective. Publications began to appear in Western scientific journals, studying various aspects of BFR training to ,000 ~ $6000 Development of KAATSU Master First training study in Western Journal Takanada et al. J. Appl. Physiol Kaatsu Systemic Published References Kaatsu on BFR Kaatsu Mech over Local the past 20 Safety years 1.2 Efficacy Protein anti-dvt Kaatsu 1 Prox & Distal synthesis Efficacy 0.8 Muscle Kaatsu Muscle 0.6 Safety 0.4 Survey Published References on BFR over the past 20 years Kaatsu systemic Mech mtor Rats BFR mech ( 66 ) 2017 nachr Rats BFR eff

3 Blood Flow Restriction Training: Mechanism(s) Two Local and one Systemic Mechanism(s) 1. mtor pathway to up-regulate protein synthesis 2. Recruitment of additional motor units as initial ones drop out. 3. Afferent nerve traffic (type III, IV) to CNS to release neuro-immuno-humoral systemic response Disturbance of Homeostasis in Working Muscle Reduction in po 2 Reduction in ph Increase in [Lactate] Increase in [P i ] Decrease in [(PC)] Decrease in [ATP] Altering Electrolyte (K +, Na +, Ca 2+ ) gradients Apply Venous blockade e.g mmhg 3

4 Consequence of afferent nerve traffic Skeletal muscle adaptations following blood flow-restricted training during 30 days of muscular unloading Journal of Applied Physiology. Volume 109 Issue 2, August 2010 Pages Norepinephrine The general function of norepinephrine is to mobilize the brain and body for action. Norepinephrine release is lowest during sleep, rises during wakefulness, and reaches much higher levels during situations of stress or danger, in the so-called fightor-flight response. GH is a stress hormone that raises the concentration of glucose and free fatty acids.[1][2] It also stimulates production of IGF-1. Low load BFR 3 sets at 20% MVC 1.3x systolic pressure use on proximal thigh to volitional failure with 90s. Rest between sets Metronome used to pace contractions at 2s. 6x83cm Hokanson cuff 8.5 minutes total time (band inflated 3 days per week for 5 weeks Conclusion: Muscle mass, strength, and endurance following low load blood flow resistance exercise performed during 30 days of unloading was preserved in the knee extensors compared with no intervention. Training with blood flow restriction. Mechanisms, gain in strength and safety. (REVIEW) J Sports Med Phys Fitness May;55(5): Epub 2015 Feb of 30 studies show improved strength. Hypertrophy in men and women Positive impacts on bone health Non-exercised limbs have shown gains in strength without exercise. Controversial but promising reports on aerobic capacity Rheologic investigations after BFR have shown no evidence for increased risk of thrombosis. Up to now no standard BFR training guidelines exist. Occlusion pressure, intensity of training, number of sets and duration of a training unit remain unclear. Presently, an occlusion pressure of 150 (20-50% AOP) mmhg may be recommended with an intensity of 20 % 1-repetition maximum (1 RM), and wider cuffs are more efficient than narrow ones. 4

5 Mechanisms of Blood Flow Restriction: The New Testament. Techniques in orthopedics Jessee, Matthew, B., MSc; Mattocks, Kevin, T., MSc; Buckner, Samuel, L., MSc; Dankel, Scott, J., MSc; Mouser, J., Grant, MSc; Abe, Takashi, PhD; Loenneke, Jeremy, P., PhD *Limbs of different size use different occlusive pressures Rest Near Infra Red Spectroscopy (NIRS) without and with Blood Flow Restriction Biceps SmO 2 (%) No BFR bands, 25 Arm curl exercises Recovery100 Hyperem Rest Biceps SmO 2 (%) mmhg Recovery Hyperemia Failure of Exercise, bands released Muscle failu With normal blood flow Without blood flow NM spectroscopy spectra demonstrating a Disturbance of Homeostasis Note: the rise in Pi and decrease in PC with exercise and then with ischemic exercise. Also, the decrease in area under the curve in the 3 ATP curves. Local and Systemic Effects of BFR Systemic effects IGF-1 is a hormone similar in molecular structure to insulin. It plays an important role in childhood growth and continues to have anabolic effects in adults. Local effects 5

6 Evidence of angiogenic stimulation from BFR CONCLUSION: Acute BFR increases post exercise expression of mrna related to skeletal muscle angiogenesis, plausibly in response to changes in muscle Hb concentrations. Larkin et. al. Blood Flow Restriction Enhances Post-Resistance Exercise Angiogenic Gene Expression Med Sci Sports Exer Vol 44, No 11, pg , 2012 Takanada et. al. J. Appl. Physiology 88: , 2000 These results suggest that resistance exercise at an intensity even lower than 50% 1 RM is effective in inducing muscular hypertrophy and concomitant increase in strength when combined with vascular occlusion. Sequential Recruitment of Motor Units for different exercises To have a muscle get bigger/stronger, it must be recruited and fatigued Normal recruitment and fatigue pattern BFR recruitment and fatigue pattern With BFR and easy exercises, as slower motor units fatigue because they are not getting the blood flow they normally get to sustain contraction, faster and faster units are recruited that fatigue even quicker and soon the entire motor unit pool is in a metabolic crisis. This Disturbance of Homeostasis leads to both a local anabolic response and a systemic neuroimmuno-humoral anabolic response. + BFR + BFR + BFR 6

7 The Effects of Blood Flow Restriction on Upper-Body Musculature Located Distal and Proximal to Applied Pressure. Low-load BFR training increased he muscle size and strength in limbs located proximal (chest, shoulders) and distal (biceps, triceps) to the restrictive stimulus; while volume-matched exercise in absence of BFR did not elicit beneficial muscle adaptations. Some of the musculature in the upper body cannot be directly restricted by the application of BFR. Despite this, increases in muscle size and strength were observed in muscles placed under direct and indirect BFR. Blood-flow Restriction Resistance Exercise Promotes Lower Pain and Ratings of Perceived Exertion as Compared to Either High or Low-Intensity Resistance Exercise Performed to Muscular Failure. INTERVENTIONS: Four sets of 45 leg press exercise in three different conditions: i) BFR-RE (15 repetitions; 30% 1-RM); ii) HI-RE (80% 1-RM to muscular failure) and; iii) LI- RE (30% 1-RM to muscular failure). RESULTS: RPE and pain levels increased throughout the exercise sets for all RE protocols (all, P < 0.05). HI- and LI-RE protocols showed similar increase in RPE and pain levels during all exercise sets (P < 0.05); however, both protocols demonstrated higher RPE and pain response as compared to BFR-RE after each of the four sets (all P < 0.05 between-group comparisons). CONCLUSIONS: Our results demonstrated that both HI- and LI-RE to muscular failure resulted in similar and significant increases in RPE and pain levels, regardless of exercise intensity. In addition, non-muscular failure BFR-RE also increased RPE and pain response; however, to a lower extent as compared to either HI-RE or LI-RE. Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Physical therapy in Sports Korakakis V1, Whiteley R2, Epameinontidis K2. 30 patients with anterior knee pain Shallow and deep single leg squat as well as step down Exercise (generally performed with pain) as test 4 sets of knee extensions to failure AOP Average 60% reduction in reported pain Significant effects were found with greater pain relief immediate after BFR. Time analysis revealed pain reduction was sustained after PT session for all tests. Acute response and subcellular movement of HSP27, αbcrystallin and HSP70 in human skeletal muscle after blood-flowrestricted low-load resistance exercise. Acta Physiologica 9 participants 5 sets of leg extensions on one leg 13.5cm cuff, mmHg Opposite leg did work matched exercise without BFR CONCLUSION: Translocation of HSP27 and αb-crystallin from cytosol to cytoskeletal structures indicates that cytoskeletal proteins are stressed during BFRE. However, overt signs of myofibrillar disruptions were not observed. Interestingly, the stress response was more pronounced in type 1 than in type 2 fibres and coincided with low glycogen levels. HSP accumulate as a result of myofibrillar damage. Important for repair and stabilization of damaged proteins Found unbound in unstressed cytosol. Translocate and bind to accumulate in stressed and damaged tissue 7

8 Ischemic Preconditioning and Exercise Performance: A Systematic Review and Meta-Analysis. International Journal of Sports Physiology and Performance Short bouts of high pressure occlusion before high intensity training Has Has been shown to be protective against muscle damage with no exercise 100% limb occlusive pressure for 3-5 rounds of 5 minutes with 3 minutes of deflate x 4 Largest results on anaerobic exercise BFR rehabilitation progression First two weeks Arms 150mmHg (20-40% AOP) Legs 200mmHg (20-40% AOP) 2-4 single joint exercises (3x15-25) to volitional failure minutes Weeks 3-4 Arms mmHg (30-60% AOP) Legs mmHg (30-60% AOP) 3-5 multi-joint exercises (4x15-25) to volitional failure minutes *Note: These occlusion pressures are Specific to the Bstrong bands which are a Multi chambered system. Possible contraindications for use Schonach Jan 10, 2014 Pregnancy History of blood clotting Uncontrolled HBP Sickle cell disease Cancer Active infections Multiple co-morbidities (diabetes, hbp, obesity) No resistance training experience 8

9 Day of Injury Jan 10, 2014 Elastic BFR Jan 15, 2014 Opening Ceremonies Feb 7, 2014 June 10 th year old USL soccer player, with grade 3 MCL tear, post horn tear medial meniscus, partial PCL tear, lateral tibial bone bruise 1. locked brace 30 degrees & crutches for 2 weeks 2. RICE (rest, ice, compression, elevation) 3. B Strong BFR sans pain from Day 3 4. Alter-G ambulation sans pain from Day 3 9

10 Day degrees flexion, near full extension, no swelling, mild tenderness over MCL. Released from care at 5.5 weeks Careful soccer 6 weeks Normal 8 weeks 10