Build Muscle, Increase Strength & Improve Recovery | Blood Flow Restriction Exercise with Dr. Sten Stray-Gundersen

Show Notes

What if you could get close to the strength and muscle gains of heavy lifting using nothing but a resistance band, a water bottle, and a set of cuffs?

Restricting blood flow during light exercise turns out to produce strength gains roughly on par with training at heavy loads, and the muscle under the cuff can desaturate down to 5 to 10% oxygen, which is about as intense as exercise physiology gets.

In this episode, Dr. Ravi Kumar sits down with Dr. Sten Stray-Gundersen, an assistant professor at the University of South Carolina who has spent more than a decade studying hypoxia and exercise physiology. Blood flow restriction training runs in the family. His father, Dr. Jim Stray-Gundersen, helped pioneer the field and developed BStrong, the only BFR cuff built by a medical doctor. Sten used BFR himself as a soccer player, and once spent about six months sleeping, eating, and doing homework inside a hypoxia tent as a competitive cross country skier.

The mechanism comes down to which blood vessels the cuffs are damming. Positioned high on the arms or legs, they restrict venous outflow while arterial inflow keeps working, so metabolites pool inside the muscle instead of clearing. That accelerated fatigue lets a load as light as 20 to 30% of your max recruit the same high threshold, fast twitch motor units that normally require heavy weight. Sten points to a seminal 2000 study in older women doing bicep curls: the heavy load group and the BFR group ended up with equal gains in force production, while the light load group without cuffs barely improved at all.

Dr. Kumar presses hard on the safety question, because a neurosurgeon hears “restrict blood flow to a limb” and immediately thinks about ischemia, blood clots, and blood pressure spikes. The answers are reassuring. You are never occluding the artery, and because the muscle pump keeps blood moving, you never get stasis. One study found a significant rise in tPA, the body’s own clot busting factor, during BFR exercise. The 2015 concern about an exaggerated exercise pressor reflex did not hold up a decade later. Decades of KAATSU use in Japan, with tens of thousands of sessions happening daily, show very rare complications, and sickle cell disease is the one absolute contraindication.

They also dig into what makes a session actually work. The target is a real fatigue pocket: 3 to 5 sets of 15 to 20 reps where the last 5 reps are a struggle, cuffs staying inflated between sets, resting only 30 to 60 seconds. In Sten’s own review paper, perception of effort and proximity to failure sit at the top of the hierarchy, with cuff pressure at the bottom. The discomfort should come from the muscle, not from the band digging into your skin.

The back half goes deep on mechanism, and this is where the episode gets fun. Local muscle hypoxia shares the HIF-1 alpha and VEGF pathway with altitude training but does not stimulate EPO the way sustained altitude living does. mTOR and growth hormone rise as if a major insult occurred, except there is almost no tissue to repair because the mechanical work was light, so the signaling upgrades the whole system for 48 to 72 hours. Muscles above the cuff grow too. Aerobic BFR studies show VO2 max and quadriceps size increasing together, which almost never happens. And lactate, long treated as a waste product, is now being investigated as both a brain fuel and a signaling molecule that activates BDNF.

Dr. Kumar closes with four real people, his aging parents, his son, his daughter, and himself, and asks Sten to write the protocol for each one.

Episode Resources

• BStrong Website
• Dr. Sten Stray-Gundersen, PhD, CSCS on LinkedIn
• Dr. Ravi Kumar’s Website
• Dr. Ravi Kumar on LinkedIn

In this episode, you will discover:

• It is the veins, not the arteries: The adaptation comes from damming venous outflow while arterial inflow keeps working, because true arterial occlusion risks ischemia, muscle damage, and rhabdomyolysis
• Why light loads work: Accelerated fatigue under restriction lets loads of just 20 to 30% of your max reach the high threshold motor units that normally require heavy weight
• The seminal 2000 study: Older women doing bicep curls saw equal gains in force production between the heavy load group and the BFR group, while the light load group barely improved
• The fatigue pocket: 3 to 5 sets of 15 to 20 reps where the last 5 reps are a real struggle, with the discomfort coming from the muscle and not from the band
• What actually matters most: In Sten’s own review paper, perception of effort and proximity to failure sit at the top of the hierarchy, with cuff pressure at the bottom
• Where the cuffs go: High up, where the deltoid meets the bicep and where the hamstring meets the glute, never at the elbow, the knee, or the calf, no matter which muscle you are training
• Check your pulse: A strong radial pulse means you are not occluding the artery, and the same check works at the popliteal and posterior tibial arteries in the legs
• The safety record: Decades of KAATSU use in Japan, with tens of thousands of daily sessions, show very rare complications, and sickle cell disease is the one absolute contraindication
• The clotting question, answered: Because the muscle pump prevents stasis and BFR raises tPA and nitric oxide, the technique may actually lower clotting risk rather than raise it
• Keep the cuffs inflated between sets: Resting just 30 to 60 seconds with the cuffs still on is what keeps the muscle from recovering back to homeostasis
• Hypoxia, but local: BFR shares the HIF-1 alpha and VEGF pathway with altitude training, but it does not stimulate EPO the way sustained living at altitude does
• The muscle gets remarkably hypoxic: Near infrared spectroscopy shows tissue saturation dropping as low as 5 to 10%, on par with the most intense exercise you can do
• Muscles above the cuff grow too: Pecs and lats adapt alongside triceps and biceps, through greater reliance on unrestricted muscles and a systemic anabolic response
• VO2 max and muscle size together: Treadmill walking in a clinical population and uphill walking in basketball players both raised VO2 max and quadriceps cross sectional area at the same time
• The over response: mTOR and growth hormone rise as if a major insult occurred, but because the mechanical work was light there is little tissue to repair, so the signaling upgrades the system for 48 to 72 hours
• Lactate as brain fuel: Emerging work suggests BFR generated lactate may serve as an alternative fuel and a BDNF signaling molecule in the brain
• You need almost no equipment: Body weight squats, lunges, glute bridges, wall push ups, water bottle curls, and a cheap set of resistance bands will do it
• Four real protocols: Dr. Kumar walks Sten through his aging parents, his son chasing a planche, his daughter chasing a sub six minute mile pace in the 5K, and his own arms

Key Takeaways

Blood flow restriction is a dam, not a tourniquet. The cuffs sit high on the limb and let arterial blood in while intermittently blocking venous return. Metabolites pool, fatigue accelerates, and the body responds as though you had lifted heavy. If you were actually occluding the artery you would be creating an ischemic environment, which is exactly what causes muscle damage. A strong radial pulse is the simple check.

Light load plus restriction reaches the same motor units as heavy load. Under Henneman’s size principle, high threshold motor units only switch on under high force or high fatigue. BFR gets you to fatigue at 20 to 30% of your one rep max, which is why the strength gains come close to matching heavy training in study after study.

Effort is the variable that matters, not pressure. The hierarchy from Sten’s review paper puts perception of effort and proximity to failure at the top and cuff pressure at the bottom. If the last 5 reps of a set are not a struggle, the session is not doing much. And the struggle has to come from the muscle burning, not from the band hurting.

The safety concerns have largely been answered. No stasis means no clot setup, and BFR actually raises tPA and nitric oxide. The blood pressure response looks like the response to ordinary high intensity exercise. The technique is now being studied in cardiac rehab, Parkinson’s, multiple sclerosis, and prehabilitation for abdominal cancer surgery. Sickle cell disease is the one hard no.

It works because it is hormesis. A small, controlled dose of hypoxia makes the whole system more adaptable. Sustained hypoxia is destructive, and brief hypoxia is a signal to upgrade. Like cold immersion, heat, and light, the benefit lives in the middle of the curve, and it only shows up if the nutrition and sleep are there to support the rebuild.

It lowers the barrier to entry. A 5 to 10 minute session with body weight and a set of cuffs delivers the therapeutic effect of a workout, which is often enough to get someone who is tired, stressed, or traveling to keep training at all.

Transcript

[00:00:00 –> 00:00:45] Dr. Ravi Kumar: Welcome back to the Dr Kumar Discovery. My name is Dr. Ravi Kumar, and on today’s episode, I’m sitting down with Dr. Sten Stray-Gundersen, one of the world’s leading experts in blood flow restriction training and the physiology of hypoxia. Now, when most of us hear of building muscle, our minds go to a few places. Heavy barbells, hours in the gym, being so sore the next day you can barely walk down the stairs. That whole no pain, no gain idea has been drilled into us for decades. But blood flow restriction is a very different story. By placing specialized cuffs on the upper arms or upper legs, you can slightly slow blood flow in and out of working muscles.

[00:00:45 –> 00:01:37] Dr. Ravi Kumar: And that lets you train with very light loads, sometimes 20 to 30% of what you’d normally lift. And you still get the kind of strength and muscle gains we used to think came only from heavy lifting. Now, the heavy load camp isn’t wrong. Heavy training does work for gaining muscle and strength, and it’s still one of the best tools we have. But I really wanted to understand how blood flow restriction exercise works, and how we can utilize it to make physiological fitness more attainable. And that’s where Dr. Stray-Gundersen comes into this conversation. He has spent more than a decade studying hypoxia and exercise physiology. His father, Dr. Jim Stray-Gundersen, helped pioneer the field of blood flow restriction exercise, and Sten has carried that work forward as a researcher, and now as an assistant professor at the University of South Carolina.

[00:01:37 –> 00:02:27] Dr. Ravi Kumar: So by the end of this episode, you’re gonna understand what blood flow restriction actually is, and what it’s doing inside your body, why light loads can drive the same adaptations as heavy loads when using this technology. You’ll understand who benefits from this, from elite athletes, all the way to people who can’t even get in the gym at all, and how you can actually put this into practice for yourself using these blood flow restriction devices. It’s going to be a great episode, and I hope you enjoy it. I just want to give you a quick disclaimer. I’m a doctor, but I’m not your doctor. This show is for informational purposes only. Everything you learn from my conversation with Dr. Stray-Gundersen is meant to empower you. So take this knowledge, ask better questions, and work with your own doctor to build a more informed, healthier life. And just to be clear, this show is separate from my role as assistant professor at UNC.

[00:02:27 –> 00:03:06] Dr. Ravi Kumar: All right, let’s get into it. My name is Dr. Ravi Kumar. I’m a neurosurgeon in search of the causes of human illness and the solutions that help us heal and thrive. I want you to join me on a journey of discovery as I turn over every stone in search of the roots of disease and the mysteries of our resilience. The human body is a mysterious and miraculous machine with an amazing ability to self heal. Let us question everything and discover our true potentials. Welcome to the Dr Kumar Discovery.

[00:03:06 –> 00:03:51] Dr. Ravi Kumar: Dr. Stray-Gundersen, thanks so much for joining us on the Dr Kumar Discovery. I’m super excited to talk to you because you’re an expert in hypoxia, and specifically how to apply it to human health through something called blood flow restriction exercise. And I think most of our audience, they may have heard of this, or they may not have heard of it at all, but it’s a technique that’s been around for a while, that your father helped pioneer, and now that you’re actually developing this through commercial interests and your research as a professor at University of Southern, of South Carolina. So please tell us, yeah, so please tell us first, what is blood flow restriction exercise, and how, what does it do to the human body?

[00:03:51 –> 00:04:18] Dr. Sten Stray-Gundersen: Yeah, so first of all, for having me on Dr. And it’s a privilege to be on here. So blood flow restriction is, like you said, it’s been around for, really surprisingly been around in the world for about 50, 60 years, for decades at this point. But kinda just made its way over to the West in the last, I would say, 10 to 20 years. So BFR is the application of bands or cuffs on the upper arms or upper legs, in order to partially restrict arterial inflow into the muscle, while intermittently occluding blood flow out of the muscle.

[00:04:18 –> 00:05:02] Dr. Sten Stray-Gundersen: And by setting up this slight impairment on the normally fine tuned circulatory system, we’re able to accelerate fatigue using light loads, specifically, and that’s a key here, is we’re using light loads as opposed to heavy loads with traditional resistance training, or high intensity, traditional sort of interval training. We can apply it in aerobic sense. And this essentially signals the body that there’s a major disturbance in homeostasis, and that is really only achieved when we have a high load or high intensity type stimulus, And so the body recognizes that, as opposed to this low load, or low low intensity stimulus, and we sort of have this systemic, and also local adaptation response to that disturbance in homeostasis. So essentially what we can do is 20 to 30% of the regular lows that we’re typically lifting, with the application of this BFR,

[00:05:02 –> 00:05:22] Dr. Ravi Kumar: this blood flow restriction, in order to generate adaptations that we can really only achieve with that high intensity or high load exercise. Okay. So that’s very interesting. So basically, you’re saying that by slowing input of blood into the limbs, and slowing outflow as well, you’re inducing this stress that stimulates larger amounts of work.

[00:05:22 –> 00:06:17] Dr. Sten Stray-Gundersen: Yes, exactly. So, and I think the key there is really damming up the venous side of things. Okay. Because we’re not having the normal clearance of metabolites. It’s not that we’re necessarily restricting the arterial inflow compared to let’s say rest. It’s that when we go from a resting state to an exercise state, we don’t get as big of an increase in the arterial inflow that we’re that we’re normally seeing. And actually when we go and try to occlude the the artery, we can get an ischemic event, or ischemic condition within that muscle, and when you’re contracting and during an ischemic sort of condition, that can actually cause muscle damage, rhabdomyolysis, and all these negative things that are with occluding or ischemic exercise, or an ischemic heart attack, right? Yeah. The real key is to kind of dam up the venous side in order to accelerate that fatigue response, and then there’s this neurohumoral immuno response that is normally associated with that high intensity type exercise.

[00:06:17 –> 00:07:02] Dr. Ravi Kumar: Okay. So, yeah, so normally when we exercise, our blood pressure goes up, and perfusion of our muscles increases. So you’re actually not cutting off blood flow, but you’re preventing that increase in hyperemia, or increased blood flow to the muscles during exercise, and you’re slowing down venous return to the heart from the limbs, right? And that induces this condition where you’re not ischemic, but you are kind of accumulating these metabolites that induce stress in the muscles, And my guess is that with doing that, you’re actually causing the same kind of injury to the muscle that high intensity work would induce, and you’re getting hypertrophy and muscle gains. Is that what the goal of this is?

[00:07:02 –> 00:07:53] Dr. Sten Stray-Gundersen: Yeah, and I would just say maybe the injury is probably an overstatement, it’s probably like an insult, or just disturbance in its normal You’re sort of simulating the micro environment that you would kind of achieve with high load or high intensity exercise. And really, one of the things, and hypoxia is very related to this, or involved in this process, is you’re getting recruitment of the high threshold motor units that are responsible for producing large amounts of power, and force. So by essentially restricting the normal blood increases in blood flow that we see with high load or high intensity exercise, combining this with low intensity light load exercise allows you to stimulate those motor units, which are innervating those type 2a and type 2x fibers, in order to stimulate those maximally, and reap the benefits of light load exercise as if it were high load exercise.

[00:07:53 –> 00:08:13] Dr. Ravi Kumar: Right, okay, so I do want to come back to that a little later, because I think understanding that will help us understand better how this is working. But first, describe to my audience what this actually looks like. Mean, you’re describing this, you call BFR blood flow restriction, right? And then it’s a device that you wear, correct?

[00:08:13 –> 00:08:30] Dr. Sten Stray-Gundersen: Correct, yes. So they look like, you kind of think of like a blood pressure cuff. Okay. You know, they’re about, you know, 5 centimeters, or 5 inches wide. There’s various widths of different cuffs and things like that, but essentially you’re placing this cuff on the very upper arm.

[00:08:30 –> 00:09:30] Dr. Sten Stray-Gundersen: So I like to say kind of where the deltoid meets the bicep on the arms, and then right where the hamstring meets the glute on the legs. And essentially we’re creating compression around those areas, and that is just enough to allow for a certain degree of arterial inflow, while impeding intermittently the venous outflow. And that’s the key here, is actually the muscle pump, as you know, we have these one way valves within our veins, and so when we actually squeeze the muscle during contraction, this squeezes the blood within those veins, the blood only has one way to go, and that’s back towards the heart. So at rest, when you’re not contracting the muscle, that pressure is enough, is sufficient to restrict, completely occlude the vein, but when you go to actually contract the muscle, that overcomes the impediment from the band itself, or the cuff itself, and allows some flow to get back in. So kind of instead of this normal kind of lazy river sort of venous system that we typically associate with the veins, it’s now kind of going from a dam situation to a really big you know spout, essentially like releasing the dam you know intermittently.

[00:09:30 –> 00:09:48] Dr. Sten Stray-Gundersen: And that is enough to sort of, as you know, the circulatory system is very fine tuned, and this slight impairment on the system is enough to cause this major disturbance locally within the muscle, which then feeds up back to the brain, and we have this systemic response to these local changes.

[00:09:48 –> 00:09:53] Dr. Ravi Kumar: Okay. So these cuffs, are they pneumatically insufflated?

[00:09:54 –> 00:10:45] Dr. Sten Stray-Gundersen: Yes. Then there’s a bunch of different types out there. So there’s things ranging from non pneumatic kind of like belts or resistance bands and things like that, to you know rigid cuffs, are essentially adapted blood pressure cuffs, they use a pneumatic gauge to actually increase the compression there. Then you have things like KAATSU and BStrong, which are using a semi elastic material, and then we we have a pneumatic aspect to that to then control the pressure from there. Kind of a broad range of types of devices, but ultimately what they’re trying to do is to restrict the venous side, partially restrict the arterial side. And again, you place these on the upper arms and upper legs only. I get a lot of questions whether to place it, you know, at the elbow if you’re working on your on your forearm or your elbow or things like that, or or if you’re working on your calves, do I put it around my knees? Whatever muscle group you’re working, they’re gonna go up on the upper arms or the upper legs.

[00:10:45 –> 00:10:56] Dr. Ravi Kumar: Okay. So how do you know that you’re not blocking off arterial blood flow, right? Because if you get above systolic blood pressure, you’re essentially cut off blood flow to the limb, correct?

[00:10:56 –> 00:11:20] Dr. Sten Stray-Gundersen: Correct, yeah, and actually that’s a really good point. The reason why we can, you know, at rest occlude the veins without occluding the arteries is because the pressure required to do so is much higher for the arteries than it is the veins. Right? We go into a doctor’s office, our our systolic blood pressure evaluated, 120 over 80 let’s say. So 120, that that is the pressure at rest required to completely close the vein, or completely close off the artery.

[00:11:20 –> 00:12:05] Dr. Sten Stray-Gundersen: And so, yes, in order to find that point at which you’re not occluding, some devices will have the ability to occlude, and so they’ll go up to what we call that occlusion pressure. This may or may not, depending on your position, depending on your body position, depending on your current heart rate, or your current state, it may or may not line up with your systolic blood pressure that you read in the doctor’s office. And so whatever that occlusion pressure is, that’s our 100% occlusion pressure, or AOP, arterial occlusion pressure, and then a percentage of that is employed during the exercise. And basically anywhere from 30 to 80% of that occlusion pressure has been shown to be effective in accelerating that fatigue response, and inducing these beneficial adaptations. Now, that’s kind of one way to do it.

[00:12:05 –> 00:12:45] Dr. Sten Stray-Gundersen: Another way to do it is to have that inability to occlude the artery completely. And that’s what the design of KAATSU and BStrong is really all about, is to prevent that occlusion in the first place. And one of the simple ways that you can actually assess this, some other devices use like a Doppler ultrasound to actually look at inflow and percent reductions and things like that. But a very simple task is to make sure that you have arterial blood flows to check your radial pulse. If you’re getting a strong pulse in that radial artery, you’re not occluding the artery in the arms. You can also look at your popliteal artery in your leg, or your tibialis artery behind your ankle.

[00:12:46 –> 00:12:54] Dr. Ravi Kumar: And so how do these KAATSU and BStrong devices, how do they prevent inadvertent occlusion of the artery? You said there was some mechanism in there, correct?

[00:12:54 –> 00:13:44] Dr. Sten Stray-Gundersen: Yeah. And so I can really speak to BStrong, because that’s kind of what I’m more familiar My dad really helped, really developed BStrong, it was actually the only BFR cuff out there developed by a medical doctor, who had a very complete understanding of cardiovascular physiology. And he understood that the way to make these bands safe was to prevent the risk of occlusion in the first place. And so it’s actually a very interesting thing, the way that it was designed was to have this sort of semi elastic component, where, you know, at non inflated, at non inflated state, the band is actually relatively inelastic, it’s relatively stiff. But then when you go to inflate it with with air, it has almost a accordion like design, or some people have referred to it as a multi chamber design, and that that design allows for when the air is inflated, it becomes an elastic device.

[00:13:44 –> 00:14:39] Dr. Sten Stray-Gundersen: That elasticity sort of matches well onto the elasticity of muscle. So it’s a very similar sort of texture and firmness and that kind of density as the muscle is in and around your arteries and veins. So it kind of matches that well, and it doesn’t And the other thing about it is when you’re having a rigid system around the limb, it becomes uncomfortable at the peak contraction, at the peak of concentric contraction, whereas the elasticity allows that band to expand with each contraction while maintaining that restriction in and around the limb as well. So that’s kind of the main difference, is it’s a semi elastic sort of system that’s pneumatically controlled, versus a rigid system that’s pneumatically controlled, versus a resistance, you know, non pneumatic sort of very elastic resistance situation. And there’s, you know, different ins and outs of of what kind of differs between these devices, which I don’t want to bore your audience with, but there is a lot that goes into both the design and kind of application with regard to that.

[00:14:39 –> 00:15:35] Dr. Ravi Kumar: Okay. Okay, so let me just recap what we’ve kind of understood so far, is that one, blood flow restriction exercises allows you to basically slow down blood flow entry during exercise into your limbs, intermittently occlude venous outflow, and that allows you to do, get the same amount of basically muscle gain or strength or hypertrophy, we’ll talk about it, but you get the similar gains at lower work by using these bands. And we talked about how these bands, they go around your upper arms, your upper legs, you can exercise with them, they can be pneumatically insufflated, and they should allow arterial entry into the limb, they should not occlude it. Okay, so we’ve got that. Before we move on to the mechanistic stuff, which I think is really fascinating, and that’s why I wanted to talk to you today, we should tell the audience why they might be interested in this.

[00:15:35 –> 00:16:08] Dr. Ravi Kumar: Because I think there’s a chance at this point, a lot of people are saying, well, I go to the gym. I’m fine. You know? Or and and there’s different situations. People recovering from strokes, or heart attacks, or people who are deconditioned. And then there’s even people like me who are moderately good conditioned. And then there’s elite athletes who are fantastically fit. Like, where does BFR fit, blood flow restriction fit into this whole spectrum of people, and why would anyone be interested in it who might be listening to this podcast?

[00:16:08 –> 00:17:09] Dr. Sten Stray-Gundersen: Yeah, it’s a great question, and there’s so many different kind of applications that, you know, a lot of these things, the answer is always it depends, like how do I apply it here? Well it depends on X, Y, or Z, so it’s a really great question. And one of the things I, before going into that, I do wanna say it’s not just that we are restricting the blood flow, and that is what’s causing the adaptation, it’s really the conscious intent behind the exercise. Meaning you have to get to a certain level of discomfort within the muscle in order to stimulate those high threshold motor units, which are really responsible for causing these adaptations, and signaling the brain to release the anabolic milieu that is responsible for adaptation from that exercise, or exercise in general. So it’s, you know, it can kind of sound like a shortcut, if you will, but it’s definitely an enhancement of a lot of exercise in my opinion, where, you know, if either you’re on that sort of elite end of the spectrum, you’re needing there’s a large degree of cost associated with getting to the intensities that are required to elicit further adaptation.

[00:17:09 –> 00:18:07] Dr. Sten Stray-Gundersen: This allows you to sort of lower that threshold in terms of the actual mechanical work being done, which necessitates recovery, and you know creates systemic fatigue, CNS fatigue, all those kind of things. It lowers that threshold so you’re able to reach that relative intensity, and stimulate that muscle microenvironment to a point where now you’re able to augment the gains from your regular exercise by either adding this as a recovery tool, by promoting blood flow, or using it as a powerful, sort of robust exercise stimulus to augment the adaptations that you’re already stimulating with your other days of training. So Okay. In that case, and sort of the elite athlete case, which is very interesting, there’s a kind of a range of different applications. As I mentioned, one is kind of recovery, so you’re using this your easier days, where maybe you’re using it on a bike, or on a treadmill, or even doing some sort of body weight exercises to just help the body recover from previous more high intensity type sessions.

[00:18:07 –> 00:18:53] Dr. Sten Stray-Gundersen: I’m working with a group, collegiate group as well, that is doing track and field, and they’re using this on their sort of moderate interval days, or their kind of zone two training, where they’re adding the bands to to that existing program. And then kind of adding it in some of their higher intensity days, where maybe instead of doing 10 intervals that day, they do, you know, six intervals without the bands, and then add two kind of finisher intervals with the bands. So definitely a lot of different applications. Another one would be sort of a pre activation type situation, where maybe they’re getting ready for a race, or ready for a game, and they’re using this as a way to sort of quickly warm up, and cause increases in hemodynamics throughout the whole body, to increase that blood flow to muscles that are going to be using it shortly thereafter. Now that’s one end of the spectrum.

[00:18:53 –> 00:19:45] Dr. Sten Stray-Gundersen: Another end of the spectrum is sort of clinical populations who can’t tolerate or simply don’t want to do high intensity or high load exercise. And I will say just as a slight caveat here, I think you know, to date, I think the gold standard for increases in strength and muscle size, and in general fitness, are going to be high loads and high intensity. So I believe you kind of fall within this, right, is if you’re able to do those high loads, if you’re able to do those high intensities, I think that is a very robust, and probably the most robust tool that we can use. But are you I think where BFR can kind of layer into that situation is, can you continually stimulate these adaptive responses on the days where you’re going lighter, or going lower intensity? So instead of you know, being able to tolerate sort of maybe one to two very high intensity days, If you’re in the gym, maybe you’re doing three days a week of sort of heavy, traditional heavy lifting.

[00:19:46 –> 00:20:50] Dr. Sten Stray-Gundersen: Now can you kinda intersperse BFR on the days where you’re not at doing that kind of thing, to then augment the and stimulate the the adaptations that we kinda get from that high intensity, essentially with less cost. So that’s kind of like, we went from kind of elite to sort of in that middle zone, and then as I meant, I started to mention clinical, for people who can’t tolerate or don’t want to do high intensity or high loads, this is a great tool for if you’re extremely deconditioned, to get away with doing one to two exercises, and stimulate those responses, and maybe get you to a place where you are able to be more functional, and are able to expose yourself to higher loads once you’ve kind of built that base. Right. So that can take the form of light intensity walking, so walking around the neighborhood with the bands on. It can take the form of doing sort of body weight exercises, whether that’s push ups or regressed push ups, you know, on your knees, or body weight squats, or single leg RDLs, deadlifts, Bulgarian squats, things like that, to really get a lot of the muscle that’s involved in that exercise very fatigued, to stimulate those adaptation responses and all those signaling pathways that go into that, which we can talk about going forward.

[00:20:50 –> 00:21:43] Dr. Ravi Kumar: Hey, guys. I need a quick favor. If you’re getting value from this show, would you please take 30 seconds to rate and review us on Apple Podcasts? I know it seems like nothing, but it genuinely changes how many people the algorithm puts the show in front of. And if an episode hits home for you, send it to someone who you think needs to hear it. I’m doing this to cut through the noise and bring you clear, honest information on health topics that actually matter to all of us. So please help me get this show to more people who need it. Cheers. Okay. So with someone who is like me, who’s working out, maybe there’s days where I just don’t have time to go to the gym and do a heavy workout, or I’m fatigued, I can put these on, do a light workout, 20 to 30% of what I would normally do on a heavy load day, and and get similar results?

[00:21:43 –> 00:22:27] Dr. Sten Stray-Gundersen: Yes. Exactly. I mean, you you just put it very succinctly and and articulately. That is, I think I’ll tell you how I use it. Okay. So I can I can manage heavy loads, high intensity kind of stuff? I typically do one high intensity interval type session per week, and then 2 to 3 sessions of high load, which kind of traditional type exercise, or resistance exercise. During those 2 to 3 sessions where I’m doing the high load traditional type exercise, I will use this as a finisher for those sessions. So whatever muscle groups that were kind of involved in that given training day, I’ll do those same muscle groups, and then add an additional muscle group, an antagonistic muscle group at the end of that session. So let’s say I’m doing more of a push day, so I’m doing kind of incline bench press, and chest press, overhead press.

[00:22:27 –> 00:23:03] Dr. Sten Stray-Gundersen: I’ll do all those kind of heavy. I’ll do kind of in a superset fashion, and then I’ll at the end of that, maybe 15, 20 minutes, I’ll add the bands in as sort of a finisher to really ramp up and make sure I’m hitting that ceiling of that anabolic response to that given exercise. This allows me also to reduce how much heavy load I would otherwise do on that day. So if I didn’t have the bands, would probably do some accessory work where I’m doing still heavy loads, and that kind of can kind of cause breakdown over time, and just kind of wear and tear. And so this allows me to do lighter loads to prevent or attenuate that breakdown or wear and tear while maximally stimulating that anabolic response.

[00:23:04 –> 00:23:16] Dr. Ravi Kumar: Okay, let me just interrupt you real quick. So you’re doing bench press, incline press, overhead press, heavy weights, and then you’re putting the bands on reducing the weight on those same exercises?

[00:23:17 –> 00:23:27] Dr. Sten Stray-Gundersen: And Yes. Yeah. Okay. Either on those exact same exercises or related exercises. Right? Instead of an overhead press, maybe I’m doing like a lateral raise, like working the same muscle groups essentially. Okay.

[00:23:27 –> 00:23:37] Dr. Ravi Kumar: And what that does is that finishes off the maximal amount of muscle adaptation that you can have for that day of exercise? Exactly. Yes.

[00:23:37 –> 00:23:58] Dr. Sten Stray-Gundersen: Okay. And and, you know, maybe getting ahead of the ahead of the curve here, but I think there’s this this therapeutic effect, this mental therapeutic effect of exercise too. And so when you leave leave the gym, and you feel like you’re Yeah. Not not exhausted, but just kinda like either pumped up, or just just feeling like you you put out an effort, and you kind of Yeah. Everybody kind of understands what I’m talking You

[00:23:58 –> 00:24:01] Dr. Ravi Kumar: feel good. Everyone knows, yeah, everyone knows what you’re talking about.

[00:24:01 –> 00:24:57] Dr. Sten Stray-Gundersen: Exactly. Feel good. To kind of ensure that, that you’re getting that response, it’s a great way to do. You also mentioned, you know, being short on time or traveling. Right? I think that’s where for the for the busy executive, for the busy assistant professor, that’s where it can be really useful. I was just at a a kind of back to back conferences, and a great way to make sure that I’m continuing my training program is to add in a 20 to 30 minute BFR session in a hotel gym, where you may or may not have access to the heavy loads that you’re used to dealing with, so you can And in a very short amount of time, you can elicit a very very robust fatigue response, get that therapeutic effect of the exercise, and kind of go on about your day. It’s a great way to do it. You know, I have a boy on the way, so I know when that comes around, I’m be a little bit shorter on time, may not be able to fit in my hour and a half, or you know, two hour session, two or three days a week, so I’m gonna try to get away with 30 to 45 minutes of BFR session, and kinda cut So that in that’s another great way to kinda implement this.

[00:24:57 –> 00:25:31] Dr. Sten Stray-Gundersen: The last thing I’ll I’ll say with regard to this programming kind of conversation is, it’s great to use during your deload weeks. Right? If you ever have a program where you’re maybe working for anywhere from 4 to 8 weeks, where you’re kind of each week after week after week you’re progressively overloading the weight, that kind of thing, to allow your body to sort of recover, recover from that systemic stress of repeated week after week progression, can you now add a deload week with the use of BFR to really reduce that overall systemic fatigue, but then still be maximizing and kind of hitting that anabolic ceiling with regard to your training.

[00:25:31 –> 00:25:56] Dr. Ravi Kumar: Okay. So what about these folks who are either sarcopenic or deconditioned, elderly, and they want, they can’t get into the gym and just do big workouts. I know you’ve already mentioned this briefly, but tell us how they could possibly practically use these blood flow restriction exercises to amplify their gains in their because putting muscle on your body is probably the healthiest thing you can do at any point in your life.

[00:25:56 –> 00:25:58] Dr. Sten Stray-Gundersen: Yes. The metabolic sponge, right?

[00:25:58 –> 00:26:17] Dr. Ravi Kumar: It is, our metabolic sponge. And your whole, the health of your body, your brain, Everything. Every metabolic input in your body is determined, or if the efficiency of your metabolic system is determined by how much muscle you have on your body. Yeah, So how can they use this to improve that aspect of metabolic health?

[00:26:17 –> 00:27:28] Dr. Sten Stray-Gundersen: Yeah, and one thing, just to piggyback off what you said, not only, you know, is it metabolically so active, but it’s also promoting these increases in blood flow, these increases in nitric oxide, which we know have all these downstream effects on health and things like that. And I think that’s one of the biggest targets for BFR is sort of clinical populations who, in my sort of anecdotal experience, in addition to the research, I’ve seen the most robust responses to BFR in these clinical populations who haven’t been able to do exercise. And you see it in their demeanor, it’s this huge shift in their thinking away from sort of this sort of depressive and anxious sort of state into better mood, know better libido, better just positive affect in terms of life. And I think they would get that from sort of exercising at high intensity or that kind of thing, but they simply just can’t do it. And so by sort of adding this in, in order to stimulate that response that we can really only achieve with high intensity or high load exercise, it allow it really gives these people a lot of hope, and a lot of therapeutic effect beyond just the physical, or the physiological, into the psychological, and that kind of thing.

[00:27:28 –> 00:28:14] Dr. Sten Stray-Gundersen: So how could they use it? What I would do is start as as simple as one exercise, and this can be anywhere from 3 to 5 minutes, maybe even less, starting out. Because depending on how deconditioned that individual is, they really don’t it’s it’s actually amazing how little work you need to do to start making small changes. And so this could take the form of, you know, you put the bands on the legs, you do 3 sets of 15 to 20 squats, and you call as long as you’re kinda getting to the point where those last, I would say 5 reps of the second, third, or fourth set are uncomfortable in the sense of it’s a struggle to complete that movement. A really important thing, just slight tangent here, that the discomfort should come from the exercise, not the restriction of the band in a specific area.

[00:28:14 –> 00:28:53] Dr. Sten Stray-Gundersen: Okay. So, if that is what is preventing that person from completing that exercise, I would either readjust the bands, reduce the pressure slightly, just kind of figure out various ways to address that pain sensation you’re getting from the band. The thing that we want to actually get the person to cease the exercise is the muscle discomfort, that metabolic acid burn that we typically associate with lactic acid. It’s more of the hydrogen accumulating, but that seems to be a really good target, a really good trigger for the body to respond to the BFR exercise. So I think that metabolic burn, that burning sensation is going to be critical for whatever exercise you’re doing.

[00:28:53 –> 00:29:25] Dr. Sten Stray-Gundersen: And that’s why these, I mentioned you know, 3 to 4 sets of 15. Typically what I’ve seen is that is a good target to be able to hit that point consistently, in a wide range of people. But that number can kind of ebb and flow, depending on what state that person is in, what load they’re using, and that sort of thing. So kind of getting to what I would call the fatigue pocket, and kinda staying in that for between 3 to 5 reps, is really what we’re looking for. So however you do, whatever means to achieve that, are sort of all good, all game.

[00:29:26 –> 00:29:28] Dr. Ravi Kumar: Okay. And you said 3 to 5 reps, you mean 3 to 5 sets?

[00:29:28 –> 00:29:36] Dr. Sten Stray-Gundersen: Yes, sorry, 3 to 5 sets of anywhere from, you know, 15 to 20 reps is typically Right. We can come at that point.

[00:29:36 –> 00:30:09] Dr. Ravi Kumar: We always, yeah, we always hear about maximal muscle adaptation and gains coming from taking your exercises close to failure. I don’t think you actually have to go to failure is what the research says, but within that close to failure, here these bands are creating this situation where you get to failure at much lower loads. And so with these older folks, or people who are deconditioned, haven’t exercised in a long time, they can go basically do body weight exercises with these bands on, see gains.

[00:30:10 –> 00:31:02] Dr. Sten Stray-Gundersen: Yes. Okay. And actually, that I think you brought up such a good point. You can achieve that level of fatigue with light loads. Like it’s it’s totally possible. It’ll probably just take you twice, or maybe even three times the number of reps to get to that So all the bands are doing is sort of accelerating that response to light loads, to then manifest adaptations that are typically associated with that high load. But again, if you were to do 100 reps instead of 15 of let’s say bicep curls, you’d probably get to that same, sort of the same robust response in the muscle. The problem with that is that sort of very very high rep situation is going to incur a lot of cost on the system. And you’re gonna have to recover from that in order to then do it again, or start the adaptation process. So sort of twofold, it accelerates that response such that you hit that trigger point faster.

[00:31:03 –> 00:31:31] Dr. Sten Stray-Gundersen: Mhmm. So there’s a time saving aspect there, but then also the recovery following that exercise is so much more rapid, because the actual mechanical work that was done is so much lower than what is normally required to get to that point. And I don’t it’s the body is sort of responding as if there was a lot of damage to the system, and so it just sends out this flood of anabolic milieu, that, and signaling, and activates signaling pathways that are typically associated with recovery, and trying to recover from a very, a major insult to the body.

[00:31:31 –> 00:32:01] Dr. Ravi Kumar: Yeah. Okay. Yeah, and that overuse cost on the system that you’re talking about, that’s basically these repetitive motions on the joints, correct? And tendons? Because our body, our motion, we’re meant to move, and impact, and work all the time, just not repetitively. I mean, there’s no natural situation. I do curls all the time, but there’s no natural situation where you do this 100 times in a row, multiple times a week, you know? Everything that

[00:32:01 –> 00:32:01] Dr. Sten Stray-Gundersen: we

[00:32:01 –> 00:32:22] Dr. Ravi Kumar: do is complex and compounded. And so you’re saying that if someone took five pound dumbbells or whatever it is, and did 150 of these until they were, they hit their failure, there’s a cost on the elbow joint or the shoulder joint that there wouldn’t be with just doing 15 of blood flow restriction exercises the same way, correct?

[00:32:22 –> 00:32:46] Dr. Sten Stray-Gundersen: Yes. Just a 100% to add on to that, I think there’s also systemic stress to the central nervous system from having to repetitively do that, and the time required to recover from that is a factor there too. So we can kind of maximally stimulate the nervous system with BFR, without having the nervous system have to recover to the same degree as well. So both kind of local mechanical

[00:32:46 –> 00:32:47] Dr. Ravi Kumar: Mhmm.

[00:32:47 –> 00:33:47] Dr. Sten Stray-Gundersen: You know, aspects of recovery, and then also sort of nervous system recovery as well. And I will say like, there is benefit to doing sort of those higher rep stuff. Like, if you’re a marathon runner, you need to be able to run a marathon, and you need to have specific adaptations within the lower limbs to be able to tolerate the mechanical load time over course. You know, again, kinda always depends, whatever sport or whatever goal you have, your training needs to be specific to that. Way I see BFR kind of funneling in into, or integrating into any program, is a way to augment those responses. So you’re kind of base of the training, if we’re kind of looking at the athlete context is, okay, what adaptations, whether local or systemic do I need to stimulate with my typical training? And now I’m adding BFR essentially to make the nervous system and other tissues more plastic to that training stimulus. So that’s sort of the athlete bucket. And then if we look at the clinical, they just simply can’t tolerate the work required to do that base training. Right?

[00:33:47 –> 00:33:57] Dr. Sten Stray-Gundersen: And so, they maybe don’t want to have to recover from that training. Can BFR become a complete replacement to that, so they can augment that training aspect as well?

[00:33:57 –> 00:34:19] Dr. Ravi Kumar: Okay. So let’s let me ask you this question next. What type of gains can you see from BFR specifically in all those populations we just talked about, the elder or the, you know, the deconditioned, the, you know, weekend warriors like me, and then the elite athletes? What kind of, are can we see hypertrophy? Can we see increased strength? Can we see increased endurance? What are Yeah. The

[00:34:19 –> 00:35:15] Dr. Sten Stray-Gundersen: So it’s it’s been really interesting to follow this over the last fifteen years, because originally it was, you know, BFR can stimulate hypertrophy, growth of the muscle, and that in and of itself was a really cool finding. But there was skepticism over whether it would actually improve strength, or these other parameters of muscle function. And what we found is, you know, there probably is a little edge that high load exercise gets when it comes to absolute strength. It may be a function less of what’s going on in the muscle, and more of a function of what’s going on in the nervous system. Sports specificity is one of the major principles of exercise science, and so if you’re specifically training yourself to handle high loads, like you’re gonna be able to handle those high loads better. But we do see, what’s really interesting, we do see almost on par with strength gains when we do BFR training. Which is really, it’s somewhat surprising, and kind of I think makes us have to reframe how we’re thinking about adaptation in general.

[00:35:15 –> 00:35:19] Dr. Ravi Kumar: Okay, do mean by that, you see on par? Explain that a little bit better.

[00:35:19 –> 00:35:44] Dr. Sten Stray-Gundersen: Yeah. So, there’s been several studies. Maybe the one to bring up is really a seminal study back in 2000, is often cited, where they had older women perform bicep curls, and then they had them on an isokinetic machine looking at elbow flexion and extension. And essentially it was a really elegant design where they had a control group who basically did nothing. They had a high load group who was doing kind of heavy heavy curls.

[00:35:44 –> 00:36:22] Dr. Sten Stray-Gundersen: They had a low load group which was doing lightweight curls, and then they had a low load group with BFR. And essentially, the low load group kind of improved very very minimally, and really across one aspect of velocity, the velocity that they were training at got better. The high load group and the BFR group had equal improvements in force production with this elbow flexion extension type exercise across a range of velocities. So again, was it was a bit surprising, kind of makes sense on the hypertrophy side. Okay, you’re stimulating this microenvironment muscle, the brain’s responding by increasing anabolic hormones, but we’re also seeing this increase in strength that is on par.

[00:36:22 –> 00:36:59] Dr. Sten Stray-Gundersen: And I would say almost on par because there’s been sort of mixed results as far as like sometimes it’s on par with the high load condition in a lot of studies, and sometimes it’s slightly below. There’s been times where it’s slightly above, so it’s just a bit mixed. But in general, can stimulate substantial increases in strength with BFR training. Okay. Where I might hedge my bets a little bit, and kind of what I do in my own training is, okay, sort of minimally mechanically load? Can I do one to two reps, or one to three reps of a high load to get that specific stimulus? And then can I ramp up everything else with the BFR to really improve my recovery from that session on that side of things?

[00:36:59 –> 00:37:11] Dr. Ravi Kumar: Okay. So you can see hypertrophy, which is big muscles. You can see increase in strength. What about endurance? Yeah, and so this has been another more recent development in the BFR literature,

[00:37:11 –> 00:37:16] Dr. Sten Stray-Gundersen: is more and more aerobic type studies. We do see increases in VO2 max, and not enough Not only that

[00:37:16 –> 00:37:18] Dr. Ravi Kumar: to the audience what VO2 max is.

[00:37:18 –> 00:37:58] Dr. Sten Stray-Gundersen: So, yeah, maximal oxygen uptake, essentially how well our our body, and really our heart, can deliver oxygen to the muscle, and how readily that oxygen is extracted at the muscle level, and then extracted, that blood is sent back to the heart, and the cycle repeats. So our ability to consume oxygen, really, and lot of different podcasts are saying, you know, VO2 max is the number one predictor of longevity, and it’s very very important. So improving that metric can be vital, not only to athletes, but also clinical populations, so we can improve that. We can better handle exercise intensities, but we’re also just better at getting oxygen to where it needs to go within the body, whether that’s in the muscle or otherwise. So what we’re seeing is increases in VO2 max.

[00:37:58 –> 00:38:58] Dr. Sten Stray-Gundersen: There’s debate as to which as to whether this is more of a peripheral adaptation, it’s sort of within the mitochondria, and the mitochondria’s ability to take in oxygen and produce ATP, or if it’s a sort of central adaptation where we’re increasing things like blood volume, to ultimately increase stroke volume and cardiac output, that’s responsible for delivering that blood to the muscle. So there’s some sort of debate or more to be found out in terms of the mechanism by which we’re increasing VO2 max, but what’s really cool is not only we’re increasing VO2 max, but we’re also stimulating increases in muscle size. So in some of these studies, two to speak of, there were, one was a treadmill walking study in a clinical population, another was in basketball players, I believe they were doing uphill walking at a slightly higher intensity, and they showed increases in quadriceps CSA, cross sectional area, in addition to increases in VO2 max. We’re kind of simulating both increases in muscle size, but also increases in ability to consume oxygen and perform higher intensities, and higher mechanical work as well.

[00:38:58 –> 00:39:07] Dr. Ravi Kumar: So do you see that normally in a marathon, or someone training for a marathon, will they see increases in the size of their muscle, and VO2 max at the

[00:39:07 –> 00:39:41] Dr. Sten Stray-Gundersen: same time? So, I think in those particular studies, they were either in clinical populations, or a population that either is eating in a caloric surplus, or at maintenance, and are more explosive type exercises. I think when you have a marathon case, the other training they’re doing outside of that is really dictating their body composition to a greater extent. So, yes, all things being equal, being a caloric surplus, having the right nutrition, that is totally possible. But sort of the things have to sort of align for that to actually induce that effect.

[00:39:41 –> 00:40:33] Dr. Sten Stray-Gundersen: And we haven’t seen that in the literature. I will say implementing this stuff with long distance runners or marathoners, they feel stronger, they feel like they’ve increased their power, or force and velocity relationship. And so, they feel stronger, they feel more endurant, and that sort of thing. And I think within this conversation, I think it’s important to talk about the psychological effect of just being comfortable with that fatigue state. As I mentioned, getting in that fatigue pocket, as a soccer player I was using this, and it really, you know, whether this was a physiological reality, or sort of a psychological reality, I felt more comfortable being uncomfortable, and kind of in that pocket where I have a lot of lactate production, a lot of hydrogen production, and I’m just, I’m okay with being there for longer. There could be that aspect of it too, and in addition to the physiological adaptations that we’re seeing.

[00:40:34 –> 00:41:31] Dr. Ravi Kumar: Yeah. Okay, so that’s all very interesting, and I do want, at the end, just tell the audience, we will talk about some protocols, you know, if you’re trying to accomplish certain goals, we’ll get your thoughts and recommendations on that. So, but let’s move on next to, are there contraindications to this? Because, you know, there’s a couple things I think about. One is, you know, if you cut off blood flow to a limb or a part of the body, your body’s blood pressure naturally goes up to try to overcome that. And I know we’re not cutting off blood flow, but I imagine there’s some increase in blood pressure associated with this. Also, the other thing I think about is deep vein thrombosis, or DVTs, is a blood clot in your leg, or something, rarely your arm, that can cause big problems because you’re, you know, and that’s usually when people aren’t moving. So they’re not pumping blood out of their, the veins in their legs. Do you see any of those problems with this, and who, is there anyone who shouldn’t use blood flow restriction exercise?

[00:41:31 –> 00:42:18] Dr. Sten Stray-Gundersen: Yeah. So these are great points, Ravi, because these were things that were definitely a concern, especially early on 10, 20, 30 years ago. But the safety data on BFR is really compelling, and they’ve been doing blood flow restriction in KAATSU in Japan for decades now, and they’ve had these sort of series of safety studies where they do surveys, and you know 32,000 sessions daily happening across all these different clinics, and there’s just really very very very rare instances of really any untoward complication arising from BFR. I would say that the few sort of things that commonly come up is potentially if someone’s extremely deconditioned, they push too hard, and they can get nauseous, or lightheaded, that kind of thing. But that also happens when they perform a high intensity exercise.

[00:42:18 –> 00:43:09] Dr. Sten Stray-Gundersen: So it’s really Okay. Gradually getting introduced to this stuff, as opposed to just jumping right in and trying to be a masochist. So coming back to your question related to DVTs, what’s really interesting, and the point that, and was nodding my head when you were saying this, the point is that we’re never having an ischemic environment, and we’re always And we also never have stasis. So because we’re engaging that muscle pump, and driving, you know, going from that lazy river venous kind of example to that dammed, then massive rush of blood, that is enough to stimulate adequate flow through the veins intermittently. And a colleague of mine did a study where he looked at BFR on three limbs, because they were taking blood on one limb, on an assault bike, and actually saw a major rise, significant rise in tPA concentration within the blood.

[00:43:09 –> 00:43:43] Dr. Sten Stray-Gundersen: And so that is, you know, a clot busting factor that’s responsible for breaking up those clots. If anything, similar to traditional exercise, we’re seeing actually a reduced, a potential for a reduced capacity to form clots. Because again, you’re stimulating the the endothelium, or stimulating the vasculature to release nitric oxide, which is also going to help prevent clots and increase blood flow. And so as as sort of ironic as the name implies of blood flow restriction, you’re actually increasing blood flow, especially when you start exercising, and then take the bands off, you’re getting this reactive hyperemia. Correct.

[00:43:43 –> 00:44:18] Dr. Sten Stray-Gundersen: So the DVT question is of concern for a lot of people, but as long as you’re not occluding, as long as you’re not having stasis of flow in addition to that, in my estimation it’s very it’s safe for people who have a history of DVTs and that kind of thing. It may actually be a treatment for preventing that in the future. Yep. This is some of the work that laboratories around the country are kind of looking into right now. There was a article published, I want to say in 2015, and it was a call for concern with regard to blood flow restriction training, and the metaboloreflex and mechanoreflex, or the exercise pressor reflex.

[00:44:19 –> 00:45:13] Dr. Sten Stray-Gundersen: Which is that your blood pressure increases in response to stimulation of group three and group four afferents, that are innervating the muscle, their sensory neurons that are responding to increases in metabolite concentration, and increases in mechanical tension within the muscle. And so during regular exercise, our blood pressure goes up. Part of that is due to a redistribution of blood flow, and some, basically some systemic vasoconstriction mixed in with some local vasodilation to optimize blood flow. But the other component of that is by stimulating these group three and four afferents that are feeding up to the medulla, and causing an increase in blood pressure. So the concern was, okay, if we’re trapping metabolites, and really ramping up the metabolite production, or really, should say damming up the metabolites from getting out, are we then kind of exaggerating this exercise pressor reflex that is well documented, especially in clinical populations.

[00:45:14 –> 00:45:47] Dr. Sten Stray-Gundersen: And what’s kind of been found ten years later is there just doesn’t seem to be this effect. We’re seeing similar increases in blood pressure that we see with traditional high intensity type exercise. Okay. So that has kind of been proven to be not moot. I think things like major caffeine intake, extreme dehydration, you know, not being adequately fueled can kind of set you up for failure when it comes to these things, but as as you’re in a state to be able to perform exercise, you don’t really have to worry about those increases in blood pressure.

[00:45:48 –> 00:46:38] Dr. Sten Stray-Gundersen: Actually using this as a way to help cardiac rehab patients as well, because they’re not able to go at these intensities for a certain amount of time, and their recovery is really not good from these things. And so, can they do a light intensity walking protocol to help stimulate muscle growth, and improve their cardiovascular function? Okay. So yes, it has been a concern in the past, it is not an absolute contraindication. One absolute contraindication that I tell people is sickle cell disease, where there is actually they don’t have the trait, they have the disease for it. It can cause some issues there, but generally those people are not able to perform exercise in general, and so they’re not even in the bucket of people that would qualify this type of exercise. Yeah. Okay. So it’s being looked at in Parkinson’s, multiple sclerosis. We did a study at UT where we looked at a pre habilitation program for cancer patients, abdominal cancer patients.

[00:46:38 –> 00:46:53] Dr. Sten Stray-Gundersen: So I’m happy to talk about that, but I guess the point of me saying that is, this is being investigated in extremely what we consider clinical populations, desperately clinical populations, and it’s working to great effect without any untoward safety complications. Okay.

[00:46:53 –> 00:47:04] Dr. Ravi Kumar: That’s great. Yeah. You know, I think it’s important to note that whenever you exercise, your blood pressure goes up. It can go up I quite a mean, can go up into the systolic 200s even, if you’re really going intense, and

[00:47:04 –> 00:47:10] Dr. Sten Stray-Gundersen: Those old McDougall papers go up into the 400s, at maximal heavy, high load exercise,

[00:47:10 –> 00:47:34] Dr. Ravi Kumar: which is And that’s nuts, and it’s, if you hear systolic 400, I mean, they call me and say, Hey, a patient’s got a systolic of in the 200s, I’m worried, right? That they’re gonna have a brain bleed or whatnot. But exercise, within the realm of exercise, it’s physiologically normal. Want In fact, if you don’t get that hypertensive response to exercise, something’s wrong. You’re not gonna do well.

[00:47:34 –> 00:48:23] Dr. Ravi Kumar: You’re not gonna be able to perform. So it’s a normal part of our physiology. And I think it’s I just think it’s fascinating that they’re using this on, you know, post cardiac arrest rehabilitation, because it makes sense that it would be something that would help facilitate getting your ability to function back, right? It’s increasing this rapid muscle hypertrophy, and strength, and endurance, and then just having hypoxia in your muscles makes your body say, Hey, listen, let’s update our metabolic machinery so that we can tolerate this better, and then you’re more efficient when you have normal oxygen and blood flow. The whole thing, it makes sense, and it’s really cool that they’re finding it safe. So, okay, so back to what you said as far

[00:48:23 –> 00:48:23] Dr. Sten Stray-Gundersen: as

[00:48:23 –> 00:48:35] Dr. Ravi Kumar: contraindications, really the only person who there’s an absolute contraindication is people with sickle cell trait. Yes. And I assume sickle cell anemia as well.

[00:48:35 –> 00:48:36] Dr. Sten Stray-Gundersen: Yes. Correct?

[00:48:36 –> 00:48:51] Dr. Ravi Kumar: Yes. Okay. So, and those are people who get occlusion of vessels because of abnormally shaped red blood cells. Correct. And so you don’t want to basically precipitate that through hypoxia, or mechanically exacerbate it, is my thought.

[00:48:51 –> 00:48:59] Dr. Sten Stray-Gundersen: Exactly. I will say trait seems to be okay. It’s really the disease anemia where people should avoid it completely.

[00:48:59 –> 00:49:01] Dr. Ravi Kumar: Okay. The trait seems okay.

[00:49:01 –> 00:49:28] Dr. Sten Stray-Gundersen: Okay. You know, to your point, this functions as a hormetic stressor. Right? It’s a dose of a poison, it’s a dose of a stressor, that is going to yield adaptation to be able to be more resilient to further stressors. It’s the same thing, that hypoxia example is perfect. Sustained hypoxia, terrible for the body. You know, the body cannot adapt to that. Little bouts of hypoxia can be very beneficial for the overall resilience of the system.

[00:49:28 –> 00:49:29] Dr. Ravi Kumar: Yeah. So,

[00:49:29 –> 00:49:30] Dr. Sten Stray-Gundersen: it’s really

[00:49:30 –> 00:50:19] Dr. Ravi Kumar: And we come back to hormesis all the time on this show, because you know, the hormetic stress is what makes you more resilient and strong. Right. Ex, you know, heavy exercise is hormetic stress. Yes. You know, red light is hormetic stress. You know, a little bit of UV light is hormetic stress. Heat is hormetic stress. Cold immersion is hormetic stress. It’s these things that hurt you a little bit so that you come back stronger. Yes. And, you know, not being able to get enough blood flow while you’re doing heavy work in your limbs is a hormetic stress. And before we move on to the mechanisms, I’m really excited to talk about, is there, besides the people with sickle cell anemia, do you think everyone should be, have a pair of these bands in their house, be integrating them into like making themselves a maximal potential of their cells?

[00:50:20 –> 00:50:43] Dr. Sten Stray-Gundersen: Yeah, and I mean, this is where, you know, scientist hat on off, practitioner hat on off, and obviously I’m familiar with BStrong, but I tell all of my loved ones about this. I I every you know, my wife has has a set. We we do BFR workouts together. I use this on a regular basis. I think, you know, it it is a such a great tool to be able to have in your toolbox, to be able to use when you need to use it, to be able to integrate it into your program.

[00:50:43 –> 00:51:24] Dr. Sten Stray-Gundersen: That yes, I mean, is is it a 100% necessary for everybody to have this? Probably not. But it is it is a very nice to have modality at your disposal. And it’s there’s also things within the literature that, you know, we’ve investigated to a certain extent, but there seems to be something going on that we don’t we can’t quite capture yet, that we’re seeing, especially as I mentioned in these clinical populations, the most robust responses in mood, the therapeutic effects of exercise, this I think this sort of neuroplastic state that hypoxia can put you into, to be able to adapt to whatever hormetic stressor that you’re engaging with. I think it just makes you better at adapting to your environment.

[00:51:25 –> 00:52:16] Dr. Sten Stray-Gundersen: And at very sort of basic simple standpoint, I think the body is registering similar to as you go up to altitude, and you get exposed to low levels of oxygen. Your ability to adapt to the environment is up regulated. Like all these things are enhanced, and I think this hypoxic blood flow restriction, fatigue, you know, build up of lactate, and hydrogen put your body into a state of, okay, environment unstable, must be ready to adapt. Know, as kind of dumb and maybe as simple as that sounds, think there is something to that. It just makes sense. Yeah. And so, I think more than gains in muscle mass and strength and these things like that, I think it just makes you more resilient and more adaptable to whatever other stimuli you’re putting your body through. Okay. Very

[00:52:16 –> 00:53:15] Dr. Ravi Kumar: cool. So, yeah, I mean, you think about it, you look at our ancestors going back, you know, generations, millennia even, and or you look at these populations of people with high rates of centenarians, they all do pretty extreme exercise in their daily life. They’re going up and down mountains every day to herd their sheep, or they’re migrating long distances, or they’re in search of food every day. That was just part of their life, and it kept them healthy because of this extreme And we can’t do that, right? We have to go we gotta go to the office, or we gotta go, you know, pick up our kids. I mean, we live a different life now that’s mismatched from what we, the world that we evolved to live in. This kind of helps us, this device, basically is like a trick, a hack, essentially, to stimulate some of that hormetic stress that we evolved to live with that we’re not getting anymore, honestly.

[00:53:15 –> 00:54:08] Dr. Sten Stray-Gundersen: Yeah. So, I think it is, it truly is a biohack, because you are hacking the same, you know, evolutionary, like millennia, millions of years of evolutionary advancement to be able to adapt to this exercise stimulus, you’re just hacking into that mechanism, and it’s allowing the system to recover faster, because the actual damage to the system is so much less than what you would normally have to achieve to do that. And I do wanna say with these hormetic stressors, it’s important to it’s not done in a bubble in isolation, like you have to have nutrition, you have to have a supplementation, you have to have the raw substrate to be able to adapt properly to those stressors. And so that’s something I just I know, I’m sure you voice this often, but I think, you know, those hormetic stressors in a vacuum without the proper substrate and nutrition backing it, you’re not gonna get the outcomes that you want.

[00:54:08 –> 00:54:51] Dr. Ravi Kumar: No, absolutely. Yeah, I mean nutrition is something that is very hard to have proper, even when you’re totally attuned to it. In today’s modern society, we just we don’t get it from food anymore, unfortunately, unless you’re growing all your own food, monitoring the soil, and, you know, avoiding toxins and things that block, you know, nutrient absorption. So yeah, that is a tough one, and I think everyone needs to think about that. You can’t just do some hormetic stress like a red light sauna and think, that’s going make me healthy, if you’re So nutritionally yeah, you gotta have the crucial got to nutrients there to allow the systems to run properly for them to be stressed and then come back better.

[00:54:51 –> 00:54:58] Dr. Sten Stray-Gundersen: Yes, absolutely. And sleep, right? Sleep. Just keep hearing that’s the foundation of it all. I’d be remiss Yeah, Yeah. If you didn’t mention that

[00:54:59 –> 00:55:21] Dr. Ravi Kumar: yeah. No, I mean, we talk a lot about sleep on this podcast too, because, yeah, you can’t be a good person without good sleep, you know? So, okay, let’s talk about some of the mechanisms behind blood flow restriction. We’ve touched on a lot of them already. But one thing we’ve come back to over and over is this idea of neurological adaptation.

[00:55:21 –> 00:56:07] Dr. Ravi Kumar: And I think when most people think about getting strong, they think about, Oh, you just get a bigger muscle, and now you’re stronger. But that’s one part of it, and you can actually get bigger muscles, but if you don’t have the neural input into those muscles, you’re actually not stronger. And you can actually see this in real life. You’ll see this laborer, someone who works every day, heavy labor, carrying hundreds or more pounds of cement on their shoulders, hauling heavy loads, and they can do it very well, and they’re not big muscled. And then you’ll see the big guy from the gym who’s taking so much testosterone that they’re hyperanabolic, they can’t lift nearly as much as this guy.

[00:56:07 –> 00:57:08] Dr. Ravi Kumar: Right. And the difference there is not muscle mass, obviously, it’s neurological adaptation. And if you ever go, when you start your exercise, oftentimes you’ll start out with a lower weight, right? And it’s the hardest set of your exercise, for some reason, right? And it’s because is an acute neurological adaptation, there’s a chronic neurological adaptation, and right then, you’ve got to get your nervous system online, and that’s why a lot of times people say, Hey, grease the groove first, and that’s, you know, just do a high rep, low weight, so your brain starts recognizing, okay, this is the motion we’re doing, let’s recruit the motor units, which we call, you know, muscle fibers that the nerves hit in your muscles, and get you back online. So, that’s neurological adaptation for the audience, is the ability to use your nerves to stimulate your muscles. And how does BFR play into this? Yeah. So this is this is great because I I think this is often lost on people. Like, people

[00:57:08 –> 00:57:59] Dr. Sten Stray-Gundersen: see big muscles, think strong. People see small muscles and think weak, and that’s not that’s obviously not the case. You know, I will say when looking at a population level, generally the people who are bigger are stronger. Right? So there is some relationship between muscle size and muscle strength, but sort of the neuromuscular coupling of this is kind of it’s multi it’s multifold. So, obviously you have certain sensitization of that muscle to an action potential, and and the depolarization signal that comes out from that action potential into the muscle. And then you stimulate the release of calcium from the sarcoplasmic reticulum. That calcium then then binds to various aspects of the actin and myosin molecules, allowing for crossbridge cycling. That crossbridge cycling is responsible for actually moving and changing the length of the sarcomeres, bringing Z lines together. There’s a role of titin, which is sort of the backbone of that sarcomere.

[00:57:59 –> 00:58:58] Dr. Sten Stray-Gundersen: All to say that the neurological component, or the neuromuscular component is essential for triggering this cascade of events that ultimately leads to muscle contraction. And not only do we see the actual activation activation of specific motor units, and what I deem the high threshold motor units that are innervating those type 2, you know, fast twitch fibers, which necessitate heavier loads, or higher levels of fatigue to actually recruit. Not only are you doing that, but you’re also improving the pattern of recruitment as well. So let’s say if someone, you know, someone could have great sort of raw strength, they may be in Jiu Jitsu for example, and their ability to pull and tug on someone is really really good, but they’ve never done a deadlift before. And so their ability to actually do a deadlift maybe is, know, maybe they can do 100 pounds on a deadlift, but their ability to express that strength in another sport, in their sport is much better.

[00:58:58 –> 00:59:49] Dr. Sten Stray-Gundersen: So they train okay, let’s say they train the deadlift for 8 weeks, and now their deadlift is 400, 450, 500 pounds, it’s not that they put on the muscle responsible for getting all that strength gain, they’ve improved their ability to recruit muscles in a coordinated fashion to do that specific movement. So there’s kind of like those three tiers of the neuromuscular neurological side. The sensitization of the muscles to specific action potentials coming from the neurons, the coordinated activation of specific high threshold motor units within that, and then all the system together, all the muscle groups working together in sophisticated pattern of recruitment to then complete a complicated or dynamic movement. So all those are completely separate from any kind of muscle growth. And I think that’s just an important concept for people to understand when it comes to this.

[00:59:49 –> 01:00:41] Dr. Sten Stray-Gundersen: And so one of the things I think to bring BFR into this conversation is loading something ends up to be able to complete something under a heavy load, you may do a dysfunctional pattern to then complete that exercise movement. Because you’re loaded, it’s potentially dangerous if you don’t get this weight up. And so with something like BFR, where you’re able to do very light weights, you can really hone in on really proper technique, and engage these stabilizing muscles that are involved that may or may not be on or switched on when you’re doing kind of heavy loads. So that’s kind of one way to remain safe while lifting, as well as can you kind of perfect your form with something like BFR, you’re still stimulating those increases in strength and muscle size, but not risking poor technique, which then can manifest in an injury over time.

[01:00:41 –> 01:01:10] Dr. Ravi Kumar: Okay. So one, you’re able to lift smaller loads, you’re able to use perfect technique to really isolate and perfect that movement with that muscle work. What about the recruitment of muscle fibers? How does BFR change that? Because normally if you’re lifting, what, you know, if I’m bench pressing 45 pounds on the bar, I’m not recruiting much, correct?

[01:01:10 –> 01:01:10] Dr. Sten Stray-Gundersen: Correct.

[01:01:10 –> 01:01:13] Dr. Ravi Kumar: Am I recruiting more when I have BFR bands on?

[01:01:14 –> 01:01:51] Dr. Sten Stray-Gundersen: Yes, and it’s a slightly different pattern of recruitment as well. Okay. And so when I say pattern of recruitment, what I mean is separate from, okay, I activate this muscle in this phase of the lift, I activate this muscle, this part of the muscle in this phase of the lift, that’s slightly different. But the pattern of neural recruitment is, okay, I’m gonna Henneman’s size principle. The larger, the higher threshold motor units are innervating the muscles that are able to produce the highest force. So with a high load exercise, let’s say you’re working at 90% of your one RM, those high threshold motor units are gonna be activated almost instantly under that load.

[01:01:51 –> 01:01:53] Dr. Ravi Kumar: One RM is one rep max,

[01:01:53 –> 01:01:53] Dr. Sten Stray-Gundersen: just so the

[01:01:53 –> 01:02:01] Dr. Ravi Kumar: audience Yeah. One rep So if you could lift 100 pounds, then 90% is 90 pounds.

[01:02:01 –> 01:02:28] Dr. Sten Stray-Gundersen: Yeah. Right. Okay. So in order to So you get a rapid recruitment of those high threshold motor units. With low load exercise, without BFR, you have to fatigue the type 1 motor units first, which are smaller, they’re oxidative, so they’re much more endurant, they’re resilient to fatigue, before you can tap into those high threshold motor units.

[01:02:29 –> 01:03:22] Dr. Sten Stray-Gundersen: That are really responsible for activating those type 2 fibers, which are the things that are more prone to grow, to actually increase muscle size and strength. So what BFR does, and this is this is kinda why I keep coming back to accelerating that fatigue response, that fatigue response in the context of low load exercise, is how we’re able to tap into those high threshold motor units. Mhmm. So instead of a rapid recruitment of those motor units with a high load type exercise, we are more rapidly than low load without, but we’re gradually recruiting those type 2 motor units. And that’s why I kinda emphasized the last 5 reps of those sets, where you’re kind of in that fatigue pocket, are so crucial, and it’s the time for you to switch on, and really have good technique, and really, you know, you can even squeeze the muscle as you get to the top of the contraction, to really maximally stimulate those motor neurons that are innervating those fibers.

[01:03:23 –> 01:03:35] Dr. Ravi Kumar: So you wouldn’t want to do 5 to 8 reps, I mean you would miss out on that window, correct? Of recruiting the maximum amount of motor units? Right. So if the load is such that at five

[01:03:35 –> 01:04:19] Dr. Sten Stray-Gundersen: to 8 reps, you’re not approaching fatigue or failure, then yes. Right? Let’s take out BFR for a second. If you’re doing If you’re 8 rep max, right? So the weight that’s required, or the weight that after eight reps, you can’t move that weight anymore. Right. So, if you’re doing 5 to 8 reps of that weight, without BFR, you’re going to maximally recruit those high threshold motor units, because you’re approaching that failure, that fatigue. But with, But again, that incurs a certain amount of cost, and recovery associated with that. When you’re doing a very lightweight, which maybe, as we kind of mentioned, maybe you have to do 100 reps to get to that same place. You’re now able to do 15 to 30 reps, depending on where you are in that range, to get to that same activation of those motor units.

[01:04:20 –> 01:04:50] Dr. Sten Stray-Gundersen: So Okay. So yes, to your point, if the weight that you’re lifting, you know, let’s say you’re doing a 10 pound dumbbell, or bicep curl, and that’s to be that’s light for you. If you’re only doing 5 to 8 reps of that, with BFR, it’s not gonna be doing a whole lot. You’re probably still stimulating some increases in blood flow after, and like there’s some recovery component to that, But in terms of maximizing muscle growth, and maximizing strength, you’re not going to be recruiting those motor units that you need to actually induce that response.

[01:04:51 –> 01:05:13] Dr. Ravi Kumar: Right, okay, that makes sense. Okay, so what happens then after you’ve taken off the cuffs, and you’re doing a normal workout, or you’re living your normal life, how has that forced neurological adaptation at lower weights with the BFR cuffs, or how does that change the rest of your life or your body? So, one of the

[01:05:13 –> 01:06:14] Dr. Sten Stray-Gundersen: things that happens is we stimulate mTOR, which is sort of the mother gene for signaling pathway responsible for increasing MPS, or muscle protein synthesis. So you’re up regulating these signaling pathways in response to this activation of high threshold motor units, and fatigue, and you know, lactate accumulation, all these different things, hydrogen accumulation. And so in the hours following that session, you are up regulating these signaling pathways, which is going to trigger your body to put down more muscle, whether that’s more motor units, or I mean, sorry, more muscle fibers, or increased sensitization of those fibers to that neurological signal, or bigger calcium stores within the SR, a variety of different adaptations within muscle locally. So, you know, and this can persist for 48 to 72 hours post. And so during that time, this is where the nutrition really comes into play, like you need to be able to have substrate for for that process, that mechanical process of laying down new tissue to actually occur.

[01:06:14 –> 01:07:08] Dr. Sten Stray-Gundersen: So in that follow-up, you’re supplying the body what it needs to actually lay down new tissue, and actually adapt from that stimulus that you cause with the BFR. One of the things that we see is an on par increase in growth hormone that we see with high intensity type training. It’s as if the body thinks that a major insult to the body, or injury to the body has occurred, and now we’re sending out anabolic milieu to actually address and heal that tissue. The caveat here is there’s not much tissue to heal, because the actual mechanical work was so low. So it’s almost like this over response to that stimulus. And so one of the things that we anecdotally hear all the time is sleep improves, growth hormone is released at night, and it helps you go to sleep. So we typically see that. We also see increases in appetite, because growth hormone can have a big effect on appetite as well. And we also see increases in caloric expenditure not associated with exercise, or NEAT. Right?

[01:07:08 –> 01:07:23] Dr. Sten Stray-Gundersen: So kind of every level has been sort of up regulated to then heal the body, but the caveat there is there was not much to heal in the body, and so the whole system improves and becomes more resilient to further stress. Yeah.

[01:07:23 –> 01:07:49] Dr. Ravi Kumar: Okay. And I think, you know, I did a podcast with Matt Kaeberlein, he’s a longevity researcher who studies rapamycin and Okay. Inhibition of mTOR. And so I Uh-huh. You know, mTOR is this nutrient sensor, and it basically promotes either, when it’s turned on, promotes growth and basically puts you in an anabolic state. And when it’s turned off, it stimulates recycle and repair, basically.

[01:07:49 –> 01:07:49] Dr. Sten Stray-Gundersen: And

[01:07:50 –> 01:08:33] Dr. Ravi Kumar: to live long, the idea is that you want mTOR periodically turned off, so you recycle, and you repair, and maintain your body. But you can’t live without it turned on at certain points, and when you’re trying to build muscle, it’s got to be turned on. Because without mTOR on, you can’t grow. And we’re not talking about growing our guts or putting on fat, we’re talking about growing muscle, is metabolically active. And, you know, once that stimulus ends, then mTOR switches off, essentially. So it’s this healthy cycle of mTOR. So I just want people to think, It’s turning on mTOR? I don’t want that. No, you do want that to maintain a healthy body.

[01:08:33 –> 01:09:21] Dr. Sten Stray-Gundersen: So glad you said that. Yeah. Because, yeah, I often get the questions like, is this BFR, or exercise in general, going to accelerate my cancer growth, for example? And it’s it’s within the context of a healthy exercise stimulus and stress, which is which and and again, to your point, it’s happening locally within certain regions. It’s not like this this mTOR activation is going throughout the whole body, and going to your gut, and going to your splanchnic region, causing growth of these things. That’s what exogenous growth hormone and testosterone and these things can do. Right? But when you have this in a controlled setting where the machinery involved is associated with exercise, it seems to be regulatory. It seems to modulate these things rather than you know, have this sort of systemic global, okay, increase mTOR, everything must grow, kind of response. Right.

[01:09:21 –> 01:09:31] Dr. Ravi Kumar: Yeah, that makes sense. So have they actually done studies showing that growth hormone release at night, and the peak in the morning is elevated after blood flow restriction exercise?

[01:09:31 –> 01:09:59] Dr. Sten Stray-Gundersen: So not So they haven’t looked at that time period, they’ve looked at acutely, immediately after exercise, or up to I think 60 minutes to an hour and a half after exercise, they’ve looked, they’ve seen these increases in growth hormone. But anecdotally, what I would say is, you know, it’s not no no question in my mind whether you’re seeing this increase in baseline growth hormone responses as well. It’s well documented in regular exercise or traditional exercise, so I see no reason why this would not be the case with BFR.

[01:09:59 –> 01:10:33] Dr. Ravi Kumar: Okay, so let’s talk about hypoxia inducible factor and VEGF. And just for the audience, we’re not going deep on the biochemistry here, but we’re just trying to understand the mechanism so you can know why this would affect your body. And this is actually pretty fascinating, because hypoxia inducible factor is constitutively expressed. Basically, it’s always being made, but if you’re in an environment of normal oxygen, it just gets broken down and put away. And it’s this, basically induces the transcription of this molecule called VEGF, which increases blood vessel growth into tissues.

[01:10:33 –> 01:11:09] Dr. Ravi Kumar: And a lot of people who’ve had cancer, or have had a relative with cancer, know that there’s a drug called Avastin that actually blocks VEGF, because you don’t want cancer having these blood vessels grow into it, and feed it, and grow. So VEGF is normal, and it’s safe, and in the realm of physiological fitness, you want to vascularize your tissues so that they can operate efficiently. But tell us what role blood flow restriction exercise plays in hypoxia inducible factor in VEGF, because you’re essentially inducing hypoxia in the muscle during the exercise, correct?

[01:11:09 –> 01:11:49] Dr. Sten Stray-Gundersen: Correct, yes. Okay. And this is maybe a good thing to sort of outline the difference between systemic hypoxemia, which is what you kind of experience when you go up to altitude, or if you’re in a hypoxic chamber, where the saturation of oxygen on your red blood cells has come down, and this is a global systemic reduction in oxygen throughout the whole body. That also, right, when you go up to altitude, you have this response, you have low oxygen, you’re stimulating the kidneys to produce EPO, that goes to the bone marrow, starts making new reticulocytes, and then that will increase your oxygen carrying capacity. So that’s kind of a chronic exposure to hypoxia.

[01:11:49 –> 01:12:19] Dr. Sten Stray-Gundersen: But with BFR, it’s happening at a more local level within the muscle. And this typically happens with very high intensity, or or very high load exercise, and one of the ways that what is typically associated with that is a high degree of lactate production, and hydrogen ion production. So you it when your muscle becomes very it burns a lot, and you get that metabolic burn that we’ve been talking about, that’s a good indication that the muscle is getting pretty darn hypoxic. Okay? Okay.

[01:12:19 –> 01:13:38] Dr. Sten Stray-Gundersen: And we’ve looked at this using near infrared spectroscopy, where we can actually outline just how desaturated that tissue is getting, and it is on par with the most intense, high intensity exercise you can do, getting down to as low as like 10%, maybe even 5% saturation within that muscle. So it’s a very robust, very severe level of hypoxia within the muscle, to then stimulate maintenance, HIF-1 alpha maintenance, which then, as you said, can signal other angiogenic factors, VEGF being one of them. Also producing, increasing endothelial nitric oxide synthases as well, concentration, so you’re not only are you helping promote angiogenesis, building bigger and better blood vessels within the tissues, the capillaries themselves, improving the walls of the endothelium as well, and improving on the vein side too, because you get distension of the veins, and that’s a nice stimulus for the veins to maintain their structure and their function that way. So, all that being said is blood flow restriction, again as ironic as it sounds, restricting blood flow is actually a really good stressor on the cardiovascular system to make it more resilient, just as we’ve been saying, and the sort of signaling pathways involved in that is to upregulate these mRNA factors to then transcribe more and more proteins associated with building blood vessels.

[01:13:38 –> 01:14:40] Dr. Sten Stray-Gundersen: One of the adaptations that we see from traditional high intensity endurance exercise is capillary density increases. And by increasing the capillary density, the number of capillaries around each muscle fiber, we can sustain more work, and higher levels of work for longer. So by adding in BFR is doing the same thing, by up regulating the signaling pathways associated with angiogenesis or blood vessel development, we’re able to sustain work for longer, improve general circulatory health, improve some of the chemical responses as well, and nitric oxide being kind of the chief among those, to increase our reactive hyperemia, to vasodilate certain tissues when we need to, or vasodilate the arteries, and arterioles, and capillaries going to those tissues in response to whatever stress, and this is happening systemically throughout the body. So, you know, obviously we’re talking about the muscle, and getting blood to the muscle, but these VEGF factors are going throughout, and getting better blood flow throughout the gut, and getting better blood flow in the heart, and all these different things kind of work together.

[01:14:40 –> 01:15:18] Dr. Ravi Kumar: Yeah. So if, you know, you get these elite athletes and Olympians, they go up and they train in Denver, or they train up in the Rockies before they have to compete down near sea level, and the idea is, or they sleep in these tents, these hypoxia tents at night, and the idea is that they’re inducing hypoxia in their workouts, or while they sleep, so that they are more adapted to these super high, you know, relatively super high oxygen environments. Can you get the same results with blood flow restriction exercises as you can from sleeping in a hypoxia tent, or exercising in the Rockies?

[01:15:18 –> 01:16:11] Dr. Sten Stray-Gundersen: So it is a different thing. Okay. So honestly, combining the two is even better, and that’s actually one area of my research that I’m looking to go down, but it’s a very different mechanism in that the systemic hypoxemia, which hypoxemia refers to the low oxygen within the blood, rather than tissue hypoxia, which refers to low oxygen within the tissue. It’s signaling slightly different things to happen. For example, you’re not going to stimulate EPO production in the kidneys with this local hypoxia generated by high intensity exercise or blood flow restriction training. So they’re kind of two separate stimuli or stressors that are both doing very very positive things, and to your point, likely are both are stimulating HIF-1 alpha and and VEGF. So so that is kind of a common pathway between those two stressors. But it is a it’s a it’s a different sort of yeah. It’s just a different stimulus.

[01:16:12 –> 01:16:43] Dr. Ravi Kumar: Yeah. And e EPO is erythropoietin, which is this, you know, this blood cell stimulator. Basically, it’s a it’s a a signaling molecule that tells your bone marrow to make more red blood cells. And, you know, sometimes I think athletes have cheated by injecting themselves with erythropoietin Yes. To get more red blood cells and deliver more oxygen to the tissues, essentially. So Yeah. And you’re saying that sleeping in a hypoxia tent stimulates that natural production of that, but using BFR does not? To my knowledge, we have not

[01:16:43 –> 01:17:20] Dr. Sten Stray-Gundersen: seen any documentation for stimulating erythropoietin, yeah, with BFR. It is interesting, and and I think the main when it comes to altitude training, it’s actually the sustained living at altitude that is going to to serve as the basis for stimulating that EPO for long enough to remain present within the bloodstream to then stimulate the bone marrow. So there’s a time course there that’s involved that you’re simply not going to get in a 20 to 30 minute session using with local hypoxia. Makes sense. But you know, there’s some data coming out to see if intermittent hypoxia can stimulate transient elevations in EPO, and if that can have a downstream effect.

[01:17:20 –> 01:17:56] Dr. Sten Stray-Gundersen: But really, my dad’s work in the late nineties, early 2000s was really about altitude training, and the fact that you need to remain you need to live and sleep at altitude to really reap the benefits from the chronic exposure to that low oxygen. And really what the live high, train low, if maybe you’ve heard of that, was actually the idea of if you’re training in high altitude and living there, your training capacity is actually slightly lower. And so in these elite athletes who need to maintain their training intensity, they actually had to go down to a lower altitude to maintain that, but then live and reap the benefits of getting more red blood cells and more hemoglobin mass at a higher altitude.

[01:17:56 –> 01:18:05] Dr. Ravi Kumar: So hence the hypoxia tent, right? So you don’t have to drive up the mountain, you sleep in the low oxygen environment at night, and then train in normal oxygen environment I during the

[01:18:05 –> 01:18:36] Dr. Sten Stray-Gundersen: was actually one of those people. I was I turned myself to bubble boy in Oh, you did? High school. So we we had moved from Park City, Utah to Dallas, and I was still competing as a cross country skier. So in order to maintain my acclimatization to altitude, I I For about six months, was sleeping and eating and doing homework in my hypoxia tent. It a nice tent, know, it was pretty big, it was the size of my room, it wasn’t like I was in a true bubble boy situation. But yeah, so to maintain that hematocrit and hemoglobin level that I generated while I was living at altitude.

[01:18:37 –> 01:19:05] Dr. Ravi Kumar: Okay, so let’s talk about nitric oxide, I had a guest on my show not long ago, Dr. Nathan Bryan, he’s one of the world’s leading experts in nitric oxide, and he’s convinced that nitric oxide is one of the keys to longevity. And I don’t think he’s necessarily wrong because it plays such an important role in keeping nearly every tissue in your body vital. What role does BFR play in that? Can it stimulate nitric oxide production?

[01:19:06 –> 01:19:45] Dr. Sten Stray-Gundersen: Yes. So what I would say is, again, not in a vacuum, I think it’s very important to be getting nitrates from food, as well as things like L arginine and L citrulline, sort of conditional or semi essential amino acids that are involved in the nitric oxide synthase pathway. Really quick, two buckets of nitric oxide production. One we have the reduction of nitrate to nitrite to nitric oxide. A lot of that nitrate to nitrite occurs in the salivary, in the mouth really, by bacteria, reducing that to nitrite, and then further into the esophagus and the gut, or in the stomach to then nitric oxide, and then further nitric nitrite into nitric oxide within the blood as well.

[01:19:45 –> 01:20:32] Dr. Sten Stray-Gundersen: The other pathway is from the conversion of L arginine into L citrulline and nitric oxide via the enzyme, endothelial nitric oxide synthase, or eNOS. And so there’s two distinct pathways, and so by increasing our nitrate consumption, allows you to increase your nitric oxide production and synthesis, and also increasing our endothelial nitric oxide synthesis, the actual enzymes involved in that, in addition to making sure that the right substrate in terms of L arginine and L citrulline are there for the production of nitric oxide, are both kind of two therapeutic targets. You could argue maybe two and a half, potentially three. And so where I think exercise and BFR is really addressing the nitric oxide production, is on the amounts of endothelial nitric oxide synthases or eNOS within that are aligning the endothelium of our blood vessels. Okay.

[01:20:32 –> 01:21:14] Dr. Sten Stray-Gundersen: From a just a regular standpoint, when we have increases in flow, this exerts increases in shear stress. The kind of the friction of blood, and blood vessels, or blood cells along the endothelial wall, and that is triggering a flow mediated dilation. By triggering those eNOS enzymes, you’re actually causing nitric oxide to diffuse into the smooth muscle, go through a cascade of events, and ultimately lead to a smooth muscle relaxation. That relaxation allows that vessel to dilate. When that vessel dilates, we get increases in flow, and then that wherever that downstream blood, or that tissue downstream of that vessel is going, is gonna be more perfused with blood.

[01:21:14 –> 01:22:04] Dr. Sten Stray-Gundersen: So that’s sort of the basis for how number one, BFR can be effective in improving nitric oxide production, is simply through the increases in shear stress that are placed in there, and the degree of, know, HIF-1 alpha is involved, the degree of hypoxia that’s generated in the muscle, increases it signals the brain to increase more and more blood flow, and perfuse that tissue more and more. So you get, you know, consequently greater and greater increases in that flow mediated dilation, which is stimulating upregulation of eNOS, and stimulating production, and synthesis of that of those eNOS enzymes. So again, none of this happens in in a vacuum, and I think that’s why it’s so important to be supplementing with nitrates within your diet, or maybe even a supplement like Dr. Nathan Bryan has, or taking in L citrulline and L arginine as well.

[01:22:04 –> 01:22:36] Dr. Ravi Kumar: Okay. So it has to do with the increased velocity of blood flow through the vessels that causes release of nitric oxide through eNOS? Is that where BFR plays a role here? Yeah. Because when you constrict a vessel, and you’re still pushing the same amount of blood flow through it, you have a much more rapid velocity. That’s why if you put your thumb over the end of a hose, the water sprays out way farther and way faster. Is that the concept we’re working with here?

[01:22:36 –> 01:23:25] Dr. Sten Stray-Gundersen: I think that is one part of it, and then the other part is that the disturbance in homeostasis downstream within that tissue is so severe that the brain is getting signals that we need more blood flow, we need more perfusion, and so it’s also a sort of a neural cardiovascular as well. Okay. To do that. On the mechanical side, yes, you’re getting increases in shear stress, which are going to release acutely, immediately that increase in nitric oxide, that then you’re also stimulating sort of more the chronic adaptation of, okay, we need a better ability to vasodilate, because our machinery in place is not adequate or sufficient to maintain this exercise, and so we need more blood flow, we need to have better maintenance of oxygen levels, for example, within that tissue.

[01:23:26 –> 01:24:19] Dr. Ravi Kumar: Okay, okay, cool. Okay, so the next thing I want to talk about is something called PGC-1 alpha, and bet most of my audience hasn’t ever heard of this, but it is this master regular. It is extraordinarily important, and it’s actually a master regulator for mitochondrial biogenesis, meaning the birth of new mitochondria. And mitochondria are the key to respiration in our cells. We can’t make energy with oxygen without mitochondria. So what role does, and I will say this, you want more mitochondria. You are generally a more metabolically healthy person with more and more efficiently running mitochondria. So, what role does BFR play in this? Because I know there’s some decent literature on this, actually pretty strong literature on this. Yeah, so we know that it increases mitochondrial biogenesis, and one of

[01:24:19 –> 01:25:19] Dr. Sten Stray-Gundersen: the ways it does that is by very similar to the regular exercise response, by creating this hypoxic stimulus, by basically perfusing that tissue with tons and tons of blood, by getting substrate in there for the mitochondria to actually use and generate ATP. We’re number one, keeping these mitochondrial functional. But the severity of the hypoxia, level of disturbance in homeostasis, is a huge trigger locally for all of these things to up regulate, including the blood vessels to the mitochondria. I haven’t seen in my own investigation direct evidence of activation of PGC-1 alpha, but I don’t have a doubt in my mind that similar to regular exercise, we’re seeing increases in the signaling pathway, this kind of downstream pathway to increase mitochondrial biogenesis. So with all that said, yes, it’s similar to exercise, similar to these other hormetic stressors, we’re seeing increases in mitochondrial biogenesis from the use of BFR.

[01:25:19 –> 01:25:52] Dr. Sten Stray-Gundersen: Especially in the context of sort of low intensity, you you think of the zone two as your aerobic base, kind of forming that, and really getting those mitochondria to work for a prolonged period of time. By going at that lower intensity, you’re able to get your mitochondria to work at a, you know, get flush those mitochondria with substrate and be able to produce ATP from that. But you’re also stimulating the maximal capacity of these mitochondria to generate ATP as well, because you’re getting into such a situation where you’re getting extremely fatigued, and you’re having to recruit more and more muscle to complete that exercise.

[01:25:52 –> 01:26:13] Dr. Ravi Kumar: Yeah. So basically, these mitochondria are having to work under much tougher conditions, adapt, and then also they’re saying, okay, let’s proliferate, because they’re essentially like little tiny microorganisms in our cells. But, so is this the reason why VO2 max goes up with BFR? Is it because of the increased number of mitochondria, the efficiency of them?

[01:26:13 –> 01:27:12] Dr. Sten Stray-Gundersen: Yes. So in general, when we refer to as peripheral adaptations, mitochondria is huge component of that. I think the capillarization, what we just talked about, angiogenic effects, are playing a factor here too. It’s probably not just one thing, it’s the entire system getting better at handling low levels of oxygen, and being able to use what oxygen is there very very rapidly. And then also on the flip side of that, the ability to clear all those things and buffer those increases in hydrogen production, which is involved in mitochondrial respiration, to be able to maintain homeostasis a bit better. If you have more mitochondria to help do that, the better the system is going to operate. So yes, I I think kind of more speaking about it more broadly, right, you just have this major insult to to the local tissue, to that cell, and the mitochondria are going to respond to that that stress and that disturbance in homeostasis by either proliferating or becoming more efficient. Hormesis. Exactly. Exactly. Always comes back to it.

[01:27:12 –> 01:27:32] Dr. Ravi Kumar: Yeah. Okay. Alright. So great. So I think we’ve kind of covered a lot of the mechanisms. What do you do to, I mean, because your lactic acid production must be pretty significant, like probably as significant as if you were doing a frickin’ all out workout. What do you do to flush out your lactic acid? Do you just go do aerobic exercise, or what is your strategy there?

[01:27:32 –> 01:27:34] Dr. Sten Stray-Gundersen: You mean following a session?

[01:27:34 –> 01:27:44] Dr. Ravi Kumar: Yeah, following, yeah. Because I imagine you’ve got a lot of burn and soreness in your muscles after this. Am I wrong on that? Is this not create a significant amount Yes, of lactic

[01:27:45 –> 01:28:32] Dr. Sten Stray-Gundersen: yes. It does. What’s interesting, within a 15 to 30 minute period, whether you’re exercising or not, you’re gonna be pretty much have flushed all that lactate out of your system, and it’s gonna be buffered through, you know, it’s gonna be breathed out a lot of the time. Or it’s gonna be used by your brain or other tissues as fuel. So as you know, you take a glucose molecule, cut it in half, then eventually you get it into pyruvate, you can get conversion into lactate there. So lactate itself can be then used fuel source as well, and that’s actually some of the work being done with regards to lactate and cognition. And potentially, you know, stimulating these increases in lactate may lead to a alternative fuel source for the brain to be operating, that might be one of the ways that moderate intensity exercise can actually enhance cognition acutely.

[01:28:32 –> 01:28:34] Dr. Ravi Kumar: Very Oh, yeah, interesting kind of that is interesting.

[01:28:34 –> 01:28:38] Dr. Sten Stray-Gundersen: I’d love to actually take your brain, pun intended, on what your thoughts are on that.

[01:28:38 –> 01:29:00] Dr. Ravi Kumar: I don’t know, because this is the first time I’m hearing about it. So you’re, is the concept that you’re creating this lact, with exercise, you’re creating lactic acid in your muscle from anaerobic work, and then that lactate, or lactic acid, is being transported to your brain and used for energy, and that’s where you get this post workout high. Is that the idea here?

[01:29:00 –> 01:29:58] Dr. Sten Stray-Gundersen: Yes. Exactly. Actually, I just I just wanna clarify. So in in vivo, lactate and hydrogen dissociate almost immediately. So Okay. So lactate and hydrogen ions, like we kind of term them lactic acid, but in reality, lactate, that hydrogen needs to be buffered, and we have different mechanisms to actually bring down the bring up the pH from being acidic, from being low, but then that lactate will be shuttled out to nearby muscle fibers, or to the liver, or to the brain. And so I think, you know, there’s a lot, there’s obviously a thousand different things going on, but I think it does provide the brain with an alternative fuel source acutely following exercise. In addition to you’re getting endocannabinoid production and endo opiate production response to exercise and BFR as well. Right? The exercise induced hypoalgesia is really a function of those things as well, which may be contributing to that cognitive effect that we see or that therapeutic effect that we see from exercise as well.

[01:29:58 –> 01:30:26] Dr. Sten Stray-Gundersen: But in terms of relaxing it out, as soon as you’re kinda done with the exercise, and you take the bands off, that muscle burn is it pretty much rapidly dissipates. If you want to accelerate that, or just kind of feel better after that session, or if you are a little bit nauseous, sometimes that happens with people who are just starting out with this stuff, I recommend going on the bike, or just walking around, whether it’s inside, outside, for 5 to 10 minutes, and pretty much everything will be flushed out in pretty rapid manner.

[01:30:26 –> 01:30:38] Dr. Ravi Kumar: Okay. So just going back to this lactate, were you saying that lactate may stimulate endocannabinoid and endorphin release? Is there a direct link there?

[01:30:38 –> 01:31:01] Dr. Sten Stray-Gundersen: So not necessarily that lactate is stimulating those things. We typically see those sorts of things with major disturbances in homeostasis within the muscle. Yeah. So it’s like in the same way that lactate is associated with sort of anaerobic work, or low oxygen work, or glycolytic work, it’s kind of associated with that work, but it’s not necessarily causing it. I gotcha. As a flip side,

[01:31:01 –> 01:31:07] Dr. Ravi Kumar: it’s within the same metabolic realm of that’s happening after exercise. Yes.

[01:31:07 –> 01:31:54] Dr. Sten Stray-Gundersen: What I have seen more recently is that lactate is being proposed as a both a signaling molecule in the brain, and a fuel source in the brain. And on the signaling molecule side it’s activating BDNF, which is then going to have neuroplastic effects on the brain, and may improve cognition acutely. Wow. And this is probably on top of the other thousand molecules that are released from exercise that are and immune cells as well, like you get this massive activation of immune cells as well, which may be having a factor in all this. Yeah. But yeah, that’s kind of the next thread that we’re gonna be looking at, and working with the neuroscientists in our department, where we’re looking at the impact of lactate production, we’re using BFR to really induce that in a very, like, kind of calculated and very consistent way. That’s really

[01:31:54 –> 01:32:38] Dr. Ravi Kumar: cool Yeah, so, yeah, I mean, if you think about it, you just mentioned that exercise acutely improves neuroplasticity and cognition, but chronically it does too. I mean, is probably the best thing you can do besides improving your metabolic health and not smoking, but for neurocognitive benefits for older people who are worried about that, exercise is probably the best body of research behind improving cognition. And it’s free, and it doesn’t come into the ball, doesn’t have any side effects. So I think it’s just fascinating, it’s something, I just wanted to mention that, because no one really talks about it much. Yeah. You know, that just

[01:32:38 –> 01:32:57] Dr. Sten Stray-Gundersen: Well, my world they do. And you know, we’re screaming from our ivory towers over here about important exercise is and how vital it is to the human system. You know, it is free. It’s all these things, but it’s undesirable for a lot of people. People don’t wanna do it, you know?

[01:32:57 –> 01:33:25] Dr. Ravi Kumar: I mean, if you go to your doctor with Alzheimer’s disease, and instead of, you’re not going to get a prescription for exercise. Right. You’re going to get a prescription for a $15,000 monthly infusion. Yes. That does barely anything, if at all, you know? Yep. So I just think it’s really important, and I’m glad you guys are screaming it from the rooftops that exercise is one of the keys to neurocognitive health and longevity in general, so.

[01:33:25 –> 01:34:22] Dr. Sten Stray-Gundersen: It really represents a fountain of youth. I mean, like, this this is the water that we have access to. And and, you know, just like essential fatty acids or essential amino acids, like exercise is an essential nutrient that we Yeah. Have have we’ve forgotten that fact, is that it is essential Yeah. Maintenance and And not only that, but I think combining it with, you know, cognitively demanding tasks. So that’s why I think ball sports can be so vital, because they’re also fun, and they get you to exercise, and get you to critically think, and be competitive, and all these different things. And so, those sorts of things kind of wrap all these things up nicely in a bow, and then your exercise training on top of that in gym, or you know outside running, or things like that can help support that. You know, think that’s kind of bringing the conversation back to BFR briefly. As weird as it might sound, it lowers the barrier to entry a bit. Like obviously you need to have like an extra piece of equipment, but you really that’s all the equipment you really need.

[01:34:22 –> 01:35:12] Dr. Sten Stray-Gundersen: If you’re really trying to go bare bones, that’s really the only equipment you need. And it’s a non negotiable for me sometimes, I’m like, I don’t feel like working out, I’m tired, I’m stressed, whatever, not adequately fueled. But I can do a 5 minute BFR workout, get that therapeutic effect of the exercise, get a big increase on lactate very very rapidly. All of a sudden, that 5 minute workout, and be like, well I can do a little bit more. Oh, I can do a little bit more. And so it as as again, as maybe counterintuitive as it might seem at first, having these things, and an ability to rapidly get that exercise response that people are looking for, actually lowers the barrier to entry to actually doing it. And once you kind of get started, it’s like tying your shoelaces is the hardest part about it, right? It’s like, just put the bands on, start moving a little bit, all of a sudden you’re gonna start feeling like you can do more, and over time that’ll compound.

[01:35:12 –> 01:35:42] Dr. Ravi Kumar: Yeah, yeah, it’s this neurological adaptation. I do wanna come back to one other thing we just were talking about earlier, this hypoalgesia, the endorphin release, the endocannabinoid release, and that’s a real thing. You feel less pain, you feel way better. I mean, there’s no drug in the world that can have the antidepressant effects of a hard workout. It’s just, there’s nothing.

[01:35:42 –> 01:36:15] Dr. Ravi Kumar: You know, my wife, I mean, she loves riding on the Peloton. Know, she does these And spin if she’s in a bad mood, she just has to get on that Peloton for 30 minutes, and she is in the best mood for the rest of the day. She’s rarely in a bad mood, but if she does, she knows what to do. And that’s consistent across human biology. You can go to someone in Southern Africa and Norway, they’re going to have the same metabolic, physiologic, and neurologic response to exercise.

[01:36:15 –> 01:36:47] Dr. Ravi Kumar: And so I think that’s really something that if you’re ever stuck in a hole, man, go in and just busting it out hard, it’s going to make you feel good. Yes. Even if you’re like, I’m too tired, I’m not there, I can’t do this, there’s no situation where it’s not going to make you feel better, unless you’re basically not able to anatomically or physically. But yeah, it is amazing, the neurological, and anti depressive, and anti pain effects of exercise.

[01:36:47 –> 01:37:41] Dr. Sten Stray-Gundersen: Yeah, absolutely, and you know, on the flip side of that, being someone who basically trains every day, when I don’t when I go through a two, maybe three day stint of not exercising, I you know, those those symptoms you know, I wouldn’t say I’m depressed, but I’m certainly well below baseline where I’d like to be. So, you do go through, you know, is exercise addictive? Yes. You go through withdrawal, but it’s great it’s one of those great addictions to have. Yeah. Going forward, because yeah. And I think, you know, whether this is something people consciously think about, like like your wife, she’s obviously she can kind of like see that response in real time. I think a lot of people with these like F45 classes, or these Orangetheory classes, they’re looking to get that therapeutic mental effect of the exercise, and just in my estimation, I just think BFR is a great way to do that in a really short period of time. Yeah. You know, on the flip side, there is a way of kind of going overboard.

[01:37:41 –> 01:38:01] Dr. Sten Stray-Gundersen: If you do a really hard HIIT session, where you’re generating a ton of lactate, actually, your cognition will go down. So there is this sweet spot of not going too too hard, and not going too light to where you are generating but that increase in it’s not such an insult to the system to where you’re now in a decrement. So there is that sweet spot there. Just wanna clarify And for

[01:38:02 –> 01:38:24] Dr. Ravi Kumar: that’s back to hormesis again. I forgot what the hormetic curve’s called, but it’s this It’s U shaped. Yeah. And so, yeah. So it’s this period where you get this maximal benefit in the middle, and then you start getting harm after that. So you think about cold water immersion. Jumping in the cold water for a few minutes and getting out makes you feel like the best you’ve ever felt in the world.

[01:38:24 –> 01:38:24] Dr. Sten Stray-Gundersen: Mhmm. But if

[01:38:24 –> 01:39:11] Dr. Ravi Kumar: you go and get hypothermic Right. It’s gonna hurt you. Right. Same thing, you know, if you become hypoxic, you you get hurt. But if you get this brief period of, you know, hypoxia in the tissues and then come back to normal perfusion, it does you some good. It’s all, hormesis is a curve. People forget that. They’re like, Oh, if, you know, being in a short calorie restriction is good, well, what if I just never eat? You know? And they become anorexic. You know, what if, you know, they think eating too many vegetables causing gut dysfunction. Well, what if I eat no vegetables Right. You know? And we go into these, yeah, these extremes where, you know, Buddha found a long time ago that the path is in the middle, you know? Right.

[01:39:11 –> 01:39:32] Dr. Ravi Kumar: And that he defined the hormetic curve of benefit a long time ago. Sten, before we wrap this up, I wanted to just go through some protocols real quick. I’m gonna propose to you some hypothetical patients. These are based on people I know. And tell me what they should do in the realm of BFR to achieve their gains or achieve their goals. Is that will that work?

[01:39:32 –> 01:39:34] Dr. Sten Stray-Gundersen: That’s perfect. Yeah, let’s do it. Let’s So do

[01:39:35 –> 01:40:00] Dr. Ravi Kumar: the first one is my aging parents. They are probably metabolically not super healthy. They’re way lower muscle mass than they were as younger people. And they have moderate exercise tolerance. I would say they could walk maybe a mile before they’re starting to get tired. On a good day they could walk a couple miles. How could they use BFR to get healthier?

[01:40:00 –> 01:40:40] Dr. Sten Stray-Gundersen: In this sort of circumstance, I always recommend first of all a very gradual approach. So, and what I mean by that is kind of in every manifestation of that. So with regard to the acute session, to the sessions per week, and to the pressures being used. So number one is I would say, generally, that population can tolerate about 3 sessions per week, even starting What what what those sessions should look like is 1 to 3 exercises, and I would do What I would probably do is two out of those three days, I would do more resistance, or body weight sort of exercises. So things like squats, things like dead lifts where you’re doing compound movements, getting a lot of musculature involved.

[01:40:41 –> 01:41:15] Dr. Sten Stray-Gundersen: Pairing that with maybe an isolated muscle movement, so doing bicep curls, or a leg extension, or calf raise. On that third day, I would incorporate some aerobic training with with the bands. So if they’re able to walk a mile before they get tired, I would say, okay, put the bands on, and go on a 10 minute walk. I’d either deflate the bands and continue walking, or or wrap up and deflate the bands and go home. So that’s that’s what I would say, and then over time, you know, over the course of 10 weeks, I would be increasing like one exercise per week within those two out of those three sessions.

[01:41:15 –> 01:42:21] Dr. Sten Stray-Gundersen: So, you know, now you’re doing squats, bicep curls, and let’s say leg extension, then you’re doing squats, bicep curls, leg extension, calf raises. Then when you kinda hit the the point at which you’re doing about a 20 minute, 25 minute session, that’s where you can increase the number of sets, or slightly increase the weight, or slightly increase the pressure that you’re using in the bands. So just like every other kind of exercise program, you want to incorporate some degree of progressive overload, but it’s just kind of tampering with one of those variables within that system to advance that. And then I would say from the aerobic side is, see if you can walk a little bit faster, see if you can go a little bit longer, even if it’s a minute or two longer, I mean that kind of thing is a way to progress it. That seems to be you know, my parents had a clinic in Park City, Utah, where they worked with a lot of older adults, and that seemed to be the sweet spot, is three, maybe four, once they’re sort of accustomed to things, to get that done, and see really big benefits, not only in their ability to ambulate in daily function, but just like we said, mood, libido, all the things that make us enjoy enjoy living as Yeah.

[01:42:21 –> 01:42:28] Dr. Ravi Kumar: So should any of their exercise routines be without the bands, or should they be doing every time they exercise should they have the bands on?

[01:42:28 –> 01:42:54] Dr. Sten Stray-Gundersen: I would say it’s a little bit up to the to the user. If they really enjoy it, I don’t see a reason not to, especially in that kind of population. Just gonna get a little bit more out of it, especially if they’re not able to tolerate like the high intensity type stuff, you might as well throw them on. Having said that, if feels like an extra step, and you’re just not gonna train at all, then I would say make sure you’re hitting that two, three days a week of BFR, and then the rest of the week you can add in slight intensity walking and that kind of thing. But yes.

[01:42:54 –> 01:43:39] Dr. Ravi Kumar: So then, okay, so that’s pretty good advice, I like that, and I’m going get my parents to start doing that. Awesome. The next one is a 17 year old young man. He’s really into calisthenics. He’s very strong. Yep. And he’s really good at these pull exercises where he can hold these maneuvers like front levers and very difficult body movements. But with his push, he cannot achieve a planche. And guys, this is my son, by the way, so that’s why A I’m being so planche looks like an impossible move, by the way. If anyone’s ever seen it, it looks like a push up where your feet are off the ground. And when you see someone do it, you think they must have like anti gravity on or something. But you know, he is so close, but he can’t get it.

[01:43:39 –> 01:44:33] Dr. Sten Stray-Gundersen: Interesting. Okay. How could he possibly use BFR to get this? So before answering that question, I do wanna say with with calisthenics, and especially like isometric holds, they’re doing a certain degree of blood flow restriction, which is which Interesting. Is really When you’re contracting the muscle like that, you’re restricting blood flow. Okay. So what I might recommend, I I would wanna identify perhaps why he’s unable like which which parts of his of his system are are not sufficient to to sustain that. So whether it’s a is it a absolute strength from a pushing standpoint, is it a stabilizing muscle weakness compared to like relative to other parts of his body? Right. Wanna first identify where the issue is as to why he’s not able to complete that, and then I might use BFR to really isolate and target that specific, and I’m saying weakness, not saying your son is weak, but relative to other the other strength.

[01:44:33 –> 01:44:55] Dr. Sten Stray-Gundersen: Yeah. You know, very high strength aspects of his physiology. I would say, you know, ramping that up, and trying to target that specifically with BFR might be able to get him there. Yeah. So, it’s a little bit of a I think there’s other means beyond BFR achieve Yeah. So, it’s not like the only way, but if you’re asking me how could you use BFR to do that, that’s how I would kinda go about it.

[01:44:55 –> 01:45:15] Dr. Ravi Kumar: And this is an interesting situation because you talk about these stabilizing muscles, there’s the latissimus, there’s back, there’s the core, all the and there’s the glutes, but you’re you can only apply BFR to the arms and legs, right? What are there any collateral benefits to these core muscles from restricting blood flow in the legs and arms?

[01:45:15 –> 01:45:44] Dr. Sten Stray-Gundersen: I’m so glad you brought this up, because we didn’t talk about it, but the anabolic response that we’ve seen in the literature is well documented, happens both proximal and distal to the cuffs. So whether it really just depends on the exercise you’re performing. For example, if you’re doing a push exercise, your pecs are going to increase in muscle size and muscle strength, similar to your triceps. Right? So if you’re working if you’re doing a pull, your lats are going to reap the benefits of that restricted exercise to a similar degree as your biceps.

[01:45:44 –> 01:46:20] Dr. Sten Stray-Gundersen: There’s kind of two schools of thought as to how this is happening. For one, the distal muscles, the muscles below the band, are fatiguing more rapidly, and so you have to complete the exercise and sustain the work, you have to rely more and more on the more proximal muscles that are not directly restricted. The second component of that is the circulatory system is all connected. So just because you have an impairment, and you’re seeing a sort of a distension of the veins, and discoloration in the distal portion, doesn’t mean that the proximal portions are also not getting restricted to some degree. And then the last one is this systemic response.

[01:46:20 –> 01:47:14] Dr. Sten Stray-Gundersen: So any muscle that was engaged in that exercise is going to be more sensitive to this anabolic milieu that the brain is then sending out in response to that exercise. Yeah. So kind of those two, two and a half reasons why we see proximal adaptation. And as I said, I have less evidence to back this up, but I do, I strongly think what is going on is the severity of this disturbance in homeostasis happening locally, is triggering the brain to be more adaptable to other stressors that you’re putting on it. So in your son’s case, is the BFR essentially making him more adaptable to his other calisthenic training? And whether that’s improving his recovery from that training, whether it’s giving him a better anabolic milieu to handle that training and respond to that training better, I think there’s probably different avenues that are going on there. But that’s what I would say, it’s making that person more adaptable to their training, and their training goals.

[01:47:14 –> 01:47:40] Dr. Ravi Kumar: Okay. Okay, cool. Alright, so the next one is a young woman who really wants to break a six minute mile. But she has not, in not six minute mile on a one mile, but in a 5K. And it’s been difficult. She’s in great shape, and she’s very strong, she’s got good endurance, but getting below a six minute mile is tough. Can blood flow restriction, exercise help her?

[01:47:41 –> 01:47:47] Dr. Sten Stray-Gundersen: Yes. So, what I would say is that I would need to know a little bit more about her training background, and what she’s currently doing.

[01:47:48 –> 01:48:03] Dr. Ravi Kumar: So, she’s a cross country athlete, so they’re, you know, they do, and you know cross country, they do long runs, they do short interval workouts, they’re pretty much all around training to try to achieve these, the fastest pace at a 5K.

[01:48:03 –> 01:48:30] Dr. Sten Stray-Gundersen: Yeah. So, number one is, I would say, if she’s trying to improve her her race pace, because I assume that she can get below a six minute mile if it was just an all out mile. Yes. But it’s sustaining that for a 5K of about 3.2 miles. So I think she would do well to incorporate more interval training days. The problem is, you can really only tolerate one, maybe two of those per week. Is she in high school?

[01:48:30 –> 01:48:32] Dr. Ravi Kumar: Is that Yeah. Okay. Mhmm. High school, yeah.

[01:48:32 –> 01:49:33] Dr. Sten Stray-Gundersen: So, what I’ve been doing with track team that I’m not gonna mention names, but we’ve been incorporating on their Not their high interval training days, but sort of their moderate intervals. So they’ll do like 200 meter repeats at race pace, for example. And I’m starting to incorporate I’m having them wear all four bands at the same at once, keep that pace, and instead of doing maybe 10 intervals of that, they do like five, six, seven, eight of those. They get a huge ramp up in the metabolic stress that is being produced there, which is going to get their body from a molecular level and systemic level a better ability to handle the increases in lactate, the increases in hydrogen ions, that is really going to limit their ability to sustain a pace for a long time. So by adding in those 200 meter repeats, or those 400 meter repeats with the bands on, I think this could kind of push her into that into that capacity to sustain that pace for a longer period of time.

[01:49:33 –> 01:50:12] Dr. Sten Stray-Gundersen: I would also incorporate some some heavier speed work to to work on her top end speed, as well as some kind of zone two aerobic base training, or even threshold training, where she’s just at that that kind of just below race pace, or or right at race pace, where she feels comfortable. And what she can do is she can set her race pace to be, know, 5:59 for a mile. Maybe she only does a mile at a time, a mile repeat. Gives herself adequate rest. It would also be a good idea to program all of this based on her VO2 max or her heart rate, and so she’s working at and also maybe even do the lactate threshold test to determine her lactate threshold.

[01:50:12 –> 01:51:00] Dr. Sten Stray-Gundersen: Then you can get a little bit more fine tuned with how you’re prescribing her training. Lactate threshold is essentially the capacity of your body to clear out lactate. With that, hydrogen ion, which is really the major contributor to fatigue and inability to continue that exercise, that lactate threshold happens at about between 70 and 90% of your VO2 max, depending on your training. In this individual, I would expect her to be around 80, 85, so pretty high already, but by increasing the lactate threshold, the point at which your blood lactate accumulate, or blood lactate levels rise, indicating an accumulation of lactate within the muscle that’s then going to the bloodstream. Once we and it kind of follows this exponential curve. Right?

[01:51:00 –> 01:52:06] Dr. Sten Stray-Gundersen: We have we have a very flat line of lactate accumulation, or lactate showing up in the blood, then we kind of get to our our first lact our LT1, which is kind of like the first inflection point, and then our LT2 is when that inflection point becomes exponential, and now we’re producing way more lactate than we can handle, and that will kind of indicate that is more of a marker of the intensity of the exercise, rather than lactate being the issue, But that will indicate the point at which we can no longer sustain a given pace, or we may only be able to sustain it for a minute or two after that. Okay. So if she can essentially raise that point at which that happens, her the pace at which she’ll be running, her maintenance of that pace will be longer if she can get that lactate threshold higher. Okay. And if we can use BFR through this sort of interval, kind of 200 meter repeats, this 400 meter repeats, to increase her lactate threshold, her ability to handle the lactate and acid associated with that intensity of exercise, it should be able to get her to a place where she can sustain that pace for the entire 5K.

[01:52:07 –> 01:52:07] Dr. Sten Stray-Gundersen: Is that

[01:52:07 –> 01:52:09] Dr. Ravi Kumar: Okay, very, yeah. That was That a

[01:52:09 –> 01:52:11] Dr. Sten Stray-Gundersen: was probably an overly long winded explanation, but

[01:52:11 –> 01:52:17] Dr. Ravi Kumar: I think you sounded very well qualified to answer that, because it sounds like you’re training young athletes right now.

[01:52:17 –> 01:52:27] Dr. Sten Stray-Gundersen: Yes, exactly. So that’s great. Yeah. And there’s so many little knobs that go into that, so it’s but it’s I hope that provides you enough of the principle to kind of fine tune it.

[01:52:28 –> 01:52:30] Dr. Ravi Kumar: That’s perfect. Yeah, and that hypothetical young woman’s my daughter,

[01:52:31 –> 01:52:31] Dr. Sten Stray-Gundersen: so I

[01:52:31 –> 01:52:40] Dr. Ravi Kumar: think she’ll really appreciate it. Okay, good. Okay, so the next one is a hypothetical, is a 49 year old neurosurgeon who That’s me.

[01:52:40 –> 01:52:41] Dr. Sten Stray-Gundersen: Yeah, So I got

[01:52:42 –> 01:53:03] Dr. Ravi Kumar: who wants to basically, you know, I’m already very strong, but I’ve never had a lot of hypertrophy, and I don’t want to look like Arnold Schwarzenegger. I don’t want to look, but I want to basically increase my muscle mass size, especially in my arms. Is there a way that blood flow restriction exercise can help me in that?

[01:53:04 –> 01:54:01] Dr. Sten Stray-Gundersen: For sure. Kind of a few different ways of going about it, and I’ll kind of tell you, at the beginning of this conversation I kind of told you how I integrate it into program. I’ll do sort of a minimal amount of mechanical loading. So I’ll do really two sets of rep range of between six and eight for three exercises, and those will be high load. And I’m approaching fatigue, I’ll maybe have two or three reps in reserve on those exercises, but I’m the mechanical stimulus of that heavy load. But I’m not taking it to a point where I’m exaggerating the wear and tear on my body. Then switch over to the BFR, and I use it for my accessory work where I’m doing And I might have weak points. So let’s say in a press, my shoulder strength is relatively weaker than my chest strength, or my pec strength. So okay, I’ll work on my front delt a little bit more, as an example. Not saying happens, but So using it as a sort of a finisher for your existing workouts.

[01:54:01 –> 01:54:59] Dr. Sten Stray-Gundersen: Or another approach to do it, and I’ve seen people have a lot of success with this, is using it as your only exercise modality, and just hitting it every day, or even twice a day. And this can be in the form of like a 5 to 10 minute workout, where you’re you’re approaching failure, or hitting failure within a given exercise. So if it’s like, if it’s push ups, you’re doing 3 to 4 sets, and by the end of that second, third, and fourth set, you are really struggling to complete that exercise. Immediately go into a bicep curl from there, and I People have been playing with like the circuit training, where they’re gonna go, you know, exercise two, exercise two, exercise three. Stick with the back to back to back for now, where you’re doing one set of push ups, rest 30 seconds, another set of push ups, rest 30 seconds, another set of push ups, etcetera. That will really get you into that state of, wow, this is incredibly difficult to sustain, and that has kind of what has been shown and would have referred to to really increase muscle hypertrophy. Okay.

[01:54:59 –> 01:55:02] Dr. Ravi Kumar: And the short rest intervals, that’s important?

[01:55:02 –> 01:55:53] Dr. Sten Stray-Gundersen: Yes. So, and this is something we haven’t talked about, but between 30, and I would say 60 seconds, probably on the very tail end, wanna keep between the sets. You can take a little bit more rest in between different exercises, but between the sets, what you’re essentially doing is that gradual recruitment of motor neurons that we talked about, you’re sort of pre fatiguing, or getting your type 1 fibers sort of exhausted in that first set, and the first sets doesn’t feel all that different than regular exercise. You might feel the pressure of the band, but your actual capacity is pretty similar to what it would be like without. It’s really the second, third, and fourth, where in between those sets, you’re not allowing adequate recovery, because you’re damming up that the venous side, and that is not allowing your muscle to get back to homeostasis for the next set. Okay. So that back to back with about 30 seconds

[01:55:53 –> 01:55:58] Dr. Ravi Kumar: So you minute rest between Do deflate the cuffs in between? No. They stay up.

[01:55:58 –> 01:56:19] Dr. Sten Stray-Gundersen: Okay. And that’s very important. We wanna keep the cuffs inflated because Okay. It’s really it’s really the rest periods where you would normally be recovering from that exercise, or that or that set, that you just don’t recover much more. Like, you recover enough to con to do the next set, but it keeps you in that fatigue pocket. Yeah. For that subsequent set.

[01:56:19 –> 01:56:23] Dr. Ravi Kumar: So you’re still accumulating lactic acid during the rest periods as well, basically. Exactly.

[01:56:23 –> 01:56:28] Dr. Sten Stray-Gundersen: Or your ability to clear it is impaired still. Okay. Yeah.

[01:56:28 –> 01:56:36] Dr. Ravi Kumar: Okay. Yeah. Very interesting. So can you do, I mean, you get hypertrophy just through body weight exercises using BFR?

[01:56:36 –> 01:56:47] Dr. Sten Stray-Gundersen: Yes. But the key is, you need to approach failure, and it needs to be, you need to push yourself. There needs to be a conscious intent to drive through that fatigue. Okay.

[01:56:48 –> 01:57:06] Dr. Ravi Kumar: So if say someone’s at home, they order your BFR cuffs, and they don’t have any weights at home, what exercises specifically could they do? You just mentioned push ups, what else could they do, where they could use this technique to like really increase strength and hypertrophy?

[01:57:07 –> 01:57:39] Dr. Sten Stray-Gundersen: Yep. So body weight squats, single leg adjustments of that, or single leg variations of that. So a Bulgarian split squat, you can do unweighted, a lunge, a side lunge, glute bridges, even leg extensions, where you’re laying on your back, and you’re kind of in a hip bridge kind of situation, you’re getting some extension there. For the upper body, you can even do like wall push ups, where you’re working your triceps more, as opposed to regular push ups. You can do, you know, this requires some weight, right, but you could even do like water bottles, bicep curls, or water bottle lateral raises.

[01:57:39 –> 01:58:14] Dr. Sten Stray-Gundersen: If someone is looking to get their back going, they can always do like bent over rows, with various things. Again, I think the best pairing with BFR is gonna be some set of resistance bands. So while you can get away with body weight exercises alone, especially for some of the upper body movements, it’s nice to have resistance bands around. So any kind of pulls, any kind of pushes, overhead, lateral movements as well, all those are kind of our game. Anything basically anything that you can do a lot of reps of without the bands, is like a good Is is generally a safe way to prescribe it.

[01:58:14 –> 01:58:47] Dr. Sten Stray-Gundersen: If you’re not able to do like 15 reps in the first set, the load is too heavy. If you’re getting to a point where you’re not hitting fatigue within 30 reps, then either the pressure is too low on the bands, and that’s something that we haven’t really talked about either. Generally regardless of how it’s really interesting, and I’ve tried this, I’ve tried to prove my own theory wrong. I will just do completely unweighted curls, and if I do 3 sets of 30 unweighted curls, my bicep is screaming. Really? It’s less dependent on the load, and more dependent on the pressure a little bit.

[01:58:47 –> 01:58:56] Dr. Ravi Kumar: Yeah. And I know I read your paper, you wrote a fantastic review paper on this, and that was at the top of the pyramid, right? Was cuff pressure.

[01:58:56 –> 01:58:59] Dr. Sten Stray-Gundersen: Yeah. It was at the bottom, the was

[01:58:59 –> 01:58:59] Dr. Ravi Kumar: at the bottom, okay.

[01:58:59 –> 01:59:05] Dr. Sten Stray-Gundersen: So that was sort of in response to this hyper, in my estimation, the hyper fixation on the pressure required.

[01:59:06 –> 01:59:08] Dr. Ravi Kumar: Okay. Gotcha. Okay. The top of

[01:59:08 –> 01:59:47] Dr. Sten Stray-Gundersen: the hierarchy is the perception of effort, and the intent behind the exercise, which is how close you are, you know, proximity to failure, essentially. The pressure required to do that can be a wide range, but for in kind of the example we just discussed, for an individual, if that pressure for them is not accelerating fatigue enough, that pressure needs to be increased. Okay. If the pressure is so high that it’s painful, and you can’t complete the exercise because that band or a cuff is rigid and pushing into your skin, then that pressure needs to come down. That still leaves a very wide range for a very safe, like a safe and effective range of pressures. Okay.

[01:59:47 –> 02:00:03] Dr. Ravi Kumar: So if they buy one of your BStrong cuffs, is there like an instruction sets that tells them exactly how to do this? It’s not, I imagine it’s not hard to figure out, and there’s pretty good guidance. Yes, yeah. So number one, there’s

[02:00:03 –> 02:00:41] Dr. Sten Stray-Gundersen: an app, and number two, it comes with a pamphlet with basically starting pressures. Okay. That’ll kinda get you started, and essentially any exercise under the sun is fair game, just with the emphasis that it should be, especially starting out, very light loads, just to see how you respond to it. And then it has it has sort of a program or a modeling thing, where you can, if the pressure is too low, if the pressure is too high, you can adjust based on your kind of feedback within the app, or just with your own training, and that kind of thing. Right. Again, if there’s if you were to buy this, it comes with instructions, and all the things I’m saying will kind of make more sense, especially after Yeah. After you’ve been using it, and stuff, things Well, like

[02:00:42 –> 02:01:00] Dr. Ravi Kumar: honestly, I mean, this this podcast, we’ve been going for over two hours. Yeah. And you know, this has been fantastic. Awesome. The amount of information you’ve given us is extraordinary, and I think if people have any more questions about blood flow restriction exercise, how can they find you? How can they get in contact with you? How can they learn more?

[02:01:00 –> 02:01:29] Dr. Sten Stray-Gundersen: Yeah. So, I have a very small Instagram that people can reach me out on. I’m on LinkedIn as well, just search my name. So feel free to reach out and ask questions, really happy to I really like engaging with people, and just honestly getting their feedback and their experiences with this, and seeing how I can help there. We also have our customer service within BStrong that can answer a lot of questions, kind of like the logistics of how things work and things like that. So feel free to reach out to me, or BStrong, or what have you for more information.

[02:01:29 –> 02:01:37] Dr. Ravi Kumar: Okay. I’ll put those links in the show notes, so people can learn more about it. This has been awesome, Sten. Thank you so much for coming

[02:01:37 –> 02:01:46] Dr. Sten Stray-Gundersen: on the show. You. No, it’s been great talking to you. You asked, I see in the background there, question everything. You asked really, really great questions that really gets the heart of the matter, so I really appreciate it.

[02:01:46 –> 02:01:53] Dr. Ravi Kumar: Yeah, my teachers, I was young, were annoyed by it, but now it’s an asset, so. All right, cheers, I’ll see

[02:01:53 –> 02:01:55] Dr. Sten Stray-Gundersen: you next time. Okay, thanks again. Bye.

[02:01:57 –> 02:02:58] Dr. Ravi Kumar: Okay, so I hope you enjoyed my conversation with Dr. Stray-Gundersen. Here’s what I want you to walk away with. You can drive real strength and real muscle growth with light loads. Just by changing the environment inside the muscle, so your body responds as if you’d done a much harder workout. And you don’t need a fancy gym or a rack of heavy weights. We talked about body weight squats, lunges, glute bridges, even just walking around your neighborhood with these blood flow restriction cuffs on. For the upper body, you can get away with something as simple as curls with water bottles or a cheap set of resistance bands. The whole point is that the load is light and that you’re getting into that fatigue pocket. That’s that place where your muscles burn. And then you let the body do the rest. And remember, putting muscle on your body is one of the healthiest things you can do at any age. Your muscle is a metabolic sponge. So if you wanna try out these blood flow restriction cuffs, Sten’s company is BStrong. That’s the letter B, strong.

[02:02:59 –> 02:03:10] Dr. Ravi Kumar: I’ll put links in the show notes to his company. You can also find him on Instagram, and he says he’s happy to answer questions. So reach out if you want to learn some more. Okay, folks. Cheers, and I’ll see you next week.