Current Implementation and Barriers to Using Blood Flow Restriction Training: Insights From a Survey of Allied Health Practitioners.

ABSTRACT: Scott, BR, Marston, KJ, Owens, J, Rolnick, N, and Patterson, SD. Current implementation and barriers to using blood flow restriction training: Insights from a survey of allied health practitioners. J Strength Cond Res 38(3): 481-490, 2024-This study investigated the use of blood flow restriction (BFR) exercise by practitioners working specifically with clinical or older populations, and the barriers preventing some practitioners from prescribing BFR. An online survey was disseminated globally to allied health practitioners, with data from 397 responders included in analyses. Responders who had prescribed BFR exercise ( n = 308) completed questions about how they implement this technique. Those who had not prescribed BFR exercise ( n = 89) provided information on barriers to using this technique, and a subset of these responders ( n = 22) completed a follow-up survey to investigate how these barriers could be alleviated. Most practitioners prescribe BFR exercise for musculoskeletal rehabilitation clients (91.6%), with the BFR cuff pressure typically relative to arterial occlusion pressure (81.1%) and implemented with resistance (96.8%) or aerobic exercise (42.9%). Most practitioners screen for contraindications (68.2%), although minor side effects, including muscle soreness (65.8%), are common. The main barriers preventing some practitioners from using BFR are lack of equipment (60.2%), insufficient education (55.7%), and safety concerns (31.8%). Suggestions to alleviate these barriers included developing educational resources about the safe application and benefits of BFR exercise ( n = 20) that are affordable ( n = 3) and convenient ( n = 4). These results indicate that BFR prescription for clinical and older cohorts mainly conforms with current guidelines, which is important considering the potentially increased risk for adverse events in these cohorts. However, barriers still prevent broader utility of BFR training, although some may be alleviated through well-developed educational offerings to train practitioners in using BFR exercise.

Sessional work-rate does not affect the magnitude to which simulated hypoxia can augment acute physiological responses during resistance exercise.

PURPOSE: To investigate whether performing resistance exercise in hypoxia augments physiological and perceptual responses, and if altering work-rate by performing repetitions to failure compared to sub-maximally increases the magnitude of these responses. METHODS: Twenty male university students (minimum of 2 year resistance training experience) completed four sessions, two in hypoxia (fraction of inspired oxygen [FiO2] = 0.13), and two in normoxia (FiO2 = 0.21). For each condition, session one comprised three sets to failure of shoulder press and bench press (high work-rate session), while session two involved the same volume load, distributed over six sets (low work-rate session). Muscle oxygenation (triceps brachii), surface electromyographic activity (anterior deltoid, pectoralis major, and triceps brachii), heart rate (HR), and arterial blood oxygen saturation were recorded. Blood lactate concentration ([Bla-]) was recorded pre-exercise and 2 min after each exercise. Muscle thickness was measured pre- and post-exercise via ultrasound. RESULTS: Muscle oxygenation values during sets and inter-set rest periods were lower in hypoxia vs normoxia (p = 0.001). Hypoxia caused greater [Bla-] during the shoulder press of failure sessions (p = 0.003) and both shoulder press (p = 0.048) and bench press (p = 0.005) of non-failure sessions. Hypoxia increased HR during non-failure sessions (p < 0.001). There was no effect of hypoxia on muscular swelling, surface electromyographic activity, perceived exertion, or number of repetitions performed. CONCLUSIONS: Hypoxia augmented metabolite accumulation, but had no impact on any other physiological or perceptual response compared to the equivalent exercise in normoxia. Furthermore, the magnitude to which hypoxia increased the measured physiological responses was not influenced by sessional work-rate.

An Intense, But Ecologically Valid, Resistance Exercise Session Does Not Alter Growth Factors Associated With Cognitive Health.

The purpose of this investigation was to assess the acute changes in growth factors associated with cognitive health following two ecologically valid, intense resistance exercise sessions. Twenty-nine late-middle-aged adults performed one session of either (a) moderate-load resistance exercise or (b) high-load resistance exercise. Venous blood was collected prior to warm-up, immediately following exercise and 30 min following exercise. Serum was analyzed for brain-derived neurotrophic factor, insulin-like growth factor 1, and vascular endothelial growth factor. Session intensity was determined by blood lactate concentration and session rating of perceived exertion. Postexercise blood lactate was greater following moderate-load when compared with high-load resistance exercise. Subjective session intensity was rated higher by the session rating of perceived exertion following moderate-load when compared with high-load resistance exercise. No differences were observed in serum growth factor levels between groups. Ecologically valid and intense moderate-load or high-load exercise methods do not alter serum growth factor levels in late-middle-aged adults.

Twelve weeks of resistance training does not influence peripheral levels of neurotrophic growth factors or homocysteine in healthy adults: a randomized-controlled trial.

INTRODUCTION: There is growing evidence for a preventative effect of resistance training on cognitive decline through physiological mechanisms; yet, the effect of resistance training on resting growth factors and homocysteine levels is incompletely understood. This study aimed to investigate the effect of intense resistance training, for 12 weeks, on changes in peripheral growth factors and homocysteine in late middle-aged adults. METHODS: 45 healthy adults were enrolled into the single-site parallel groups' randomized-controlled trial conducted at the Department of Exercise Science, Strength and Conditioning Laboratory, Murdoch University. Participants were allocated to the following conditions: (1) high-load resistance training (n = 14), or (2) moderate-load resistance training (n = 15) twice per week for 12 weeks; or (3) non-exercising control group (n = 16). Data were collected from September 2016 to December 2017. Fasted blood samples were collected at baseline and within 7 days of trial completion for the analysis of resting serum brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1, vascular endothelial growth factor, and plasma homocysteine levels. RESULTS: No differences in baseline to post-intervention change in serum growth factors or plasma homocysteine levels were observed between groups. A medium effect was calculated for BDNF change within the high-load condition alone (+ 12.9%, g = 0.54). CONCLUSIONS: High-load or moderate-load resistance training twice per week for 12 weeks has no effect on peripheral growth factors or homocysteine in healthy late middle-aged adults. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12616000690459.

Hypoxia Does Not Impair Resistance Exercise Performance or Amplify Post-Exercise Fatigue.

Purpose: To determine whether performing resistance exercise in hypoxia acutely reduces performance and increases markers of fatigue, and whether these responses are exaggerated if exercising at high versus low work rates (i.e., exercising to failure or volume matched non-failure). Methods: Following a within-subject design, 20 men completed two trials in hypoxia (13% oxygen) and two in normoxia (21% oxygen). The first session for hypoxic and normoxic conditions comprised six sets of bench press and shoulder press to failure (high work rate), while subsequent sessions involved the same volume distributed over 12 sets (low work rate). Physical performance (concentric velocity) and perceptual responses were measured during exercise and for 72 hr post-exercise. Neuromuscular performance (bench throw velocity) was assessed pre- and post-session. Results: Hypoxia did not affect physical performance, neuromuscular performance, and perceptual recovery when exercising at high or low work rates. Higher work rate exercise caused greater acute decrements in physical performance and post-exercise neuromuscular performance and increased perceived exertion and muscle soreness (p ≤ 0.006), irrespective of hypoxia. Conclusions: Hypoxia does not impact on resistance exercise performance or increase markers of physical and perceptual fatigue. Higher exercise work rates may impair physical performance, and exaggerate fatigue compared to low work rate exercise, irrespective of environmental condition. Practitioners can prescribe hypoxic resistance exercise without compromising physical performance or inducing greater levels of fatigue. For athletes who are required to train with high frequency, decreasing exercise work rate may reduce post-exercise markers of fatigue for the same training volume.

Exploration of Alzheimer's disease-related gene expression following high-intensity and moderate-intensity exercise interventions.

OBJECTIVES: There are currently 29 genome regions that demonstrate associations with Alzheimer's disease (AD) risk. Regular physical exercise can promote systemic change in gene expression and may modify the risk of cognitive decline and AD. This study is a secondary analysis of a randomised controlled trial and examines the effect of a six-month exercise intervention versus control on AD-related gene expression. DESIGN: Single-site parallel pilot randomised controlled trial. METHODS: 91 cognitively unimpaired older adults were enrolled in the Intense Physical Activity and Cognition (IPAC) study. Participants were randomised into one of three groups: high-intensity exercise, moderate-intensity exercise, or inactive control for six months. Blood samples were collected prior to, and within two weeks of intervention completion, for later expression analysis of 96 genes. To explore the relationship between changes in gene expression and the intervention groups, an interaction term ("time point × intervention group") was subsequently used. RESULTS: There were no significant differences in gene expression between the three intervention groups at baseline, nor after the intervention. Within groups, five genes were upregulated, seven were downregulated and the remainder remained unchanged. None of the examined genes showed significant change from pre- to post-intervention in the exercise groups compared to the control. CONCLUSIONS: Exercise does not change AD-related gene expression in cognitively unimpaired older adults. Several gene expression targets have been identified for further study.

The intensity of a resistance exercise session can be quantified by the work rate of exercise.

PURPOSE: Athletes regularly perform resistance training, yet it is unknown how best to monitor its intensity. This study compared different resistance exercise intensity metrics to determine their sensitivity to manipulating work rate (via altering inter-set rest and load). METHODS: Following baseline testing for 10- and 3-repetition maximum (RM; squat and bench press), fourteen trained participants completed four volume-matched protocols in a randomised order: 3x10 with 85% 10RM, 60 s rest (3x1060s); 3x10 with 85% 10RM, 180 s (3x10180s); 8x3 with 85% 3RM, 120 s (8x3120s); 8x3 with 85% 3RM, 300 s (8x3300s). Internal intensity was quantified via rate of oxygen consumption ([Formula: see text]), heart rate, blood lactate concentration, and rating of perceived exertion (RPE). External intensity was assessed via previously developed "Training-Intensity" (TI) and "Intensity-Index" (II) metrics, and from exercise work rate (expressed as kg∙min-1 and joules∙min-1). RESULTS: Internal intensity and work-rate metrics were highest for 3x1060s, followed by 3x10180s, 8x3120s and 8x3300s (p≤0.027). TI and II were higher for 8x3 than 3x10 protocols (p<0.001), but not different within these configurations. Internal intensity measures were more strongly correlated with work rate (r = 0.37-0.96) than TI and II (r = -0.42-0.33) metrics. CONCLUSIONS: Work rate corroborated objective internal intensity metrics during resistance exercise, with the highest work rate session (3x1060s) also eliciting greater RPE scores than other protocols. In contrast, the TI and II did not agree with other intensity measures, likely because they do not consider rest periods. Practitioners can plan for the physiological and perceptual demands of resistance training by estimating work rate.

Load-velocity relationships and predicted maximal strength: A systematic review of the validity and reliability of current methods.

Maximal strength can be predicted from the load-velocity relationship (LVR), although it is important to understand methodological approaches which ensure the validity and reliability of these strength predictions. The aim of this systematic review was to determine factors which influence the validity of maximal strength predictions from the LVR, and secondarily to highlight the effects of these factors on the reliability of predictions. A search strategy was developed and implemented in PubMed, Scopus, Web of Science and CINAHL databases. Rayyan software was used to screen titles, abstracts, and full texts to determine their inclusion/eligibility. Eligible studies compared direct assessments of one-repetition maximum (1RM) with predictions performed using the LVR and reported prediction validity. Validity was extracted and represented graphically via effect size forest plots. Twenty-five eligible studies were included and comprised of a total of 842 participants, three different 1RM prediction methods, 16 different exercises, and 12 different velocity monitoring devices. Four primary factors appear relevant to the efficacy of predicting 1RM: the number of loads used, the exercise examined, the velocity metric used, and the velocity monitoring device. Additionally, the specific loads, provision of velocity feedback, use of lifting straps and regression model used may require further consideration.

The Effect of Exercise Timing on Glycemic Control: A Randomized Clinical Trial.

Despite the acknowledgment of exercise as a cornerstone in the management of type 2 diabetes (T2D), the importance of exercise timing has only recently been considered. PURPOSE: This study sought to determine the effect of diurnal exercise timing on glycemic control in individuals enrolled in a 12-wk supervised multimodal exercise training program. A secondary aim was to determine the effect of diurnal exercise timing on the circadian rhythm of wrist skin temperature. METHODS: Forty sedentary, overweight adults (mean ± SD, age = 51 ± 13 yr; body mass index = 30.9 ± 4.2 kg·m; women, n = 23) with and without (n = 20) T2D diagnosis were randomly allocated to either a morning (amEX) or an evening (pmEX) exercise training group. The supervised 12-wk (3 d·wk) program, comprised 30 min of moderate-intensity walking and 4 resistance-based exercises (3 sets, 12-18 repetitions each). Glycemic outcomes (glycated hemoglobin, fasting glucose, postprandial glucose) and wrist skin temperature were assessed at baseline and postintervention. RESULTS: Exercise training improved (main effect of time, all P < 0.01) all glycemic outcomes; however, this was independent of allocation to either the amEX (Hedge's g, 0.23-0.90) or the pmEX (Hedge's g, 0.16-0.90) group. Accordingly, the adopted exercise training program did not alter the circadian rhythm of skin temperature. When only T2D individuals were compared, amEX demonstrated greater effects (all Hedge's g) on glycated hemoglobin (amEX, 0.57; pmEX, 0.32), fasting glucose (amEX, 0.91; pmEX, 0.53), and postprandial glucose (amEX, 1.12; pmEX, 0.71) but was not statistically different. CONCLUSIONS: Twelve weeks of multimodal exercise training improved glycemic control and postprandial glycemic responses in overweight non-T2D and T2D individuals. However, no distinct glycemic benefits or alterations in circadian rhythm were associated with morning versus evening exercise, when performed three times per week in this cohort.

Resistance Exercise-Induced Responses in Physiological Factors Linked with Cognitive Health.

The global population is aging at an unprecedented rate giving rise to a greater prevalence of age-related illnesses such as dementia and vascular disease. Dementia affects approximately 47 million individuals globally with projections of 130 million by the year 2050. Late-onset Alzheimer's disease is the most common form of dementia, accounting for approximately 75% of all cases and is characterized by a progressive decline in cognitive function, memory, and cerebral volume. The pathogenesis of Alzheimer's disease is poorly understood; however, aging, genetics, and an individual's diet and lifestyle over several decades appear to be key determinants. As there is no current cure for Alzheimer's disease, postponing or preventing the onset of Alzheimer's disease and dementia through therapeutic methods should, therefore, be targeted at individuals decades prior to an individual showing signs or symptoms of decline. As a preventative tool, resistance exercise improves memory, attention, spatial awareness, reaction time, planning, and information processing. Improvements in cognitive performance following resistance exercise and training may be mediated by peripheral elevations in the physiological biomarkers (i.e., neural and vascular) explored in this review. The purpose of this review is to discuss vascular and neuronal degeneration as a cause or consequence of dementia and Alzheimer's disease, and the biological markers of neurogenesis and blood vessel growth, function, and regulation. We will also explore the merits of acute and chronic resistance training as a strategy to postpone the onset of cognitive decline, dementia, and Alzheimer's disease.

High-Intensity Single-Leg Cycling Improves Cardiovascular Disease Risk Factor Profile.

INTRODUCTION: Regular exercise can reduce the risk of developing cardiovascular disease through risk factor modification, with high-intensity exercise and more recently small muscle mass training providing alternatives to moderate-intensity exercise. METHODS: This study randomly assigned 53 healthy middle-age adults (age, 62 ± 6 yr) to complete 24 sessions (8 wk; 3 d·wk) of exercise training, using either high-intensity double-leg cycling (n = 17; HITDL), high-intensity single-leg cycling (n = 18; HITSL), or moderate-intensity double-leg cycling (n = 18; MCTDL). Biomarkers of cardiovascular risk (total cholesterol, triglycerides, HDL-c, LDL-c, apo-B48, and glucose), anthropometry measures (body mass, body mass index, waist circumference, and waist-to-hip ratio), resting blood pressure, and aerobic capacity were assessed pre- and postintervention. RESULTS: Total work completed was greater (P < 0.01) in MCTDL (5938 ± 1462 kJ) compared with the HITDL (3462 ± 1063 kJ) and HITSL (4423 ± 1875 kJ). Pre- to posttraining differences were observed for waist-to-hip ratio (0.84 ± 0.09 vs 0.83 ± 0.09; P < 0.01), resting systolic blood pressure (129 ± 11 vs 124 ± 12 mm Hg; P < 0.01), total cholesterol (5.87 ± 1.17 vs 5.55 ± 0.98 mmol·L; P < 0.01), and LDL-c (3.70 ± 1.04 vs 3.44 ± 0.84 mmol·L; P < 0.01), with no differences between conditions. In addition, aerobic capacity increased after training (22.3 ± 6.4 vs 24.9 ± 7.6 mL·kg·min; P < 0.01), with no differences between conditions. CONCLUSION: These findings suggest that all three modes of exercise can be prescribed to achieve cardiovascular risk reduction in an aging population.

Resistance training enhances delayed memory in healthy middle-aged and older adults: A randomised controlled trial.

OBJECTIVES: High-intensity exercise is a potential therapeutic tool to postpone or prevent the onset of cognitive decline. However, there is a lack of sufficient evidence regarding the longitudinal effects of structured resistance training on cognitive function in healthy adults. The purpose of this study was to investigate the effect of two ecologically valid, intense 12-week resistance training programs on cognitive function in late middle-aged adults. DESIGN: Single-site parallel randomised controlled trial at the Department of Exercise Science strength and conditioning laboratory. Groups allocated by minimisation randomisation. METHODS: Forty-five healthy adults (age range=41-69 years) were enrolled and randomised into (A) high-load, long rest resistance training (n=14), or (B) moderate-load, short rest resistance training (n=15) twice per week for 12 weeks, or a non-exercising control (n=16). Follow-up within seven days. Data were collected September 2016-December 2017. Cognitive function assessed using the CogState computerised battery. Assessors were blinded to participant group allocation. Secondary outcomes were maximal muscle strength and body composition. RESULTS: Forty-four participants were analysed in 2018. Delayed verbal memory performance was improved (p=0.02) in resistance training groups (g=0.67-0.79) when compared to the control group, with no differences between training groups. Likewise, increases in maximal muscle strength were observed (p<0.01) in resistance training groups when compared to the control group, with no differences between training groups. No differences in body composition were observed. There were no adverse events or side-effects of the intervention. CONCLUSIONS: 12 weeks of intense resistance training improves delayed verbal memory irrespective of training design (i.e., high-load vs. moderate-load). TRIAL REGISTRATION: This study is registered at www.anzctr.org.au ACTRN12616000690459.

Hemodynamic Responses to Low-Load Blood Flow Restriction and Unrestricted High-Load Resistance Exercise in Older Women.

Introduction: Blood flow restriction (BFR) during low-load resistance exercise increases muscle size similarly to high-load training, and may be an alternative to lifting heavy weights for older people at risk of sarcopenia. However, few studies have addressed the safety of such exercise in older people, or whether this is impacted by the actual exercises performed during training. This study aimed to compare the acute hemodynamic and perceptual responses during low-load BFR exercise to unrestricted low-load and high-load exercise in older women, and to determine whether these responses depend on the type of exercise performed. Methods: Fifteen older women (63-75 year) were assessed for maximal strength (1RM) in the leg press and leg extension. Participants then completed three protocols using these exercises in a randomized order: (1) low-load exercise (LL); (2) low-load exercise with BFR (LLBFR), and; (3) high-load exercise (HL). Blood pressure was assessed at baseline and after each set, and impedance cardiography measured cardiovascular function during trials. Rating of perceived exertion (RPE) and muscle soreness scores were obtained throughout trials. Results: Baseline hemodynamic values were consistent between trials. Systolic, diastolic, and mean arterial pressures were higher in LLBFR compared with HL and LL (p ≤ 0.021). The LL condition resulted in lower heart rate (p ≤ 0.002) and rate-pressure product (p ≤ 0.011) responses compared with LLBFR and HL. The leg press generally conferred greater hemodynamic and perceptual demands than the leg extension for all conditions (p ≤ 0.002). RPE was lower during LL compared with LLBFR and HL (p ≤ 0.008), and there were no between-condition differences in perceived muscle soreness. Conclusion: The blood pressure data indicate that LLBFR causes greater stress on the vasculature than LL and HL exercise, and that the leg press was generally more demanding than the leg extension. While additional cardiovascular measures were similar between LLBFR and HL conditions, caution should be advised when prescribing BFR exercise for individuals with compromised cardiac or vascular function. Nevertheless, LLBFR and HL exercise were perceived similarly, indicating that BFR training may be viable for healthy older people.

A comparison of traditional and novel metrics to quantify resistance training.

Common estimates of external training intensity for resistance exercise do not incorporate inter-set recovery duration, and might not reflect the overall demands of training. This study aimed to assess novel metrics of exercise density (ED) during resistance exercise, and how these related to a physiological marker of internal training intensity as well as traditional measures of external training intensity and volume. Thirteen males and seven females performed two bouts of resistance exercise focused on developing strength (5 sets of 5 repetitions with 5-repetition maximum; 180 s recovery) and hypertrophy (3 sets of 10 repetitions with 10-repetition maximum; 60 s recovery). Blood lactate concentration was measured to quantify internal training intensity. Specific metrics of external volume (mechanical work, volume load and total repetitions) and intensity (average weight lifted and ED) were calculated. Despite lower average weights and no difference in mechanical work or volume load, blood lactate was greater following hypertrophy compared with the strength condition. This finding was consistent with higher measures of ED in the hypertrophy compared with the strength condition. Greater ED during hypertrophy resistance exercise, along with the significant association with changes in blood lactate, indicates that ED metrics are reflective of the sessional intensity for resistance exercise.

Intense resistance exercise increases peripheral brain-derived neurotrophic factor.

OBJECTIVES: Brain-derived neurotrophic factor (BDNF) has been shown to increase in an intensity dependent manner in response to aerobic exercise. However, previous research investigating the use of resistance exercise to increase BDNF levels has been less conclusive, likely due to the low intensity nature of traditional resistance exercise programs. This study examined the influence of acute resistance exercise to-fatigue on serum BDNF levels and blood lactate. DESIGN: Acute crossover study. METHODS: Eleven untrained to intermediately trained males (age: 25.0±1.3 year) and five untrained females (age: 23.2±1.1 year) were recruited to undertake two bouts of resistance exercise. Strength (five sets of five repetitions, 180s recovery) and hypertrophy (three sets of ten repetitions, 60s recovery) based resistance exercise was implemented to-fatigue to examine the effect on serum BDNF and blood lactate levels immediately post-, and 30min post-exercise. RESULTS: An interaction (p<0.01; ES=0.52) was observed between conditions immediately post-exercise, with hypertrophy resulting in significantly greater BDNF levels when compared with strength exercise. Changes in lactate and BDNF from baseline to post- exercise were positively correlated following hypertrophy exercise (r=0.70; p<0.01), but not correlated following strength exercise (r=0.18; p=0.56). CONCLUSIONS: The use of a to-fatigue hypertrophy based resistance exercise protocol provides the necessary stimulus to increase peripheral serum BDNF. Mechanistically, the presence of lactate does not appear to drive the BDNF response during resistance exercise.