[Application and effects of blood flow restriction training]. / Anwendung und Effekte des "blood flow restriction training".

Blood flow restriction (BFR) limits arterial and venous blood flow and leads to blood pooling, which could increase exercise-induced training effects. Strength training at lower intensities (20-30% of maximum strength) in combination with BFR showed similar effects on muscle hypertrophy as training with 70% without BFR. Low-intensity cycling endurance training with BFR improves muscle hypertrophy and endurance performance and activates angiogenesis. After determination of the complete occlusion pressure on the corresponding extremity, it is recommended that BFR training should be performed with 40-80% of the measured occlusion pressure. During strength training of the upper extremities, an occlusion of 60-80% leads to a reduction in the arterial blood flow by 20-50%. Local ischemia and hypoxia, a stronger metabolic stimulus, swelling of the muscle cells and the increased oxidative stress are discussed as causes for the increased training effects due to BFR. In short-term studies, comparable adjustments to parameters of fibrinolytic activity, coagulation and inflammation could be observed for strength training with and without BFR. So far, thromboses after BFR have been described only rarely but need to be further clarified by appropriate studies. The BFR training leads to a stronger activation of the muscular metabolic reflex and thus to a relatively greater increase in exercise blood pressure, so that cardiovascular parameters should be controlled during BFR training. First meta-analyses with small numbers of healthy people and patients indicate the effectiveness of BFR training. Standardization or guidelines for clinical use are still lacking.

[Exercise and cellular adaptation of muscle]. / Körperliches Training und zelluläre Anpassung des Muskels.

Resistance training and to a lesser extent endurance training are capable of enhancing protein synthesis in skeletal muscle via various signaling pathways. Additionally, the expression of muscle fiber types responds to different regimes of training stimuli and immobilization as characterized by changes in myosin heavy chain isoforms (I<-->IIA<-->IIX). Eccentric resistance training has been shown to be highly efficient in inducing sarcomeric protein assembly in the longitudinal orientation of muscle cells. However, concentric contractions lead to a hypertrophic response (increased fiber diameter) in muscle which can still be activated in old age. The central signaling pathway to mediate the elevation of protein synthesis in response to training is the mTOR pathway, which is also stimulated by free amino acids. Moreover, adaptation to endurance training is mediated by the calcium-calcineurin-NFATc1 pathway which is strongly activated by the calcium transients involved in the muscle contraction process. High contraction frequency and long duration of training sessions are essential for activation and maintenance of fiber type I expression as well as for induction of transformation of type II into type I fibers. Endurance training sessions should therefore be longer than 30 min and dominated by periods of high frequency contractions. A further factor in the muscular response to training includes the recruitment and integration of satellite cells into muscle fibers. Satellite cells can respond to muscular stretch, activity and injury with increased proliferation and can later be integrated into muscle fibers. Therefore, new myonuclei are available to enhance mRNA synthesis and protein expression in muscle cells. New understanding of the cellular mechanisms of signal transduction in muscle in response to training, bed rest and ageing will help to optimize training and interventions in an ageing population.

[MR-guided core biopsy of the shoulder: possibilities and experience with a vertically open 0.5T system]. / MRT-gesteuerte Stanzbiopsie der Schulter: Möglichkeiten und Erfahrungen an einem vertikal offenen 0.5-T-System.

PURPOSE: The availability of open whole body MRI magnets and MR-compatible instrumentarium were essential conditions for the progression of interventional MRI. The advantages of an MR-guided biopsy at the musculoskeletal system are the visualization of the puncture site of a representative area for tumor histology, the absence of exposure to radiation and the free selection of imaging planes. The purpose of the study was the development of a new technique of a secure MR-guided biopsy of intraosseus lesions in the humeral head. MATERIAL AND METHODS: MR-guided core biopsy of a intraosseus lesion of the humeral head was performed in five male patients on a vertical open, whole body MRI magnet (SIGNA SP/i 0.5T, GE Medical Systems). The technique using interactive MRI and the MR-compatible instrumentarium are described. RESULTS: A secure core biopsy could be obtained from a representative area for tumor histology in all cases. No complications occurred, especially no nerve or vessel lesion, no rotator cuff lesion and no intra-articular contamination of the shoulder joint were observed. CONCLUSION: A new technique is presented to obtain MR-guided core biopsies of intraosseous lesions of the humeral head. Furthermore, clinical indications of this technique are described.

Quantification of tension in Thera-Band and Cando tubing at different strains and starting lengths.

AIM: Elastic resistance exercise is frequently used in rehabilitation programs. Precise quantification using color coded bands is not possible. A method to predict forces for any length of mostly used elastic tubings and thereby a general equation for the comparison of elastic material is presented. METHODS: In an in vitro-series the tubing tension in relation to elongation of 6 colors of Thera-Band and Cando tubings was directly measured. The relation between tension and elongation was determined depending on different resting lengths. In clinical practice tension and elongation are prescribed. Two mathematical methods to calculate the resting length as regulatory variable are presented. One is based on the construction of iso-tension curves, the 2nd on the general mathematical relation delta % tension=K* % length change+n. RESULTS: 1. The tension/elongation relation is linear beyond a threshold in the early part of elongation. 2. The iso-tension method works graphically and facilitates the precise determination of resting length. 3. The double % relation between tension and elongation method describes the general properties of all tubings, where K=0.75 is a general constant. To calculate absolute values for the resting length, corresponding to a given tension and elongation, special ''color constants'' are presented. CONCLUSIONS: The prediction of maximum tension values for any given elongation is possible by simple variation of resting length. These findings may improve the usefulness of elastic tubings in rehabilitation programs. The mathematical method further may be used for the comparison of elastic materials with linear characteristics.

Reduction of oxylabile CO2 in human blood by lactate.

The influence of lactic acid, hydrochloric acid, and sodium lactate addition (10 mmol/l each) on oxylabile CO2 was investigated in blood of male subjects after equilibration at 37 degrees C with 3, 6, and 10% CO2 in N2 and O2, respectively. The total CO2, pH in whole blood and erythrocytes, oxygen saturation, hemoglobin concentration, and hematocrit value were measured. With these data we calculated bicarbonate and carbamate concentrations and the corresponding differences between oxygenated and deoxygenated blood. The amount of oxylabile bicarbonate was not systematically influenced by the various experimental conditions. The carbamate content, however, was larger in deoxygenated than in oxygenated blood (up to 0.08 mol/mol hemoglobin) only in the absence of lactate. In the presence of lactic acid as well as sodium lactate, the carbamate content in oxygenated blood was higher by 0.06-0.13 mol/mol hemoglobin than in deoxygenated blood. The lactate effect even increased after 2,3-diphosphoglycerate depletion. We suggest, therefore, a competition between CO2 and the lactate ion at the NH2-terminal valine of the beta-globin chain in deoxygenated hemoglobin.

Determination of circulating blood volume by measurement of indocyanine green dye in hemolysate: a preliminary study.

In 8 emergency care patients blood volume was determined using Cr5I labelled erythrocytes and indocyanine green (ICG). Prior to measurement of ICG in blood with a spectrophotometer, the blood was hemolyzed with Triton-X. A close correlation of r = 0.97 between the Cr51 and the ICGTR-X estimates was found; the ICGTR-X volume was about 3% lower than the Cr51 volume. In five additional in vitro experiments the ICGTR-X method was found to reflect real volumes with an insignificant error of less than 1%. Blood volume determination with ICGTR-X cannot be applied in cases of circulatory failure. ICG should be administered in a dose of 0.5 mg/kg of body weight. For calibration purposes, a two point calibration curve (point 1: point of intersection of x and y axis; point 2: 5 mg ICG/1 of blood) is sufficient. From these preliminary experiments it is concluded that the ICGTR-X method is a rapid and simple technique of blood volume determination with multiple reproducibility which can be carried out in any clinical laboratory.

Effect of consecutive exercise bouts on plasma potassium concentration during exercise and recovery.

During and after two similar incremental treadmill tests, one with increasing, the other with initially decreasing blood acidosis, plasma potassium was measured in 11 volunteers. Independent of increasing or decreasing hydrogen ion, lactate, or bicarbonate concentrations, plasma potassium rose in relation to muscular stress with nearly equal concentrations for comparable exercise intensities in both tests. During the first 3 min of recovery, plasma potassium fell rapidly in spite of nearly unchanged blood acidosis and significantly decreasing bicarbonate concentration. After the 5th min of recovery, plasma potassium concentration was even slightly below pre-exercise values despite severe metabolic acidosis. It was concluded that there was little or no effect of plasma hydrogen ion, lactate, or bicarbonate on plasma potassium concentration during and after exercise. We propose that plasma potassium is primarily regulated by intracellular effects of inorganic phosphate, pH, and temperature on (Na+-K+)-ATPase. We suggest that these results reflect a model of grand mal seizure-induced lactic acidosis. The noted low blood potassium concentrations despite the presence of severe metabolic acidosis secondary to epileptic seizure is thus suggested to reflect the "normal" post-exercise state of potassium concentration.

Estimation of an individual equilibrium between lactate production and catabolism during exercise.

During an incremental exercise test after a preceding bout of maximum exercise, blood lactate initially decreases to an individual minimum and then increases again. To determine whether this minimum represents an individual equilibrium between lactate production and catabolism during constant load exercise, the following field tests were performed: in 25 runners and five basketball players (series 1) the speed corresponding to the individual lactate minimum (LM) was measured in test 1 (incremental test after exercise induced lactic acidosis). On two occasions, two constant speed runs over 8 km were performed, one using the LM speed (LMS) (test 2), and another at a running speed of 0.2 m.s-1 above the LMS (test 3). Results of runners/basketball players: blood lactate concentration ([Lac-]B) in test 2 changed from 3.6/4.9 mmol.l-1 to 4.0/4.9 mmol.l-1 during the last 4.8 km, in test 3 from 4.6/4.6 mmol.l-1 to 6.5/6.9 mmol.l-1. These results indicate: 1) the LM speed in test 1 corresponds to a maximum lactate steady state speed during constant load exercise; 2) only a slight speed increase above the LM speed results in continuous marked [Lac-]B increase and earlier exhaustion. Variation of the increment duration in 13 males (series 2) shows no change of the LMS using 800-m and 1200-m increments (4.49 and 4.44 m.s-1) but a marked shift to higher speed using 400-m increments (4.96 m.s-1). Effects of low muscle glycogen stores on the LMS were determined in 10 males (series 3).(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between lactic acid and work load: a measure for endurance capacity or an indicator of carbohydrate deficiency?

The influence of low and high carbohydrate diets on the relationship between blood lactate concentration ([Lac]) and work load (WL) in incremental exercise tests (cycle ergometer) and endurance tests was evaluated in trained subjects. The relationship between relative work load (WLrel) and [Lac] in arterialized blood was compared in untrained subjects (UT) and trained male athletes (TR) after 2 days without training while consuming a high carbohydrate diet (HCD). In both groups [Lac] of 2 mmol.l-1 was reached at about 60% [(mean +/- SD) UT 57.7% +/- 6%, TR 62.7% +/- 3.8%] and 4 mmol.l-1 at about 75% (UT 75.2% +/- 3.6%, TR 77.8 +/- 2.2) of the maximal work load (WLmax). In eight cyclists the relationship between [Lac] and WL was not influenced by a 13-day training camp; however, heart rate was lower after the training camp. During their normal training programme, trained subjects had high relative work loads at their [Lac] thresholds, but after an HCD combined with an interruption of the training of 3 days, the relationship between [Lac] and WLrel was the same as in UT. In six TR a low carbohydrate diet (LCD) combined with training led to high absolute (WLabs) and WLrel at [Lac] at 2 and 4 mmol.l-1; an HCD combined with 3 days without training led to low WLabs and WLrel at the same [Lac] and to higher WLmax. In spite of the apparently lower endurance capacities TR were able to work significantly longer after HCD than after LCD (23 +/- 10.5 min and 49 +/- 16.2 min, respectively) at 65% of their WLmax. The variability of the relationship between [Lac] and WL following the dietary regimes leads to the conclusion that the "typical" [Lac] versus WL curve of endurance TR may result from a permanent glycogen deficiency.

Interrelationship between pH, plasma potassium concentration and ventilation during intense continuous exercise in man.

During resting conditions plasma hydrogen ion concentration ([H+]P) is known to influence ventilation (VE), whereas the control of plasma potassium concentration ([K+]P) at rest and of both [K+]P and VE during exercise are controversial issues. To obtain more information about these variables during muscular work, eight trained men performed two successive intense continuous cycle-ergometer tests, the first (test I) during metabolic acidosis, the second (test II) with an alkalotic pH. No correlation was found between [H+]P and [K+]P or VE in the direction of change of these variables in test I. Furthermore, no correlation between [H+]P and [K+]P in test I and II was seen. Instead [K+]P and VE changed in relation to the exercise intensity. We suggest that the results confirm [K+]P as an indicator of muscular stress. In addition, the similar behaviour of relative values of [K+]P and VE changes in test I (r = 0.9, m = 1.0, where m is the slope of the regression curve) supports the hypothesis that extracellular potassium controls VE and thereby [H+]P also.

Determination of plasma volume and total blood volume using indocyanine green: a short review.

Rapid blood and plasma volume measurements gain increasing interest in order to avoid unnecessary blood transfusions. Only the indocyanine green method seems to satisfy the demand for a fast, safe and reproducible bedside method. We summarized older and newer experiences with this method, and also summarized the results for practical application.

Plasma potassium and ventilation during incremental exercise in humans: modulation by sodium bicarbonate and substrate availability.

It has recently been demonstrated that, compared to normal conditions, ventilation (VE) was increased during exercise after glycogen depletion, in spite of a marked increase in plasma pH (pHP). It was further demonstrated that VE in patients with McArdle's syndrome was reduced when substrate availability was improved. In the present experiments, six endurance trained men performed two successive cyclo-ergometric incremental exercise tests (tests A, B) after normal nutrition (N) and after a fatty meal in conjunction with a sodium bicarbonate (NaHCO3) solution (FSB) or without NaHCO3 (F), and the relationship between VE, plasma potassium concentration ([K+]P), and pHP was checked. Plasma free fatty acid concentration ([FFA]P) was markedly increased in the F and FSB trials (P < 0.001). In FSB pHP was significantly increased, compared to N and F (P < 0.001). In all the B tests, pHP increased during moderate and intense exercise and in FSB, remained alkalotic even during maximal exercise intensity. In contrast, VE and [K+]P changes were almost equal in all the trials and in tests A and B. It was found that exercise-induced changes of VE and [K+]P in the present experiments were not markedly affected by [FFA]P or pHP values and that these changes also occurred independently of changes in pHP or plasma bicarbonate concentration. The often used glycogen depletion strategy may have slightly increased VE but apparently did not overcompensate for a possible decrease in VE due to increased pHP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rope pulley isokinetic system in shoulder rehabilitation--initial results]. / Seilzugisokinetik in der Schulterrehabilitation--erste Ergebnisse.

AIM: Of this study was to evaluate the results of a shoulder rehabilitation program of different shoulder diseases, based on an isokinetie pulley system ("Moflex", Recotec/Bernina, Swiss). METHOD: In this prospective study 70 patients participated in a standardized rehabilitation program (instability: n = 19; rotator cuff disorders: n = 23; impingement syndrome without lesion: n = 16; others: n = 12; operative therapy: n = 47). The major aspect of the program was an isokinetic pulley system. RESULTS: Isokinetic training with the used device affords strict monitor-feedback to avoid critical torque values. Strength which was attained without relevant pain was almost linearly increased by a mean of 31% until the 20th day of rehabilitation, workload by 79%. At the end of the rehabilitation program the strength of the affected (mostly dominant) shoulder was 15% higher than in the unaffected shoulder; the respective workload values were almost equal. CONCLUSION: These first results demonstrate the value of the isokinetic pulley system in the rehabilitation of the investigated shoulder diseases. The equipment may be used already in an early postoperative state. First results of strength increases using an isokinetic pulley system in shoulder rehabilitation are presented.

The calculation of the osmotic volumes of distribution of hypertonic sodium bicarbonate and other hypertonic solutions: a theoretical approach.

Correction of a base deficit with hypertonic sodium bicarbonate (NaHCO3) according to the formula 0.3 x body weight (kg) x BE may overestimate the real demands, especially during shock and cardiopulmonary resuscitation (CPR). Life threatening alkalosis and osmolal poisoning may be the consequence. As an explanation, the possibly impaired functional distribution space related to low cardiac output and volume centralization during CPR is proposed. By application of our own and outside literature, data equations are specified for an approximate precalculation of osmolality and pH changes due to infusion of hypertonic NaHCO3. Calculation of the osmotic volumes of distribution of NaHCO3 during cardiopulmonary resuscitation (CPR) from emergency literature data demonstrates a possible reduction of the functional distribution spaces of about 70 to 80% compared with normal values. This is in good agreement with the reported reduction of cardiac output to about 25% of normal during CPR. The calculated amount of sodium bicarbonate to be recommended during CPR, thus, should not exceed 50 mmol given in time intervals of at least 10 min, severe acidosis and sufficient ventilation presumed.

Relation between plasma K+ and ventilation during incremental exercise after glycogen depletion and repletion in man.

1. We have examined the relationship between expiratory ventilation (VE), plasma potassium concentration ([K+]P), blood lactate concentration ([Lac-]B), and plasma pH (pHP) in five trained men before and after glycogen depletion and repletion in two successive incremental bicycle ergometer tests (tests A and B). 2. Though pHP was significantly higher after glycogen depletion (in relation to normal or repleted conditions) VE and [K+]P also tended to be higher. 3. There was no constant relation between the magnitude or the direction of change in lactic acidosis, or VE and [K+]P, respectively. Instead, a close temporal relationship between changes in VE and [K+]P was found. 4. A non-linear increase in VE occurred independently of changes in pHP or [Lac-]B, but could be well predicted from a non-linear increase in [K+]P. 5. These findings indicate that lactic acidosis had no deciding effect on exercise ventilation in these experiments. They are consistent with the idea that the potassium increase may contribute to the ventilatory drive during exercise.

[Exercise recommendation and catecholamines in patients with coronary artery disease]. / Belastungsdiagnostische Kenngrössen und Katecholamine bei Koronarpatienten.

Exercise training for patients with coronary artery disease (CAD) is recommended in a wide range between 40-85% of maximum functional capacity (MFC) or 55-90% of maximum heart rate (HR). During exercise, high levels of catecholamines and metabolic acidosis could induce arrhythmia and ischemia. But catecholamines have never been determined in CAD during constant load exercise in the upper range of recommended intensities. In 11 CAD patients (age 58+/-8 years, BMI 26.1+/-4.0 kg x m(-2), NYHA I n=7, II n=4) we tested the maximum functional capacity (MFC), norepinephrine (NE), epinephrine (E) and blood lactate ([Lac(-)](B)) in a symptom-limited incremental ergometer test. Related to the exercise recommendation, the kinetics of NE, E and [Lac(-)](B) were determined in two 30 min constant load tests in randomized order: one was performed at the anaerobic lactate threshold (CTAT), a second was performed 10% above the individual threshold intensity (CT+10%). In the incremental tests maximum workload and VO(2) were 141+/-54 W and 1766+/-532 ml x min(-1), respectively (85+/-22% of normal; [Lac(-)](B) 5.7+/-1.9 mmol x l(-1), HR 138+/-28 b x min(-1), NE 11.7+/-5.1, E 1.6+/-1.4 nmol x l(-1)). In CTAT the anaerobic threshold (63+/-7% of MFC) represented the mean range of recommended exercise intensity for CAD (40-85%) and could be validated as steady-state intensity because catecholamines and [Lac(-)](B) concentrations remained constant after the initial increase (workload 88+/-35 W, [Lac(-)](B) 3.3+/-1.4 mmol x l(-1), HR 117+/- 23 b x min(-1), NE 8.3+/-3.5, E 0.8+/- 0.7 nmol x l(-1)). In all patients CT+10% (71+/-7% of MFC) led to a continuous rise in [Lac(-)](B), to a NE overload and to earlier exhaustion, although the intensities were in the recommended training range (workload 100+/-38 W, [Lac(-)](B) 5.8+/- 1.9 mmol x l(-1), HR 129+/- 29 b x min(-1), NE 13.9+/-6.9, E 1.5+/- 1.7 nmol x l(-1); p<0.01 against CTAT for all except E). Conclusions In the upper range of recommended training intensity for CAD patients, norepinephrine and lactate were higher during endurance exercise than at MFC in incremental tests. Endurance exercise with intensities >70% of MFC could overload the cardiac patient and increase the risk of arryhthmia and ischemia. Therefore, endurance exercise should be performed below 70% of MFC or below 85% of maximum HR, respectively, whereas higher intensities should apply to interval exercise.

[Ambulatory long-term rehabilitation of heart patients]. / Ambulante Langzeitrehabilitation von Herzpatienten.

In Germany cardiac rehabilitation contains a comprehensive 3 to 4 week inpatient program. The aim of our study was to perform an outpatient long-term rehabilitation including intense exercise and behavior therapy. In this setting the health benefits could be increased over the first 6 months. Hundred and twelve patients (94 men and 18 women, age 55 +/- 11 years) after myocardial infarction (52%), bypass-surgery (37%), PTCA (23%), and others (15%) were included in the ongoing study. Cholesterol and LDL-cholesterol diminished significantly. HDL-cholesterol was increased significantly after 6 months. The endurance exercise capacity per rate-pressure-product was increased by 46% during the 6 months period. The intake of cholesterol could significantly be diminished from 307 +/- 25 to 258 +/- 19 mg per day. Five of 16 patients became free from smoking. The first results from the long-term outpatient program show that the time of intervention and also the intensity of the medical, exercise and the behavior therapy are important factors for a successful rehabilitation.

Short term volume effects of a hypertonic saline bolus during neurosurgery.

Intracranial hypertension which does not respond to customary hyperosmotic agents may successfully be treated with hypertonic saline. The absence of diuresis and the maintainance of intravascular volume are supposed to be the main advantages of hypertonic sodium chloride. Volume overload and toxic hyperosmolality from frequent application of such solutions are possible disadvantages. The presented experiments checked the time course of intravascular volume shifts after a 100 ml 1-molar saline bolus in 14 patients during neurosurgery using plasma protein concentration changes. An initial intravascular volume expansion of about 270 ml remained quite unchanged for the first 8 minutes, followed by a nearly linear decrease. Extrapolation of the curves demonstrated that the preinfusion state would have been reached after about 20 minutes. Osmolality remained increased by about 4 mosmol/kg 15 min after the bolus. Thus it appears that repetitive infusion of these amounts of hypertonic saline will cause no serious volume overload if 30 minutes intervals are kept, but osmolality should be checked before each bolus.

Relationship between plasma potassium and ventilation during successive periods of exercise in men.

During and after two successive incremental cycle ergometer tests (tests A and B), plasma potassium concentration ([K+]p), plasma pH (pHp), plasma partial pressure of carbon dioxide, blood lactate concentration ([Lac-]b) and ventilation (VE) were measured. While there was a good correlation between the increase in [K+]p and VE or pHp, respectively, in test A, in test B a close correlation was found only between the increase in VE and [K+]p (r greater than 0.9 for nearly all single cases; r was 0.84 and 0.89 for all (pooled) cases in tests A and B, respectively; the correlation coefficients between changes in pHp and VE in tests A and B were r = 0.74 and r = 0.28, respectively, and r = 0.89 and r = 0.10 between the changes in [Lac-]b and VE in tests A and B). The close relationship for individuals between VE and [K+]p in tests A and B supported the hypothesis that the extracellular increase in [K+] may contribute to the ventilatory drive during exercise. The comparison of the results of tests A and B further indicated that the relationship between pHp and VE was dependent on the experimental design, and that pHp and VE changes are unlikely to be cause and effect.