okklusionstræning

5/12/2015
Team Danmark Formidlingsseminar · Brøndby 12. Maj 2015
BLOOD FLOW
RESTRICTION TRAINING
OPBYGNING OG VEDLIGEHOLDELSE AF MUSKELMASSE
MED LAV-INTENSIV STYRKETRÆNING
Per Aagaard, Maj Lund Jepsen, Mads Brink Hansen, Jarl Pors Jakobsen,
Institut for Idræt og Biomekanik, Syddansk Universitet
Dansk Vandski Forbund · Team Danmark
Velkommen til workshop: BFRE/okklusionstræning
• 13:30-14:00:
Okklusionstræning: videnskabelig baggrund
mekanismer, anvendelsesområder - v. Per Aagaard
• 14:00-14:10:
Spørgsmål og diskussion
• 14:10-14:20:
Kaffe og fortsat snak og diskussion
• 14:20-14:50:
Vandskihop og okklusionstræning - v. Maj Lund
Jepsen, Jarl Pors Jakobsen og Mads Brink Hansen
• 14:50-15:00:
Spørgsmål og diskussion
OKKLUSIONSTRÆNING
blood flow restricted exercise (BFRE)
• Resistance training performed with concurrent
partial blood flow occlusion, and using low
• external loads (20-50% 1RM)
picture courtsey Ben Rosenblatt, UK Sports
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Free-flow low-load strength training:
No or only minor increases in muscle size
VI
Quadriceps Muscle Cross-sectional Area
RF VM
VL
*
(P<0.05)
pre training, distal site
post training, distal site
pre training, proximal site
post training, proximal site
(P<0.01)
Heavy: training loads 70% 1RM, Light: training loads 20% 1RM,
12 weeks, 36 sessions, isolated knee extension,
matched for total work load
Holm, Aagaard et al, J Appl Physiol 2008
OKKLUSIONSTRÆNING
blood flow restricted exercise (BFRE)
% Change in mid-thigh
Muscle-Bone CSA
Subjects:
Young men (n=16)
age 23.9 ± 8.4 yrs
Occlusion pressure:
160  240 mm Hg
Loading intensity/volume:
20% 1RM
2 weeks (minus sunday)
2 sessions/day
3 sets, 15 reps
Squat and leg curls
Occlusion pressure
maintained in breaks (30-s)
Total session duration
10 min
Abe et al, 2005
OKKLUSIONSTRÆNING
blood flow restricted exercise (BFRE)
Subjects:
Elderly women (n=19)
age 58.2 ± 6.6 yrs
(range 47-67)
Changes in elbow flexor CSA
and MVC with 16 wks BFRE
Occlusion pressure:
110 mm Hg
Loading intensity/volume:
~ 80% 1RM (HI)
~ 50% 1RM (LI, LI-BFRE)
16 wks, 2 sessions/wk
* LI-BFRE,
HI > LI
(p<0.05)
LI-BFRE and HI:
reps performed
until failure
LI: reps performed to
ensure equal work
matched to LI-BFRE
Cross-over design
Muscle CSA
Muscle strength
Takarada et al, J Appl Physiol 2000; in Manini & Clark, ESSR 2009
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Blood flow restricted resistance exercise (BFRE) can
induce hypertrophy in highly strength trained athletes
PRE TRAINING
POST TRAINING
Knee extensor exercise with partial blodflow occlusion (Rugby players):
4 sets to failure, ~50% 1RM training loads, 2 sessions per week, 8 wks
 12% increase in quadriceps CSA
Takarada et al, Eur J Appl Physiol 2002
Blood flow restricted resistance exercise can improve
muscle strength/power in highly strength trained athletes
Cook et al, J Sports Physiol Perform 2014
Blood flow restricted resistance exercise can improve
muscle strength/power in highly strength trained athletes
Cook et al, J Sports Physiol Perform 2014
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Blood flow restricted resistance exercise can improve
muscle strength/power in highly strength trained athletes
Semiprofessional rugby union athletes
Randomized to lower-body BFR training
(occlusion cuff inflated to 180 mmHg
intermittently on the proximal thighs) or
control intervention training without BFR
9 sessions in 3 wks
5 sets of 5 repetitions:
bench press, leg squat, pull-ups
70% of 1-RM
Cook et al, J Sports Physiol Perform 2014
Blood flow restricted resistance exercise can improve
muscle strength/power in highly strength trained athletes
BFR training
Control
Cook et al, J Sports Physiol Perform 2014
► Substantial muscular hypertrophy
can be elicited by use of low-resistance
blood flow restricted (BFR) strength training!
WHAT ARE THE ADAPTIVE MECHANISMS?
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► Substantial muscular hypertrophy
can be elicited by use of low-resistance
blood flow restricted (BFR) strength training!
PROPOSED ADAPTIVE MECHANISMS
- Enhanced cellular net protein synthesis ... YES!
-  Growth hormone secretion? ... evidence exists
-  Autocrine/paracrine IGF-1 production ... maybe
- Reduced myostatin expression? ... evidence exists
- Activation of muscle stem cells (satellite cells) ???
Effects of resistance exercise on
skeletal muscle satellite cell activity
Picture courtsey Abigail MacKey
ISMC, Bispebjerg Hospital, University of Copenhagen
Satellite cells in human skeletal muscle
Satellite cells in human skeletal muscle
Satellite cells = dormant myogenic
cells situated between the basal
lamina and the muscle cell
membrane
Myogenic satellite cells mediate
muscle cell repair and growth in
response to overloading
Cellmembrane
membrane
Cell
Basal
lamina
Basal lamina
Sarcolemma
Sarcolemma
Satellitecell
cell
Satellite
Myonucleus
Myonucleus
Myofibre
Myofibre
Vierck et al,Vierck et al.,
Cell Biol IntCell
24, Biol.
2000Int. 24, 2000
NCAM/D56 antibody staining
haematoxylin counterstaining
Kadi 2000
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Satellite cells in human skeletal muscle
Satellite cells in human skeletal muscle
Satellite cells in human skeletal muscle
Satellite cells = dormant myogenic
cells situated between the basal
lamina and the muscle cell
membrane
Kadi et al, J Physiol 2004
Cellmembrane
membrane
Cell
Basal
lamina
Basal lamina
Sarcolemma
Sarcolemma
Satellitecell
cell
Satellite
Myonucleus
Myonucleus
Myofibre
Myofibre
Vierck et al,Vierck et al.,
Cell Biol IntCell
24, Biol.
2000Int. 24, 2000
NCAM/CD56
antibody
staining
NCAM/D56
antibody
staining
Haematoxylin
counterstaining
haematoxylin
counterstaining
Resistance training, satellite cells and
skeletal muscle hypertrophy
Responders vs non-responders
Picture courtsey Abigail MacKey
ISMC, Bispebjerg Hospital, University of Copenhagen
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Mean fiber area (m2)
Satellite cells (SC per 100 fibers)
Relative satellite cells (% all nuclei)
Resistance training, satellite cells and
skeletal muscle hypertrophy
Responders vs non-responders
Changes in muscle fiber area and satellite cell content in
response to 16 wks of heavy-resistance strength training
(young, old, men, women)
Petrella, Bamman et al, J Appl Physiol 2008
Fiber CSA per myonucleus (m2)
Mean fiber area (m2)
Myonuclear number (nuclei per fiber)
Resistance training, satellite cells and
skeletal muscle hypertrophy
Responders vs non-responders
Changes in muscle fiber area and myonuclei content in
response to 16 wks of heavy-resistance strength training
(young, old, men, women)
Petrella, Bamman et al, J Appl Physiol 2008
Resistance training, satellite cells and
skeletal muscle hypertrophy
14 days lower limb immobilization → 4 wks strength training:
Hypertrophy response associated with upregulated satellite cell activity
Young (24 yrs)
Old (67 yrs)
Suetta, Frandsen, Aagaard, Kjaer
et al. J Physiol 591, 2013
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exercise, tissue injury
Exercise induced
self renewal of SC’s
1
Pool of myogenic stem cells
(satellite cells: CS)
2
3
Modified from MacKey et al,
Scand J Med Sci Sports 2007
INCREASE IN MYONUCLEI NUMBER
WITH SATELLITE CELL ACTIVATION
Satellite cell activation/proliferation
 SC fusion with myofibers

 cell volume / nuclei
sustained
cell volume / nuclei
Snijders et al, Ageing Research Reviews 8, 2009
Effects of blood-flow restricted muscle exercise (BFRE)
on myofiber size and myogenic satellite cells?
satellite cell
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pneumatic
cuff
Monday
Tuesday
Wednesday
Thursday
Friday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
TRAINING and TEST PROTOCOL
23 TRAINING SESSIONS performed in 3 wks (19 days)
Low-resistance BFR-ST (n=22) or load/work matched RE (n=8)
4 sets at 20% 1RM performed to failure, rest periods 45 sec
- total duration of occlusion: 6-8 minutes
Cuff-pressure: 100 mmHg, no cuff release between sets
15-cm cuff width
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
PRE
POST 3 days
Strength
Testing
Muscle biopsy
sampling
Strength
Testing
Monday
Tuesday
Wednesday
Thursday
Friday
Tuesday
Wednesday
Thursday
Friday
MID8
Muscle biopsy
sampling
pneumatic
cuff
Muscle biopsy
sampling
Muscle biopsy
sampling
Strength
Testing
Monday
Tuesday
Wednesday
Thursday
Friday
TRAINING and TEST PROTOCOL
POST 10 days
MUSCLE BIOPSY SAMPLING (VL muscle)
PRE, MID8 (5 days BFR-ST + 2 days rest),
POST3, POST 10 (3,10 days post training)
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
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MUSCLE BIOPSY ANALYSIS
Assessment of fibertype composition
Tripple immunohistochemical
MHC-antibody stainings performed to
determine fiber type distribution
Kosek et al 2006
IIA
Assessment of fiber area
Laminin antibody stainings performed
to visualize the fiber membrane
IIA
IIA
Immunohistochemical tripple staining marking MHC I (blue),
MHC I IA (red) and MHC IIX (black) isoforms while laminin
(green) marks the basal membrane. Scale bar: 100 m
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
MUSCLE BIOPSY ANALYSIS
Assessment of fibertype composition
Tripple immunohistochemical
MHC-antibody stainings performed to
determine fiber type distribution
Kosek et al 2006
Assessment of fiber area
Laminin antibody stainings performed
to visualize the fiber membrane
Satellite cells
Myogenic satellite cells (SC)
stained for Pax-7, with verified
sub-sarcolemmal position
Boldrin et al, J Histochem Cytochem 2012
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
MUSCLE BIOPSY ANALYSIS
Assessment of fibertype composition
Tripple immunohistochemical
MHC-antibody stainings performed to
determine fiber type distribution
Kosek et al 2006
Assessment of fiber area
Laminin antibody stainings performed
to visualize the fiber membrane
Satellite cells
Myogenic satellite cells (SC)
stained for Pax-7, with verified
sub-sarcolemmal position
Myonuclei
Myonuclei stained with DAPI
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
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TRAINING VOLUME & PAIN SCORING
Week 2
Week 3
Total training repetitions
Week 1
+13%
VAS score (max = 100)
TRAINING SESSIONS
Satellite cells per muscle fiber
+301%
Satellite cells per muscle
fiber
+284%
+160%
Type I fibers
Type IBFRE
fibers
BFRE
CON
CON
+147%
Type II fibers
TypeBFRE
II fibers
BFRE
CON
CON
different from PRE (p<0.01) *,**
different from CON (p<0.05) †
different from mid8 (p<0.05) ‡
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
Myonuclei per muscle fiber
+35%
Myonuclei per muscle fiber
+30%
+30%
Type I fibers
BFRE
+27%
Type II fibers
CON
BFRE
CON
different from PRE (p<0.01) *,**
different from CON (p<0.05) †
different from mid8 (p<0.05) ‡
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
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Myofiber cross-sectional
area
Myofiber CSA
Myofiber CSA
Type I fibers
Type IBFRE
fibers
BFRE
Type
I fibers
Type
II fibers
Myofiber
Type
IBFRE
fibers
+37%
II fibers
CON
+30% Type BFRE
Type I fibers
+28%
Type IBFRE
fibers
CON
BFRE
BFRE
CON
BFRE
CSA
CON
CON
+39%
Type II fibers
Type BFRE
II fibers
Type II fibers +31%
Type BFRE
II fibers
CON
CON
CON
BFRE
BFRE
CON
+28%
CON
CON
CON
different from PRE (p<0.01) *,**
different from CON (p<0.05) †
different from mid8 (p<0.05) ‡
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
Maximal muscle strength (MVC)
+6% +13%
different from PRE (p<0.01) *,**
different from CON (p<0.05) †
different from mid8 (p<0.05) ‡
Nielsen, Aagaard, Suetta, Wernbom, Frandsen et al, J Physiol 590, 2012
Effects of blood flow restricted low-intensity
resistance training (BFRE) on myogenic satellite cells
CONCLUSIONS
BFR-ST can be used to induce marked
increases (+30-40%) in myofiber size of
both type I and II fibers within a very short
period of time (3 weeks)
BFR-ST results in a markedly upregulated
(1½-2 fold increased) myogenic satellite cell (SC)
content in the trained muscles
The hyperactivation of SC’s with BFR-ST
is accompanied by elevated myonuclei number
- reflecting an increased transcriptional capacity
(elevated myogenic capacity)
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Effects of blood flow restricted low-intensity
resistance training (BFRE) on myogenic satellite cells
PERSPECTIVES
Short-term BFRE

marked increases in SC content (150-200%)
and myonuclear number (30-35%)

 ‘myogenic priming’ of human skeletal muscle

important potential implications - for instance:
TRAINING OF ATHLETES
(1) Rapid and amplified increases in muscle mass with
conventional strength training when preconditioned by BFRE?
(2) Increased myonuclei number in BFRE trained myofibers
 exploiting ‘muscle memory’ Bruusgaard, Gundersen et al, PNAS 2010
Effects of blood flow restricted low-intensity
resistance training (BFRE) on myogenic satellite cells
PERSPECTIVES
Short-term BFRE

marked increases in SC content (150-200%)
and myonuclear number (30-35%)

 ‘myogenic priming’ of human skeletal muscle

important potential implications - for instance:
TRAINING IN PATIENTS
Unable to perform heavy-load RT due to
musculo-skeletal-tendinous injury, with primary
or secondary loss in muscle mass, i.e.
neuromuscular myopathology (MS, ALS),
sarcopenic elderly, ACL injury, etc
Effects of blood flow restricted low-intensity
resistance training (BFRE) on myogenic satellite cells
PERSPECTIVES
Potentially allows
accelerated rehabilitation
i.e. following ACL
reconstruction
Short-term BFRE

marked increases in SC content (150-200%)
and myonuclear number (30-35%)

 ‘myogenic priming’ of human skeletal muscle

important potential implications - for instance:
TRAINING IN PATIENTS
May similarly allow
accelerated rehabilitation
in non-reconstructed
ACL injured subjects
Unable to perform heavy-load RT due to
musculo-skeletal-tendinous injury, with primary
or secondary loss in muscle mass, i.e.
neuromuscular myopathology (MS, ALS),
sarcopenic elderly, ACL injury, etc
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Use of BFRE versus general progression training
From bed rest to walking to training following limb immobilizing injury
Loenneke, Abe, Bemben et al, 2012
Accelerated rehabilitation in ACL reconstructed
patients via hyper-activation of myogenic stem
cells by use of kaatsu exercise (BFRE)
Jakob L. Nielsen
Phd-student, Cand.Scient
Institute of Sports Science and Clinical Biomechanics
University of Southern Denmark
Jørgensen et al, accepted for publication
Clinical Physiology and Functional Imaging 2015
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TV2 Sporten (SportsLAB) - 24. marts 2014
TV2 Sporten (SportsLAB) - 24. marts 2014
TV2 Sporten (SportsLAB) - 24. marts 2014
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TV2 Sporten (SportsLAB) - 24. marts 2014
TV2 Sporten (SportsLAB) - 24. marts 2014
TV2 Sporten (SportsLAB) - 24. marts 2014
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TV2 Sporten (SportsLAB) - 24. marts 2014
THANKS for your attention !
Acknowledgements
Jakob L. Nielsen
Anders Jørgensen
Ulrik Frandsen
Charlotte Suetta
Nis Nissen
Lars Grøndahl Hvid
Mathias Wernbom
Rune Dueholm Bech
Tobias Nygaard
Ben Rosenblatt
Abigail Mackey
Fawzi Kadi
Michael Kjær
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