Running head: RESTRICTED BLOOD FLOW TRAINING Restricted Blood Flow Training for Men’s Physique Bodybuilders Master of Science in Kinesiology 1 RESTRICTED BLOOD FLOW TRAINING 2 Abstract Blood flow restriction (BFR) is a unique technique that uses tourniquet cuffs to generate vascular occlusion in a limb. Researchers accredit the method for its usefulness in clinics for therapeutic purposes and muscle strength generation among athletes and footballers. This study seeks to investigate the outcome of the BFR technique among men’s physique bodybuilders. The research will utilize a small number of professional bodybuilders who have remained in the profession for at least one year. The equipment includes dumbells, barbells, and bench press, and BFR cuffs. For ethical consideration, the research will ensure that participants sign a consent form that explicitly highlights the benefits, potential outcomes, and risks involved. A two-way mixed ANOVA will be used to determine whether the type of training and the length of time the training followed have significant effects on arm size. Physique male bodybuilders who have been in the industry for at least one year meet the inclusion criteria, while those who do recreational bodybuilding will be exempt. Keywords: BFR, BFR cuffs, 1RM, Physique Bodybuilders, Arm size, Muscle hypertrophy RESTRICTED BLOOD FLOW TRAINING 3 Blood Flow Restriction for Men’s physique Bodybuilders Blood flow restriction (BFR) is becoming more of a trend in clinical and athletic settings. Applications are widespread and have been targeted by athletes for strength development and hypertrophy. The process utilizes inflatable cuffs that help generate vascular occlusion in a limb while exercising. Compared to traditional methods such as conventional resistance training, BFR effectiveness extends to aging patients. According to Rolnick and Schoenfeld (2020), Sato Yoshiaki discovered BFR in 1966 and called it KAATSU, which implies "added pressure" training. Since its discovery, various studies on the topic have taken place as quantitative researchers sought to investigate how to utilize it in various settings. Experts describe BFR as a technique involving the use of tourniquets that individuals wrap around a limb's proximal portion for partial reduction of arterial flow while restricting intravenous return (Rolnick & Schoenfeld, 2020). The reduction in blood flow from the applied pressure decreases oxygen supply, challenging local energy metabolism and reducing the time needed to reach volitional failure during aerobic training and resistance training (RT) compared with similar exercise without restriction (Fahs et al., 2015). BFR is discernible from other training methods as it uses loads that are 20% of an individual’s 1-repetition maximum (1-RM). This training technique can be used in isolation or alongside traditional resistance training, where both cases indicate a consistent muscle mass increase. BFR training has proven that muscle growth can be achieved by combining blood flow restriction and low-intensity exercise. BFR limits intramuscular oxygen supply and restricts metabolites from leaving the veins, leading to increased metabolic stress. In turn, metabolic stress stimulates systematic hormone generation, cell swelling, and amplified fiber recruitment that facilitate muscle growth. Generally, BFR training mimics high-intensity exercise effects by RESTRICTED BLOOD FLOW TRAINING 4 including a simple cuff that creates a hypoxic atmosphere. Rolnick and Schoenfeld (2020) suggest that low-intensity BFR training results in a larger muscle circumference than regular low-intensity exercise. To further support the effectiveness of BFR on muscle growth, Low-load Resistance training with BFR can provide similar increases in muscle mass compared with heavier (70+% 1RM) lifting, making it an alternative for physique athletes seeking to maximize muscle growth without additional joint stress (Lixandrão et al., 2018). BFR is ideal for increasing muscle strength as its low intensity ensures the user's safety when the correct optimal pressure is applied during exercise. BFR training, as mentioned earlier, extends to patients over fifty years. Many clinicians have adopted the method to assist athletes and other recreational trainers in obtaining muscle hypertrophy. Many athletes are adopting the technique, besides those who utilize it as a postinjury therapy. Footballers and other moderate to high-intensity athletes have been including BFR in their training methods. Despite numerous investigations that support the technique's usefulness, the recent literature does not examine if utilizing BFR training offers superior muscle size compared to traditional resistance training for men's physique bodybuilders. The present study seeks to re-affirm the impact the training will have on muscle growth after six weeks of training to answer whether restricted blood flow training offers superior arm size outcomes for physique male bodybuilders compared to traditional resistance training. The research will evaluate participants who are preparing for a tournament who, thereafter, will participate in the BFR training. A limitation of the study is that it will only accommodate bodybuilders who have trained for at least one year. It aims to most reliably distinguish the effectiveness of BFR training compared to their traditional training methods. RESTRICTED BLOOD FLOW TRAINING 5 Literature Review Over the last decade, the method used by professional and recreational bodybuilders to achieve arm muscle strength has evolved from the more traditional extreme training to modernday Blood Flow Restriction (BFR) training. As stated in the introduction, the technique was discovered by Sato Yoshiaki in 1966 and called KAATSU, implying "added pressure” (Rolnick & Schoenfeld, 2020). Sato employed the method to help aging individuals strengthen their muscles and improve cardiovascular health. BFR training denotes the use of a computerized tourniquet whereby the cuff is wrapped around the proximal portion to reduce arterial blood flow and restriction of venous return. Studies have reported that the minimized arterial blood flow reduces oxygen delivery that challenges energy metabolism. Despite studies on BFR, there is a literature gap on the possible contraindications to the application of BFR. For men's physique bodybuilders, which is the population of this study, the use of BFR is of paramount importance due to the benefits of increased arm size compared to traditional training methods. According to recent research, it is vital to utilize a load that is less than 20% repetition maximum when training using BFR (Rolnick & Schoenfeld, 2020). The study by Rolnick and Schoenfeld (2020) investigated the impact of BFR training on athletes, portraying its importance in improving muscle hypertrophy when used with heavy load resistance training (RT). This strategy modestly increases energy expenditure (EE), metabolic stress, and cell swelling compared to work-matched exercise. These aspects are crucial to men’s physique bodybuilders in maintaining caloric deficits and creating an anabolic environment during muscle growth while maximizing hypertrophic potential during the exercise session (Rolnick & Schoenfeld, 2020). Fundamentally, including BFR training into an athlete's regular training schedule amplifies hypertrophic performance and increases muscle strength while improving and upgrading the RESTRICTED BLOOD FLOW TRAINING 6 cardio-circulatory parameter function (Baker et al., 2020). However, the implementation of BFR training must be considered an essential aspect of practical training and healing muscle injuries. This kind of training has been applied as a clinical rehabilitation technique for aging patients, where a combination of BFR training with other exercises has shown some positive results on muscle hypertrophy. Hanke et al., (2020) determine this by measuring muscle thickness, mass, circumference, and cross-sectional area. BFR training demonstrates the capability to improve people's rehabilitation efforts over 50 years to comb muscle atrophy, improve muscle function, increase muscle strength and enhance muscle hypertrophy. Therefore, for an aging patient, BFR is established to enhance overall muscle performance. In a study by Loenneke et al., (2012), low-intensity BFR training was investigated to determine its impact on muscle growth. The population with the same baseline characteristics as this study indicated that the BFR training's implementation enhanced muscle growth and development, while muscle hypertrophy was enhanced due to the adequate blood supply and protein synthesis. The incorporation of protein synthesis was considered the key reason for improved muscle growth and healthy muscle development. There was a significant correlation between training duration (weeks) and strength for muscle development due to protein synthesis, but the study did not show any correlation for muscle hypertrophy (Loenneke et al., 2012). Muscle development involved positive changes in muscle mass, size, and strength. Low-intensity training with BFR is considered essential to facilitate muscular strength among different populations (The American Educational Research, 2020). A research investigation in Japan showed that BFR training stimulates muscle growth and development, indicating existing positive impacts of BFR, especially in individuals with orthopedic conditions. RESTRICTED BLOOD FLOW TRAINING 7 Despite the beneficial effects of BFR, there is evidence indicating the lack of effectiveness of BFR in specific training populations. Scientifically, the implementation of BFR training aids in inducing metabolic stress, impacting hypoxia, and reducing proteolysis. Through this training, there is an increase in muscular growth and hormone levels observed, leading to controversy about its effect on neuromuscular functions (Heitkamp, 2015). The particular argument is that even without training, BFR still reduces atrophy in muscles at the knee with a rise in immobilization strength. Research highlights that safety measures need to be considered when making any action or plan to execute BFR training (Luebbers et al., 2014). For instance, wrapping is done around the limbs on the proximal-distal on the muscle of interest, preventing venous return. This is essential since it helps prevent blood from leaving through the veins. BFR Training on Footballers Research has been conducted by Yamanaka et al., (2012) to determine the impact of BFR training on members of American football clubs. An increase in lower and upper chest girths enhanced muscular hypertrophy, and physical fitness was observed as a result of BFR training. It was an indication that the implementation of the BFR among the football players helped improve muscular strength and enhance overall muscular development. The study also confirmed that lower intensity resistances combined with the BFR training significantly impacted muscular stability. Overall, the four-week training results indicated a positive outcome in muscular development and circumference. Interestingly, research by Centner et al., (2018) showed that BFR training increased muscular activity to blood-flow restricted muscles. A combination of BFR training and low-load resistance training was shown to promote muscular adaptation. The study also assessed the impact of walking exercise to determine how it was affected by BFR training (Center et al., RESTRICTED BLOOD FLOW TRAINING 8 2018). The evidence is sparse on determining how BFR training can influence muscle strength and mass and adaptation changes, especially for older adults. Therefore, this study intends to identify the impact of BFR training on aging adults to determine clinical relevance. This enclosed study was carried out on the more aged population involved in the BFR training. BFR Training on Athletes BFR training has been reported as an athlete training and clinical training tool to strengthen muscles and treat muscle injuries (Vanwye et al., 2017). Therefore, it should be executed in a setting that has an individualized approach. As an adjunct, the BFR training has been more integral than traditional training in obtaining and maintaining personal fitness (Patterson et al., 2019). Patterson et al. (2019) provide evidence that continuous muscle hypertrophy is enhanced through BFR training showcasing its inherent benefits in clinical rehabilitation and athletic settings. Current research has established guidelines for BFR training, as discussed by Patterson et al. (2019) in Table 1 of their study. The current study aims to focus on applying BFR in muscle strength gain while being mindful of the method's safety protocol. Therefore, this research's expertise will focus on strength and conditioning development of overall musculature development and injury rehabilitation. The study by Patterson et al. (2019) concluded that BFR training is crucial for muscular development and injury recovery when compression is created, resulting in opportunities for further development of muscles, especially among bodybuilders. Despite numerous studies, it is unclear whether BFR training yields superior arm size results, particularly circumference, compared to traditional bodybuilding splits. Previous research suggests that BFR training successfully increases strength when used alongside other training forms (Patterson et al., 2019). RESTRICTED BLOOD FLOW TRAINING 9 The current study will investigate whether BFR training offers Men’s physique bodybuilders an increased arm size (Biceps and triceps) compared to the traditional hypertrophy bodybuilding training methods. The research hypothesis is that BFR training after six weeks will elicit larger arm size compared to traditional resistance training with men's physique bodybuilders. Methods This study is seeking authorization from Point Loma Nazarene University's institutional review board. This study intends to protect the rights of human participants and their welfare and privacy throughout the research process. Before participating in the study, subjects will be required to sign a consent form that will describe the study, its benefits, potential risks and discomfort, extent of confidentiality, and a statement indicating that the participation is voluntary (Biros, 2018). Subjects The randomized trial will be conducted at Point Loma Nazarene University tentatively from 2021 to 2022. Participants will be physique male bodybuilding competitors between 18 and 32 years old. They will be recruited from the San Diego area and the Kinesiology Community Group at Point Loma Nazarene University by posting study recruitment posters at the gyms and fitness centers. The Kinesiology community at Point Loma will also receive a notification email concerning the same information. Participants will be required to meet the following inclusion criteria: healthy young males between 18 and 32, professional bodybuilders with no history of cardiovascular diseases, have at least one year of bodybuilding experience and must be enrolled in some competition to validate the results. Participants with any health complications will be excluded from the study. The G* Power statistical power analysis will calculate that eight subjects RESTRICTED BLOOD FLOW TRAINING 10 would yield a power of 80%. Based on a priori power analysis, it will be established that an alpha value of 0.05 will be obtained, the actual power will be 0.88, and the effect size will be 1.15 (Baker et al. 2020). Equipment All participants will fill out a health questionnaire, included in Appendix A, highlighting any health conditions that might prevent them from participating in the study. The research assistant will show the participants how numerous pieces of equipment such as dumbells, barbells, bench press, and BFR cuffs must be used. The cuffs that will be used in the study are: RECOVERFUN Blood Flow Restriction Cuffs (BFR) Training Therapy Occlusion Air Cuffs with Gauge and Pump for Arms and Legs under Precise Pressure Tracking; they will be placed on the limbs of the participants belonging to the BFR training group. These cuffs, between 10 and 12 cm, will be tightened to a particular pressure that blocks venous flow but allows arterial flow when the training is conducted. According to Loenneke et al. (2014), these pressures can range from approximately 1.3 times greater than systolic blood pressure (SBP; ~160 mmHg) to over 200 mmHg. Safe pressures within this range will be used to restrict the participants’ blood flow during exercise. All measurements to determine changes in arm size will be taken using a flexible measuring tape. Procedures Participants will be randomly assigned to either the restricted blood flow training group or the traditional bodybuilding training group and undergo the same exercises on Monday, Wednesday, and Saturday (Gentil et al., 2017). However, each group will undergo the same arm exercises on Tuesday and Friday, with one group performing the exercises with BFR cuffs and the other group without the BFR cuffs. Arm size will be measured and assessed at baseline and after RESTRICTED BLOOD FLOW TRAINING 11 six weeks of the training program (during the first and last visit). The training exercise will be conducted at the gym and fitness center at Point Loma Nazarene University. The participants will be asked to complete fourteen separate visits. During the first visit, they will be familiarized with the testing protocol and equipment, and arms measurements will be taken. During the 6-week program, participants will attend twelve arm resistance training sessions (twice per week, Tuesday and Friday). During the second visit, each group will start their training session; one group will engage in BFR and the other group in traditional hypertrophy training. Each training session will last for 50 mins. The participants will engage in rigorous training under the research assistant's supervision during the subsequent semi-weekly visits. One-repetition maximum (1RM) will be used as a strength outcome and to determine training loads. 1RM will be assessed by finding the greatest load that participants can lift at one time, with proper form, through a full range of motion. Prior to testing, a self-determined number of unloaded repetitions will be completed as a warmup, followed by one repetition each of an estimated 30 and 70% 1RM. The load will be increased following each successful attempt. If unsuccessful, the load will be decreased, and this process will be continued until the maximum load the participant can successfully lift is determined (Loenneke et al., 2012). Tuesday and Friday sessions for both groups will comprise four exercises (two for biceps and two for triceps). The exercises are dumbbell biceps curl, Wide grip barbell Curl, dumbbell Overhead triceps extension, close grip bench press. As shown in Table 1, the hypertrophy training group will engage in the exercises using low to intermediate repetition series with progressive overload, four sets of (12, 12, 10, 10) intermediate repetitions with 70% of the one-repetition maximum (1RM). A rest period of 90-sec will be enforced between sets (Jessee et al., 2018). RESTRICTED BLOOD FLOW TRAINING 12 As shown in Table 2, The BFR training group will conduct the same arm exercises. The participant's blood pressure will be taken before starting the session (Brandner et al., 2015). Correctly sized narrow cuffs will be positioned to the upper extremities' proximal end (above the bicep, below the deltoid). The fit must be snug to ensure that the cuff does not slip. After that, while the participant is in a relaxed position, the pump will be attached to the cuff nozzle and slowly squeezed at one pump per second until the cuff is at the predefined pressure. The subject will then flex and bend their arms a few times. This should decrease the pressure slightly as some air gets trapped in the overlap of the cuff. The pressure will then be slowly increased back up to the required pressure. The required pressure will range from approximately 1.3 times greater than systolic blood pressure (SBP; ~160 mmHg) to over 200 mmHg (Brandner et al., 2015). After the cuffs are placed, and the participants begin to train at their 50% of 1RM, four sets of 30/15/15/15 with 30 seconds rest between sets and 120 seconds between the two exercises (Rolnick & Schoenfeld, 2020). Table 1: Traditional Resistance training Protocol for men’s physique competitors Monday Tuesday Wednesday Thursday Back (3 Rest Friday 2 biceps Saturday Chest (3 2 biceps exercises, exercises: low to exercises, exercises: low to (3 exercises, with 9 sets in intermediate with 9 sets in intermediate with 9 sets total, 8-15 repetition series total, 8-15 repetition series in total, 8-15 reps and 50"- with progressive reps, and with progressive reps, and 70' intervals overload, four 50"-70' overload, four 50"-70' between sets) sets of (12, 12, intervals sets of (12, 12, intervals 10, 10) between sets) 10, 10) between intermediate intermediate repetitions with repetitions with Quadriceps RESTRICTED BLOOD FLOW TRAINING Monday Tuesday Wednesday 13 Thursday Friday 70% of the one- 70% of the one- repetition repetition maximum maximum (1RM). A rest (1RM). A rest period of 90-sec period of 90-sec will be enforced will be enforced between sets between sets Anterior and 2 triceps medial exercises: low to (1 exercise, exercises: low to (1 exercise, deltoids (2 intermediate with 8 sets in intermediate with 4 sets exercises, repetition series total, 15-20 repetition series in total, 8-15 with 4 sets in with progressive reps, and with progressive reps, and total, 8-15 overload, four 50"-70' overload, four 50"-70' reps and 50"- sets of (12, 12, intervals sets of (12, 12, intervals 70' intervals 10, 10) between sets) 10, 10) between between sets) intermediate intermediate sets) repetitions with repetitions with 70% of the one- 70% of the one- repetition repetition maximum maximum (1RM). A rest (1RM). A rest period of 90 period of 90-sec seconds will be enforced between sets Abdominals 2 triceps Saturday Hamstrings RESTRICTED BLOOD FLOW TRAINING Monday Tuesday Wednesday 14 Thursday Friday Saturday Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets) Abdominals (1 exercise, with 8 sets in total, 15-20 reps, and 50"70' intervals between sets) Table 2: BFR Resistance training Protocol for men’s physique competitors Monday Tuesday Wednesday Chest (3 2 biceps Back (3 exercises, exercises: After with 9 sets in Thursday Rest Friday Saturday 2 biceps Quadriceps (3 exercises, exercises: After exercises, the cuffs are with 9 sets in the cuffs are with 9 sets in total, 8-15 placed, and the total, 8-15 placed, and the total, 8-15 reps and 50"- participants reps, and 50"- participants reps, and 50"- 70' intervals begin to train at 70' intervals begin to train at 70' intervals between sets) their 50% of between sets) their 50% of between 1RM, four sets 1RM, four sets of 30/15/15/15 of 30/15/15/15 RESTRICTED BLOOD FLOW TRAINING Monday Tuesday Wednesday 15 Thursday Friday with 30 seconds with 30 seconds rest between rest between sets and 120 sec sets and 120 sec between the two between the two exercises exercises Saturday Anterior and 2 triceps Abdominals 2 triceps Hamstrings medial exercises: After (1 exercise, exercises: After (1 exercise, deltoids (2 the cuffs are with 8 sets in the cuffs are with 4 sets in exercises, placed, and the total, 15-20 placed, and the total, 8-15 with 4 sets in participants reps, and 50"- participants reps, and total, 8-15 begin to train at 70' intervals begin to train at 50"-70' reps and 50"- their 50% of between sets) their 50% of intervals 70' intervals 1RM, four sets 1RM, four sets between between sets) of 30/15/15/15 of 30/15/15/15 sets) with 30 seconds with 30 seconds rest between rest between sets and 120 sec sets and 120 sec between the two between the two exercises exercises Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets) RESTRICTED BLOOD FLOW TRAINING Monday Tuesday Wednesday 16 Thursday Friday Saturday Abdominals (1 exercise, with 8 sets in total, 15-20 reps, and 50"70' intervals between sets) Data Analysis The study's independent variables are the six-week training period and both BFR training and traditional resistance training. The dependent variable is arm size. Furthermore, descriptive statistics (mean, variance, and standard deviation) will be used to calculate the data cross-time (pre and post) and exercise interventions (BFR and traditional resistance training). The data will be analyzed using the R Studio software, and the parametric test used will be a two-way mixed ANOVA. The two-way mixed ANOVA will be utilized to compare the mean differences between two independent variables to determine whether there is a two-way interaction between and within-subject factors. The two-way mixed ANOVA will also assess the within-subjects factor, which is time, and the between-subjects factors, which are the training (BFR and traditional resistance training) (Baker et al., 2020). In case the type of training and the length of time for which the training was followed have significant effects on arm size, a follow-up test called "simple main effects" should be conducted to identify differences at each time point between the training groups. Ethical Considerations RESTRICTED BLOOD FLOW TRAINING 17 The present study evaluates restricted blood flow training effectiveness in enhancing arm size and circumference outcomes for men’s physique bodybuilders. Therefore, the research will recruit participants who will volunteer to participate and ensure that they provide their consent before the study's onset. The study will be formatted to ensure a smooth process and eliminate any possible harm to the patients. All the participants will complete the form that explicitly describes the benefits, discomforts, and potential risks involved. The study acknowledges the importance of confidentiality and will guard the participants' records against third parties, only sharing information when the participant provides consent. Bias The study aims at investigating the impact of using BFR training on muscle growth and strength, specifically arm circumference and strength, as compared to the traditional training methods. The study introduced bias by selecting only professional male bodybuilders who have undergone training for at least one year. Those who intend to participate for a recreational purpose and those who are female will be exempted. Assumptions The study will assume that the BFR method does not facilitate muscle strength. Thereafter, the experiments will be conducted, the data of which will determine if the assumption is rejected or not. If the outcomes are positive, this assumption will be rejected, while if the outcomes are negative, this assumption will not be rejected. Limitations of the study Various studies have investigated the impact of BFR training on older patients and their effectiveness in healing muscle injuries as a therapy. This study is limited to contrasting the BFR method's effectiveness with that of traditional hypertrophy training. The study will also only assess RESTRICTED BLOOD FLOW TRAINING 18 a small sample due to time constraints. Future research will include a similar study on the female bodybuilding population, with the same restrictions as the current study, to determine if male bodybuilders' muscle-building results are influenced by sex. A separate study involving those individuals interested in including BFR during recreational training may also be conducted. RESTRICTED BLOOD FLOW TRAINING 19 References Baker, B. S., Stannard, M.S., Duren, D. L., Cook, J. L., & Stannard, J. P. (2020). Does blood flow restriction therapy in patients older than age 50 result in muscle hypertrophy, increased strength, or greater physical function? A systematic review. Clinical Orthopaedics and Related Research, 478, 593-606. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31860546/ Biros, M. (2018). Capacity, vulnerability, and informed consent for research. The Journal of Law, Medicine & Ethics, 46(1), 72-78. Brandner, C. R., Kidgell, D. J., & Warmington, S. A. (2015). Unilateral bicep curl hemodynamics: Low-pressure continuous vs. high-pressure intermittent blood flow restriction. Scandinavian journal of medicine & science in sports, 25(6), 770–777. https://doi.org/10.1111/sms.12297 Centner, C., Weigel, P., Gollhofer, A., & König, D. (2018). Effects of blood flow restriction training on muscular strength and hypertrophy in older individuals: A systematic review and meta-analysis. Sports Medicine, 49, 95-108. Retrieved from https://link.springer.com/article/10.1007%2Fs40279-018-0994-1 Fahs, C. A., Loenneke, J. P., Thiebaud, R. S., Rossow, L. M., Kim, D., Abe, T., Beck, T. W., Feeback, D. L., Bemben, D. A., & Bemben, M. G. (2015). Muscular adaptations to fatiguing exercise with and without blood flow restriction. Clinical physiology and functional imaging, 35(3), 167–176. https://doi.org/10.1111/cpf.12141 Gentil, P., de Lira, C., Paoli, A., Dos Santos, J., da Silva, R., Junior, J., da Silva, E. P., & Magosso, R. F. (2017). Nutrition, Pharmacological and Training Strategies Adopted by RESTRICTED BLOOD FLOW TRAINING 20 Six Bodybuilders: Case Report and Critical Review. European journal of translational myology, 27(1), 6247. https://doi.org/10.4081/ejtm.2017.6247 Hanke, A. A., Weichmann, K., Suckow, P., & Rolff, S. (2020). Effektivität des "blood flow restriction training" im Leistungssport. . Der Unfallchirurg, 123, 176-179. Retrieved from https://link.springer.com/article/10.1007/s00113-020-00779-6 Heitkamp, H.C. (2015).Training with blood flow restriction. Mechanisms gain in strength and safety. The Journal of Sports Medicine and Physical Fitness, 55, 446-456. Retrieved from https://europepmc.org/article/med/25678204 Jessee, M. B., Buckner, S. L., Mouser, J. G., Mattocks, K. T., Dankel, S. J., Abe, T., Bell, Z. W., Bentley, J. P., & Loenneke, J. P. (2018). Muscle Adaptations to High-Load Training and Very Low-Load Training With and Without Blood Flow Restriction. Frontiers in physiology, 9, 1448. https://doi.org/10.3389/fphys.2018.01448 Lixandrão, M. E., Ugrinowitsch, C., Berton, R., Vechin, F. C., Conceição, M. S., Damas, F., Libardi, C. A., & Roschel, H. (2018). Magnitude of Muscle Strength and Mass Adaptations Between High-Load Resistance Training Versus Low-Load Resistance Training Associated with Blood-Flow Restriction: A Systematic Review and MetaAnalysis. Sports medicine (Auckland, NZ), 48(2), 361–378. https://doi.org/10.1007/s40279-017-0795-y Loenneke, J. P., Fahs, C. A., Rossow, L. M., Abe, T., & Bemben, M. G. (2012). The anabolic benefits of venous blood flow restriction training may be induced by muscle cell swelling. Medical hypotheses, 78(1), 151–154. https://doi.org/10.1016/j.mehy.2011.10.014 RESTRICTED BLOOD FLOW TRAINING 21 Loenneke, J. P., Thiebaud, R. S., & Abe, T. (2014). Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence. Scandinavian journal of medicine & science in sports, 24(6), e415–e422. https://doi.org/10.1111/sms.12210 Loenneke, J. P., Wilson, J. M., Marín, P. J., Zourdos, M. C., & Bemben, M. G. (2012). Lowintensity blood flow restriction training: a meta-analysis. Europeans Journal of Applied Physiology, 112, 1849-1859. Retrieved from https://link.springer.com/article/10.1007%2Fs00421-011-2167-x Luebbers, P. E., Fry, A. C., Kriley, L. M., & Butler, M. S. (2014). The effects of a 7-week practical blood flow restriction program on well-trained collegiate athletes. .Journal of Strength and Conditioning Research, 28, 2270-2280. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24476782/ Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., … Loenneke, J. (2019). Blood flow restriction exercise: considerations of methodology, application, and safety. Frontiers in Physiology, 10, 533. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530612/ Rolnick, N., & Schoenfeld, B. J. (2020). blood flow restriction training and the physique athlete: A practical research-based guide to maximizing muscle size. Strength and Conditioning Journal, 42, 22-36. Retrieved from https://www.researchgate.net/publication/340836828_Blood_Flow_Restriction_Training _and_the_Physique_Athlete_A_Practical_ResearchBased_Guide_to_Maximizing_Muscle_Size RESTRICTED BLOOD FLOW TRAINING 22 The American Educational Research, (2020). AERA offers definition of scientifically based research. Retrieved from: https://www.aera.net/About-AERA/Key-Programs/EducationResearch-Research-Policy/AERA-Offers-Definition-of-Scientifically-Based-Res Vanwye, W. R., Weatherholt, A. M., & Mikesky, A. E. (2017). Blood Flow Restriction Training: Implementation into Clinical Practice. International journal of exercise science, 10(5), 649–654. Yamanaka, T., Farley, R. S., & Caputo, J. L. (2012). Occlusion training increases muscular strength in division IA football players. Journal of Strength and Conditioning Research, 26, 2523-2529. Retrieved from: https://journals.lww.com/nscajscr/Fulltext/2012/09000/Occlusion_Training_Increases_Muscular_Strength_in.29.aspx RESTRICTED BLOOD FLOW TRAINING Appendix A Health Questionnaire 23 RESTRICTED BLOOD FLOW TRAINING 24
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