Evaluating Arterial Blood Flow Limitation Using Muscle Oxygenation and Cycling Power.

OBJECTIVE: To explore the combination of measuring muscle oxygenation with near-infrared spectroscopy (NIRS) and cycling power during provocative incremental exercise for the detection of iliac arterial blood flow limitation (IAFL) in an otherwise healthy, well-trained cyclist. DESIGN: Case report and methodological pilot study. SETTING: University research setting. PATIENT: A well-trained amateur competitive male cyclist, aged 31 years, presenting with symptoms consistent with IAFL, but in whom diagnostic imaging was equivocal. INTERVENTIONS: Four ramp incremental cycling tests performed on separate days to exercise intolerance, in a randomized order, in either typical race position (RP) or modified upright position (UP). MAIN OUTCOME: A novel ratio of unilateral cycling power to NIRS-derived muscle oxygenation termed "power-deoxygenation factor" was measured during provocative incremental exercise and compared with other NIRS-derived measures of vascular responsiveness and performance outcomes across the 2 body position conditions. RESULTS: The power-deoxygenation factor was able to show clinically important, progressive differences between the affected and unaffected limbs, coinciding with worsening performance impairments related to the body position that were not detected with traditional measures of vascular responsiveness taken after exercise. CONCLUSIONS: This method was used to detect bilateral differences consistent with IAFL in a cyclist where traditional diagnostic criteria were equivocal, but subsequent intraoperative findings confirmed the diagnosis. A similar screening test could be performed noninvasively and without requiring specialized medical care. Future work should investigate the validity and sensitivity of this methodology to improve the ability to identify and monitor athletes with IAFL.

The Additional Effect of Training Above the Maximal Metabolic Steady State on VO2peak, Wpeak and Time-Trial Performance in Endurance-Trained Athletes: A Systematic Review, Meta-analysis, and Reality Check.

BACKGROUND: To improve sport performance, athletes use training regimens that include exercise below and above the maximal metabolic steady state (MMSS). OBJECTIVE: The objective of this review was to determine the additional effect of training above MMSS on VO2peak, Wpeak and time-trial (TT) performance in endurance-trained athletes. METHODS: Studies were included in the review if they (i) were published in academic journals, (ii) were in English, (iii) were prospective, (iv) included trained participants, (v) had an intervention group that contained training above and below MMSS, (vi) had a comparator group that only performed training below MMSS, and (vii) reported results for VO2peak, Wpeak, or TT performance. Medline and SPORTDiscus were searched from inception until February 23, 2023. RESULTS: Fourteen studies that ranged from 2 to 12 weeks were included in the review. There were 171 recreational and 128 competitive endurance athletes. The mean age and VO2peak of participants ranged from 15 to 43 years and 38 to 68 mL·kg-1·min-1, respectively. The inclusion of training above MMSS led to a 2.5 mL·kg-1·min-1 (95% CI 1.4-3.6; p < 0.01; I2 = 0%) greater improvement in VO2peak. A minimum of 81 participants per group would be required to obtain sufficient power to determine a significant effect (SMD 0.44) for VO2peak. No intensity-specific effect was observed for Wpeak or TT performance, in part due to a smaller sample size. CONCLUSION: A single training meso-cycle that includes training above MMSS can improve VO2peak in endurance-trained athletes more than training only below MMSS. However, we do not have sufficient evidence to conclude that concurrent adaptation occurs for Wpeak or TT performance.

Muscle reoxygenation is slower after higher cycling intensity, and is faster and more reliable in locomotor than in accessory muscle sites.

Introduction: Wearable near-infrared spectroscopy (NIRS) can be used during dynamic exercise to reflect the balance of muscle oxygen delivery and uptake. This study describes the behaviour and reliability of postexercise reoxygenation with NIRS as a function of exercise intensity at four muscle sites during an incremental cycling test. We discuss physiological components of faster and slower reoxygenation kinetics in the context of sport science and clinical applications. We hypothesised that reoxygenation would be slower at higher intensity, and that locomotor muscles would be faster than accessory muscles. We quantified test-retest reliability and agreement for each site. Methods: Twenty-one trained cyclists performed two trials of an incremental cycling protocol with 5-min work stages and 1-min rest between stages. NIRS was recorded from the locomotor vastus lateralis and rectus femoris muscles, and accessory lumbar paraspinal and lateral deltoid muscles. Reoxygenation time course was analysed as the half-recovery time (HRT) from the end of work to half of the peak reoxygenation amplitude during rest. Coefficient of variability (CV) between participants, standard error of the measurement (SEM) within participants, and intraclass correlation coefficient (ICC) for test-retest reliability were evaluated at 50%, 75%, and 100% peak workloads. A linear mixed-effects model was used to compare differences between workloads and muscle sites. Results: HRT was slower with increasing workload in the VL, RF, and PS, but not DL. VL had the fastest reoxygenation (lowest HRT) across muscle sites at all workloads (HRT = 8, 12, 17 s at 50%, 75%, 100% workload, respectively). VL also had the greatest reliability and agreement. HRT was sequentially slower between muscle sites in the order of VL < RF < PS < DL, and reliability was lower than for the VL. Discussion: This study highlights the potential for using wearable NIRS on multiple muscle sites during exercise. Reoxygenation kinetics differ between local muscle sites with increasing intensity. Moderate-to-good reliability in the VL support its increasing use in sport science and clinical applications. Lower reliability in other muscle sites suggest they are not appropriate to be used alone, but may add information when combined to better reflect systemic intensity and fatigue during exercise at different intensities.

Conservative Management and Postoperative Return to Sport in Endurance Athletes with Flow Limitations in the Iliac Arteries: A Scoping Review.

BACKGROUND: Flow limitations in the iliac arteries (FLIA) is a sport-related vascular condition increasingly recognised as an occupational risk for professional cyclists and other endurance athletes. Surgical reconstruction is the definitive treatment for athletes wishing to continue competition. However, less information has been published regarding conservative management options and return-to-sport (RTS) guidelines. OBJECTIVE: Our aim was to review the existing literature on conservative treatment of FLIA, identify knowledge gaps and propose an RTS framework for athletes returning to competition. METHODS: A comprehensive literature review was performed using the Ovid-MEDLINE, PubMed, Embase and PEDro databases for publications relevant to conservative management of FLIA. A scoping review was conducted following PRISMA-ScR guidelines. Original, peer-reviewed publications in English describing conservative or postoperative management for athletes with FLIA were included. Additional grey literature and clinical expertise were consulted to inform RTS guidelines. RESULTS: Overall, 62 studies were included in this review. In total, 11 categories of conservative modalities were extracted and presented qualitatively in terms of the information source (discussion or results statements) and perspective of the authors (positive, negative or mixed). We have proposed RTS guidelines covering pre-operative preparation and postoperative rehabilitation based on the available literature, clinical experience, and drawing from other areas of sports medicine research. CONCLUSION: There is insufficient literature evaluating the effectiveness of conservative management options for FLIA to establish best practices. Considering the importance of RTS for competitive athletes, we proposed practical guidelines to help with clinician and patient decision making. Future consensus should be sought for RTS best practices.

Comparing the reliability of muscle oxygen saturation with common performance and physiological markers across cycling exercise intensity.

Introduction: Wearable near-infrared spectroscopy (NIRS) measurements of muscle oxygen saturation (SmO2) demonstrated good test-retest reliability at rest. We hypothesized SmO2 measured with the Moxy monitor at the vastus lateralis (VL) would demonstrate good reliability across intensities. For relative reliability, SmO2 will be lower than volume of oxygen consumption (V̇O2) and heart rate (HR), higher than concentration of blood lactate accumulation ([BLa]) and rating of perceived exertion (RPE). We aimed to estimate the reliability of SmO2 and common physiological measures across exercise intensities, as well as to quantify within-participant agreement between sessions. Methods: Twenty-one trained cyclists completed two trials of an incremental multi-stage cycling test with 5 min constant workload steps starting at 1.0 watt per kg bodyweight (W·kg-1) and increasing by 0.5 W kg-1 per step, separated by 1 min passive recovery intervals until maximal task tolerance. SmO2, HR, V̇O2, [BLa], and RPE were recorded for each stage. Continuous measures were averaged over the final 60 s of each stage. Relative reliability at the lowest, median, and highest work stages was quantified as intraclass correlation coefficient (ICC). Absolute reliability and within-subject agreement were quantified as standard error of the measurement (SEM) and minimum detectable change (MDC). Results: Comparisons between trials showed no significant differences within each exercise intensity for all outcome variables. ICC for SmO2 was 0.81-0.90 across exercise intensity. ICC for HR, V̇O2, [BLa], and RPE were 0.87-0.92, 0.73-0.97, 0.44-0.74, 0.29-0.70, respectively. SEM (95% CI) for SmO2 was 5 (3-7), 6 (4-9), and 7 (5-10)%, and MDC was 12%, 16%, and 18%. Discussion: Our results demonstrate good-to-excellent test-retest reliability for SmO2 across intensity during an incremental multi-stage cycling test. V̇O2 and HR had excellent reliability, higher than SmO2. [BLa] and RPE had lower reliability than SmO2. Muscle oxygen saturation measured by wearable NIRS was found to have similar reliability to V̇O2 and HR, and higher than [BLa] and RPE across exercise intensity, suggesting that it is appropriate for everyday use as a non-invasive method of monitoring internal load alongside other metrics.

The effect of severe intensity bouts on muscle oxygen saturation responses in trained cyclists.

Near-infrared spectroscopy (NIRS) quantifies muscle oxygenation (SmO2) during exercise. Muscle oxygenation response to self-paced, severe-intensity cycling remains unclear. Observing SmO2 can provide cycling professionals with the ability to assess muscular response, helping optimize decision-making. We aimed to describe the effect of self-paced severe intensity bouts on SmO2, measured noninvasively by a wearable NIRS sensor on the vastus lateralis (VL) muscle, and examine its reliability. We hypothesized a greater desaturation response with each bout, whereas, between trials, good reliability would be observed. Fourteen recreationally trained, and trained cyclists completed a ramp test to determine the power output (PO) at the respiratory compensation point (RCP). Athletes completed two subsequent visits of 50-minute sessions that included four severe-intensity bouts done at 5% above RCP PO. Muscle oxygenation in the VL was monitored using a wearable NIRS device. Measures included mean PO, heart-rate (HR), cadence, and SmO2 at bout onset, during work (work SmO2), and ΔSmO2. The bouts were compared using a one-way repeated measures ANOVA. For significant differences, a Fisher's least square difference post-hoc analysis was used. A two-way repeated measures ANOVA was used using trial and bout as main factors. Intraclass correlations (ICC) were used to quantify relative reliability for mean work, and standard error of the measurement (SEM) was used to quantify absolute agreement of mean work SmO2. Both PO and cadence showed no effect of bout or trial. Heart-rate at bout 2 (168 ± 8 bpm) and 4 (170 ± 7 bpm) were higher than bout 1 (160 ± 6 bpm). Onset SmO2 (%) response significantly increased in the final two bouts of the session. Mean work SmO2 increased across bouts, with the highest value displayed in bout 4 (36 ± 22%). ΔSmO2 showed a smaller desaturation response during bout 4 (27 ± 10%) compared to bout 3 (31 ± 10%). Mean work SmO2 ICC showed good reliability (ICC = 0.87), and SEM was 12% (CI 9-15%). We concluded that a non-invasive, affordable, wearable NIRS sensor demonstrated the heterogeneous muscle oxygenation response during severe intensity cycling bouts with good reliability in trained cyclists.

Comparing the Respiratory Compensation Point With Muscle Oxygen Saturation in Locomotor and Non-locomotor Muscles Using Wearable NIRS Spectroscopy During Whole-Body Exercise.

The relationship between the muscle deoxygenation breakpoint (Deoxy-BP) measured with near-infrared spectroscopy (NIRS), and the respiratory compensation point (RCP) has been well established. This relationship has also been reported using wearable NIRS, however not in locomotor and non-locomotor muscles simultaneously during whole-body cycling exercise. Our aim was to measure muscle oxygen saturation (SmO2) using wearable NIRS sensors, and to compare the Deoxy-BPs at each muscle with RCP during a ramp cycling exercise test. Twenty-two trained female and male cyclists completed a ramp exercise test to task intolerance on a cycling ergometer, at a ramp rate of 1 W every 2 s (30 W/min). SmO2 was recorded at the subjects' right vastus lateralis (VL) and right lateral deltoid. SmO2 and the Deoxy-BPs were assessed using a piecewise double-linear regression model. Ventilation (V̇E) and gas exchange were recorded, and RCP was determined from V̇E and gas exchange using a V-slope method and confirmed by two physiologists. The SmO2 profiles of both muscles and gas exchange responses are reported as V̇O2, power output (W), and time of occurrence (TO). SmO2 profiles at both muscles displayed a near-plateau or breakpoint response near the RCP. No differences were detected between the mean RCP and mean Deoxy-BP from either the locomotor or non-locomotor muscles; however, a high degree of individual variability was observed in the timing and order of occurrence of the specific breakpoints. These findings add insight into the relationships between ventilatory, locomotor, and non-locomotor muscle physiological breakpoints. While identifying a similar relationship between these breakpoints, individual variability was high; hence, caution is advised when using wearable NIRS to estimate RCP in an incremental ramp test.

Diagnosing Sport-Related Flow Limitations in the Iliac Arteries Using Near-Infrared Spectroscopy.

Background: A flow limitation in the iliac arteries (FLIA) in endurance athletes is notoriously difficult to diagnose with the currently available diagnostic tools. At present, a commonly used diagnostic measure is a decrease in ankle brachial index with flex hips (ABIFlexed) following a maximal effort exercise test. Near-infrared spectroscopy (NIRS) is a non-invasive technique that measures skeletal muscle oxygenation as reflected by the balance of O2 delivery from microvascular blood flow and O2 uptake by metabolic activity. Therefore, NIRS potentially serves as a novel technique for diagnosing FLIA. The purpose of this study is to compare the diagnostic accuracy of NIRS-derived absolute, amplitude, and kinetic variables in legs during and after a maximal exercise test with ABIFlexed. Methods: ABIFlexed and NIRS were studied in 33 healthy subjects and 201 patients with FLIA diagnosed with echo-Doppler. Results: After maximal exercise, NIRS kinetic variables, such as the half value time and mean response time, resulted in a range of 0.921 to 0.939 AUC for the diagnosis of FLIA when combined with ABIFlexed. Conversely, ABIFlexed measurements alone conferred significantly worse test characteristics (AUC 0.717, p < 0.001). Conclusions: NIRS may serve as a diagnostic adjunct in patients with possible FLIA.