30. Mario Novo, DPT - Part II of II: Blood Flow Restriction Training Applications

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. Alright guys, welcome back to the show. Our guest today is Mario Novo, Mario returns to the show for part two of our discussion on blood flow restriction. In part one, we discussed the origins, the development, and the mechanisms behind BFR, and now in part two, we touched on the broad applications of blood flow restriction. Mario at first dives deeper into the molecular and physiological explanation of how BFR may influence protein and muscle metabolism, and then we switch gears and talk about the role of BFR with fractures, bone remodeling, and even in limb salvage programs. Mario does a great job giving us insight into how we can use BFR with our aerobic and resistance training programs, as well as using BFR to augment performance, and lastly he talks about the differences between the various BFR systems on the market. Now, before we get started, do you know what can be an annoying process? Having to listen to ads in order to listen to podcasts? Do you know what's not an annoying process? Working low-com tenants with the weather by healthcare. Weather by expert streamline everything from credentialing to housing with industry leading technology and know how so you can simply focus on what you love, practicing medical. Head to financialredancy.com, slash weather by to get started, and feel free to keep your podcast on while you're at it. Maybe a podcast like this one. Just a thought. Alright guys, I'd hate to keep this awesome discussion from you any more than I already have. So please enjoy part two of our discussion with Mario Novo. Alright guys, we're back with Mario Novo. Mario, welcome back to the show, man. Hey, thanks for having us. Pleasure. Yeah, man. We're going to get right back into this. You know, last time you came on the show, we talked about of course the BFR, the origins of BFR, your beginnings and how you got started in, of course, the field, but also how you incorporate BFR into your practice and what I really enjoyed is we had this mechanistic discussion of what the science shows and how it relates to what we're doing in the field of rehab, but also performance. And so today I think we're going to talk a little bit more about the applications of it and how to incorporate it and how to do some programming. We touched a little bit on exercise prescription, but let's dive a little bit deeper. So for those who actually haven't listened to the first episode, I would encourage you to just hit pause right now, go back and listen to that because I think it's extremely important for us to understand that science. And then come right back and we'll be right here to pick that up. So, you know, Mario, I think that probably the most robust evidence that we have is in the orthopedic literature, right? And the musculoskeletal medicine, probably as you mentioned in the previous episode, that's kind of where it started, right? Dr. Sato, he had realized that and was like, okay, this is really kind of working for that. So I think that's probably a good place to start. And of course, that's what you're doing primarily with musculoskeletal medicine. So I would love to kind of start on the continuum of rehab. So maybe you know, either we can use a kind of a case study where you have somebody with either rotated cuff pathology or ACL rehab kind of thing. How do you take a person who's recently injured, perhaps in the acute phase, maybe a little bit further, doesn't necessarily have to be post-op, although I'd be interested to kind of hear your thoughts both post-surgical and nonsurgical management and then take them through bridging that gap between rehab and performance. How do you kind of walk through that spectrum? Okay. So first, I would say, you know, listening to episode one will just lay down the foundation of a lot has been done in healthys. And that's really laid the ground workout first for safety and efficacy. Because as you know, we're not going to just really nearly try something, you know, in rehab without some sort of shred of protection because of litigation. Right. So my ability is a big thing across the board realistically speaking. So there's enough data on healthys and as we roll now into rehab where things have been looked at specifically, you know, starting off with something orthopedic based really was in the actual genesis of what started to be a far to begin with in the first place here in the United States. And that's Lume Salvinch. So you're talking about people that are, so the majority of this here in the United States starts in San Antonio Military Medical Center, SAMHC. And it starts with attempting to find a way to augment muscle loss in all of these wounded soldiers that are coming back, right? This is, mind you, now we're post-Afghanistan war. It's an interesting place to be in time. And the afar is really a part of that war, much like with every single piece of technology that comes at our pleasure to dispose of, you know, turnikits is something that genesis is through war, right? It starts off as battlefield turnikits to save its life or limb, right? So when we get to working with somebody in the field of rehab, the data really starts first with Lume Salvinch and shows us that we can take individuals that are unable to really, you know, participate in much physical activity, we can at least slow down the rate of muscle loss. And we can do this through a number of inflate and deflate rounds that stimulate a mechanism that is associated with the increase in mTOR, which is, again, this target protein kinase pathway that leads to the development of muscle tissue, right? It's what literally triggers and turns on the process to use amino acids, to use whatever antibiotic hormones may be associated with that particular period of time, you know, because health and age, these things change and we maintain muscle sometimes, let's say a similar way, but it still changes over time. So let's start off kind of there, you know, you were mentioning there's a lot in the injured population, but again, when we kind of start here from Lume Salvich, I think it's a good place because it'll allow me to kind of cover everything from there forward. So as I was mentioning, these individuals generally cannot do a lot and the real risk of not helping them to return back to a high level function is it can lead to substance abuse, obviously, creonicity of pain, comorbidities, death, and yes, suicide associated with it. So the military had a big kind of goal to try to achieve with this group and that's what greenlit a lot of the early research that allowed us to start having some conversations about do we do rehab without or with BFR in particular situations when individuals cannot undergo much physical activity and or are in need of even making the actual amputation and now having a rehab to a prosthetic device. So what the literature showed us was that we can slow down muscle mass, like I mentioned, we might be able to increase low levels of strength, increase a return back to function, you know, measured with like a timed up and go as to to stand test, you know, an actual strength test, you know, whether it be a manual strength test or a diameter, you know, taking a force and pounds and newtons and that's what really kind of began the process of blood flow restriction, making its way into medicine. It showed us that it was safe to use, that all of the previous research in turnickets was applying in this field as well, that individual is going to be underneath pressure, relatively low, considering pressures required for surgery and pressures required for austere, you know, literally lifesaving scenarios and at the time duration that they would be under would be quite low. So the protocols that were first used in this particular area start off with something we discussed last time, which is like a scheme pre-conditioning, which is a method that's used pre-surgery to improve survivability of that individual via increasing blood flow to the heart, blood flow to the organs, improving mitochondrial function and decreasing like metabolic stress, like decreased inflammation. So all that stuff was there and they go, let's just apply it and the protocol that was used is essentially five rounds of five minutes where the individuals put up what we call like a super hypoxia, super, you know, a maximal hypoxic level. Like we find out where the systolic blood pressure is and we cut that off and then we go even above that to ensure that there's no blood flow happening in there. And that would be held for five minutes and then it would be deflated for three minutes and repeated again five minutes on, three minutes on, five minutes on, three minutes off. And again, what they noticed was that there was an increase in mTOR, but it was occurring via a mechanism known as cell soiling or what Arnold Schwarzenegger said was the pump. Like Arnie was like on the money when it came to this ahead of his time, man, ahead of his time. Wait, in a lot of ways, you know, and I think it's because he was so engaged with his body. I mean, if you really kind of think about it, you know, at an at an organism level, you know, like here's this conscious who is using reps, reps, reps, reps, reps over and over and he starts to really connect in some like profound ways that I think he obviously had a platform to express himself, different era, whole other conversation. Good one though. But yeah. Thank you for next time. So Arnie was right. The pump had a mechanism that could also improve, you know, hypertrophy, muscle hypertrophy, muscle growth. So the mechanism worked in short via an increase in a shift of plasma. So interstitial fluid pushing itself from the interstitial into the actual muscle tissue. So muscle, yes, has a semi permeable state that can increase and decrease some sort of plasma level. And with this process happening, much like a red blood cell would increase in fluid, you know, in these, these like hyperhydrosis states where there's that classic story of the lady drinking gallons upon gallons of water to win her son. I think it was a game that of all consoles and dies due to having too much hydration in her system and causing for red blood cells to essentially engorge itself in first, right? So muscle cells undergo a similar mechanism. All this plasma shifts in during these five minutes of hypoxia because mind your arterial flow is now stopped, venous flow is stopped and it's kind of like a tissue is just in a state where it's got to, you know, the cells in there have to make some sort of determination. So what do they start to do? They start to dilate and as they dilate, fluid just starts to move in different places and it appears that then when you deflate and all this fresh blood flow comes back in, there's already this inflammation mechanism that's been started. So every round that you do it, it gets more and more engorge and then it seems to have this like pressure effect, whereas the, as the literal muscle cell, mind you, your muscles are multi-nucleidated, so there's many of these nuclei and these little nuclei are getting expanded and as they get expanded, they trigger a mechanism that, that kind of works on like the M-A-P-K level and what it does again in short and I'm not a complete whizz on this because there's a lot of steps guys and I'm just a physical therapist. Oh, stop it. Yeah, I like, I tease out on like, I know those and I'll come back out, interleukin six, okay, cool, I know that one, you know, that's what it's, that's what we're going for. So it has a mechanism that can have things like epinephrine and a few other mediators that Indian trigger mentor and so you get this stimulation to say we've, we've got to adapt. Like it's, that's all it is, it's a, it's a really metabolic stimulus to have adaptation and it seems again muscle is this amazingly adaptive organ, you know, I can't stress that enough how many times people need to be reminded, muscles are organs. Look how many there are and they're all functioning in this very intricate way that requires that we simply just move around, explore the world, enjoy it and, you know, eat and don't be completely lazy, you know, and obviously take care of yourself. And this is one of those things that we have to say from our position of the globe, I get fizzy water and a can, you know, put these things in a perspective. But anyways, they're amazing, we use them for survival and benefit. So that starts off a conversation. There are situations in rehab where individuals cannot do much of anything and it shows that there could be a way to augment, you know, the amount of muscle loss during these periods of time where weight bearing are going to be very difficult if not completely contraindicated. So that's also been used in ACL studies where a very kind of prominent study back in 2005 where they took a bunch of individuals that had ACL injuries and just had them undergo regular rehabilitation. Because remember, when you do these studies in humans that are injured, there's a difference with simulated pain and real pain. You know, simulated pain, those studies they get undergone through an IRB and a whole process, right? When it's real people being treated, everybody has to still receive treatment, right? And then essentially, the independent variable is that extra thing you're adding. So this extra thing they added to this general ACL rehab was, I think it was twice a day for five days, that five minutes on, three minutes off for five sets. What they saw was that those groups had less muscle loss. We can talk about that in a moment because that's why M2R is kind of so important to talk about how it offsets muscle loss. But they had less muscle loss in their quad, in their hamstring, and I don't know if they measured their calf. They measured two muscles, I think, oh, the 80 doctor, pardon me, an 80 doctor. I think that was the third one. And what they, no, it was a calf. Sorry guys, there's a lot of studies, but it was a calf. So what they saw was that, yeah, these ACL groups had a lot less muscle loss. They still had some, but a lot less. They equally had a faster turnaround for force production via an isoceneic device, like a seeded biodex. These are devices that you push against them, and they, in a sense, it's a dynamometer. And they're designed to move with you. So you can test eccentric strength, you can test max concentric strength and isometric. So you get maximal velocity contraction, all the other things. So they test them out, and the BFR groups almost lost no actual strength, although they lost muscle mass, they didn't lose strength. And that was an interesting one, because that talks about motor units and how motor units are, we know when we're in pain, both simulated pain and real pain, motor unit recruitment drops. You know, and to this day, we don't, we're kind of still scratching our heads like, how are we able to still maintain force production while we're in pain? But mechanism is causing that. Are we circumventing it? Is it endogenous opioids? Questions still come up in the air. But anyways, we see that these groups, they maintain strength. And the groups that just received regular ACL rehab, they really did it. Now mind you, this study has been replicated a few different times with the replicated studies showing similar benefits and other ones showing no benefit, no change at all. And I think it has to do with the cuff you're using that always changes it. And it's not like there's one cuff better than another, but it simply just means that when you change the pressure, that changes everything, including your sample size, like where in their season were they at, how well conditioned were they? And then yada yada yada, it's all that, it's all that intersubject stuff that happens that I think, which is why you see it and sometimes you don't. We can say the mechanism is there, and the mechanism what it does is it reverses what we can simply say is net protein balance. So let's kind of, in your mind, just think for a moment, okay, I got net protein balance and there's an equation that equals the net protein and that's muscle protein breakdown minus muscle, both part of me, muscle protein synthesis minus muscle protein breakdown. So building minus breaking equals the net amount. Now, the thing the first question most people ask is like, okay, so breaking, I get the building part, I got to eat protein, I got to move my body and I build. So what happens with breaking? A lot of times the assumption is that when you're injured, there's an accelerated rate of breakdown. And that is not truthfully the case in all examples of an injury, right? That could be, let's say, rabdo, right? That could be in the case of like inclusion body myocytis. It could be in the case of some sort of bacteria in the muscle or a direct muscle trauma right into it, you know, some sort of like heavy contusion. But when you go out into, you know, orthopedic land, like let's say an ACL, for example, we're talking about a couple of body parts here, with the ACL, you know, you're having something done like to the joint. So what ends up happening is that the muscle itself realistically every day goes through a breakdown process, just like our skeleton. So just like we have osteoclast and osteoblast in competition all day, right? You're also having this competition between end tour, right? And then something that's basically called myostatin, right? So this thing called myostatin is part of, from my understanding, a family of other protein mediating, let's say pathways. They're protein structures themselves, okay, it's important to know that. But they have, they're like, they have mediating pathways that they slow down the rate of synthetic buildup. And again, this just goes back to survival. You shouldn't always be on a state of building. And what you build might need have other resources elsewhere. It might need to be broken down into its nitrogen constituents and use elsewhere. So this process always happens. So it looks like this. It's like a flowing up and down. And when you kind of see like, oh, you know, why did it go up? It usually goes up during periods of fasting, right? And what do we call it? Catabolism. That's what that implies. So as that catabolic effect happens, when you eat, then it obviously starts to augment and come down. And then you have a reflective, right, wave, which is muscle building. So it's almost like there's an inverse relationship between this muscle protein synthesis and muscle protein breakdown, such that if they are even, what's your net protein balance? Neutral. You maintain muscle mass. So what they saw in these studies was that in a lot of cases, putting the tourniquet, creating a self-swelling, stressing the cell out, stressing the, you know, the actual literal cytoplasm of the cell. And it undergoing this into our activation was done only because it offset the myosat. It turned it off. And then when you look at the myosat family, all the other things associated with it are things like scar tissue, both of two. And those are things that they saw also that, hey, maybe this could have some potential in these areas. And maybe that's even why we've seen some, you know, again, these are throwaway ideas that are happening in papers. These are just parts of discussions that I think still need a considerable amount of research in them. And they provide a framework to say, you know, this may also have benefit in these other x-worthy places where a myosat and m-tort have this anabolic, catabolic balance to one another. And again, like anything, it's just, it's homeostasis. So it's trying to find a way to regulate itself. And when you can't undergo with any exercise, what happens? The building also doesn't occur. So the breakdown that maintains itself becomes more, right? The problem becomes the dominant of the two, and that's how you get a negative net protein balance. And that's what atrophy really is. It's the lack of stimulating m-tort. So this is where, if you take a step back, you go, okay, what can I do then? Again, I can stimulate it with protein intake, because we know it's simply just ingesting amino acids that's the specific, obviously, losing, but in conjunction, all the essential amino acids appear to play a, you know, a good role, and they're all given, you know, to a patient with a bolus. And there's been studies that have, look, literally looked at that. They take patients pre-op, and they tell them, you know, twice a day, you're going to have a protein bolus of weight protein. And then you're going to do that before surgery, and then we're going to go ahead and perform surgery. I can, I'll find a study for you, but that, believe that one, was a total near replacement. They looked at, you know, the total knee leg and the, obviously, the non-surgical leg. And they even protein. And what they basically saw was a group that had protein, guess what, lost less muscle, and retained more strength, right? So even though we know that muscle size and strength in healthys aren't necessarily, you know, associated like you can get bigger, not get stronger, or you can not get bigger, and get stronger, maybe when we're in pain, that's part of that mechanism, right? Maybe there's other things that are happening in that pain process that has to do with, again, when we think about motor unit recruitment, that's kind of where things get a little bit more interesting. Because now what you're talking about is, is there a way that when we have pain, we can still use other mechanisms, like not just the mechanical receptor transmission, but metallur receptor transmission, like these are, like, these, you know, type three, type four, group three, group four a-farence, that literally when a muscle gets acidic, what does it do? It makes heart rate go up, and it makes type two motor units contract, right? So it increases, so that's like one of those proposed mechanisms, and they think that's why these patients even let it into any exercise, just having this thing increase in their leg decrease, increase in the leg decrease, or pardon me, that we're still doing some rehab, because there is that factor, they were still doing something. That's maybe why they had that extra benefit, right? Because every time they took themselves into that hypoxic state, these metabolur receptors were conveying information for low level recruitment, somewhere in there. So if they were still able to retain recruitment, you maintain those muscle fibers that are associated with those motor units, and therefore less atrophy, right? And you're maybe holding on to the higher end ones, as opposed to just the lower end ones. And even then, it just shows maybe you just lose less of the higher end ones, because even if you can just stimulate them a little bit, that's probably better than nothing, right? So far, are we following? Yeah. Just a quick follow up on that, then Mario. So for that specific study that you're talking about for ACL rehab, I mean, I imagine they're you alluded to kind of how we make nutritional adjustments when athletes are injured, or just individuals are kind of going through some type of dysfunction or pathology. Right. If people go way back in the archives, Dr. Arnt was on here talking about how, you know, athletes when they are injured, they tend to eat a lot less, and again, you kind of are talking about this catabolic state and preventing issues atrophy, and your body actually still needs more energy, not quite to the extent where you are when you're training, obviously. But, you know, you kind of already explained that my question for you is, in that paper, I imagine all the nutrition, everything is controlled for, or are they also looking at those types of variables? And if so, then the question, because how do we tease out of BFR itself is the, you know, is the true thing that's causing the effect? That's a good question, and that is a limitation in those studies, you know, that's why when you look at the majority of these, any orthopedics study across the board, many of them don't have things like that controlled, because you're dealing with real human subjects that you can only really have so much, you know, kind of a signing over of their rights to be like, I will participate in this study for weeks, and then you also introduce a lot of other things that happen with patients, allergies, specific diets, you know, comorbidities. So, it gets complicated to ice, like, to tease it out, that's why we look at the healthys, and you go, okay, what if I take a group of healthy people, and I do control what they eat, and I do control their protein intake, then you start to see, yeah, it does have an isolated effect, but it may be a little bit less sometimes in the healthys, and we think that's just because they're starting off at a higher level, and it may require more stimulus to make things happen. You know, I don't know how more specifically to say that we just need more research in it. You can at least say it's safe to use, and the groups that it has been used in, again, across all the studies, this show that there is some effect. So if we then kind of extrapolate that and say, if we have an option that's safe to use in the benefit of this patient, and we combine it as we usually do in clinical care, we always combine things. That's kind of the reality of where we live in, we can say, we're not adhered to a specific one single protocol, right? We are allowed to practice within our licenses and say, let's try a couple different strategies at different levels, you know, some of these are maybe behavioral strategies, some of these are maybe pharmacological strategies, some of these might be physical strategies. You know, I live in the physical world, and then I provide education on like, hey, when people are healthy in the exercise, they generally do consume a little bit more protein. Safe proteins to consume are XYZ, you know, there's new data now suggesting that red meat is likely a causality for certain types of cancer. So, you know, if I've got somebody coming in who is a little older, I might say, hey, you know, here's a study, look at that, that's generally what I do in clinical care. I just, I pass things that undergo a process of screening and then provide it to the patient and say, hey, here's some things to consider to have the best outcome. But I would generally say the mechanisms show that there is a foundation for this process. So mind you, this is like low level of just inflating, deflating, you know, again, I would say in the health ease, it also shows that there may be a slight benefit in some aerobic sports, like namely, like cycling or running, because what you're doing, like in pre-schemic conditioning, is you're increasing right more blood flow to the heart, right, to coronary flow, you're increasing more oxygen and blood flow to wear, the kidneys, and that's what we're always trying to protect patients from the hospital. So an healthy people shows there may be some improved physical function and then the mitochondrial improvement as well, like they undergo more mitochondrial biogenesis. So pre-surgical and in healthys. So there is some data that suggests like, you know, we might be getting some additional benefit with this, if it's safe for the patient, but you have to think realistically, it's five rounds of five minutes on. For those types of protocols, Mario, that is going to be pre-conditioning, is it just two limbs that are being occluded and kind of released with the blood pressure, you know, excuse me, with the BR or is it all four? You know, for the schemic pre-conditioning, I've heard the studies that are on the legs, but I know it can be done on the arm as well, but you never want to do all four limbs at the same time from what I understand, is that correct? I've not come across anything that was just safety in doing so, even in pre-schemic conditioning scenario. It's typically going to be from the lower extremities or from the upper extremities, but not all four. And then in terms of, you kind of alluded to just increasing pre-load, which will, you know, convey a lot of those cardiovascular benefits, is that typically when you're deflating the cuffs, that's when you're getting it, because when you're occluding, you're not getting that you're almost, you're actually getting reduced, which is why heart rate goes up. Right, right. Okay. So that kind of, I think that's a good segue into maybe, what about for individuals? I know that there's some literature kind of looking at it, you know, obviously cardiovascular disease is the number one killer in this country for sure, right? So what about individuals who might have coronary artery disease? There's some stuff I think that they looked at it individual, but heart failure, that kind of stuff. Would this be a contraindication, or if not, name how, how can you incorporate that into practice? It could be a contraindication when you factor in and compound anything within the peripheral peripheral arterial system that has this function. So if there is a PAD, a peripheral arterial disease state going on, whether that be diabetic, whether that be lymphatic associated, or whether that actually be, you know, again, simply just having aphyscarosis or a history of smoking, right? Those are all things that you're like, nah, the plumbing is bad, right? You want to think of it like simple like, okay, if I do this thing, it's going to help the pump. Why would it help the pump? Well, there's less preload. So in that scenario, there's less stress to the heart to begin with. And the heart is a muscle, and it does need to undergo some exercise. So what if I let it increase some heart rate, but without as much arterial stretch, because it's not as much actual, and minding those tissues, they get damaged. So we know a place in the heart under less stress can be beneficial. So in those studies, that was kind of the thought process, right? And then obviously once they deflate, more blood flow comes back, you increase in preload, that seems to improve factors with, you know, MAP, that mean arterial pressure, it seems to reduce effects of things like orthostatic hypertension, right, improve standing, blood pressure, tolerance, increase in function, again, you know, whether that be like walking down the hall. I don't know if there's a faster discharge rate from the hospital, I've not looked further into that topic, but it has been used for those situations where it is safe to perform, where there's no arterial issues going on. And even with the arterial issues, it kind of again, like you start going down like the levels, like, again, where on a physician's standpoint do you want to be at with that? Do you want to assume the risk or not? You know, if there's varicostes, you know, might you blow on while you're doing this? Might that increase chance for clotting, you know, and then you go down that level, like are they, you know, what medications are they on? So I think when you're in the hospital setting, it's a lot more iffy. Once you get out of the hospital setting, and patient has been discharged for outpatient physical therapy, and they've undergone, you know, a recent echo, they've undergone maybe a recent calcium score, and things look good in the docs as you're ready to do some exercise, definitely can be very beneficial for those exact reasons. You know, you're reducing preload, you're helping to increase heart rate, and you're doing it with lower level activities, right? That would otherwise require a higher barrier eventually. So I can get benefits that have been seen with things that like 40% of heart rate reserve for like 15, 20 minutes. That would otherwise maybe take me double that amount of time at that same heart rate reserve rate to have adaptations regarding, you know, improvement of mitochondria, improvement of VO2, improvement in what was another variable they've looked at. I think they were looking at resting heart rate and blood pressure, but also just tolerance, like just tolerance to walking, tolerance to physical activity, subjectively. So if I can go up from that level, you know, if I've got somebody who's safe to perform this with, and then there's a couple of applications. You can be applied with a bite, there's studies on that, applied with a treadmill, applied in the water, aquatics, that's been done with things like osteopenia, osteoporosis, fibromyalgia, and low back pain in women mostly, but they've had some men. And then so what you basically get from those studies is that shows this aerobic conditioning with blood flow restriction can be a benefit to the heart itself, measured via our typical routine measurements of cardiovascular capacity and cardiovascular function in the interpopulation. That are safe to perform it, of which does include individuals that do have a past history of cardiovascular disease. But again, you just, you have to kind of like go down the line and find, you know, is a safe person realistically, because the studies enroll people and you know, participants they sign away their risk, like they do also with us, you know, patients sign consent, but I think you still have to be, I'm always very careful, I've been in this for a while. And you know, I've had, I've had healthy people, all right, out of physician, put this thing on his leg and like scream the dickens, like, oh, oh, my side of nerve pain. And I'm like, what? You know, dude was sitting in a really odd way on a bike. And I mean, he lost his mind. I've had a couple people like, you know, just get base of ego on me, out of the guy that today, I put it on both his arms, how to be a strong dude, put it on his arms and the guy's like, just sitting and he's like, oh, oh, man, I think I'm in dizzy and I'm just like, whoa, you know, what is happening? So you know, you have to, you have to be careful when you do it. But I've applied it in the way that the studies have suggested. So I've had patients with OA combined with, you know, hypertension controlled, high blood, you know, on some sort of, you know, path of, path of mimetic drug, something that's either a calcium channel blocker and a combination of just different other, you know, diabetes how we'd say is when you got to be really careful with just because of the pressure you're applying on, the fact that there's already neuropathy down there, likely because of a considered amount of vasoconstriction. So just poor arterial health, you know, in general, because the studies on improving arterial health aren't really all that great and be a part. So, you know, that's just a reality. So I just avoid those, I try other techniques. But in those cases, I've had good benefit of patients basically saying, my legs are getting a heck of a lot stronger, I'm walking further, I'm standing more often. And in general, they just feel like they are making some progress because, again, the mechanisms in the healthy studies and the mechanisms in these, again, injured populations that we've seen do suggest that there are safe benefits that we can achieve, you know, to, again, heart rate, blood pressure, VO2, and then all the other functional ways that we measure cardiovascular capacity, you know, two-minute walk test, six-minute walk test, timed up-and-go, and then just cardiovascular stress test. Yeah. So, yeah, I think where you're going, which is actually a really good kind of way, I'll add myself, and then you can go with this, is that we just went from, like, not doing anything, you know, almost being like, bed arrest, and this is where, if you want to have the talk of fractures, that's also another good place that we can think about maybe more realistically that those five minutes of high pressure and release really do make some better benefit, mass and do with hypoxic and hypoxic factor, what, what, what, hold on. HIF-1A, hypoxic, inducible factor, when alpha. Yeah. It's a mouthful. It's a mouthful. It's a mouthful. So, I think where you're going, we went from, like, limb salvage, these people aren't doing much anything. To now, hey, cardiovascular patients, they're doing a robeg exercise, and the next thing is in resistance training would be a part. So, if you want to just end there, and then I'll just kind of talk maybe about some odd things, like bone healing, which is a really, probably a really profound one. Yeah, I know. Hit it on. I'd love that. What I would say, I do remember coming across a systematic review. I think Johnny Owens actually was on that paper, I don't know, he was a good author. Yeah, yeah. I think this is a couple of years ago in one of the orthopedic journal, but they looked at whether or not hypertension, you know, if you had a significant effect adversely, at least. Obviously, we talked a lot about that, it's increasing pressures, and in this paper, I think they had maybe five or six studies, the end that they had was less than a hundred. So, it's not really, we don't have a lot of data on it, but at least in that review, they had show that really you don't have significant adverse effects, and it is a safe modality to use. But, again, I go back to the data is it's meager at best. Yeah. Weightlifting definitely has a stronger effect on things like heart rate and blood pressure by a lot, you know, that I think that's where, again, you always kind of, you look at it as a tool, right? It's not something that applies in all scenarios, but it can have some particular, you know, applications when all things are considered, because again, you go back to the mechanisms and you go, okay, what is, what is before done for us in medicine? It's provided for us, I think, a review of these mechanisms through a way that can be augmented, you know, from the external, like it's something that we can do. So, we're kind of in control of pulling the levers, how much pressure, you know, how much time with what, you know, and what, you know, with exercise, with that exercise, what kind of exercise, you know, with neuromuscular or no neuromuscular stem, with protein without protein. You know, we can like pull these levers and we can think, you know, how do we create a system? Again, just, this is a high practice, obviously, in an evidence-lit way. It's just kind of giving me always ideas, you know, and that's what be-a-fars within for me is, it's open up a lot more ideas on what is the true role of exercise, you know, in these painful, you know, deconditioned, impaired states, but the heck, why do we, why do we pick exercise? You know, again, I always come back to that. Why do we pick exercise? Because patients always kind of scratch their head, you know, a lot of people, especially here in Tennessee, are like, oh, treatment comes in a bottle, you know, or just of that generation, that biomedical generation, treatment comes in a bottle, or you go to the chiropractor and you just slams you around the bed and, you know, tells you you're all out of whack, you know, it's like, you want me to do exercise? Like, I avoid this, you know, I sit on the couch for a reason, I don't know what everyone is doing, you know, so when you now kind of, we're just from a different generation. We just truthfully are, we're thinking about this, I think a lot more, as we naturally should be, because the proverbial crap is at the fan, it's really expensive now. And not a lot of people can all afford it, so we don't have time for low level treatment. You know, we need high value treatment, like that's the only way to aim for it. The irony in that situation, Mario, is the geriatric population could arguably benefit the most after in the rehab realm. Did you? You talked about that last time. Yeah, that's great. Yeah, yeah, yeah, those are the people that they seem to be most challenging with. Yeah, there's studies that look at elderly men and women mixed with things like, I think it was a six week and eight week and a 12 week study. And each of those looked at training, it's like open chain, like bicep curl knee extension, you know, I think one of them maybe had like a hamstring curl in there. And what they saw was like, as they just went through time, measuring these people, the ones that did be a fart, yeah, they got stronger. I don't recall if they measured cross-sectional areas, specifically these studies for hypertrophy, because you can kind of get in the weeds with that, you know, but they saw them get stronger. And then over the course of deconditioning, the same rate, you know, you're going to train for six weeks, eight and 12, and then we're going to decondition to the same, groups that did be a far had a lot less loss at all. And then once they even detrained the amount of 24 weeks, the 12 week subject groups still held onto some strength compared to their control groups that, you know, we're doing the same low level exercises without BFR. So you kind of like sort of thinking about, you know, this isn't just on the patient level, you know, this seems like a very interesting tool to apply in just the concept of, you know, human beings in general, you know, having another option for exercise, they just another category. That's it. Just another option for exercise when things get bad, when your joints cannot take load, when your heart can't handle high, high pressures really placed on it, could it be an option for you? Yeah, it could be totally. And then you just go down from there, like we were talking about, you know, somebody with a fracture, again, for example, to just touch on this and leave it. Your bones don't just get stimulated with compound, you know, compressive movements on them. We've learned this now because of BFR, right? It showed us that when you provide a tourniquet around the limb, there's also this interstitial fluid pressure between the pre-osteum and endosteum of the bone that increases. And that pressure similarly has a mechanism that stimulates osteoblastic activity, much like the pressure stimulates m-tore, much like the pressure stimulates, again, augmentations and blood pressure. So it's just one of these pressure gradients that, again, nature has provided it. I think it's like a fundamental mechanism when we do look at physics, and then you kind of go backwards from there as an organism of the species evolving on planet Earth. Why do we have those? And it's like, because that's all that there's a round to make, you know, like why do we all have this daily systems that use fluid to orient gravity? It seems like that's the easiest distance between these two points to make evolutionary. So yeah, when you put a tourniquet on, you know what, it stimulates a muscle contracting around a bone. So it's not just a combination of the bone being compressed by gravity, and that stimulating osteoblastic. It's also the compressive force of muscle, and it shows it when that happens, blood flow gets reduced. A hypoxic environment is created, and then you stimulate something called hip-1A, hypoxic and useable factor in alpha from the bone, and that is a process of then further increasing Vegev. That's going to do a growth factor, more blood flow to the bone, increasing bone phosphate uptake. It appears that you also stimulate receptors that now kind of open and say, hey, we're ready to receive, you know, more of this material, including of which, if there is exercise perform with it, and it kind of gets a little back and forth in some of the research, like how often does it always happen in what level of exercise, like, super high level seems to be what we need, but growth hormone, right, seems to be a byproduct of stimulating the pituitary gland with high levels of lactobacid, which happens when you perform exercise with BF4, right, whether that be isometrics, or whether that be an open chain or close chain exercise, and you can go out from there, if the patient can do weight bearing, can they do isometrics, or open chain, if they can't do open chain, because of where the fracture is at, and it may, you know, it may be a contraindication for them to move the joints, whether they're in a cast, you know, so mobilizing the joint, can we maybe just do then, you know, isometrics, or let's say, out of the cast, because there's been kind of a debate, can we put it with a cast, can we put it without a cast, you know, as the limb undergoes cell swelling, might that create a risk, you know, on the limb, you know, in the actual cast itself, so I think that kind of goes back and forth, but you can kind of see the different layers that it can be applied, you know, clinically. And what does it do? Again, it improves the ability for that bone to continue to maintain a strong matrix, and it continue to have adaptation, you know, so again, what do you have, you just have a faster return to function, and that's kind of, to end that topic, that's I think the last thing you'll get from just doing it without, you know, heavier types of exercise, but that's again, one of these are the little side rants I think that goes on to just provide another option for why we should use it, you know, again, with good debate, there's always that, there should always be a healthy debate in this topic, and I'm never one of these people that shows like it's all or nothing. It's like I'm just telling you one side of the coin, it shows that have these mechanistic effects, does it always have that? I mean, that's science in general, right? It's hard to generalize always, you know, larger studies, you know, it shows us that hey there, if you could do it with exercise, you get this collagen benefit because of growth hormone, like I don't know, are you guys privy with that? How growth hormone is associated with collagen synthesis? A little bit, I think so, but I mean, yeah, I think it's worth kind of quickly touching on it if you want to go forward. It's so simply, you know, when we're injured, it shows that our body uses this myoset pathway to shut off mTOR, which would otherwise dynamically continue this process of, you know, putting on more skeletal tissue, which just means more calories needed to sustain that tissue. So there's some sort of mechanism that says we're going to turn on the scar tissue pathway, and along with the scar tissue pathway, there seems to be, right, an upstream stimulus to the anterior pituitary that says I'm going to release growth hormone, and growth hormone, once it makes its way to deliver, it appears that if there is, you know, in the dietary, in the environment, in the liver, due to the dietary intake of vitamin C, you can then have the synthesis of collagen. Does it always need vitamin C? I'm not sure, but to my best understanding, vitamin C ascorbic acid is associated with growth hormones kind of step into, you know, promoting collagen synthesis, which is just different proteins that get stimulated, that are not made from predominant essential amino acids, right? These are made from kind of like conditional amino acids, and then just your, your, your common everyday amino acids that we make on our own. So why is that important? Because collagen is what we use to heal bones, what we use to heal tendons, so it's this ultra-structure, and it shows that exercise improves it, and it also shows that maybe BFR might be a mechanism to also have that process undergo as well, and that's kind of where the debate has been at, in the BFR world has been, you know, when we use it for like an example, an acute, an acute yeast tendon repair, there's been a, a study on that looking, you know, does BFR maybe have a faster turnaround with this? And it did, it showed that it had healthier healing to the tendon, obviously the individual was able to undergo, you know, low levels of higher metabolic stimulus before their control groups, because as you know, an acute yeast tendon repair is going to take, you know, anywhere up to about like eight, if not sometimes longer, 12 weeks before that person might actually start being able to put and tolerate load because the health of the tissue, you know, if it's been chronically interintended, it may take longer. They may want it to really scar down, you know, before you start actually putting a little load through it. So, you know, I think when you, when you factor that, that in there, you know, that ability to maybe have that, that in my department is really beneficial because I can't order up growth hormone in the syringe to inject a patient with. And it does show studies in, you know, animal studies. Not legally, but, yeah. Yeah, I mean, like you can literally look at like Sylvester Stallone, Arnold Schwarzenegger, Ricky, what's his name, Mickey Rooney, and a few of these other like rap, Dolph Lundrum I think was his name also like all these 90s action heroes that all took growth hormone because they all thought it's stuff is going to make them jacked and all it did was make their facial structures get bigger because it's more collagen and bone. And there's this. I have a dragon, right? You're talking about having a dragon there, Dolph Lundrum? Yes. Yeah. Yeah. Yeah. Dolph Lundrum from Rocky, but also from your roots of soldier one. If you've not seen that movie, that movie is the best man. I love the good one. I do agree. Man, I used to like walk around I remember in the 90s, like with I think like a highlighter, like taped onto like a headband with a pair of like my dad sunglasses and just being like being in the backyard, like universal soldier. I was a kid man. That's Van Dam right? Yeah. Yeah. That's Van Dam. Yeah. That's good. Great movie man. Great movie. The second one or the third one? Nah. The first one yet. Yeah. Maury, I wanted to want to get into kind of practical uses now. Obviously from everything you've been talking on the last two episodes, BFR has a lot, lot of upside, right? From rehab to performance to just the physiology that you're talking about. My, my brain's been blown honestly. It's probably too much blood going in the brain. I need to, need to cut it off a little bit. It's right. It's right strap around the neck. Don't, don't do that to anyone listening. Don't put a strap around your neck. But with the high upside, right? Comes some of the safety concerns, right? So for our listeners, how do they get started? After hearing about all the benefits, is this something that they need to go to a practitioner for? Is this something that they can just go on Google, type in BFR and buy some cups? How do you suggest our audience gets started with this process? So probably, I mean, if the audience is healthy and they're like, I want to use this in exercise, know that beyond the aerobic training, you've got a whole list of applications in, in resistance training, you know, studies showing open-chain and closed-chain exercises could be very beneficial. Definitely exercises in a more upright position seem to be more safe than inverted positions. I can invert it like press. That could actually, has shown in the literature to have a high effect on just increased blood flow, you know, to the heart and to the brain. And that could be kind of detrimental. So you're always thinking like at the horizontal, you know, or vertical against gravity. But in all of those studies, it shows, you know, in healthys. So, I mean, if you want to like finish off like all the injured populations, things like, yeah, the eye of the knee, ACL, patella femoral, meniscal issues, Achilles, repair, total knee, total hip. There's not, it's, you know, I think this is where you get into the proximal and distal studies. You know, limb, anything distal seems to fare really well with it. Things that are more proximal are a bit more complicated. It shows that there may be some benefits systemically, just considering the anabolic environment. It may have some benefits with some pain, but it may not be largely like changing much of the strength and maybe muscle size the same way because the blood pressure dynamics right are a bit different, you know, but it can so benefits, you know, the hemostasis reduced clot formation. That could be highly beneficial for somebody still, you know, in a hip replacement scenario and a shoulder replacement or rotator cuff scenario. But yeah, like for like a Tommy John surgery for wrist, very beneficial in those areas, bicep repair, pack repair, you know, again, that's more proximal, maybe not as beneficial there, but it does show that bench press because the tricep right is an, is an assisting muscle for the bench press. It can increase more, more pack demand, much like you can get more glute demand with, you know, doing BFR for your legs because your quads just tax out and so does your soleus, so you get more in the glutes that way. But trunk not really, not really much in the trunk, but yeah, somebody who wants to get started know that there's a lot of data kind of covering this whole area, meaning you can apply it on a weekly walk in the treadmill, on a ride on a recumbent bike, is usually a bit more comfortable than an upright bike just because of the way that the cuffs and the seat kind of hits you. Guys will have a harder time with that, I think girls will. And then, you know, it depends on what kind of cuff, but, you know, could they be using the water? There's some that are waterproof, they can be put in the water, they have like, you know, one way valves, you can go in the water and water won't come back in. And those studies have actually been quite beneficial for showing, you know, improvement in reduced mild, you know, reduced time to complete a certain yardage, you know, swam the pool, including time and including lactate threshold. And that's what it's also shown like riding a bike. It's shown that individuals have a higher lactate tolerance, a potential higher peak power or mean power. Actually got to do a study with the Titans that that's actually what we saw. We never got to freaking publish it for some reasons, but it was a good case study that showed that, yeah, you could definitely get some really good benefit from doing this, you know, you know, like a preseason standpoint. So, anyways, on the liver of the point, you can apply it on those scenarios, and then you can apply it in a resistance training protocol with the aerobic being like four to five days a week, and the resistance training protocol being somewhere between like two to three days a week, it can be applied. And that kind of makes sense in general, you know, because you're kind of stimulating more than metabolic route, which means that you're not using, you know, heavier weights to augment an increase in motor unit recruitment, you know, with that heavier weight having an ability to generate more torque and a subsequent increase in type two muscle fire recruitment, right? With BFR, it's more, it's all metabolic, right? So what you're doing is you're stimulating those type three type four a-farence, they come up to the, you know, the heart increase heart rate, they come to the brain and say fire more, and you get that process that happens. Are they equivocal in muscle protein synthesis? Some studies suggest yes, they can be. Much like study suggests that low level training taken to failure can have similar hypertrophic benefits as high load training taken to failure, with the change in repetitions obviously being, you know, the main difference between the two groups. But, but Mario, with that metabolic, you know, more of a metabolic demand, are you getting more of a type one recruitment as well? You always recruit no matter what. Yeah, so yeah, are still recruiting even when you're doing high load training, because remember, hand in size principle, right? It's kind of covered there, because there are a couple other scenarios where motor units can be recruited in different ways, but hand in size principle just tells us that there is a, a size associated with it. So we always start from low type one, and then we always get the larger ones type two. So that, that happens no matter what. So let's say if we're doing the low load and high load, the high load, those guys all kick in and then obviously the type two's kick in there. You know, with low load, there's more of a build up, you know, you've got to ramp up to there, and it doesn't usually happen in the first set, which is why the protocol for beer far has so many repetitions in there. You know, 30 reps kind of set the stage metabolically, you know, and then you've got three sets of 15 that appear to be like the working sets, where now there's a high level of motor unit recruitment because of the hypoxic environment, and also some of the other metabolism receptors that have the ability to tell the brain fire, contract more. So you mentioned that last time, again, you know, the first set being 30 and the subsequent three sets being 15, do you ever beer off that? I mean, that's the convention protocol, but when in which maybe you touched on a bunch of different pathological states that it's applicable in, is it more like what's your thought process when you do beer off that 30, 15, 15 protocol? And like when will you do it? So let's say again, you know, audience of healthy people wanting to apply it to themselves, I would say it's just shoot for the research protocol as a baseline. Like for example, you should run yourself, like, let's say start this. You've agreed and you said, you know what? I think I'm going to try this method. Maybe I'm getting a little bit older. Maybe my joints can't handle as heavy weight. I can't, I don't like to go running anymore, or I just don't have the time, right? I want something that's maybe a little bit less time dependent, you know, 15 minutes doing some cardio versus maybe 30, 45 minutes. Or you know what? There's some days of week that I just can't get underneath the heavy weight and I want to do this. I'm giving you all kinds of scenarios, like listening. Right. Yeah. Or or you're like, you know what? I like training. I like training heavy. And I want to make sure I'm not going to leave anything behind on the floor. So those are all possible scenarios that you go, BFR will likely fit. And then the next things are, am I healthy enough to do it? You know, and if you are, let's move on. So let's say you are, the first thing I would say is, you know, try to first assess yourself. You know, if you're going to apply BFR, you know, spend about a couple weeks, you know, trying to see, you know, can you tolerate either the protocol alone without BFR? Like, let's say it's a body weight movement, like a push-up or a squat. Those crush people, because no one really does, you know, 75 something push-ups in a sitting in like eight, maybe six to eight minutes. Some people might think, well, I'm going to do that, you know, you've got to build up to it. So if you're like, I can't do push-ups, okay, do double chest press, okay? Now with that, there are some studies that show you don't have to do a one repetition max test. Because that, we can already be saying it's pretty dangerous to do. Yeah. I don't ever do a one rep max test unless I've got people around me. I haven't known it in a number of years. But let's say, for example, I'm going to use a 10 rep max test. And there actually is, you know, a mathematical way that you can go just Google it, 10 rep max, estimated one rep max. And you'll see that there is a quantifiable measure. You get your 10 rep max, which your 10 left, you're like, yeah, obviously you should still have safety pins, whatever you're doing. And you get that number and you go, here's my estimated one RM. So here's my training percentage for BFR. Set yourself up with that training percentage. And the next thing is you have to assess your pressure. So buying cuffs is probably where that next topic comes in. So I generally tell people, I generally promote companies that I know you can just reach out and grab. Especially if you want to apply it to yourself, you know, again, kudos to you. You've done your homework. You think you're safe. Okay. I am not liable for you doing something for yourself. Please, let's all get that across. Well, I think you would agree. No, no, no. This is not medical advice. This is not any advice. You have to discuss it with your physician. So, but these are just hypothetically for academic purposes. Yes. So what the literature shows is that you do this 10 right max test because that's how let's let these do. And then what you do from there is you set up your weight and then again, applying pressure the cuffs system. So purchasing cuffs, I would say the gamut of cuffs that I've covered. And to throw it out there, yes, I do have an affiliation with one of the cuff companies now. It's another PT. We're working together for a number of years. And he makes this good sound quality cuffs. That's all I can say of all the cuffs I've tried. He's been open and receptive to things that we need in the clinic. Like easy to clean should be contour so that it always fits the limb as appropriate as possible. It requires less pressure if it's contour versus straight. It should be a good single blotter. So it doesn't have a multi chamber system which doesn't have really any evidence behind it. So a single blotter means that when you inflate it's kind of even pressure all the way around. Yeah. It should have an ability to like rapidly deflate. So like a deflate button that you press. Not something that you maybe have to reconnect the gauge back to because that can, you know, again, it could be, it could take long. You want to get it off if you can get it off. And the next thing is you want something that's not too narrow. So his cuffs are kind of built based off of just what the literature showed us is safe. So that is an H plus cuff. You can go on Amazon and find them. And I think that if you want it to, again, he does have, he gave me like a code and just you tell me if you guys see you want me to plug it or not. Yeah, go for it. I'm sure people would appreciate that. Let me see here. So it is, I don't know why he made it my name, Mario 10. And that gets him what? And it just gives you 10% off on the cuffs. I think it's like on your total purchase. But anyways, like those are good cuffs to get. If you went down the list from there, I probably would say from those, you can probably come down to something like H plus. I mean, part of my H plus fit cuffs. Yeah, fit cuffs will be the next one. Now you do have to reconnect the gauge. But they do have a system that you plug it in. And if there's an app on your phone and it will figure out your pressure for you, which is kind of cool. The H plus ones, you don't, you're going to have to get a Doppler and check this out on your own. Or you just go and get your blood pressure taken from your leg or your arm from somebody who knows how to assess blood pressure, like, you know, for the puppeteal faucet or from, you know, radio. So, um, yeah. And then from there, the next ones I think you can buy outright on their own is maybe like smart tools. Maybe I think you can get them on your own. You can. Yeah. And then I think if you go to computer systems, I mean, there is MATUP. They are in Europe. And I can, if I can give you the show notes, like, their contact information, but that's like a two system. It's like one screen with two, um, two plugins. Like, if you go to my Instagram, like, you'll see I get one of the past. It's a cool system. Touch screen, like, it automates everything. And then you have the old ones recovery science one. But I, that one you need to take is class. Like, you can't buy a throny system without getting certified, which I think that if you're really interested in BFR, and you want to apply it to yourself and you're maybe thinking about doing it in the clinic, I had an ad for years, because I used to work for him. So I have for years, like, those cuff systems with me. Um, and man, I've streamed with those all the damn time. Just made it easy. Just hit the start button. You know, it detects who you're ready to go. Now, I think most people will agree that, you know, the ones of these who are using this routinely, that that's kind of the gold standard, right? The Delphi system is pretty much the gold standard. Of course, um, financially, it is, um, much more of an investment. But yeah, again, I think that, you know, if you're really doing it for, and I'm talking to, you know, the healthcare practitioners who might be interested in this. And last time you talked about physical therapy, this is going to be a staple in just the education in the next five years, hopefully. Um, then, then you really want to make sure you're doing it the right way. And you want to be certified, you want to be educated, you want to be updated on the literature and you know where and where it applies. Yeah, you know, I don't know if you can get CEUs, you know, for it particularly, but you might, yeah, I mean, if anything, also go to a conference, you know, go to a worth of conference, you know, invest them, obviously with COVID, I know this, yeah, things annoying to be able to do that for all the right reasons, though, just as it is. But, um, yeah, if there's one where they're speaking about it, that's a great opportunity, because you're likely going to get somebody who's, I mean, I've been considering doing that myself, just kind of putting in a bid for a couple of talks at orthopedic symposiums to have that talk with physicians, to kind of like scratch our heads a little bit and think about, you know, PT plus this, you know, like if you're already thinking rehab, okay, let's think rehab plus this, what does this give us and why, why should we choose this? Right. But yeah, what I would say that I think a lot of, at least in the orthopedic literature, physicians are up to, I mean, I know one of the companies actually is founded by, I think he was a general surgeon and now it's like an all-side exercise physiology, um, his name's Jim Stray Gunnerson, I think I figure out what his company's called, maybe be strong, I think, you know, so it is, it's, but that's an interesting concept by itself, because be strong, again, this is kind of where you get into that multi-chamber system, and, you know, Gunnerson just went one way with it, and it was just like, we're going to design this cuff that even at a maximal pressure of 500 millimeters of mercury, which is where that, that actual gauge maxes out at, you're still not at 100% occlusion arterial, you know, to speak, speaking on the area of the arterial system, still not at 100%, and it was like, touted to be a safety mechanism, but none of the studies are doing that, the studies are using pressures that are a percentage of that, you know, that maximal arterial pressure, and I think statement is like, even at 500 on the gauge, it's still closer to like 220 in the cuff versus the other cuffs that do have the ability to fully occlude you, like what about the original cotsu system, is that multi-chambered? No, cotsu is single, yeah, cotsu is a single band too, interesting, you know, yeah, and that thing, the cotsu master is what it's called at little, it's a new master. Yeah, that thing takes you, the cotsu program, it takes you to about 220, I think 250 millimeters of mercury, and they scale you up in percentages, so like you start at a low percentage, and like you, you progress percentages over time, and I think what that does is it's a fail-safe mechanism, it means you start off at levels that start to provide less stress, cardiovascular speaking and metabolic speaking, and if somebody gets flagged for something dangerous, you're gonna flag them in the process so you stop. Much earlier on, right? Right, so I mean, I always understood that, and then obviously if you're able to do those maximal pressures, then you get the benefits that you generally do see with BFR, because there's no way around that the pressures are just way up here, you know, yeah, so those kind of like the cuffs, again, that you can get, and again, that the thought would be, if you feel like you're safe, and you want to apply it, again, four to five days a week on cardio, anywhere from 15 to 20 minutes, you could combine that around an exercise session where you are doing some weights, I did that for a number of years, where I might do that like early in the day, and now give myself four hours, and then I'll actually just go have a training session, because it's such a period of time, like I literally would just set up my computer for like, you know, my bike, or set up my computer in front of a treadmill, and if I had to do some notes that morning, or if I just wanted to catch up on, you know, podcasts with a little earlier, do that, listen to music, you know, I would just walk the treadmill, and then go train weights later without it, and I did that for a while, and that helped tremendously with, I had some left knee, minuscule pain, a pretty significant tear, and just unable to really run past the mile without pain, and you're everything else fine, but that was really a savior, and it meant it kept on some quad-size, let me tell you, man, dude, walking uphill, like 3% grade, at like a 2.5, 2.8, bro, it feels like you've got like a rough sack on you, your quads are just screaming, it's fantastic, I'm like, oh, I just got there, I didn't take a long to get there, and that sounds swelling, you know? There's much more than that, man, having a walk, much more, much more, but you know, that's how it could be applied, and I've had a number of friends of mine that, you know, they cycle with it, you know, on their off-season, or as part of their training, you know, as you're thinking about progressing into, you know, higher peak levels, it's hard to stay getting up there for a long period of time, because the amount of energy it takes that output on the bike to wattage, and you're sure you can increase the resistance, and that's a way to do it, but maybe your bike doesn't have resistance, or a couple other ways, it could be a tool that maybe helps in that regard. Can I ask Mario, is there a certain heart rate that you're trying to achieve when you're doing it aerobically? I mean, automatically, the heart rate's going to go up, but is there a certain zone you want to be in? You know, if you're thinking of, like, danger zones, then, you know, there's, there's definitely, you should be assessing yourself for, like, your, like, your 85% of your heart rate reserve, as kind of like a, like, a do not train mechanism, you know, like, I just, like an early stopping point, if you've never done a cardiovascular stress test, don't be stupid here, like, legit, don't be, because you're kind of surprised how quick your heart rate's going to go up when you do before, you know, because, again, it's not even just what it's doing to your anxiety is going to go up, when it's your first time, especially if you're by yourself doing it, everyone I was doing it to myself, I was like, what am I doing? You know, I've questioned it so many times, you know, but, and each, each, each session I've always done with BFR is always kind of like a, like, it's like a come, a come to reality moment. Some people would say it come to Jesus moment, but I don't want to, you know, I don't mean that in any way it's a perform, to be disrespectful, but that kind of situation where it's on you, you're like, what am I doing? What am I doing? Like, this hurts. What's you understand? Mechanisms, and then you're like, that's why I'm doing it. That's why I'm doing it. And it sells pop kicks in. But, um, yeah, and then the weight training again, you know, two, three days a week, it could be used in kind of a, you know, a preseason, kind of situation, or like, hey, I'm going to get back into doing some weights. So I might, you know, do some weights without it. And again, I might just include it in another training session that week, you know, as we know for hypertrophy, it's best if you're training muscle, you know, two to three times a week similarly. Why? Because it's a smaller stimulus recovery ability is much greater, um, return to proper levels of motor, you know, recruitment, it's strength for there. And you want each exercise session to feel good, you know, and be a far, I'll be honest with you. I mean, you'll get bit by the bug for a little while when you first started. And then, you know, I myself, I think the longest training routine I had with it was about close to like 16 weeks. And by the time I was done with it, I was done with it. I was like, I'm good. But man, let me tell you, like, just pa squats, um, uh, pause deadlifts, deficit deadlifts, hip thrusters overhead press, you know, like actually the overhead press went up considerably just from building a strong base to be able to balance weight overhead. Um, and I was probably the healthiest at that point coming off that 16 week that I had ever been really in all the other times. That multiple injuries and things that happened. I really went at it kind of in that, in that vein of let's apply the science, just like freaking, you know, um, uh, the start of all this, you know, I don't know what name just alluded from me. Um, uh, the creator of blood flow restriction, uh, kind of, so yes, sorry. I have so many people's head names in my brain right now, because I'm doing another paper. Sorry, everybody. Yeah. No, no, it's all good. But Mary, this actually, you know, kind of leads to my follow-up question. So why is it that for, let's just say for aerobic exercise, if somebody's using it, not doing just regular walking on a treadmill, maybe they're doing cycling, right? You're still going through the action of knee flexion and contraction of the hamstrings and quads when you're going through knee extension, which is akin to doing bicep curls, right? It's a similar hind joint. It's like a lice. Yeah. So the question is, you know, why is it that we can do five days, whereas for maybe bicep curls or trisive extensions or whatever it might be, the frequency has to be less to get the same effect. Why is it the case? Muscle size, pinnation angle, um, you know, tendon tolerance, um, the actual joint itself, you know, there's deaf, I mean, load bearing and non-load bearing structures make a big difference with it. Like, I challenge you to do an upper body, like a UBE, an upper body bike. I try to do that sucker for five days a week. Your arms won't tolerate it. It's the same thing, you know, and that's kind of like where, you know, when you look at, at BFR and its potential application, you know, if you're healthy, you're kind of just thinking about how it can sprinkle some things into your training, maybe spruce up some training. And again, maybe you just can't be training with heavier weights anymore. And you're just kind of there, like, welcome, you know, I'm, I'm, I'm going to be for in a couple of years, guys, like, I'm also in that same bandwagon where I'm like, keep the tread on the tire. Like, don't wear it out. Be smart. Um, and then yeah, if you're injured, it's, it's a, it's a tool that I think with safety bearing in mind is excellent. I have rehab many, a very fit person who's got injured with what I thought was, if not a faster return to function, an overall improved return to function in maybe the same relative time, but that individual expressing lower levels of, of just resting pain, um, better quality of life. And I think, uh, I think the process of applying it and rehab, because there's always the educational piece kind of connects things for patients in a really different way. They kind of look at their body differently after that. I've had a number of patients tell me, like, you know, just you explaining, be a part of me and me trying it and feeling what it does has really kind of made me think a little bit differently about what I want to do now, you know, when I go back to exercise. And, um, and I've had a number of patients discharged to purchasing their own cuffs, you know, and just staying in contact with me throughout the years. Um, and, you know, having definitely, um, a point of stopping and not returning, you know, and just saying, like, where are your cuffs? I am in the closet now. But where are you at? Oh, man, I'm back out doing the things I like to do, you know, where I found some consistency, you know, and, and I'm able to maintain what I'm doing. And I think that ultimately the medicine is like, oh, right, I taught this person how to fish in their pond. Like, congratulations, I did my job, you know, um, so yeah, it's a, it's a cool tool with application. Definitely. We, yeah, we need more research in it, I think, in general. Um, and I think that's where again, it's always going to be all over the place because we're just all a little bit different. So I think we should always kind of look at, you know, the healthy studies, the mechanistic studies as kind of a basis. And then when you look at, you know, injured individuals, they might be able to like fall into that research protocol. And that's why when you ask me to go, if you're off of it all the time, man, all the time, I try to find what they're capable of doing with the subjective feedback of them feeling fatigue. You know, so if they're like, like my quads burning, and I'm like, okay, they got 20 in, they didn't get 30, but they got 20, and they're saying it's burning. I probably want good buying, and I don't want to create too much delayed on to muscle soreness. So I may say, you know what, if it's the first session, go ahead, let's take that 30 second rest, and then let's move on and see what we get to and build them up over time. You know, but you just have to be like that in medicine. You know, it's such a tailored process, at least I try to approach it that way because you make somebody do that full research protocol and rehab and watch how quick they don't come back. Watch how quick they like, they just like, nope, that was too much for me. That was too painful. And that's where like, you have to factor in training age. You know, how long have they been training for? Does it have any training experience? Have they ever done anything like a peer to a periodized model, progressive model? And then, you know, you build from there to go from there. I mean, this is the art of medicine, you know, this is the art of knowing all this stuff, and just figuring out how to bake a cake, you know, at the end of the day. No, I mean, we can agree more. I mean, and we know what I enjoyed about this episode is that again, we've talked a lot about the data and Darshan, I talk about this all the time, everybody who's come on is you can allow the data to kind of inform your practices, but not dictate your practices, right? And so that's kind of what you're talking about. You're talking about individualizing the approach to the person in front of you. And that's absolutely awesome. I do want to ask though, look, in the event, the example that you gave, let's say somebody was able to knock out 30, 15, 15, 15, no problems. Would you rather increase the pressure if you haven't already maxed out versus increase the load? So what do you reach for first? So the training pressures for the upper extremity are generally, in the research, about 50% of the occlusion pressure, the arterial occlusion. Yeah, that's the upper end though, right? That's the upper end, right? Yeah, I've started people that have freaking 20 dude, just getting comfortable, you know, little old Mary, who's like 60 something years old, who, you know, is right now in a scenario that she is like absolutely no contraindicated, you know, to do any sort of like grasping or anything, you know, or shoulder, I might have her just do some gentle little elbow things. If she rolls out that she safe to do it with, you know, but yeah, you may start lower and then, you know, factor your way up there. For the lower extremities, it's generally going to be, you know, the higher end is 80%. You don't do exercise above that generally. Has there been, yes, there has been like semi-professional rugby players that trained at like 100% occlusion and got some amazing freaking numbers in all the stuff they were measured. But yeah, try that. That sucks. That's horrible. That feels, it's really like, yeah, no, don't do it. Sit like you're doing box squats and yeah, it's terrible. But yeah, the pressure is in the limb. I would say this, if it's, you're healthy and you're getting started and you've got your pressure, you've got your numbers and you know them, okay? I would say realistically, for the legs started around 60, for the lower extremities, I mean, for the upper extremities started around 40. Complete the protocol at that weight. If you can complete the protocol, bring the pressure up then another value. For the arms, just go right for 50, for the legs, go to 70. Again, complete another full protocol. Awesome. Because what do you generally see in a periodization model? You generally see first, you're going to have, you need to have an adaptation to repetitions, right? So almost like you need to first be able to get this strength high enough that they can perform enough repetitions to stimulate something. And then you can load on the strength. And then you de-load and then you do it again. And then again, you make those little pursuits, you know, get the endurance, then go for the strength, then de-load, help the joints in the audio, that's kind of like a certain model that you can use. I use kind of the similar thing in BFR, you know, start at lower pressure, get the weight where it needs to be, complete the protocol, the pressure adjust. Once the pressure's up there, by that time, you're ready to sort of adjusting now the weight. Now you're ready to start going, well, your original weight is not your original weight anymore. So it's time to go up. Then you progress the weight, right? Or let's say if it's cardio, lower pressure, complete the time duration, complete 10 minutes, you know, complete 15 minutes, complete 20 minutes, and then go up on the pressure. So I would say like, low pressure, complete 10 minutes, got it, up the pressure, complete 10 minutes, excellent. Lower the pressure, go to 20 minutes, then bring the pressure back up, complete 20 minutes. You know, so that way you're kind of also helping, you're just thinking about physiologically what you're doing to your body. At least that's how I think about it. There's not studies on this. I'm just trying to be like the extra little, you know, thought of like, hmm, I'm about to go for longer. Maybe I want to just give myself a small, you know, easing point to break into this and then make the logical progression. And you can discuss that any way you want. That's just one person's opinion, you know, on maybe how to do it. I'm just always thinking about safety. I've had a couple of things happen in my clinical experience that like earth shattering changed my perspective on, you know, just safety. Always, always be thinking about safety. It's a, it's a bad day when something goes wrong. And you have to write an incident report. It's a bad day. And it's never been situations where, you know, I was held ever like responsible for being the person who did something wrong. It's, it's been in scenarios where they're like, it's completely out of your control. And something just happens, you know, it just shakes you. It's like, damn, you've got to be really always on your ball. So yeah, if you're going to do this, take, take kind of those approaches. You know, there, there, there, there was a point in time that I wrote some of these protocols down and had them in book because again, the conversation can be a little lengthy, you know, because it's like a whole new world. You're like, that's why literally we've got weight training. And now we have a whole column which basically says weight training would be a far because there's a whole other area to think about. So you just got to be a little bit more conscientious about what you're doing. And then why you're doing it. You know, a lot of some people go, oh, it's just too much to help with. I'm just not going to do it. And I go, that's cool. To each of their own, you know, but if you're on that other end, because again, I've had some awesome, awesome top athletes make some big head weight with it. Where again, the longer you train for those adaptations are harder to get at. Sometimes having that little extra stimulus, metabolic speaking, without the expense of more joint loading, that the expense of more tended stress because of the higher weights or torques needed. Hey, that might be beneficial. You know, under certain training conditions. And this is your factor all those things. And so I mean, I've used it in CrossFit, swimming, running, football, basketball, soccer, a lot of soccer. And in general, with nothing, you know, and they've always been considerate to where the person is in their training program. You know, where they in a scenario where they needed to de-condition, right? Realistically, where they in a scenario where they needed to just have higher metabolic stress, like right to achieve, you know, higher heart rates, higher lactate training, higher, higher peak performance training. And then just like kind of measure those two, where am I with that person, usually with a number of police officers, firefighters, and military, like, you know, pre-screen, so that if they have like a fitness test, excellent freaking tool, man, try putting those on your legs and drag a shuttle. You know, put those on your legs and get on the Jacobs ladder. Put those on your legs and get on, you know, a freaking Versa climber. Yeah. Or on an aridine. Whoa, man, aridines are ridiculous. And just see what happens, you know, like even short, short, like four, four weeks training, two, three days a week doing it. Man, some drastic changes. Yeah, no, I think what's fun of you, you're talking about the lenticular for our audiences, we had set a timer because, you know, we had the whole world. We've shattered that because, but it goes back to the point that you just made is, you know, this is a conversation that you can't kind of combine it to limits of an hour and stuff, because again, there's so much more that we, I know, wanted to touch on, but we just unfortunately didn't have the time. But just to kind of recap, all the things that you mentioned is, again, one thing that I hope people take away that this is an awesome tool that's well supported by the evidence, it has widespread utility, but it's just another tool and tool belt. And going back to this pendulum that we talk about, it does not replace good, basic strength, the conditioning principles. I know you touched on that earlier. And then of course, you talked about rule number one is do no harm. So safety first, I think you've only said that about 87 times in the last two episodes. So I want to bring that home as well. Yeah, absolutely. But Mario, listen, man, before we let you go, I do want to know what the next steps for you are. What are you excited about? What you got coming on the pipeline for you? Anything, you know, we'd love to hear that. Yeah. So again, you know, going to be taking a stab at just making some connections with some potential virtual conferences that have, you know, open opportunities for speakers on the topic of BFR likely in kind of a couple of those areas, you know, maybe potentially an orthopedic rehab or even being cardiovascular. And that's just because I just finished the whole entire eight weeks of, you know, advanced cardiovascular and my brain is like losing things out of my head. So I might as well like put it to use. But also chronic pain, you know, there's an excellent opportunity that I've seen again, respectively understanding how motor unit recruitment augments, you know, pain experiences, modulates, you know, they go response to the heart. There's a lot of things that we can go into with it. So that's kind of one area. And I've got, I think there may be a webinar at some point coming up from MATUP. They've kind of asked me and invited me to see if I want to get on that. And if you guys just, you know, Google MATUP, I think they do have an English site. So you can kind of see some stuff there. And we're kind of in discussion with that webinar, maybe. And it's probably going to be just focused on something. So obviously it will be slides and pictures. And Mario will have to follow a script. So, you know, we won't jump all over the place. But yeah, that's going to be it predominantly, you know, I will probably be doing some more stuff on Instagram, shortly coming up, just trying to kind of figure out life right now. It's a lot of extra responsibility. Yeah, yeah. And that's kind of where you guys will probably, if anybody wants to just find more, just, you know, check out Instagram at lifter's clinic. That's probably where I will just be dropping some things over time. And yeah, again, if you want to pick up some cuffs, you know, feel free to check out H++, great company, good builds, affordable. And how you can use that code, Mario 10, that'll give you a discount off of that. So you just get started. And maybe, maybe I'll do a training manual one day. Cool. I'm always like, should I go back that way? Things are kind of good now for me to try. So I'll just leave it there. Maybe we'll get the energy to do one. Absolutely. And we will post all of those links in the show notes. Mario, one last question for you. But before I ask you that, I just wanted to say thank you so much. Man, I know you're a busy guy, but taking out, you know, a couple of hours of your time just to educate us and the audience and going into that much detail, honestly, I mean, we all know that you're on the forefront of BFR and mean, ultimately, are super excited to kind of see what's next. So the last question for you here is how do we put the health back in health care? And I know you touched on this a little bit in part one. You know, I think it really just stems from just an understanding, like we're all in this bubble together right now. So putting health back in health care, I think kind of starts first with yourself, you know, like really applying these strategies to your own personal life. And taking them seriously, that they do affect how, you know, the second saying goes, I keep your act sharp, you know, you need to keep your mind sharp. That's literally the point of even this podcast, you know, and all the people you've had on this is to expand your mind. And this is such a fundamental way to do it, right? We're humans are so astute at being able to listen and use our imagination and apply these things in such a fast way that we assimilate that data. So yeah, start with you. And that means start with education and focus there. And then, you know, always practice with, I just say, just practice with your heart and your hand, you know, practice always being authentic, you know, to the patients you're working with because they also have, you know, their own lives. And, you know, in the end of the day, again, we are with each other right now and only now. That's it. There's no other time other than right now that you're going to be able to impact that person's life ahead of you. So, you know, you know, do it that way, do it responsibly and stay stayed up to date. That's beautiful said. Thank you, Mario. All right, guys. Woo! That was an information packed episode. I hope you guys were able to follow along because we did get into the weeds a bit, but because it's somewhat of a novel modality in our clinical practices, it's worked truly understanding the why behind what we're doing. As always, Darshan Eye are going to revisit many of these points in our lessons learned episode. And perhaps that will help elucidate the applications further for you. Meanwhile, timing can be more perfect than head to financialresoncy.com slash weatherbite for a streamlined, local attendance experience. Whether you're new to Locombs or Pro, weatherbite is here to get you where you want to go. Before you sign off, guys, please remember this important disclaimer that everything in this podcast is for educational purposes only, it does not cost you to practice a medicine nor should it be construed as medical advice. 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