29. Mario Novo, DPT - Part I of II: The Science and History of Blood Flow Restriction Training

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Before we get into the show, let's talk about this week's sponsor, Deputy. In healthcare, there are a smart pieces of technology that businesses can't live without. Deputy has become one of those essential platforms for more than 250,000 workplaces. It's helping medical practices schedule their staff more efficiently to meet peaks and patient demand, and it makes it easy to adjust schedules when the unexpected happens, like staff calling it out sick. You can use Deputy on any device on the go. Within a few minutes of picking it up, you'll see why it has hundreds of glowing reviews for managers and staff alike. To find out more and try Deputy for free, go to Drpodcastnetwork.com slash deputy. Our guest today is Dr. Mario Novo. Mario is a doctor of physical therapy with expertise in human biomechanics, tissue regeneration, pain neuroscience, and sports performance. He's also a clinical researcher, university professor, and a nationally recognized expert in the field of strength conditioning and blood flow restriction rehab. Mario completed his undergrad and doctoral training at Florida International University and is currently a PhD candidate in health and human performance. In our discussion with Mario, we dive deep into the world of occlusion training, which is more widely recognized as blood flow restriction or BFR. This is yet another two part series because we really discussed physiology in detail, and we wanted to make it as visible as possible for you guys. So in part one today, we discuss the origins and development of BFR. We of course define the various types of occlusion training, but we spent a lot of time exploring the mechanisms behind this not so novel, but increasingly popular modality. We end with a brief discussion of application, but put that part of the discussion for part two, which will come in the near future. Now my exercise science of his sonados were really appreciate this episode, but for those of you without a background and ex-phys, I encourage you to really understand this as well, even if it means having to listen to it more than once, because it will empower us to better grasp the contents of part two. Now without further delay, please enjoy this episode with Mario Novo. All right. Hello, everyone. Welcome back to another episode of Medicine Redefined. Today our guest is Mario, Mario, welcome to our podcast. I thanks for having me guys looking forward to it. Yeah, absolutely. So, you know, today we're going to talk about blood flow restriction, which I've heard about. And I think many people may have heard about, but it seems like it's on the come up. There's a resurgence of it, and there's a reason why, and this is kind of why we brought you onto our podcast because you're the expert in this. But before we delve in, can you just give us a little bit about your background and what got you interested in researching BFR? So currently I am a licensed doctor of physical therapy, graduated out of Florida. I've been now in this industry for about 11 years, and it's been a combination of treating and teaching, working in undergraduate sports science programs here at Middle Tennessee, having ran human performance lab back in Florida as well. And BFR kind of came about just due to the natural kind of conversation happening within our field, specifically at the time, looking at further opportunities to be able to lower the threshold or the barrier of entry for patients to gain the benefits of things like strength training or cardiovascular conditioning. And so I currently practice here in Middle Tennessee as a physical therapist, completing a PhD in health and advanced human performance, with the goal of being able to kind of expand some research in BFR, mostly going to be focusing a lot of research into chronic pain, specifically looking at autonomic dysfunction, which BFR plays a role with because autonomic dysfunction happens as a effect to also the cardiovascular system. Your brain controls your heart when you're in pain a lot, this process continues to go on and does change the landscape of the heart, right? Changes the morphology of the heart, changes the morphology of the brain, and BFR is just a really interesting tool that I've been messing around with since about 2014 coming off the tail end of the US military, really getting a big launching point for it and expanding the literal technology, the actual apparatuses that were being used to perform it. In a way that improved, I would say, some of the conversation for safety and it allowed us to expand it into our scope of practice, which now as a 2018 physical therapist throughout the entire United States can practice blood full of restriction training. They need a certification to do so. I used to teach it. There are other companies that do an excellent job of that now, which I'll share at the end of this if there's anybody listening out there who is also a licensed PTOT chiropractor, an athletic trainer, and you guys as well. If you do any form of treatment hands-on to patient and build for any of that, BFR is a tool that can fit in there. Or if not, obviously, who's in your network that's certified that you can refer to? Absolutely. Is it getting taught now? Is it part of the curriculum, like for PTOT school and things, or? Not yet. It is with any industry. It's always a slow kind of process, but I can at least happily say that in the universities that I collaborate with it is, and it's because of my collaboration with them, the introduction of the science to what they're doing, and it just expands the conversation. It really expands the conversation further with exercise physiology. What is happening at the mechanistic level with exercise that promotes all these benefits we want for our patients? How can we better fine-tune that for each patient? Then as well, obviously, the conversation about cardiovascular adaptation, bone remodeling. That is a big topic that has kind of resurged in the world of blood flow restriction, specifically having to do with things like vascular and ethereal growth factor, things like increased phosphate and, obviously, calcium uptake to the bone, and more importantly, collagen synthesis, which happens as a result of exercise. To anybody who's broken a leg before, you can't do a lot of exercise when that happens, but we now have other ways to go about that. A good example is Conor McGregor, who, if you search for that guy right now on his Instagram, dudes riding a bike with BFR cupsong. He's doing that for very good sound scientific evidence to be doing so. It's definitely the conversation BFR is coming back up. It will likely make its way further into education. I would say maybe over the next give or take four or five years. I'd say probably the hardest reason why it hasn't been and why things like manual therapy and dry needling made their way into the curriculum of a physical therapist is money. They have a specific billing CPT code to them, so because you can bill a unit of manual therapy, you can bill a unit of, or really dry needlings, almost like a cash service here, which circumvents insurance a lot of times, so obviously, you know, PTs and businesses like that. But there's a reality that there's no CPT code for BFR yet. So we have to bill it underneath pre-existing exercise codes that some therapists feel, because they're likely unfamiliar with hemodynamics. They're likely unfamiliar with homeostatic regulation, or hemostatic regulation, even to be more specific, clot formation, fibromyalysis. These things are really important, and most of the time people go, you're going to put a turning it on. Doesn't that like create a clot? And that alone is always one of these eye-opening experiences. When you know the majority of the material, and you're like, clearly, I have to build a bridge for you, because that's not how our systems operate. When it comes to, you know, spontaneous changes in blood pressure, like our systems are designed to manage clots all day long, and manage fluctuations in blood pressure all day long. So, you know, if you're a healthy individual and you meet the criteria, right, you can do BFR and gain a lot from it. If you're an unhealthy individual, there's, you know, certain cutoff points that we just don't treat, you know, but sometimes, you know, in certain conditions, you know, if it's a fracture, like I mentioned before, you can't be weight-bearing. We'll try some things and, you know, see what we can do to maybe fit that in there. But, yeah, it ebbs and flows, man, the conversation of blood flow restriction. I've seen it since about 2011, kind of come and go in the landscape. So, I'm happy that we're, you know, having a podcast on it now. Like I had mentioned to you, I just did a recent presentation here in Tennessee for our board, and that was fantastic to get. I think I had like 127 PT's on that talk, and the review back to me, not to, you know, I did a good job, but it was like, you had those therapists at the edge of their seats, and I was just like, that's cool. It was just another Friday, you know, just sharing, you know, cool stuff, you know, trying to get people just interested into it. Yeah, hopefully we'll get more traction. Absolutely. I mean, I think that that's certainly the case. I go on PubMed and do a quick search, and I feel like there's just papers being published. And, you know, it's promising because the evidence is quite strong. And you touched on so many different things that I think we're going to get into a little bit further time allows, but I think it's important, you know, to understand where we're going, but before we can do that, let's take a step back and think about where we came from. I mean, be a far, as you mentioned, maybe about a decade old, and mainstream, maybe five years or so. And I know you were saying next four or five years of education, I would argue. I would say that's a little optimistic. We know that change takes a long time into, and it's implemented to practice. I would love to see that in the educational system to talk, maybe even in medical school type stuff, but more specific to just PT. Yeah, yeah, no, like our profession, yeah, and there's, there's a lot of talk right now about potential CPT code. Okay. That's been kind of, that's why I'm saying like, we're probably going to get it sooner than it expands to anywhere else. Okay. But I'm with you there, man. Yeah, the more we share, it's important for, I think, any practitioner that's working, or, you know, clinician that's working with patients that will be referring for exercise that, or physical therapy, occupational therapy, cardiovascular rehab. If you're thinking in your mind, I want this patient to be moving, and I'm going to be looking at the effects of their body, you should know about it. The same is you should know about exercise in general, and maybe even a sliver more of, you know, sit with a dietitian, get it, get a firm understanding of just, you know, energy in general, the conservation of energy in the body. Little things can go such a long way to a patient who is, unfortunately, medically illiterate, like a lot of people are that just walk into our office. You know, they have the basics down. Sometimes that one or two percent can really make a difference. It's really save somebody's life, you know, get them in the right direction. So, yeah. Yeah, so for those people who don't know about it, let's continue educating them, right? I mean, so you've obviously touched on a lot of great things. So talk to us a little bit about the history, because as I mentioned earlier, like katsu training that has been around forever. And obviously, anybody who's been in the bodybuilding space, they've been using some type of quote-unquote tourniquet therapy where not true complete, complete occlusion for a long time. And so for to those individuals wrapping up, you know, at the proximal side of their limb, and they know that it's been working for a long time. So what can you tell us about katsu training, you know, how it started, and then how it evolved into what we are now discussing BFR? So, historically, the use of a tourniquet has had more of a presence in wartime scenarios. And that really starts kind of on a mechanism standpoint, a physical tool that you're applying, you know, you're applying this to a patient. So tourniquets have a wide breath of history, you know, stemming back again to, you know, the first vessels being ligated, you know, in pre-civil war, pre-World War I, but they're very rudimentary. And there's not a lot of understanding of, you know, what are the risks associated with it? We just know that there's this fluid blood. It comes out of the body. If enough of it does, my patient goes, you know, into a comatose state and eventually, they die. So if I can keep that fluid in there, keep that essential fluid in there, right, this patient stays alive. Obviously, fast forward, we understand that there's oxygen, we understand that there's hemodynamics and maintain, you know, a pressure. And that takes us into many, many years of safety with tourniquet research, which is why we use it today safely in surgery. Now, somewhere around the 1960s, right, the idea of applying it with exercise in a prolonged manner really starts to gain some traction. And this is happening in Tokyo. But it's also gaining some attention within the United States, because we have a very important enterprise, NASA, who's looking at ways to also, you know, how do we improve anything up there in zero G? So the natural tendency to see what happens when you cut off blood flow in certain things, what happens when you change the most static dynamics on, on an astronaut exercising. So it's kind of like there's these competing things happening around the 60s, but Sato really starts the first put down, you know, a pen to paper and make it public. And it becomes public because his parents are physicians. He has a natural interest in understanding how to build muscle. And he himself eventually becomes an MD and does become a physician in Tokyo. So you have this young gentleman in the 1960s, who starts, cuts who training specifically. So now again, this is think of it like you have like the Marvel Cinematic Universe, you have like the one main timeline, which is turnikits. And then Sato starts to build his own, you know, universe in another direction. So all the turnikits are going one way showing us safety, you know, how to reduce risk of nerve damage, what are the effects of prolonged turnikit use, you know, tissue necrosis, all of that tapping one way. Sato is like, let me put this on and do some exercise. And it's kind of like a peanut butter story, meaning like he discovers it accidentally. He's sitting on the ground in a traditional kind of, you know, on both knees, stance, his leg falls asleep. He rubs it, his calf feels pumped afterwards. And because he's already been exercising for some years, he says, this feels a lot like what happens when I exercise. I want to learn more and spends the next almost decade experimenting on himself, like kudos to you, man. Turnikits can be dangerous, but guy had it in him. He just kept seeing, I guess, you know, the vasodilation. He kept seeing just more and more of what he wanted to. And that led him to really start working with, you know, some local doctors. And it's not really until he has a fracture that the medical society in his little town, so there's paying attention. They go, hold on, that was supposed to take 16 weeks to heal. You quote unquote, recovered much faster. And there's now again, a interest of what he did. And quite literally, he combines his efforts once he goes through his, you know, educational process with cardiologists. He consults with exercise physiologist. He gets on board with the space program of Japan. And because my new NASA is doing something like that too. So there's now these lines that intersect. And Sato now is really starting to see people are gaining interest. And there's now some legitimacy, you know, to this question that's being asked, which is if we ligate a vessel, if we cut off blood flow and have an individual perform exercise, it appears that it doesn't kill them. And it appears that it doesn't lead to tissue necrosis. It doesn't make, there wasn't a clot that happened. Their muscles got bigger, at least for the interim period of time. And the individual might even be telling me that they have less pain. So a lot of these subjective things started happening. And if fast forward to like around 2010, 2011, now the United States military here is gained a lot of interest because of a new field in limb tissue salvage, which is a department that's out in San Antonio, it's called the SAMHC San Antonio Military Medical Center. And they have a limb salvage program there that was now taking in a bunch of men and women from our different wars happening across the world that are in real risk of having an amputation. Now, otherwise, these people would have died. But guess what? The intersecting line of turnipids comes back in and these battlefield turnipids save them out there on the battlefield, brought them back home, and now we're going to rehab them. But we realize that our rehab strategies are just very poor. At this time, systematic reviews are being done in 2012, 2013, demonstrating that low intensity exercise is just really not optimal for attempting to increase in any appreciable amount of strength in either healthy individuals and in obviously individuals that are in pain. And this draws a lot of attention to the physical therapy industry because we are kind of sometimes stuck in this world of low intensity resistance training and also low intensity cardiovascular training. So by definition, anything less than 60% of a one rep max or 60% of a heart rate reserve, right, or even less, maybe like less than 50% of VO2 max. Explain what that is, a heart rate reserve. So when we measure out the amount of ventilation needed in your body to efficiently move oxygen right from your lungs out to your body, we're going to use things like your heart rate, your resting heart rate, part of your resting heart rate, your maximal heart rate, and then look at a couple other characteristics which could be your gender and as well maybe weight. And mathematically, we can quantify a percentage of heart rate that's reflective of intensity. So in the end, we can say if you're operating at a percentage of this heart rate reserve, the intensity is so profound that you're not going to be, you know, this is going to be very difficult to complete the task or this is going to be very easy. And at this point, we know which percentages provide us optimal adaptation to the heart and to the vascular system. So in general, individuals exercising less than 60% of a heart rate reserve usually are not going to see profound benefit to their cardiovascular system in short order. They typically have to exercise for a lot longer in duration in both their weekly, you know, total and obviously throughout months. If you can train at higher percentages, you gain additional benefits, right? Benefits like, you know, a lower resting heart rate, lower blood pressure, improvements in circulation, reduced pain, improved function, improved mood, a lot of good things, a lot of pluses we would say. So heart rate reserve is an important thing for us to understand and apply clinically. And I do this all the time for my patients side. I figure out what their number is and I told them we're going to train in this percentage. And we do that with the hopes that the evidence will shine upon them to end up somewhere in the, you know, middle of this bell shaped curve of data. And they'll go, all right, you're responding, you're doing well. So we use that MPT. And in the world of making benefit, we just found at that time those early 2000s that we weren't making as much benefit as we would like. We just weren't. It was just a reality check. You know, very few therapists even knew what a repetition max was, let alone applying things like calculating heart rate reserve or or VO2 max for their patients and providing them estimates and guidelines. It was mostly kind of stretch and do some reps, three sets of 10. Hey, that was a delure model. Everybody does three sets of 10 and you get somehow magically stronger. And some people accidentally just started having people do 30 repetitions with no rest. And the patients are going, gosh, my muscles are burning. And they're like, okay, whatever, you know, that's that horrible bad lactic acid. And now we just kind of laugh at all that we're like, oh, gosh, if we only knew. But around those times, you know, these research studies are being done at SAMHC. And there's a physical therapist there who was my mentor at one point, Johnny Owens. And Johnny starts collaborating with some of these cardiologists from Japan. And some of these other exercise physiologists here in the United States that have begun to look at this with the interest of bodybuilding. You know, Jeremy Loneke over at Ole Miss has published many articles on blood flow restriction and many landmark papers that provide it safety and efficacy and application standards. And as they were in conversation, they solidified a piece of technology and a methodology that would work. And across many studies, Johnny had a lot of success and a lot of these soldiers were being able to preserve their limbs. A lot of them that did have amputations were able to go on to much more rapid return to amulation, return to walking, return to even a couple of people going back to full service. You know, I've got many, many wounded warriors here that I've rehab myself that are amputees that are, you know, police officers, firefighters, you know, and I rehab them with BFR, you know, made a big quad out of a leg, you know, that survived an explosion at some point or, you know, whatever kind of trauma. But from the military, it blew up because the NFL over in San Antonio, the Texans, the giants, and then a bunch of division-win universities, and then it just kept going. And now, you know, it's here. It's all over Tennessee. I've got no work here with the Titans, the Preds use it, and they use it for rehab, and they use it for performance also because that's where I've come in as a consultant is to help them kind of understand like you can do this stuff during off season, you can do this stuff during in season and, you know, mitigate certain risks associated with continued heavy resistance training while you're playing, you know, a sport, you can get more banged up. So, yeah, that history, again, from Japan to today, has always had its foot heavy in evidence. Although the world of bodybuilding kind of, lack of better words, you know, kind of perverted it a little bit, and people are just wrapping whatever they can around their body. It stems from a very strong route in evidence that starts off with safety because we're using tourniquets. So, there's a lot of safety rooted in performing blood flow restriction. Again, that's why it's part of a physical therapy, American Physical Therapy Association's scope of practice. It soon will be also in France, in Canada, and in the Netherlands. Already is in Japan. In its motherland, there's gyms you just walk in there and it's caught two stuff hanging on the walls, and people just go and work out. Yeah. So, there's a lot of evidence behind it. At this point, we're no longer questioning if it works. Right now, we're questioning who gains the most benefit from doing it, and how should they do it? And what are the long-term benefits now? Because there's a lot of stuff we're learning with, like, ischemic cardiovascular disease that's showing us, man, this could really have a lot of potential at saving some people's lives, at reducing clot formation. Especially, like, when a near-deer friend of mine who just passed away, I was trying to get him on this too, as just too late, you know, lost them due to something similar to what I was actually trying to help get him to understand. So, yeah. Yeah, and I think that I couldn't agree more. I mean, it sounds like, at least from my just brief understanding of it, from the literature that I've looked at, it's really a matter of refining the protocol. It's a how can, you know, optimize what works well for who, whether it's talking about clinical use, or it's performance, kind of things that you touched upon. And, you know, my next question, I wanted to ask you about the mechanism of action, because you touched on VEGF, you talked about some of the local responses and all those cellular responses, but I think that maybe you touched on the safety aspect of it. And I think maybe it's important for us to understand, because we're all clinicians here, and that let's figure out, we want to, before we start any modality, we want to make sure that we understand the indications of counterindication. So, I want to start with the safety aspect, again, going back to the body building, or just a tourniquet therapy, how is this different, right? Why can I not just wrap something around, like, on the upper part of my arm, and then just go, go to town, and until I feel that, that pump and get real swollen, like, what, how is this different than tourniquet treatment exactly? Like, is the elasticity of it, like that kind of stuff? I definitely will say, Sato laid the ground workout by attempting to put tourniquets around his head, and also around his body. So, this guy was, like, the proverbial experimenter of this. I've literally had people ask me, if I put it around my head, does it make my brain? No, man. Wow. It doesn't work that way, you maybe get a wicked headache. Um, but, at least I put it on their neck for the, I've had, I've had somebody ask me that, because they were like, but if I want to get it here, could I just make it proximal to there? And wouldn't it be safer? And I'm like, no, don't, don't, don't ever do that ever. So with stopping you, nothing's really stopping you, you know, the safety with wrapping a knee wrap around your arm is relatively high. Most people will intuitively go sh dang at my arms, turning white, and it hurts. And so, I probably should have loosened this thing. So intuition saves a lot of people. Thank goodness for, for barrel receptors and metabol receptors that play a role in blood flow restriction and the mechanisms of it, but that they also supply mongoloid people that want to do this to extremes, data that keeps them alive. So you can put a run your arm like the hood is, you're going to take it off if you put it too tight, but they're in lay the reason why as clinicians, we use something that requires a sphignon thermometer so that I can measure the actual millimeters of mercury. Because if I just put this thing around your arm with a knee wrap or, or, you know, a mattress or a voodoo floss, it's not very standardized, you know, which we can say reduces the reliability, and obviously does increase the risk. So as a licensed clinician, I would advise other licensed clinicians to get certified and use FDA listed products that cover yourself from liability. Because that's ultimately why we have these conversations. That's why we have peer review journals and all of this because it's a lot of liability out there and all of us took the same hypocritical to do no harm. So we obviously want to use, you know, the most efficient way that has reliability and standardization built into it. So that's why we use cuffs that, you know, that you can inflate with air. There's a lot of them out there on the market, a lot of them can be purchased on Amazon without even a certification. And in general, what the data has shown us is that, you know, there is some standards. Okay, there's a reason why we use wide turnip kits versus narrow ones for the legs. It's just specifically for the legs we use wide ones because much like you and a couple buddies standing shoulder to shoulder on a fire hose can more efficiently reduce the amount of pressure coming out the other end. Right, you need a wider turnip kit to blanket the amount of pressure to, uh, that's being placed on a deep artery because when you apply a turnip kit on somebody's armor leg, you are effectively at 20 millimeters of mercury already shunting off blood flow in the superficial venous system. It doesn't take a lot to do that, right? That's why we use compression stockings and Ted Hoses that have a minimal amount of compression but seem to improve venous return, right? They improve situations of venous insufficiency. So it doesn't take a lot to do that, but to get down to the artery, you need more pressure. You need sometimes upwards of about 200 millimeters of mercury, which is generally over somebody's, you know, upper body, brachial systolic blood pressure. So when you're doing this thing on somebody's legs, you typically need wider turnip kits that help you to use lower pressures to achieve arterial restriction, right? How are you talking? Maria, can you put some numbers on it, like what? Yeah, inches, generally, millimeter centimeters. Yeah, so in inches, because we're going to use, it's about 3.5 to four inches wide for the lower legs. For the upper body, it can be anywhere from like two to 2.5. It's hard. The wider it goes from the upper body, the more uncomfortable it can be. It kind of gets in the way of the bicep. And as well, you don't need to have as much high pressure on your upper extremity, because by just the circumference, the volume of tissue where the cuff is being placed is much less than on a leg. So you don't need to apply a lot of high pressures to the upper body versus the lower body. In general, the upper body will sufficiently have a restriction range somewhere between 50, all the way to 80 millimeters of mercury, and the lower legs will often need somewhere between like 130 to about maybe 250 give or take with a professional athlete. So we have these numbers pretty well established now, and they are associated with limb circumference size, the resting blood pressure of the individual, and then you have some secondary things like gender and ethnicity. So the wider the limb, the more pressure needed. That's why we use wide turnip kits to not have a high number, because if you use something like you know a knee wrap on your thigh, you may have to take that sucker up to like an estimated maybe 400 millimeters of mercury, double the amount to achieve what a pneumatic system can do, because of the difference in how the pressure is being applied. Now, if the person doesn't know how much they're putting on their leg, they put it on and they go, man, this feels I'm getting a pump, it's working out well, fantastic. But if there's some risks associated with them already being hypertensive, you know, you're going to create some endothelial, you're going to create some some vascular trauma, you know, and that would somebody who has maybe like a high calcium score, atherosclerotic plaque, then you can then you can kind of have some issues happen that way, or somebody who already has some junky arterial systems. So, you know, that's why we, let's use a pneumatic system that lets the pressure get really low. So this isn't going to hurt somebody. And then the upper the upper extremities, you know, in general, don't need that much pressure. So, you know knee wraps for the upper body tend to be just as effective as a pneumatic system. But obviously, again, you're not as you're not a standardized, you know, what the heck the number is on the other side. So, yeah, because there's risks, you know, you can get a bruise, that's the least amount. You can make a limb go, you know, cyanotic, and that clears itself. So, cyanotic just means it goes bluish, you know, you can get, you can get a little bit of some, like, you know, puckering of some blood vessels, some redness of the skin. And in general, that's about what you'll get. If there's an extreme amount of pressure, for an extreme amount of time, you can get nerve demyelination. But that stuff's not really seen ever in any of the studies performing BFR for exercise. That's seen in just surgical studies. And they're mostly case studies where stuff goes south, you know, it's like an emergency situation, or it's just a prolonged surgery. And then, you know, they come out of the surgery and they're like, hey, you did open a heart surgery for me, but I have dropped foot. Yeah, thanks. You know, it's like, yeah, we, sorry, be your alive. I'll get you, I'll get you a PT. Yeah, with an AFO. That's right. So, Mario, there's obviously a lot of physics and biochemistry that's going on with BFR, right? Yeah, I mean, one could, one could say it's, we've now taken those dives to better understand what we're doing. Yeah. Yeah. Can we, can we systematically kind of break this down? Because I think, I think we, we like to get nerdy on this podcast. And I think our listeners will really enjoy understanding the mechanisms of kind of how blood flow restrictions actually working, right? So when you say, like, my blood pressure is probably 120 over 80. Can you take me through it? If I were to use BFR, what am I setting the pressure to? What is it exactly doing? Am I losing complete blood flow? Is there some blood flow going through the arm? Can you kind of just take, take us through the physics and the hemodynamics of that? Sure. So if I measured your upper extremity and I get 120 or 80, right? Which that's typically again taken from upper extremity. Usually your lower extremity is going to be a little bit higher, right? So just, just remember that you do have an ankle brachial index that does have a percentage change that varies with any body position, okay? Because it's important for the audience to just again recall from going from supine to standing, there's generally a 300 to 800 millimeter of mercury change in overall fluid dynamics in the body. So our, our heart and our vascular system is massively adept at managing constant changes in blood pressure. That very widely. And a lot of that is because of, you know, the role of our endothelium, right? It's current to date considered an organ. It's not just considered connective tissue anymore. It's considered an organ all on its own, responsible for vasodilation, right? Responsible for what we call the barrel reflex sensitivity. And that ties into our brain, right? So when you alter blood pressure, your brain knows that you alter blood pressure and that changes your heart rate and your body goes through a quick adaptation to bring you back down to baseline, okay? So when I say, hey, you know what? Darshan, I'm going to do some BFR with you. I've assessed you and how I assessed you would be by putting attorney on your arm. No different, all right? So far. But rather than putting in my headset and listening in, I'm going to be putting an eight megahertz Doppler, you know, on a number of different arteries, right? In this case, we're going for the radio, okay? And what that will allow me to do is just be more precise, because human ears are good, but I play guitar and bass and drums, and my ears aren't as good anymore. So I usually will have to use this and I get a much more accurate reading, okay? So it's probably going to be a little bit above 120, all right? So that and that number, that systolic blood pressure number, that is one, that is what we would consider 100% of arterial cutoff. So that would be your 100% limb occlusion pressure or systolic blood pressure, right? And that's the number that I'm going to start with. I'm going to say, all right, Darshan, 120 is your 100%. The literature tells me that for your upper extremities, if we train at 50% of that, so 60. Again, you fall in that range, right there. That's 60 millimeters in mercury. We can use intensities, so weights as light as about, let's say, maybe 25 to 30% of your one repetition max. And we will see some influential change in muscle size, in muscle strength via how quickly and how more efficiently you can recruit muscle fibers that are at the top end designed for high output work. So these are muscle fibers that are usually only going to fire under critical situations, not postural ones. It's like the type two muscle fibers then. Correct. Yeah. So and that's how we would start. I would say I've got your blood pressure assessed for your your limb occlusion pressure. That's 100%. We're going to train at a percentage of that for the upper body. It would be 50%. That's what the literature shows. And now I can select different exercises and use different protocols. And all of those protocols are typically designed to do a number of things in this order. The first thing they're designed to do is to set the microenvironment in the muscle and the working muscle that is going to be distal to the cuff. So it starts to set that microenvironment to begin to become a hypoxic. That means that at 50% arterial restriction, if I give you a weight that's around 25 to 30% of your 1 rep max and have you exercise at a one second up, one second down, it will generally lead to a pretty high level of arterial restriction, even a little bit higher than 50%. Because using that repetition tempo, it's probably going to take you closer up to maybe like 60 to somewhere maybe even closer to 80 in that time frame that you're working out. Now let's talk about what's actually happening in those and this is how the research does it. They say you're going to do 30 repetitions, take a 30 second rest, 15 repetitions, take a 30 second rest and then repeat that two more times. So it's 30, 15, 15, 15. That's a lot of volume. But let's start here. The first one is designed to set the microenvironment to be more hypoxic. So those initial repetitions, there's still a sufficient amount of arterial flow in, but the venous system at 50% has already been cut off because what did we say is the percentage you need to already restrict, you know, veins, 20 millimeters of mercury. So that venous system is stopped. That means that that limb is now under congestion and that limb is starting to fill up right with blood, plasma, okay. And as you're working out, you're also, the muscle is also now releasing a lot of metabolites and these are basically byproducts of muscle contraction. Some of them are inorganic phosphate, cleaved off of ATP, to turn it into ADP. Some of them are the byproducts of the Krebs cycle, which produces things like carbolic acid. But there's also things like hydrogen that are being produced. And hydrogen carbolic acid, these things are acids and they burn. And that's why in those first 30 repetitions, that person starts to tell you, I'm feeling a little something. It's getting, I'm feeling a little tired, right? Because as that oxygen level drops and the pH starts to drop, the metabolism receptors and the barrel receptors are communicating now via special nerves that we all have in our bodies to our heart, to our sympathetic chain. And they're basically starting to scream at our brain up the spinal cord, hey, phalamus, it's time to start getting stuff serious. And what happens, there's a descending, you know, stimulation down the vagus nerve to the sinusoidal node and the sinusoidal node says, parasympathetic system withdrawn, sympathetic system kick in and now you start to have that heart rate pick up. As that heart rate is picking up, there's subsequent changes happening in how the spinal cord and the brain are starting to undergo selecting muscle fibers for further contraction. And there starts to be an inhibition of some of the slower twitch muscle fibers. And there starts to be more now of a shift for the type two muscle fibers, as you mentioned, right? Humans have a combination. I like to call us like the Swiss army turkey, so to speak, because like turkeys, I always use that example to explain to the patients, turkey breast and turkey thigh are two different types of protein. turkey breast is like type two muscle fiber. It's really, really dense in, you know, it's meant to be kind of tough and it's not really well vascularized, that's why it has a white kind of color. It's meant for high explosive contractions, because turkeys don't fly, but they can sure enough hover and get over something, you know, but their legs are for walking. And that's why they're very well vascularized and that's why it has a different color, it has a different texture, it has a different flavor all to it, okay? Humans, it's all mixed. All right, because it's mixed, we can be a jack of all trades, we can go slow, we can go fast, we can be at rest, we can be explosive. So in those first 30 reps, oxygen's dropping, pH is dropping, brains getting alerted, and now we start to have a shift in now these specialized muscle fibers kicking in. And as they start contracting, other things start to happen. With each contraction, more and more congestion occurs, and now you're starting to see a shift of some of the fluid be pushed into the muscle fiber itself. It's no longer resting in the interstitial space, it's, the muscles have a semi permeable membrane, it's making its way into that membrane. That person now rests for 30 seconds, and that short rest period is meant, because A, if you rest any longer, most people tap out, because they're just like, I can't keep going, but also B, that short rest period allows for there not to be a overburdening of the influx of arterial system overcoming the pressure on the tourniquet, thus influencing a ejection of fluid. It's the body attempting to try to regulate the pressure that's happening in the limb. It's going to push you into the muscle, because it's got nowhere else to go, and that's what leads to the pump. That's what leads to what we call now. For anybody out there, when you're in the gym, if you want to sound smart, you say, look at my cell swelling, because the pump is 20th century. Cell swelling is 21st century. If you imagine the cell swelling, you know, it would have sounded so cool. So yeah, so you're getting the pump, and in this process, a few other things start to happen, right? You start to release some nitric oxide. So dilation is starting to, you know, your body is trying to write the ship, okay? This happens in seconds when we change our body position. It's happening while you're performing this. And as a result, there's less blood also in the system. So if you guys remember cardiac output, which is a measure of how much blood is ejected, typically from the left ventricle, the heart, it's based, it's a product ratio based off of heart rate time stroke volume. So stroke volume, if you remember, is also a measure of venous return. So by virtue of me putting a tourniquet on you and creating all this congestion, there is some change in stroke volume. So heart rate's going up. So your sympathetic system is purring. And as a result, endogenous opioids go up, different Enky founds in the brain. You're having a receptor binding to cannibanoid receptors in the brain. And now the person is starting to feel less threatened. And they're feeling less pain. And now you go, you're going to do another rep of 15. And now they try, you're going your second set of 15. And now this is basically, if we understand the world of exercise physiology, is where you start to get all of your sweet spot repetitions. These are the repetitions that are performed at maximal efforts that have a way of shaping, right? They change the whole morphology of the muscle. It's what initiates things like muscle protein synthesis. It's what initiates vascular growth. It's what starts to initiate the changes in the satellite cells of our muscle. Again, if the audience remembers muscle is a multi-nucleated organ. So it has many, many nuclei, right, per section, which means it could undergo rapid division, if need be, and just adaptation. And these satellite cells are what we call mesenchymal stem cells, which mean that when you, in general, exercise, because right now, let's take a step back. Right now, nothing has happened that's universally profoundly different than when you exercise with weights that are of maybe an intensity of above 60% of a one rep max. Because when you're lifting with weight that that's heavy, your muscle itself acts as a tourniquet. Your muscle itself is squeezing down on the deep artery, reducing oxygen, changing also barometric receptor input, changing metabolic receptor input. Sympathetic system still kicks in. Chemical downstream is still happening. Type 2 muscle fiber still gets recruited as a muscle swells, swells swelling, as it gets a pump. It also temporarily pushes against the superficial venous system, right? And as a process, both of them, both BFR and weight training are both releasing, uh, fiber, uh, uh, fiber analytic enzymes. That means they're, they're releasing chemicals that are meant to lice and break apart clots. Because when you weight train, you're also including arterial and venous flow intermittently, right? Like isometrics are the closest thing you can get to be a far for a moment, which is a contraction with no concentric or eccentric motion. It's just muscle contraction pushed against an object and it doesn't move, right? We use that in PC all the time because what does it do? It changes, right? In information to the brain receptor input and that has a downstream effect at reducing things like pain, right? Because of the way how altering blood pressure changes the expression of, or the release of endogenous opioids and also changes, again, communication to the thalamus and the threat areas of the brain, right? Isometrics reduce pain pressure threshold, cardiovascular activities reduce cold tolerance and heat tolerance and we know these things pretty well in the research and that's why we apply them in clinic because there's something that's called blood pressure-related hypoallergenia or hypertension associated hypoallergenia. So anyways, so so far there's no different. Now those following reps that are being done, they follow what's known as the strength curve and the strength curve, okay? Just it's curve that comes up and goes down and on the y-axis is force on the x-axis is speed. So the faster you go away from zero, the lower force you produce at the level of the muscle fiber. The closer you are to zero, slow speed, the higher force you produce and as a result of this force, mechanically, as a result of the metabolic chemicals that are being released, that are largely associated with the process of anabolism for the anabolic process, which has many other cascading hormones that follow in the number of days, if weeks after that. That's what's happening afterwards, okay? That basically we use the tourniquet to simulate what happens with heavier weight training, but we do it in the hopes that we can get you to safely lift lighter loads or lighter intensities when warranted, which has a number of ways that you can cut that, a number of things that you can cut that. So in the acute stages, once we're done and I deflate the tourniquet from you, there's a huge rush of lactic acid that if you understand a little bit about energy constituents within the body, it's a closed system, nothing likes to get lost. Lactic acid is a molecule that is formed in the presence of hydrogen. When your muscles are working out and you are burning through glucose and your body is basically breaking glucose down to make something called pyruvate. If you guys remember the Krebs cycle, pyruvate allows us to more systematically and efficiently produce a crap ton of ATP for a little input. I think we just lost half our audience when you mentioned Krebs. They said I'm out of here. Yeah, let's just say if you keep breathing and you've got some stored fat, you're good. You'll keep going. So let's just say the reason why we do this, okay, in general, in short, is when we deflate that tourniquet, you've been given now an awesome opportunity to reduce the chances of disuse atrophy. And that happens in a number of cases, a sprain ankle. All it takes is two weeks to have a reduction in the amount of protein that your body can fabricate. In two weeks, you lose about 30% of that productivity. Given another week or so, you can lose up to 30% of the strength that you originally had. So it doesn't take a lot. Our human bodies are really efficient at maintaining dynamic structures that require energy. And that means that when you're not using it, it's out of the back door. You lose it. Yeah. And that's why I was mentioning lactic acid because when I deflate that tourniquet, all that lactic acid, which is basically energy, okay, we call it, it's like a conditional carbohydrate. It forms in the presence of hydrogen. You're branding your heart, love to use it. You guys are in residency. You'll learn that patients that are having an ischemic cardiovascular incident or patients that have had a traumatic brain injury, their bodies and those organs preferentially use lactic acid because it is a predigested form of sugar that doesn't require the crev cycle. Oh, no. To be able to break it apart. It's already broken apart. So it already happens somewhere else. So that's why those organs like to use it because it's more efficient. And it has a big value system for your brain because that's what sugar is for your brain. That's why when you exercise, your brain feels better. Your brain's like, thank you for the snack that you were storing in your muscles. I got it back. And now what am I going to do? I'm just going to shed it. I'm going to send it right back to the liver. And I'm going to just reconvert it back to glucose. And that's this constant cycle of energy in the body. That's why it's very rarely broken. So if you did this for a number of weeks, you likely would increase in muscle size by virtue of the chemicals associated locally in the muscle that can stimulate something called mammalian target of rapamycin. It's a big word and it is involved in cancer research. So I get a lot of times people ask, they're like, oh, mTOR, isn't that something with cancer? Isn't that bad? Like, yeah, it can make bio masses, but it can also make structural protein, especially when it's found in the muscle. So mTOR C1, which is found in the muscle, is responsible for keeping your muscles big when you need them. All right, when you use them. So when you do this, you get that benefit. You get a growth hormone benefit because all that lactic acid, all that reward for your brain, it seems to meet a threshold for the anterior pituitary to go, I've got energy to make stuff now. And it typically will make things like growth hormone and other things as well, IGF. There's some mild studies that show improvements maybe in testosterone, but testosterone's a funny thing to talk about sometimes because they're salivary, and then there's within the blood, and it can vary. So that's what happens initially. If you do this over a period of time, generally you see adaptations of improved strength and size, sometimes starting around week four, with things being a little bit reversed in general training. With people that generally train, they'll typically get stronger before they get bigger. And that just has to do with how your brain gets more efficient with the repetition of a task, but it requires recovery. So there's always a step back that you can't necessarily build that much muscle, right? The building of the muscle takes more time. In the be a far world, it kind of changes a little bit. You're starting to build muscle a lot sooner than you get stronger. The strength benefits tend to occur much later. So it's like you get bigger by week four, you get stronger by week eight, and that's kind of flipped in the world of resistance training. You get stronger by about week four, and you get bigger by about week eight to 12. So that kind of flips it a little bit, but there's good understanding why that happens now. And if you also, you would do this maybe about two to three times a week. That's the general prescription. Okay, it's about two to three times a week. You generally pick an exercise per body part. You know, like you'd pick an exercise for the bicep, you pick an exercise for the tricep, you pick one for the forearm, flexor extensor group, you know, same for the lower extremity. And you're kind of picking maybe one to two exercises per body part because any more than that, and you're going to feel like gum be the next day, you're going to feel like jello. And you might actually, you know, you can harm yourself if you do too much, you know, because it's a lot on your immune system. You know, most people kind of don't see the tie-in with their immune system and everything else, but it's a lot for your body to handle. So the general prescription is two to three days a week. You'll maybe pick if you're doing upper body that day, like maybe four three or four body parts, each one about two or so exercises. And if you're doing this for cardiovascular benefits, you can do it up to four to five days a week. And you can walk on a treadmill or ride a bike and have heart rate response is similar to if you're jogging or running because of how we mentioned cardiac output and the change in stroke volume. Remember that? Long ago in this meeting already. So yeah, that's how that's how you can gain some benefits with that. And then you also gain some additional benefits because all that growth hormone makes collagen. And that's great because that's an ultra structure of your body. So if you're recovering from a fracture, a man, it's perfect time to do it. If you're recovering from a surgery, specifically like a tendon-based surgery, tendons love collagen during that early recovery period, and you're going to be barred from doing any weight anyways. So it fits the bill. That's why there are studies on patellar tendon, Achilles tendon, rotator cuff, and hip. If you could not do any exercise at all, right, you could still use it in a fashion where it inflates for five minutes and deflates for three minutes. And you do that for a series of five times. It's a long, prolonged process, but what it can do is initiate some cell swelling because of every time that you're creating an intermittent congestion, you guys might actually know this in the world of medicine, you know, on an MD side, as doing something called esteem ischemic preconditioning. Okay, this is done to prevent further hospitalization via kidney stress. And the reason why, and as also it improves mitochondrial function, it improves vascularization to the heart itself. Very, very good just before you go into open heart surgery to do ischemic preconditioning because it can really drastically improve the recoverability of the heart and it getting back onto a normal rhythm. So you can do that, you know, and I do it in the clinic with like a neuromuscular to re-aid unit, put that on somebody's muscle and just have them contract and relax, contract and relax. Remember that that's for that force velocity curve that's back to your head zero. Yeah, and we gain benefit that way if they can't do, you know, weight bearing stuff. Yeah, I love them. I really thank you so much, man. It's so much to be learned about this, and I think that that was a spectacular job. I think for most people, understanding that if you put it in the proximal aspect of your limb, distally, you'll get that cell swelling, right? The pump that we talked about. But that's easier for people to register cognitively, but the systemic benefits that you're talking about, when we're talking about M2, we're talking about, you know, the environment, the increase in hydrogen ions and the lack of response and the subsequent growth hormone, IGF response that you get, that's part of the reason why you'll have those adaptations more at the proximal level and also at the systemic level. And yeah, I mean, there's so much more. I know that you're a little short on time and you want to respect for because you got to dinner with your family. So I think that this is probably a good place to end it. Let's just agree that you'll come back in the future. We'll talk a little bit more about application because there's so much more I want to ask you about in terms of performance. I want to talk about stuff about, you know, how can we amplify PRP and orthobiologist because that's something that we talk about quite a bit. So yeah, if you're if you're willing to, we can save that for a future episode. But before we let you go, man, where can people find out more about you, what it is that you do, tell us how much your website, your social media, all that kind of stuff. So the website, I've, I've phd's busy guys and I used to run a website by myself. Long ago, my website used to be this nice place with all these articles that I'd write when I had a life outside of being in front of the screen all the time. But yeah, so the website, you won't find anything there at this point, but a picture of my face. Smiling, saying, something's coming. Very handsome. So yeah, no promises when it's coming because it's too busy. But I tend to do some stuff, you know, still kind of on Instagram every now and then, so at the handle lifters clinic, that used to be actually the name of my private practice. And so you can find stuff there. There is, let's see here, what is still out there right now. I think you can find, I mean, if you just Google my name, you're going to find a bunch of other, you know, podcasts and stuff that I've done that kind of go into some like nitty gritty conversations, you know, some of them are on like, you know, what are some things that we see happen with insulin sensitivity? What are some things we see happen with, you know, cardiovascular fitness, specifically, again, in the ischemic cardiac world. How might we benefit from this low intensity, low barrier of entry opportunity to influence chemicals that directly reduce the risk of clot formation, that specifically improve vessel health, blood flow to tissues, specifically the heart itself. And then, you know, some other ones that are like on, you know, exercise, CrossFit, I think I did one on that at one point. I got to work with some some games athletes, that some friends knew and just with the handoffs, it was like, hey, why don't you try this? And they did. And then some of them went to go win the games and we were like, no, we didn't have anything to do with it. No. And of which, of which there's been some Olympians, like as of 2014 that used this mix again of all field sports, you know, FIFA, a women's professional soccer, NFL, NBA, MLB. So there's a lot out there. If you just Google my name, you'll find some stuff. You know, I definitely would say if you're in the field of wanting to get certification, you know, check out Johnny Owens and the stuff he's got at Owens recovery. I can't really say enough about that. They're very up to date. And Johnny is involved with many multi-site research trials, both domestic and foreign. So guys up to date, you know, he's the legit deal with it. I kind of consider myself, you know, again, a student of his in that capacity. There are some other companies that do education. Smart tools is another one. I was their chief medical advisor for a little over a year. So, you know, they've got, you know, a fair program as well. And there's one that's kind of maybe more tailored towards like bodybuilders, which is from the BFR Pros, a company that I used to belong to. So I think it just varies kind of where you're looking at, you know, if you're in medical field, you're going to be applying it, you know, stick with Johnny. I think that's a great approach you'll get with a with a very fair course reference book. Very good. You know, I've probably gone back to that thing hundreds of times, you know, in some of the studies that I've been here in Tennessee, just again, to try to synthesize this for students. And I put it to this way, if the audience somewhat understood what I've said, which hopefully, hopefully a lot of them did, I can break it down even easier because I've had my 10-year-old son ask me to explain this to him. So I follow the model of if I can, if I can teach off fifth grade or I should be able to teach him the adult what's happening. So hopefully, hopefully we got that across today and got some good interest. And yeah, it'd be my pleasure to come back, you know, and do another one on, you know, any specific stuff you want to talk about because there's a lot. There's a lot. Yeah, no. And especially, I mean, you touched on insulin sensitivity or insulin resistance to something that we've kind of talked a lot about. I mean, especially the prevalence of that and cardiovascular disease, I think it would be if we did not, yeah, absolutely, if we didn't actually dive further into that, which is why I do think it's a part two because I would hate to keep you away from your 10-year-old son waiting for Dad for dinner. But yeah, I guess pretty rare in Bunches, man. Dinner time is... It's a special time, man. I do agree with the Delphi system that they have. That's the one that we use at our facility here. And yeah, I mean, we'll link to his podcast, Owen's Recovery Science, awesome podcast, awesome resource, you know, and yeah, like you said, they're always bringing out great experts and their experts within the field of self. So we'll link to all that, man. We'll link to your social stuff and can't wait for our two, man. Thank you, Mario. Yeah, sounds good. All right, guys, thank you. Thanks, Mario. Appreciate it. Yeah. Man, what a great show with Mario. Now, before we end, here's a quick reminder that if you want to boost efficiency across your practice and make staff schedule and easier, try the deputy app. You can try this smart technology for free by going to drpodcastnetwork.com slash deputy. That's drpodcastnetwork.com slash deputy. Now hang tight for this important disclaimer. Remember that everything in this podcast is for educational purpose only. It does not cost you practice medicine, nor should it be construed as medical advice. 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