Jim Stray-Gundersen – Blood Flow Restriction Training: Anti-aging medicine for the busy baby boomer
[Music]
this lecture is being brought to you in
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good evening it’s really a pleasure to
be here and what I’d like to start out
with is kind of give you where we’re
headed and that is there’s some
interesting technology that’s actually
quite old originated in in Japan and 50
years ago but recently has gained
traction in in the United States and I
also I’ll take you a little bit through
a journey that I’ve had where I’ve first
gone to Japan to study under the experts
but a couple years ago we we had some
ideas of how to build a better mousetrap
and so my partner and I sean whalen
who’s actually in the in the entryway he
and i have put our heads together and
developed a blood flow restriction
product that we think solves a lot of
the problems that were that we’re
existing so with that let’s get going
one of the thing to say is that how long
we live and how well we live is a
function of our genes and our
environment and since at least at the
moment we can’t change our genes we need
to optimize how we interact with our
environment to maximize health wellness
and fitness and you know one of these
days we’re going to have some pill that
we can take but there’s problems with
that kind of approach the first thing to
say about wellness and health and
fitness is that we have to live
ethical lives that we are happy to
have the the sunshine principle or to
have have what our acts are exposed so
you have the ten commandments on the
left-hand side and you have the golden
rule up in the right-hand side and you
have that other golden rule that really
isn’t appropriate to contaminate the
contaminate thing so once we have our
ethics and honesty out of the way then
as general statements the key to a long
life health and fitness and wellness can
be stated as do’s and don’ts don’t use
tobacco particularly cigarette smoking
don’t do drugs particularly pertinent
during this current opioid crisis don’t
ride motorcycles or other risky physical
behaviors and what I mean by that is
that there’s particularly in sports
there the participation in that sports
may be fun and may be rewarding but
there can be very serious long-term
consequences for example as we see with
the concussion problems that NFL players
have had as well as sports like alpine
skiing or ski jumping that we’ll see in
a little bit racecar driving surfing
these things have hazards that can be
fatal from time to time on the other
hand what are the do’s do alcohol in
moderation and modestly great
so so there’s a lot of epidemiologic
data that cultures that consume regular
small amounts of alcohol actually live
longer than those that either abstain or
have excessive use of alcohol same thing
for nutrition balance and moderation are
really the message here and so that’s
that’s an important facet and then what
this talk is going to kind of focus on
is do incorporate regular exercise into
your lifestyle and so this is kind of a
cute little thing here where this guy’s
challenging why this guy believes the
regular exercise is aging and he’s 147
so so what happened what happens when we
age there’s a lot of not necessarily
good things there’s a reduction in CNS
or brain function cognitive function and
also in the ability of the brain to
control what aspects that it has to deal
with for example body parts moving in
various ways and in the brain are there
what are called primary neurons and then
there are secondary neurons that take
those commands to the muscles or
information from the in the peripheral
nervous system take it from the tissues
back to the brain there’s a reduction in
muscle fiber number and size as well as
the contractile function of each one of
these muscle fibers there’s a reduction
intent and tendon tensile strength so
much so that it’s possible with normal
activity to rupture tendons there’s a
reduction in bone density and we have a
big medical problem with particularly
senior women who have lost or bone
density and as a result end up having
fractures and and that carries its own
morbidity mortality there’s a reduction
in capillary density and this is the
small blood vessels
that surround pretty much all tissues
and this reduction capillary density
prevents the delivery of blood and and
clearing of waste that that it had that
happens when we’re younger and then
there’s a reduction in mitochondrial
density and mitochondria are really the
energy factories of the cells and so ATP
or intracellular phosphates are made in
these mitochondria and they power pretty
much everything we do and so if you look
at from all the way up in the in this
case the motor cortex all the way down
the brainstem out to the muscle and then
here this is from the spinal cord out to
the muscle and all each one of these
fibers of a given motor unit are
innervated by the motor neuron and then
this thing is connected to a tendon and
then there’s a bone attach this whole
pathway in various ways various places
along the way end up degenerating over
time and particularly if they’re not
used so there’s a little truth to the
better use it or lose it idea so kind of
honing in on on one aspect of this and
that is the aging process whether it has
to do with motor neurons and there’s a
reduction in a number of myelinated
nerve fibers myelin is is a substance
that coats a lot of you can think of it
as insulation and a wire and when these
wires are insulated they their nerve
their conduction velocity is greater and
they’re just they’re basically better
quicker nerves and then there’s a
decrease in nerve fiber diameter that
also is probably related to this
decrease in myelin and then at the
neural motor junction which is depicted
here there is a decrease in a number of
these pre synaptic vesicles which carry
the neurotransmitters and then these
neural transmitter these vesicles when
they come to the when there’s an
electric there bio electric charge
coming down the thing the it releases
the
acetylcholine into this kind of space or
nerve gap and then on the other side of
this on the muscle there’s these
nicotinic receptors that bind to the
siedel choline and they’re then
discharged the the muscle fiber in
addition to that there’s denervation of
the motor fibres so all these things go
away but then in some cases that
actually the nerve loses contact with
the motor fiber and then a lot of
changes a motor fiber or muscle fibers
are very dependent on what kind of
neural activity they’re getting and so
when they become d nerve ated they just
kind of shrivel up and go away and then
something that’s that will be a parent a
little bit later is this idea of
converting fast twitch fibres or type
two fibers into slow twitch fibres or
type one fibers so regular exercise can
mitigate the age associated changes to
this neuro motor unit but the intensity
and duration of the exercise that is
necessary to get these changes is rarely
tolerated as we age then in addition out
of disuse we have this kind of
transition going on as in my case you
know what I was 50 years ago is 50
pounds ago so these things these things
do creep up on you
as we age there is one event after
another maybe you felt alpine skiing on
a nice vacation which made you be
sedentary for the next three months
well that three months of sedentary
behavior caused a lot of the tissues to
atrophy and maybe gain some weight and
then when you try to get back you’re not
you’re not able to do the things that
you were able to do in the first place
so in addition to that we like to eat
and we kind of our appetite as more
related to our activity and stuff like
that but there’s a lag face so that when
we become the sedentary we don’t
necessarily lose our appetite and so
then now we’re in a positive caloric
balance over time and that’s probably
the main reason for this increase in in
weight so we think we have a solution
for that and it’s called blood flow
restriction training and by restricting
the blood flow and performing light easy
exercise that’s doable
in a short amount of time one can gain
the health benefits of intense long
duration exercise and so one of the ways
to think about this is that we have kind
of short-circuited the body’s normal
systems and I’ll explain I’ll explain
more of that in detail as we go through
this but the key to all of these things
is this disturbance of homeostasis in
the working muscle and what I mean by
that is the environment that that muscle
operates in becomes disturbed and it
goes out of ranges of pH temperature
variety of other things that we’ll we’ll
mention briefly this disturbance of
homeostasis is the thing that stimulates
local and systemic antibiotics
mechanisms and so this is kind of where
this no pain no gain idea comes from you
have to really stress yourself before
the body will say oh I’ve got some
problem here I better react to it I
better get better so that I can continue
doing things and and then further
because typically the exercise that it
takes to get this disturbance of
homeostasis ends up doing damage by
doing the restricting blood flow and
light easy exercise we don’t get that
damage and so adaptation happens on a
quicker timeframe then than usual here
this is the kind of a model of the
system that
Shawn and I have come up with and
there’s a couple things to point out
here there’s basically a pair of
armbands a pair of leg bands a little
pump to inflate these things and very
importantly there’s an app that can
guide the person through these things so
that in essence you don’t need an expert
around to take you through this stuff be
strong training systems are used by a
wide variety of people from adolescents
to elite athletes injured or operated
patients to baby boomers to nonagenarian
s– and everybody in between and here
these guys aren’t exactly adolescent
they’re they’re sixteen and seventeen
years old but we use this down to pretty
much nine year olds and on the other
hand here we have a young young lady 95
years old who’s got her bands on and
she’s going for a walk with her Walker
one of the things that is a really big
problem that I think we can address is
we have someone who’s otherwise
motivated to play sports but their their
lifestyle between the job and family and
work and everything else has just gotten
to be so hectic that there’s no time for
them even if they’re motivated to go out
and do things then there’s another group
of general adults who we could
characterize as couch potatoes and they
end up developing metabolic syndrome
what’s something called metabolic
syndrome which is high blood Sugar’s
high cholesterol high blood pressure and
an obesity and this is an entirely
preventable problem by regular exercise
alone along with some good new nutrition
modulation so we one of the things here
is if we get back to this idea that
regular exercise can fix these things
then we amp but in many cases regular
exercise is too intense for people to do
enough of to get the benefits we’ve now
figured out a way to shortcut that and
to provide this exercise
stimulus in a way that’s doable for
people so one of the things to say is
anytime you’re gonna do something to
another human you want to make sure that
you’re safe and blood flow restriction
training in one form another has been
practiced for 50 years in Japan today
today there are approximately 300,000
blood flow restrictions effective
sessions daily in Japan with no reports
of serious complications and this means
that there’s just a fantastic experience
and if there was going to be something
bad happening it would happen in this
kind of population in our particular
situation we basically had systems that
we’ve had out for approximately a year
to a year and a half we currently have
approximately 1,500 systems out there
and for us we’ve had tens of thousands
of sessions with be strong and no
reports of any serious untoward effects
there’s a reason for that and that is
that the only way to get really serious
effects is by occluding arterial inflow
so when you put our bands on we want to
make sure that what we’re doing is we’re
adjusting the circulation and just the
right way to optimize the effects and
for many of the other devices some of
them for example started out life as
surgical tourniquets which are very good
at occluding arteries so you don’t have
bleeding all over the place they they
have to go through quite a rigorous
thing to avoid this occlusion of the
arterial inflow and and and their way of
doing this is they end up tethering you
to a stand where there’s where there’s a
doppler flow meter that assures that
flow is denver totally occluded but
anyway so if if you can if you do shut
off blood flow to for an extended period
of time and some other things happen
it’s possible to do severe muscle damage
and the end of that spectrum is
something called rhabdo my
alysus and that can end up putting you
in renal failure and needing to go on
dialysis or it can cause arrhythmias
cardiac arrhythmias which can lead death
in addition it’s possible to get deep
venous thrombosis or DBT s and then
these DV tees can migrate into the lungs
and cause pulmonary emboli which also
can be fatal so as long as we stay away
from including the arteries we’re in
good shape so we have designed these
things specifically not to include the
arterial inflow and by up to the maximum
capacity of our hand pumps so this way
we’re eminently safe and the safest bfr
devices on the market one of the other
things to say is that income you know
safe in comparison to what we’re we get
the same results you get from really
heavy lifting with very trivial light
exercises and this is this guy’s not 90
yet but he’s 87 and this weight looks
like it’s gonna fall on his on his foot
or hurt his back and this little ball is
not going to do much so blood flow
restriction training is safer than the
standard kind of training that we had
out there so now let’s get into a little
bit of the mechanism because it’s not a
it’s not quite straightforward but
obviously with blood flow restriction
training we want to restrict blood flow
but we want to do it in a specific way
what we want to do is at rest we want to
block the veins from blood getting out
of the extremity but if you just block
the veins and then let things go their
way
first the the limb would engorge or
distend with blood that’s coming in from
the artery and nothing’s getting out and
if that went on long enough the artery
would stop because there’s no more room
to put anything in so then what we have
is we have this muscle contraction so
when you do when you do a muscle
contraction you’re actually squeezing
what’s blood in the blood in
muscle and you’re sending it somewhere
and because of the valve system in the
veins that where it goes is it oh it Oh
over goes our it overflows the venous
blockade and you end up changing the
character of the venous flow from what I
kind of call a lazy river where it’s
kind of continuous to one in which it’s
blocked for a period of time and then
with muscle contraction all of a sudden
all this blood is pushed out of the
extremity and so you actually get almost
pulsatile venous flows going from zero
to very high rates and this actually is
is preventive for any kind of clot
formation because what you’re doing is
you’re flushing this thing out
repeatedly and keeping the thing moving
but in in many ways which we’ve done is
we’ve just slowed down and inhibited the
blood flow so that when when we have
this situation the exercising muscle is
not going to get the blood it normally
gets nor needs to continue contractions
this is this is the bit again about what
we do is we actually by putting these
bands on we don’t really change resting
flows but normally when you go from rest
to exercise the arterial inflow picks up
and we’re really preventing that
increase from happening and then to all
said and done this these vascular
changes result in an angio genic
stimulus building more and better blood
vessels and I’ll show you some data
later on that kind of indicates this so
the working muscle the bottom line is
the working muscle is denied the blood
flow it normally needs to sustain this
these contractions so what happens in
this muscle now this is where the
disturbance of homeostasis takes place
and I’ll show you some information about
the amount of oxygen in the muscle goes
down the pH or the amount of the pH goes
down the amount of acidity goes up and
the the intracellular phosphate stores
are depleted
in addition the lactic acid is increased
as well as inorganic phosphate which is
a breakdown product from these
intracellular phosphates taken together
these changes produce a metabolic crisis
which has several main consequences as
these early motor units fatigue faster
and better bigger units must take over
the work eventually leading to
recruitment of all muscle fibers in a
muscle and this is actually important
because generally for there you can
divide the world into type 1 fibers and
type ii fibers or slow twitch and fast
twitch and normally when we’re doing
everyday activities we’re relying on our
slow twitch muscle and that those fibers
being activated are very dependent on
the blood supply and you go along you’re
a happy camper and you’re able to do
work but if you’re doing intense
exercise or heavy weight lifting or long
duration things like marathons you end
up needing to tap into these faster
twitch fibers and the only way that
those fibers get trained is by having
contractions so when you’re thinking of
explosive sports or very very big
strength oriented tasks you need to use
all the fibers in the muscle to do this
and so it’s very hard to recruit these
but we found a way by restricting the
blood flow that we start having these
faster and bigger units have to take
over the work because the the easy ones
are the early ones that dropped out and
so this leads to recruit total
recruitment of all fibers of the muscle
also these this disturbance of
homeostasis stimulates local protein
synthesis in an attempt to repair the
damage that’s being done and in addition
the cell surface
anabolic cell surface receptors are
upregulated so that now this muscle
fiber has these little catcher’s mitts
on on its surface looking for anabolic
hormones to come by and activate even
more protein synthesis in addition the
signal of distress
is sent to the CNS versus a kind of
afferent nerve fibers called Group three
in Group four so we’ll get into a little
bit of this here this is this is a
technique called near-infrared
spectroscopy if for those of you who
have been in a hospital setting and
somebody has put a little pulse oximeter
on your finger to see that you’re
saturated with oxygen on the arterial
side here this is the same sort of thing
but instead of looking at moving blood
this is looking at hemoglobin that is in
the muscle itself so these numbers give
you an idea of what’s called SM o2 or
the saturation of oxygen in the muscle
so in a percent thing and so here we
have just regular exercise doing arm
curls and normal levels of oxygen and
muscle at rest or abouts let’s say 65%
and then you start doing exercise and it
drops down in the mid 30s and then you
stop and rest a little bit and comes
back up and this this kind of goes back
and forth here but you kind of see the
baseline as you get warmed up you
actually don’t go down as far and you
when you recover you’re going up even
higher and then when you really stop
you’ve got this recovery hyperemia where
you have very high levels of oxygen in
the muscle if you do that with blood
flow restriction bands on we’re starting
out more or less in the same place again
and then you just put the pressure into
the band and all of a sudden it’s
dropped the oxygen with even out without
out any exercise and here we we continue
on with some of the exercise and now
instead of in the mid 30s we’re in the
mid 20s we increase the prayer we
continue to increase the pressure and
the muscle gets worse and worse and
before you know it we’re really down in
the basement this is extreme hypoxia
which is a very good stimulus for number
one causing a disturbance homeostasis
and number two stimulating protein
synthesis this is some other data the
from nuclear magnetic expect excuse me
nuclear magnetic spectra
Skippy and just and identifying this
sort of thing if you look over here this
is these are spectra that go from
without any kind of blood flow
restriction from rest to exercise and
what you see is that inorganic phosphate
peak is increased from rest exercise and
the fossil creatine peak is severely
reduced indicating this kind of use of
phosphate in the muscle or the ATP ATP
and here’s these are the curves for ATP
and they’re down a little bit as well
after exercise but then if you restrict
the blood flow to this muscle now all of
a sudden the inorganic phosphate peak is
much higher and the remaining
phosphocreatine is much lower than the
comparable thing where blood flow is
going on and you still have the ATP
curves showing showing degeneration so
between the last slide and this one this
shows that that muscle with blood flow
restriction training gets very hypoxic
and basically runs out of its energy
stores now so this gets back to what
this what the consequences of those kind
of things so when the po2 gets to a
certain point and when the energy stores
empty out then that those muscle fibers
that are working they just stop they
fail they can’t do it anymore and that
is the typical kind of thing that you
see over here these are arm curls tricep
extensions but then as these fibers drop
out you start recruiting faster and
faster and faster fibers still using the
same easy weights and before you know it
you’re getting into the same fiber
populations that you’re using with very
explosive powerful movements kind of
depicting this thing in another way the
typical way of for recruitment and
fatigue pattern is if you use light
weights or you increase the weight and
increase the weight you get more and
more of these fibers contracting until
you need to use very heavy weights and
near maximal weights to contract all of
the
fibers in the muscle blood flow blood
flow restriction recruitment and fatigue
pattern is such where the weight stays
the same but because we have restricted
the blood flow now these early fibers
they start to drop out and you recruit
faster and faster fibers and before you
know it with light weights you’re
recruiting the same percentage of fibers
in the muscle that you are with really
heavy weights and this this is actually
one of the big take-home points that
essentially we can become trained with
very light weights and blood flow
restriction to the same extent that you
can with heavy weights so this is this
is a little bit more of the mechanism
this is the mTOR pathway the thing to
point out here is that the reduction in
energy stores and the reduction in
oxygen or hypoxia are very strong
stimuli in this pathway to activate the
mTOR pathway that ends up resulting in
protein synthesis in addition these cell
surface receptors are activated and up
regulated so they’re looking for growth
factors to come along and and amplify
the process so what we really have the
next aspect of this yet and by the way
the point of showing this slide is that
our bands go anywhere and can be used
anytime she’s actually doing handstand
push-ups which is quite remarkable and
on top of that she’s 57 years old she
happens to be my wife but
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so there’s something called a systemic
neural immuno hormonal response or an
anabolic response and and and by
triggering this met this disturbance of
homeostasis message is sent up to the
brain and the brain then releases this
systemic response and there’s autonomic
hormones and antibiotics or moans that
that end up then going throughout the
body and that will be important in some
of the data that I show a little later
so this systemic response amplifies
these local responses to upregulate
proteins and synthesis and any muscles
that were exercising whether their blood
flow was restricted or not adapt to this
situation because little damage was done
there’s an increase in strength and
fitness very quickly so if you think of
all of our processes it’s a balance
between breakdown and build-up and in
under normal training circumstances we
get some break down along with the
stimuli to build up and things pretty
much progress if for example you I end
up getting a trip to the Space Station
then all of a sudden the build-up stops
because you’re not doing any exercise
but the break down the body recognizes
that it doesn’t need all these all these
things that are up there so you end up
losing bone density you lose blood
volume you lose muscle mass you lose
cardiac mass just by spending a two
weeks on a on a space shuttle mission so
anyhow whoops let’s see yeah so what we
have here is that this balance between
break down and build up is altered in
favor of building up and so the changes
that occur happen readily and on a
relatively quick timescale so for
example as few as five sessions of blood
flow restriction training can end up
prompting an increase in strength and
fitness so
again I stress this earlier all tissues
that were involved in the exercise
whether they were proximal or distal to
the blood flow restriction bands enjoy
this systemic antibiotics are tune that
depicts this problem so here’s this
muscle doing arm curls with a blood flow
restriction band in place and and this
disturbance of homeostasis is being
communicated through metabolism round up
here for a while and there comes out a
sympathetic response that increases
sweating increases heart rate increases
breathing and that’s one thing but in
addition there’s a reflex that ends up
through the hypothalamus and and then
into the pituitary releasing a number of
anabolic hormones including growth
hormone that then again go throughout
the body and this this basically shows
this and here we have this is whole
blood lactate and the open squares are
the control exercise where it’s just
exercise alone and then with the same
exercise but the blood flow restriction
bands in place you have a much more or a
highly significant increase in blood
lactate and lactate itself is stimulates
protein synthesis in the in the tissues
that it’s it’s being generated in
addition coming back to some of these
vascular changes here we see that VEGF
or vascular endothelial growth factor is
stimulated by the blood flow restriction
training which you see in the in the
closed or filled in circles here
compared to the control exercise itself
and these two things are basically local
effects or examples of the local effect
that what we were talking about earlier
but now here we have the systemic
effects so here this is this is growth
hormone and the control exercise or the
same exercise when there’s no blood flow
restriction bands in place
has this nice little gray line and
basically nothing’s moving and here this
is before they exercise this is after
the blood flow resistance restrictive
restriction training and here you have a
ten minutes and at thirty minutes very
robust increases in growth hormone
production and this growth hormone then
goes and among other places to the liver
where it stimulates an increase in igf-1
or insulin growth factor one which is
also a very anabolic substrate so taken
together here you have some indications
of a local effect and also evidence of a
systemic effect that is highly anabolic
so that’s nice and that’s a nice story
but how does this really apply and how
do we how do we actually make this
happen and on january 10th 2014 this is
one of my athletes not having a good day
and he ended up breaking his arm and he
has a comminuted humeral head fracture
and you can kind of see there’s like
five different pieces here and he also
broke a rib he also had a bit of a head
injury and he tore the labrum of his
rotator cuff so here’s the where the
labrum would normally be and essentially
what he did is in this particular piece
is this is where a muscle called a
subscapularis inserts and so he just
ripped that all whole thing all all out
and this happened on a Friday in Germany
he flew back to Park City Utah on
Saturday and he saw our shoulder
orthopod on Sunday and the the doc said
you know Todd you know this this I I
really need to go in there and put some
screws and plates in there and I need to
fix it
but if that’s the case you’re not going
in the Olympics and Todd had been from
the date of this thing this is 2014
the opening ceremonies for the Sochi
Olympics were February 7th 2014 four
weeks from the time of this injury and
normally this kind of thing is a
season-ending injury if he was operated
on it would be six months rehabilitation
under normal circumstances well Todd
didn’t like that answer and I had been
working with this stuff this actually
was with the katsu equipment and we said
okay well let’s give katsu a try and if
it doesn’t work then you can go put your
screws in and his seasons ruined anyway
but this is the only way that we might
be able to get him back to compete in
the Olympics and this Todd is at this
time as 37 years old this would be his
sixth Olympic Games and most likely his
last one so he wanted to do everything
he could to to make the team and so what
we did is we started twice a day Todd
was used to working out twice a day so
now and as is typical with any injury
all of a sudden you have to stop what
you’re normally doing and that is very
hard on these athletes there’s a lot of
atrophy that happens when that occurs
and even if we got his shoulder to heal
the time off from normal training that
would happen in the is time period would
ruin any kind of performance that he
might have in the Olympics and so here
we’re doing basically what we do is with
any injury we want to train all three
normal extremities as much as possible
while not causing any problems with the
healing site so he’s immobilized in a
sling and you can kind of see here he’s
got a hand grip in his left hand and so
he’s actually doing forearm exercise
Wally’s doing a polling motion with his
right arm and and one of the keys to
this kind of exercise is that it’s
exhaustive and this is
exhaustion from the from the exercise as
opposed to anything in his shoulder and
Todd is what’s called an or 2 combined
athlete and so he ski jumps and he
cross-country skis and here he’s
practicing what he would be doing with
his on it on a ski jump but with the
bands on and his shoulder mobilized in a
way that we’re not causing any pain in
the in the shoulder and then similarly
here we have on our we have a treadmill
you can roller skiing on that simulates
cross-country skiing and it’s and
normally he’d be using poles but he
can’t on his left side and so we’re
doing exhaustive intervals with with
this kind of thing and these these
workouts are exhaustive but they’re not
if he were doing a normal kind of thing
they wouldn’t be tolerated long story
short the opening ceremonies were on
February 7th and Todd was elected flag
bearer for the United States team and
just to annoy me he’s carrying the flag
in both his right and left arm and we
were following him along with x-ray so
this was three days after the opening
ceremonies in Sochi and we got a regular
x-ray and you can see this this piece is
not where it’s supposed to be but what
is amazing is we’re starting to see
callus formation and ossification across
the fractured main fracture site and so
this is really early healing and why
would that be one of the principles is
we immobilize a fracture we don’t move
it so it has the best chance of healing
but we feel that this systemic response
that we elicit by this very hard intense
exercise produces a hormonal milieu
which which optimizes the rate of
healing and to further illustrate this
this is now February 12th and here he is
doing an olympic practice jump and
and his left arm is not doing exactly
what the right is but if you remember
when when you try to heal these
fractures you have to internally rotate
and fix the arm here but if you try to
go off a ski-jump with your arm like
this you’d probably do the same thing on
on the other side that he did in the
first place so over time we had to
externally rotate the arm and be able to
put it back so that he could get into a
normal jumping position and all of this
stuff we did without any pain in the
fracture site this is a week later and
now we still it’s even but there’s now
even more bone healing that’s going
across this fracture site and he has no
pain in his shoulder and he’s able to
cross-country ski and he’s able to ski
jump so then on February 20th 40 days
after the injury he ends up placing well
in the jump portion of the Nordic
combined competition and he skis 5
kilometers the the event was a 5
kilometer cross-country ski race which
under the best conditions he might do in
12 minutes in 10 seconds or 12 minutes
and 15 seconds and he was able to
complete it in 12 minutes in 28 seconds
and that basically this is unheard of
progress in a very short timeframe to be
able to be competitive in an Olympic
Games with fracture as an injury as he
had so that was kind of that’s kind of a
dramatic kind of application that we
have and now let’s look at some of the
literature about this so this is an
article that came out in the journal
applied physiology in the year 2000 and
I want to kind of go through these
graphs and detail what we have here on
the x-axis is the basically the speed of
the movement and on the y-axis the
amount of torque generated so and where
you have negative speeds that’s
extension of the arm where you have
positive speeds it’s it’s flexion of the
arm
and what you see here is if you take if
you take an untrained control group and
you test them twice with four weeks in
between they basically have no change
and it’s a very reproducible test so now
going on the other side of this this is
standard weight training this is about
using 80% of a 1 rep max it’s a bit of
an artificial situation but it’s typical
along with the kind of recommendations
that we get for normal strength training
and here we have the pre-training values
and then what we see is that at all
speeds there’s a significant improvement
in strength or torque generation with
standard heavy lifting or high-intensity
training then on the other hand if we
use low intensity training and instead
of 80% of one rate of maximum we use 30
to 40% of maximum here we have not much
is happening there’s a little bit of an
increase but basically easy weight
training really doesn’t cut it in terms
of improving strength but if we add
blood flow restriction to the same
weights that were added here now all of
a sudden we have the same kind of
advantages that we get with the heavy
lifting so you saw that graph where the
Olympic lifter was kind of losing
control of the weight that kind of
training compared to the stuff that 87
year old guy was doing with a big
exercise ball you end up getting the
same percent improvements in in strength
this is an amazing finding to be able to
use very light training that doesn’t
really that’s possible for particularly
seniors and to get these dramatic
improvements in in strength another
study that recently came out showing
essentially the same thing is now this
is with high school students and they
were doing back squats and the
conditions here are they had low
intensity work less than 30 percent of
one of one repetition maximum or heavy
work greater than 65% of one repetition
maximum or the combination of this kind
of weight training plus B fr and what
you see here is that the low intensity
weight training with the bf are actually
has a robust improvement in the amount
of weight that they could move pre and
post-tests where light weights by
themselves did nothing and you had a
good but not as good improvement in
strength with the heavy weights by
themselves and this is consistent this
this is the same kind of results that we
got on that first slide that I showed
you and the again the reason for this
probable difference it the reasons even
better is because we’re not doing damage
to the tissue when we’re working it out
and so you don’t have to kind of repair
the damage it was done before you can go
on and and do more so not only that here
we have this on on the x-axis here are
days and they were doing a bfr workout
once a day and what you see is compared
to the same weights light training alone
but light training with katsu there was
an in there’s an increase in the muscle
bone cross sectional area that is
happening very rapidly and so this is
you know one two three four five six
seven buy a week they had actually
gotten two significant gains compared to
the control situation so very quick
thing and that that is also consistent
with this idea that we’re not doing the
damage so we don’t have to repair the
damage first and then get better we’re
getting better right from the get-go and
here we have something else that is kind
of unusual this is where they’re doing a
bench press one rep one repetition
maximum and here’s the percent change in
strength and this is basically light
weight training and then this is the
same training with with the bfr but
what’s interesting here is you use both
your pecs and your triceps to do a bench
press the triceps have their blood flow
restricted but the pecs don’t they’re
your the they’re well above the thing
and both of these muscles are showing
improvements in strength and
improvements in cross sectional area so
now so here we have improvements in
strength and in size of muscle from this
muscle is attached to bone and here we
have in a different study they were
studying leg press and they had with
katsu they had a nice improvement in its
to sit-in in leg strength over control
where there was really no change and in
thigh cross sectional muscle again a
nice significant improvement in the high
cross sectional area of muscle compared
to the control but then also we have a
significant improvement in bone specific
alkaline phosphatase and this is an
enzyme that’s used in Brook bone
turnover and when this is going up it
means that something’s happening to the
bone and it and indicating that there’s
improve there’s increased bone turnover
and likely improved bone density as a
result of this here is igf-1 in this
case it’s not statistically different
but still a in it and an increase so now
we have positive changes in muscle we
have positive changes in bone and we
have positive changes in building new
and better blood vessels what we have
here is mRNA expression on this axis and
these are markers for vascular
endothelial growth factor it’s receptor
something called Heflin alpha which is a
hypoxic Olinda scible factor and then
various isoforms of the nitric oxide
synthase system which is also all of
these things are involved in building
new blood vessels and so these the what
you have here is a is the open bars are
with blood flow restriction training and
the black with the same kind of weights
but no restriction
another kind of neat study and of all
places coming out of Iran but basically
what they did is they took these poor
little rats and they tied off their
femoral artery’s okay and then they made
them run on treadmills and so this is
their model for restrictive blood flow
training and what you see these are this
is an indication of muscle hypertrophy
what they did is a sacrifice the rats
after a few sessions and and then they
measured the ratio of the size of in
this case the soleus muscle and the EDL
or extensor digitorum longus muscle in
these rats and this this six condition
over here is a treadmill walking or
jogging a little rat treadmill with with
the blood flow restriction conditions
where these things are various control
situations and this this one over here
this third graph here is just blood flow
restriction alone without the treadmill
walking so but here we have very
significant results with a form of blood
flow restriction training in these rats
and then also we have the receptor for
the neural transmission of the nicotinic
acetylcholine receptor and if you recall
back on that slide where I was talking
about what’s happening to the motor
nerves this is indication that these
these receptors are coming back and
you’re increasing the receptors with
this form of blood flow restriction
training and and I must say that when
you tie off the femoral artery and a rat
it doesn’t mean that the whole thing
dies it just means that their blood flow
is restricted they’re not able to get
the normal amount of blood flow with
with exercise that they otherwise would
so this is in a rat model and this is
showing that the same kind of thing is
happening in rats too as to people so
now we’ve had a tremendous experience
with this sort of stuff and this is some
of the
different kinds of people that were
working with this guy had a bad knee
injury from playing soccer and you can
see here he’s doing arm work and it’s
hard to see here but this this is his
right leg is in a is in a is in a
stocking that he’s using to keep down
swelling in the injured side this
gentleman was in the Pentagon on
September 11th and he’s also a Iraq and
Afghan Afghanistan veteran and he has
post-traumatic stress syndrome and he
ends up claiming that this is the only
way that he gets some of his relief this
guy has two things going on one is at
one point he had a PRP and stem cell
injection in in his shoulder for sure he
happens to be 81 and he also had a total
knee replacement and so this is a very
good therapy for total joint replacement
as well as some of these things this
this young man had low back pain and he
had an MRI that showed there’s these
discs bulging into his spine and and his
orthopedic surgeon said well we should
operate on this and we should take him
out in the meantime he showed up at our
clinic and he ended up doing a be strong
program and then he was scheduled for
surgery dutifully went down and was on
the gurney and and he goes wait a minute
doc I don’t think I need this anymore
and the guys what are you talking about
and he says well here look and he got
off the gurney and goes bends over and
touches toes and my back’s not hurting
surgeon says get out of here and so in
in in literally the two weeks between
the time he made is he had his
appointment with the orthopedic surgeon
and the time that he was due to be
operated on we were able to take his
pain away this is an example of using
for
and training and a otherwise healthy
young woman and this this young man had
had rotator cuff repair surgery and
again showing the same sorts of kind of
thing so the theme here is that almost
no matter what’s wrong with you we end
up being able to address it with blood
flow restriction training these are
actually two nurses and this one happens
to suffer from osteoarthritis and this
one from rheumatoid arthritis the doing
the B strong system got her out of the
wheelchair she has eliminated the pain
that she normally has in her hands and
so it’s effective for that kind of thing
and in addition this kind of easy
lifting or strength training is
something that’s possible for these
women where the normal kind of training
that you might want to do to improve
this kind of strength is just impossible
to do more of these cases this this this
guy is 83 and he had a sole shoulder
repair she’s in her mid 50s
and the same sort of thing and you’ll
notice that in many of these cases
there’s bands on both arms and legs at
the same time this guy had ankle surgery
and was interested in getting his golf
swing back and we were able to allow him
where before with his foot he he was in
so much pain that he he couldn’t do
anything got operated on and then to
rehab him we ended up using these
altered G treadmills in the back as well
as to be strong and now he’s playing
better than he ever has again here’s our
here’s one of our guys doing more
vigorous exercise with the bands on and
this is the total knee replacement one
of our total joint this young lady had
low back pain and ends up not having an
more he had a rotator cuff repair and a
total knee replacement so here’s also
some fascinating things this this is one
of our women jumpers who had a fall and
she had a fracture in her thoracic spine
she did not have any spinal cord damage
at the time but we were doing a beast
drawing exercises that she could
tolerate without having the the her
fracture hurt and she’s now back to
normal this young man over here is in
his mid 60’s and he had a cardiac
arrhythmia that long story ended up he
was taken to the cardiac surgery thing
and he had he had a median sternotomy
where they opened up his chest to repair
what was going on and in addition he has
ankylosing spondylitis of the neck and
before he was doing the be strong stuff
and before he had his cardiac surgery he
his his head was bent over he could not
get his neck into this normal position
and we were able to again doing exercise
gently that didn’t disturb the healing
tissues we were able to bring him around
this guy in the middle is a was a
complete quadriplegic and and he had he
had suffered a he was surfing and he
ended up getting dumped on as on his on
his head on the bottom of the Pacific
Ocean and he was for two years he was in
a spinal cord injury rehab unit and
unable to walk and everything else and
little by little it wasn’t a complete
lesion but we were able to bring him
back and with doing this and I don’t
know if you saw this but we take these
things to absolute exhaustion and
failure and so he’s really working it
there
and we were able to get him back so that
he’s just walking as normal so in
addition this stuff is is is good for
any kind of exercise it just amplifies
the effect here is roller skiing on the
treadmill again with all four bands on
cycling with leg bands on and in this
little video this is swimming in the
Pacific with the bands on and so this
these blood are be strong cuffs that we
don’t want them to inhibit the normal
technique that’s being used and but they
they go anywhere in any kind of
environment some more cases both these
are cases of ACL repairs and in this
case a professional goalkeeper for the
New York City Football Club and in this
case over here ted Ligety is one of our
Olympic gold medalists in in skiing this
is this is doing these kind of easy
exercises and it’s it’s his left knee
that had the ACL replaced and this is
two weeks after the surgery and you can
kind of see that as his legs are about
the same size that’s kind of unheard of
same thing for Ted here the character of
this stuff is that these are very
exhaustive exercise this is this
simulates his craw his Alpine Skiing
where it basically you’re flying down
these slopes on a very unstable surface
and you have to use a lot of muscles to
do this but you couldn’t ask ask him to
go alpine skiing right now because it
would likely tear up his repair but here
we can take them to exhaustion in a
protected way and get them back to doing
this kind of stuff
so here we have one more of these things
and this is when it’s used as training
device she’s not particularly hurt here
but we have a Alpine Ski simulator and
doing it with the band on just magnifies
the difficulty of the work in here she
has bent over exhausted she’s another
one of our gold medalists so okay how do
you how do you how do you make this
thing work
so our prescription is basically a
20-minute whole-body bfr exercise
session three times a week first thing
in the morning before the day starts
getting away from us and in the
convenience of your own home so it’s
very convenient before you take a shower
it’s everything’s going on and or you
can take your be strong kit and the
thera-band and you can do this anytime
anywhere whenever you happen to be
whether you’re on the road whether
you’re over in Europe whether you’re at
the office or at home and so you recover
quickly from these kind of workouts even
though they’re exhaustive you recover
quickly so you can manage the other
things that are going on in your day so
the product that we made is affordable
it’s easy to use it’s comfortable it’s
time efficient effective and above all
it’s safe here we have the same thing
that basically is saying the same sort
of message where we basically take these
bands that are suited for you we use
light loads and by working these muscles
we end up getting this systemic response
and we don’t get the damage that it
would otherwise take to do that there’s
a couple of higher-end systems
this is katsu and this is something
called Delfy and these things are in the
thousands of dollars where ours are in
the hundreds of dollars
and then there’s a lot of little wraps
and straps and all sorts of things out
there they are affordable but they’re
unlikely to be safe and they’re unlikely
to be effective compared to our
situation where we have this controlled
with a pump and an apt to guide you
through it so it’s a pretty simple
process our app can be obtained at app
go be strong calm and you put the bands
on and then you do generally you’re
looking to get muscular failing or
fifteen to twenty minutes and the
general protocol is three sets of
fifteen to thirty reps and doing it on
three to five different exercises
so in summary be strong VFR is safe
there are no contraindications to a be
strong VFR session other than ongoing
medical emergencies and you ought to go
to the hospital if you’re having a heart
attack for recent injuries or operations
train the three uninvolved extremities
normally and exercise the injured or
operated tissue gently without pain be
strong
VFR works VFR as is effective in
improving strength and fitness
even when normal training methods are
not possible as in Todd’s case blood
flow restriction training can improve
all tissues from the nerve to the muscle
to the blood vessels to the bone here we
have Beast be strong BFRs portable
comfortable and convenient able to be
used with any exercise be strong can be
done anywhere anytime without additional
equipment be strong VFR is a promising
solution for everyone to reap the
benefits of regular exercise and we’d
like to think of it as a great
anti-aging medicine mat medicine and
with that thank you for attention and
we’ll take some questions
[Applause]
yeah let’s use the microphone and then
hi I enjoyed your presentation I do have
a question once you stopped doing this
training how long do the results persist
I would say similar to other sorts of
training so if you stopped doing
whatever generally in two weeks you’ve
lost a lot of the effect that you’ve
gotten okay there was a question up here
so if I have my normal weight lifting
routine I could use these straps and use
the same weights and then I would have
to go down and wait to get the benefit
so what I would recommend is that you
put the bands on and then you take
approximately 30% or 33% of the weights
you normally use and do the do the same
exercises and you’ll get the same
benefits with 1/3 less weight and less
wear and tear and in a shorter period of
time but the key to all these workouts
is going to failure and it’s hard to go
to failure with heavy weights you lose
control the weight and drop it on your
footer somewhere what is the
relationship of occlusion pressure to
central venous pressure well there’s a
couple ways of answering that so firstly
if we if we take the condition of having
a band on your arm the pressures that
are inside the inflatable part are way
higher than any kind of venous pressure
so so let’s say it’s a your venous
pressure at the level of your heart
standing up is approximately 40
millimeters of mercury the pressures
that we put in the bands on the arms can
go up to 300 but that’s the pressure
that’s in the inflatable cuff that’s not
exactly the pressure that’s
impinging on that vein and what we do is
we find ways that we find the balance
between mean arterial pressure and mean
venous pressures such that when at rest
we’re occluding the venous side but
we’re allowing the arterial side to stay
Payton and then what happens is when you
have muscle contraction that pressure
generated by the muscle overwhelms the
venous occlusion and causes a return of
the venous blood to the heart so we
really don’t have any it’s hard to get
pressure measurements right at at these
things we could try to do that with
putting in some catheters and pressure
sensors but we really haven’t done that
we empirically are able to see that we
maintain arterial inflow we have you put
these bands on and you check your pulse
and you’ve got a pulse so the arteries
Peyton and we know that from the
engorgement of the the veins on the
venous side that we are distending the
venous side but that we know we empty it
and we overcome the venous blockade with
muscle contraction two more questions
you know you’ve talked about strength
and muscle mass what about the effects
of this kind of training on endurance on
the Wet Ones endurance Oh endurance yes
there actually are two publications
which show that by doing a program like
this you can improve vo2 max there was a
very nice study that was done in the
August Krogh Institute in Denmark where
they basically put femoral artery and
femoral vein catheters into a subject
who was doing bicycle exercise and
measuring the blood flow that was going
in there and the oxygen consumption if
you have arterial and venous blood gases
you can see what the oxygen uptake was
and that a program of blood flow
restriction training improved the oxygen
uptake out of that muscle so it’s likely
or the way that we would do this is that
if you’re like in those irani and rats
the idea was that they had these rats
walking on a treadmill they improved
their treadmill walking performance by
by doing this
and even with the with their filmers
tied-off so I would say that the kind of
training you do dictates the kind of
benefits you get so a lot of this
started out with weightlifting so you
get better at weightlifting when you’re
doing this stuff in a whether it’s
cycling or running or cross-country
skiing or speed skating you get better
at these endurance events one more
question
get in trouble whoever I choose
I know super thanks well and I had a
multi-prong question and so answer
whichever parts you have time for I
thought one of the citations I thought
maybe it said mm so I wondered if some
of the research had been around for that
long and if that’s the case you know I
just I think this is super important
super exciting super impressive results
and so why hasn’t been picked up in
mainstream why don’t we hear about more
professional teams engaging in
professional triathlete
at other athletes and and then do you
know of any place locally where there’s
physical therapy or some place where
it’s available other than for home use
yeah
great questions you’re very right that
first that study I showed you on
efficacy where you had the four panels
with the weightlifting that was
published in the journal Applied
physiology in the year 2000 by the
Japanese group that was doing this since
then it’s been yeah
this technique has not really gotten out
of Japan for many many years it was
really not until 2007 or eight that it
really started getting into North
America people pooh-poohed it and they
said wow this can’t work and bla bla bla
bla bla and then there’s another
complication that because they couldn’t
get a hold of the Japanese equipment
they started using their own stuff and
they weren’t getting the same results of
the Japanese were getting with their
stuff and so it’s it’s just starting now
I would say starting in about 2012 it
started to gain some traction in North
America we happen to have all sorts of
this gear outside in the lobby so and
we’ve written our
we’ve written our apps such that you
don’t need to have some expert to help
you with it so we feel that’s a
self-contained situation right here and
all you need is a credit card on that a
happy note let’s thank our speaker
[Applause]
