Abstract
Objectives:
Blood Flow Restriction (BFR) training provides partial occlusion at the proximal upper and lower extremities and has been shown to improve muscular strength and hypertrophy following an injury or surgery. By eliciting hypoxic intramuscular conditions, we can stimulate adaptive processes in skeletal muscle in a similar manner to high intensity resistance training but at substantially lower and safer exercise workloads (20-30%1RM). While much of the literature has focused on tissues distal to the site of occlusion, recent findings (Lambert et al 2021, Bowman et al 2020) have observed proximal benefits (increased muscle mass, work capacity, and performance) to upper extremity BFR in the shoulder region during rotator cuff training in both general population adults and pitching athletes. These findings were partially attributed to increased muscle activation (via electromyography, EMG) observed while extremities were under occlusion. However, only one standardized occlusion pressure (50%LOP) was utilized during these investigations as typical in current literature. The purpose of the present study was to compare muscle activation (EMG amplitude, EMGa) of the shoulder region during BFR training at variable occlusion pressures in order to optimize application and muscle-specific targeting of BFR for rehabilitation and preventative shoulder training.
Methods:
Institutional review board approval was first obtained. Fifteen healthy subjects (7 males and 8 females; age 29.4 ± 4.26 y.o.) from a sports medicine physical therapy clinic were recruited and consented to participate in this study. Individuals were excluded if they had any pre-existing shoulder pathology in the dominant limb, active participation in a structured upper body weight regimen, or any history of vascular compromise that may render use of BFR inappropriate. Each participant underwent 4 different experimental sessions, which included performing 3 common exercises for the shoulder to failure on the dominant limb; dumbbell scaption, cable external rotation (ER) @ 0°, and cable internal rotation (IR) @ 0°. Exercises were completed with BFR using an automated tourniquet system (Delfi Medical Innovations®) at a different pre-assigned occlusion pressure (0, 25, 50, 75% LOP) each session. Load was determined using 20% of a one-repetition maximum (1RM) for each exercise utilizing a maximal voluntary isometric contraction (MVIC) test. EMGa data utilizing surface electrodes (Delsys, Natick, MA, US) were recorded from target shoulder muscles proximal to the occlusive cuff during testing - anterior deltoid, middle deltoid, posterior deltoid, infraspinatus, teres minor, and upper trapezius muscles. Repetitions to failure (RTF) and assessments of discomfort (VAS, 0-10) with each exercise at the various occlusive pressures were also collected for analysis. Raw EMGa measures were averaged across the first 30 contractions for IR and scaption as well as the first 20 contractions for ER following normalization to 5 calibration contractions at 0% LOP. A mixed model ANOVA repeated on occlusion pressure was performed followed by a Bonferroni post hoc test for pairwise comparisons. Type I error set at ∝=0.05.
Results:
EMG findings are presented in Figure 1 demonstrating a significant effect of occlusion level on shoulder muscle activation for all exercises (p<0.05). Of note, continued significant increases in EMGa were not observed above 50%LOP with the exception of the teres minor during IR (Figure 1A) or the posterior deltoid during scaption (Figure 1C). As shown in Figure 2, significant decreases in repetitions to failure relative to 0%LOP were observed at 75%LOP for all exercises as well as at 50%LOP for scaption (p<0.05). Also shown in Table 1, a linear increase in discomfort was observed for all exercises with increasing LOP (p<0.01).
Conclusions:
There appears to be several distinct differences in muscle activation about the shoulder complex based on the exercise as well as occlusive pressure; including a common trend of heightened EMG activity being concurrent with an increase in LOP. These findings may indicate that added occlusion leads to greater muscle utilization, enhancing exercise selection and prescription dependent on the targeted muscle group. However, based on these data, there may be an element of diminishing returns past 50% LOP for the exercises and musculature studied, ultimately limiting efficacy past this occlusion stimulus when considering discomfort or total achievable exercise volume. While limited to the population study, these findings paired with those found in general and athletic populations may be used to establish BFR guidelines which may be suitable for shoulder rehabilitation or injury prevention.
