Inspiratory Muscle Training, HIIT or RT for Your Kids? Cold Water Immersion & Altitude Training - Who Benefits, When?

This is about as intense as it gets in PA sessions. What about HIIT and RT in schools?

With the ahead-of-print publication of articles for one of the future issues of the Journal of Strength and Conditioning, it is about time for another SuppVersity Exercise Research Update in the short news.

Today's installment revolves around five question: (a) Who benefits from acute cold-water immersion? (b) Which athletes benefit most from altitude training? (c) Is inspiratory muscle training actually ergogenic? And (d) will exercise in the cold impair your immune function?

Read more exercise-related articles from "on short notice" and other columns

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• Acute Responses to Resistance and High Intensity Interval Training in Adolescents (Harris. 2016) - HIIT may no longer be in the news daily, but it is still appealing to athletes of all ages - including adolescents. Accordingly, a recent study took a closer look at the acute physiological responses to HIIT and compared it to resistance training (RT) sessions that were matched for time and required comparable effort, in a school setting.
  
  Seventeen early adolescents (12.9 +/- 0.3 y) performed both RT (2-5 repetitions perceived short of failure at the end of each set) and HIIT (90% of age predicted maximum heart rate), equated for total work set and recovery period durations comprising of 12 'sets' of 30 s work followed by 30 s recovery (total session time 12 min). Variables of interest included oxygen consumption, set and session heart rate (HR) and rate of perceived exertion (RPE), and change in salivary cortisol (SC), salivary alpha amylase (S[alpha]A), and blood lactate (BL) from pre- to post-session.
  

  

  Figure 1:  Acute rel. increase in VO2 and lactate levels after resistance training and HIIT (Harris. 2016)

  Analyses were conducted to determine responses within and between the two different protocols. For both RT and HIIT there were very large increases pre- to post-trial for SC and BL, and only BL increased greater in HIIT (9.1 +/- 2.6 mmol/L) than RT (6.8 +/- 3.3 mmol/L). Mean set HR for both RT (170 +/- 9.1 bpm) and HIIT (179 +/- 5.6 bpm) was at least 85% of HR maximum. VO2 over all 12 sets was greater for HIIT (33.8 +/- 5.21 mL/kg/min) than RT (24.9 +/- 3.23 mL/kg/min).
  
  Eventually, the study does therefore confirm that intermittent forays into high, but not supra-maximal intensity exercise is a potent physiological stimulus in adolescents. What I would like to highlight, though, is the fact that this isn't true only for HIIT, but also for resistance training which is still falsely regarded solely as strength and muscle builder.
• Controlled Frequency Breathing Reduces Inspiratory Muscle Fatigue, but is Another Training Technique that does not translate into Real World Benefits (Brutch. 2016) - Controlled frequency breathing (CFB) is a common swim training modality involving holding one's breath for about 7 to 10 strokes before taking another breath.
  
  In their latest study, Burtch et al. sought to examine the effects of CFB training on reducing respiratory muscle fatigue. Competitive college swimmers were randomly divided into either the CFB group that breathed every 7 to 10 strokes, or a control group that breathed every 3-4 strokes. Twenty swimmers completed the study. The training intervention included 5-6 weeks (16 sessions) of 12x50-m repetitions with breathing 8-10 breaths per 50m (control group), or 2-3 breaths per 50-m (CFB group). Inspiratory muscle fatigue was defined as the decrease in maximal inspiratory mouth-pressure (MIP) between rest and 46s after a 200 yard free-style swimming race [115s (SD 7)]. Aerobic capacity, pulmonary diffusing capacity, and running economy were also measured pre and post-training.
  

  

  Figure 2: Mechanisms by which inspiratory muscle training improves performance (Brunell University)

  Pooled results demonstrated a 12% decrease in MIP at 46s post-race [-15 (SD 14) cm H2O, Effect size = -0.48, p < 0.01]. After four weeks of training, only the CFB group prevented a decline in MIP values pre to 46 s post-race [-2 (13) cm H2O, p > 0.05]. However, swimming performance, aerobic capacity, pulmonary diffusing capacity, and running economy did not improve (p > 0.05) post-training in either group.
  
  "In conclusion, CFB training appears to prevent inspiratory muscle fatigue yet no difference was found in performance outcomes," the authors write and forget to highlight that this is not the first study to show that many experimentally verified benefits on potential determinants of exercise performance (cf. Figure 2) leave the actual performance variables unchanged - or, at least not significantly improved (here: -0.1 +/- 1.5s in CFP vs. +1.8 +/- 4.6 in the control group - a tentative benefit).
• Can cold water immersion enhance recovery in elite Olympic weightlifters? An individualized perspective (Schimpchen. 2016) - I hope you still remember that your goals determine whether you should or should not use cold water immersion, right? The thing about the impaired gains if you do it in a training phase...?
  
  

  

  Using Ice / Cold Water Immersion After Workouts Will Impair Muscle & Strength Gains and Vascular Adaptations | more

  That does not mean, though, that its acute beneficial effects were void. In fact, previous studies have show - albeit ambiguously - that cold water immersion following intensive training sessions can enhance recovery athletes. In a new study, Jan Schimpchen et al. did now test (a) whether this is also the case for elite Olympic weightlifters, and (b) whether the differences could be explained by each athlete's individual response pattern.
  
  The entire German male Olympic weightlifting national team participated in the study (n=7), ensuring collection of data from elite athletes only.
  
  Using a randomized cross-over design, the athletes went through two high intensity training microcycles consisting of five training sessions that were either followed by a cold water immersion or passive recovery. Barbell speed in a snatch pull movement, blood parameters as well as subjective ratings of general fatigue and recovery were assessed throughout the study.
  

  

  Table 1: Statistical analysis of all parameters. Overall P-value refers to the interaction of condition x time (Schimpchen. 2016) | Of particular interest: The column in red! Why? It tells you the ratio of "responders" to "non-responders" to those whose performance actually suffered; eg. VO2max 21/60/19 %.

  Physical performance at two snatch pull intensities (85% 1RM: -0.15% vs. -0.22%, P=0.94; 90% 1RM: -0.7% vs. +1.23%, P=0.25) did not differ significantly (condition x time). While questionnaires revealed a significant decline in ratings of overall recovery (P<0.001) and a significantly higher rating of overall stress (P=0.03) over time, no significant differences between conditions (P=0.14; P=0.98) could be revealed. Similarly, neither of the analyzed blood parameters changed significantly between conditions over time (CK: P=0.53; Urea: P=0.43; Cortisol: P=0.59; Testosterone: P=0.53; Testosterone:Cortisol ratio: P=0.69).
  
  "In general, CWI did not prove to be an effective tool to enhance recovery in elite Olympic weightlifters over a three day intensive training period," Schimpchen et al. conclude, but add: "However, even though the group was rather homogeneous with regard to performance, there were considerable inter-subject differences in their response to CWI. It appears that athletes are best advised on a case-by-case basis" (Schimpchen. 2016).
• The maximal mechanical capabilities of leg extensors muscles to generate velocity and power improve at altitude (García-Ramos. 2016) - For long altitude training has been thought of (especially by non-athletes) as a PEDish (performance enhancing drug) performance enhancer. More recently, however, several studies have shown that the benefits may - as in so many other cases - be significantly overrated.
  
  In a recent study, scientists did now aim (a) to analyze the effect of an acute exposure to terrestrial altitude on the force-velocity relationship parameters (maximum force [F0)], maximum velocity [V0)], and maximum power [P0)]) during a loaded squat jump (SJ), and (b) to compare unloaded SJ and countermovement jump (CMJ) performance between sea level and altitude conditions. Seventeen international swimmers were tested at sea level (295 m asl) and 7 days later at terrestrial altitude (2320 m asl) during their first 24 hours of altitude exposure. The maximum values of force and velocity were recorded during a loaded SJ (25-100% of body weight) to determine F0, V0, and P0 parameters.
  

  

  Figure 3: Rel. (in %) and Effect Size ES for inter-group differences (Garcia-Ramos. 2016)

  As the authors point out, "[i]nconsequential differences between environmental conditions were found for F0 (P = 0.993, 0.02%)" (ibid.). However, V0 (P = 0.038, 7.6%) and P0 (P = 0.004, 6.8%) were higher at altitude. Peak values of force (SJ: P = 0.420, 1.19%; CMJ: P = 0.010, 3.6%), power (SJ: P = 0.028, 3.5%; CMJ: P = 0.005, 3.82%), and take-off velocity (SJ: P = 0.071, 1.6%; CMJ: P = 0.009, 1.9%) recorded during the SJ and CMJ were also higher at altitude.
  
  "These results highlight the potential effect of an acute exposure to terrestrial altitude on enhancing vertical jump performance," the authors highlight and explain: "The increase in maximal power of the leg muscles at altitude is caused by an improvement in the theoretical maximal velocity at which lower limbs can extend with no significant changes for the theoretical maximal force" (Garcia-Ramos. 2016).

If someone markets his program the way Hof does, i.e. as a means to "Become A 'Super' Version Of Yourself In Just 10 Short, Life Transforming Weeks" (WimHof-Method.com), you should rightly be skeptical | Find out if it's a winner routine or just another transient fad.

Bottom line: That's it? Not exactly... there's still Lara Carlson et al.'s study that compared the salivary lymphocytes (s-LYMPH) response to aerobic training in cool vs. thermoneutral environments and found that "exercise in a cool environment produces smaller fluctuations in salivary immune cells as compared to resting levels" - a result that puts a question-mark behind the common assumption that exercise in the cold would increase your risk of infections.

Speaking of question-marks, you will find similar question marks after (a) the question whether cold-water immersion is good for you (not w/ every workout, because of impaired adaptation and not even acutely, because of individual differences), (b) which athletes benefit most from altitude training (with the latest study pointing away from the usual subjects, namely endurance athletes) and (c) the notion that every improvement in potential determinants of exercise performance will actually translate to practically and/or stat. significant performance increases | Comment!

References:

• Brunell University. "Cardiovascular & Respiratory Physiology Research Group." College of Health and Life Sciences < http://www.brunel.ac.uk/chls/life-sciences/sport-health-and-exercise-sciences/research/csmhp/physiology > 
• Burtch, et al. "Controlled Frequency Breathing Reduces Inspiratory Muscle Fatigue." Journal of Strength & Conditioning Research: Post Acceptance: August 16, 2016 - doi: 10.1519/JSC.0000000000001589
• Carlson, L. "Salivary Lymphocyte Responses Follwing Acute Anaerobic Exercise In A Cool Environment." Journal of Strength & Conditioning Research: Post Acceptance: August 16, 2016 - doi: 10.1519/JSC.0000000000001593
• García-Ramos, A. "The maximal mechanical capabilities of leg extensors muscles to generate velocity and power improve at altitude." Journal of Strength & Conditioning Research: Post Acceptance: August 16, 2016 - doi: 10.1519/JSC.0000000000001592
• Harris, N. "Acute Responses To Resistance And High Intensity Interval Training In Adolescents." Journal of Strength & Conditioning Research: Post Acceptance: August 16, 2016 - doi: 10.1519/JSC.0000000000001590
• Schimpchen, et al. "Can cold water immersion enhance recovery in elite Olympic weightlifters? An individualized perspective." Journal of Strength & Conditioning Research: Post Acceptance: August 16, 2016 - doi: 10.1519/JSC.0000000000001591

Bright Light Exposure Improves Your Workouts Sign. (~8%)

Would be interesting to compare sunlight and artificial light in future studies.

You will remember the circadian rhythm series in which I have previously discussed the relevance of light exposure as a means to set, reset and entrain your internal clock in order to reap all sorts of health and performance benefits.

Bright (>4000 lux), preferable blue (at least having a blue component) light has repeatedly been shown to increase athletic performance. Studies like Kantermann et al. (2012) show, however, that the efficacy of bright light exposure significantly depends on the chronotype of an athlete.

Learn more about the health effects of correct / messed up circadian rhythms

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Sunlight a La Carte: "Hack" Your Rhythm

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Vitamin A & Caffeine Set the Clock

Pre-Workout Supps Could Ruin Your Sleep

In said study, the athletes were exposed to 4420 lux for 120 min before and right before a 40-min time trial. Significant performance increases were observed only for those subjects, though, who were performing ∼14.8 h after their midpoint of sleep on free days (MSFsc). Subjects who trained "earlier" on their internal clock (in this case ∼11.8 h after the MSFsc), on the other hand, did not record any benefits.

Back in the day, Kantermann et al. speculated that a short(er) exposure or mudaltion of light intensity and/or timing could likewise have affected their results. Thus, the hypothesis Knaier et al. used in their 2015 contribution to the "light for performance" research was to that different bright light (BL) exposure regimes prior to and during a time-trial applied during the “sensitive” phase of the circadian rhythm result in a dose dependent increase of time-trial power output - meaning: longer exposure and brighter light = maximal performance benefits.

To test this hypothesis the scientists assigned young (25.1 ± 3.1 years) men to three groups with two different light intensities (A = BL, 4420 lx vs. B = ML, 230 lx) for all three randomly chosen exposure times (2h pre + exercise time, 2HEX | 1h pre + exercise time 1HEX | 1h pre 1H).

Figure 1: Study protocol for 2HEX, 1HEX, and 1H. Time-trial: 40 min in duration; bright light/moderate light (BL/ML): continuous randomized exposure (slightly rearranged version of a figurr from Knaier. 2015).

As Figure 1 illustrates we are thus dealing with a total of three trials and their moderate light counter parts which are not illustrated in Figure 1. Thanks to the use of a cross-over design this means that all subjects were exposed to either bright light (BL, 4420 lux) or moderate light (ML, 230 lx).

Figure 2: Total work (in kJ) during the 40-minute time-trial to exhaustion (Knaier. 2015).

The scientists' analyses of the studies results and the normalization of the results according to the subjects' individual chronotype (estimated based on the Munich Chronotype Questionnaire) yielded the following two primary study outcomes:

• Total work performed during the time-trial in kJ in the 2HEX group was significantly higher in the BL setting (527 kJ) than in ML (512 kJ) (P = 0.002), but not in 1HEX (BL: 485 kJ; ML: 498 kJ) or 1H (BL: 519 kJ; ML: 514 kJ) (P = 0.770; P = 0.485). 
• There was a significant (P = 0.006) positive dose–response relationship between the duration of light exposure and the work performed over the three doses of light exposure. 

Overall, the study does therefore confirm that "[a] long duration light exposure is an effective tool to increase total work in a medium length timetrial" - what's new (compared to the previously referenced Kantermann study is the observation that this advantage holds, even if the results are normalized for the subjects' individual chronotype.

Whether and to which extent the "more light equals more performance" equation will hold with (a) even longer or (b) even more intense light, however, is something that will have to be investigated in future dose-response studies. Studies like O'Brien et al. (2000) which has already proven that shortening the exposure time (in this case to 20 minutes only during exercise) will reduce the effects of bright light exposure on cycling performance to zero.

Bottom line: While one hour of bright or 2h of medium intensity light appears to allow for too little 'light accumulation' to have physiologically relevant affects, long duration of exposure to bright light is, as Knaier et al. point out "an effective tool to increase total work at least for the initial phase of a medium length time-trial" (Knaier. 2015); and what's important, the performance increase of ~8% which was observed not just in the Knaier study, but also in a differently designed trial by Thomson, et al. (2015 | cf. Figure 3), is large enough to be relevant for any competing athlete.

Figure 3: A study by Thompson, et al. (2015) suggests that pre-bed exposition to bright light (30 min) can increase the time-trial performance of athletes on the subsequent morning. Since this will also suppress the melatonin levels of practitioners this is yet a strategy that should not be employed regular (competition only).

The results of Knaier are thus in contrast to a similarly recent study by Nelson et al. (2015) who found that acute short-term dim light exposure can actually lower muscle strength endurance (-18%, albeit with high inter-individual variability). Against that background it should be obvious that, even though, bright light exposure is indeed "likely to increase alertness and reduce sleepiness and help athletes to compensate for disadvantages in competitions at unfavorable times and improve performance" (Knaier. 2015). And don't forget - the scientists from the University of Basel are right: "The ideal duration of expo sure to increase performance and simultaneously interfere as little as possible with athletes’ routine still needs to be found" (Knaier. 2015). In fact, even timing and strategies like the pre-evening light exposure that increased the time trial performance in Thomson et al. (2015 | see Figure 3) must be tested as alternatives | Comment on Facebook!

References:

• Kantermann, Thomas, et al. "The stimulating effect of bright light on physical performance depends on internal time." PloS one 7.7 (2012): e40655.
• Knaier, R., et al. "Dose–response relationship between light exposure and cycling performance." Scandinavian journal of medicine & science in sports (2015).
• Nelson, Arnold G., Joke Kokkonen, and Megan Mickenberg. "Acute short-term dim light exposure can lower muscle strength endurance." Journal of Sport and Health Science 4.3 (2015): 270-274.
• O'Brien, Patrick M., and Patrick J. O'Conner. "Effect of bright light on cycling performance." Medicine & Science in Sports & Exercise (2000).
• Thompson, A., et al. "The effects of evening bright light exposure on subsequent morning exercise performance." International journal of sports medicine 36.02 (2015): 101-106.

Drop-Sets Build, Don't Destroy Older Muscle - 50-Y+ Agers Gain >200% More Lean Muscle W/ Extra Creatine | What do Other Studies Say About the Power of Doing Drop-Sets?

Should she drop the weight and add another set? Whether dropsets are superior to regular workouts is unfortu-nately a question the study at hand cannot answer. To learn more, you should read the information in the red box.

What I really like about having a few thousand friends on Facebook is that you point me to the few interesting studies I may not have read yet. One of these studies comes from Darren Candow who posted a link to an interesting "dropset +/- creatine in the elderly" study (Johannsmeyer. 2016) on the ISSN Facebook page.

The study was published ahead of print a few days ago and deals with the "[e]ffect of creatine supplementation and drop-set resistance training in untrained aging adults" (Johannsmeyer. 2016). More specifically, the objective of the study was to investigate the effects of creatine supplementation and drop-set resistance training in untrained aging adults. What the study did not do, unfortunately, is to compare drop-set to regular training... bummer.

Are you looking for muscle builders for the year 2016? Find inspiration in these articles:

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Full Squat for Size, Partial for Strength

Study Indicates Cut the Volume Make the Gains!

Unfortunately, the participants were randomized one of only two groups: Creatine (CR: n = 14, 7 females, 7 males; 58.0 ± 3.0 yrs, 0.1 g/kg/day of creatine + 0.1 g/kg/day of maltodextrin) or Placebo (PLA: n = 17, 7 females, 10 males; age: 57.6 ± 5.0 yrs, 0.2 g/kg/day of maltodextrin) during 12 weeks of drop-set resistance training (3 days/week; 2 sets of leg press, chest press, hack squat and lat pull-down exercises performed to muscle fatigue at 80% baseline 1- repetition maximum [1-RM] immediately followed by repetitions to muscle fatigue at 30% baseline 1- RM). A non-dropset control and non-dropset creatine group were missing, though.

Practically speaking, this means that all subjects did the same "Drop-Set Resistance Training Program" where every set was performed to muscle fatigue (defined as the inability to perform the concentric phase of a muscle contraction; Candow et al., 2011), the scientists describe as follows:

Figure 1: Overview of the study design.

"During the study, participants exercised 3 days/week, on non-consecutive days, to reduce the risk of injury. Participants performed 2 sets of drop-set resistance training for the leg press, chest press, hack squat and lat pull-down exercises. Each set consisted of performing repetitions to muscle fatigue at 80% baseline 1-RM immediately followed by repetitions to muscle fatigue at 30% baseline 1-RM" (Johannesmeyer. 2016).

What is a bit odd, is the fact that the training load was not increased over the the 12 weeks of training and supplementation, as the purpose of the study was to overload the upper and lower body musculature by increasing the number of repetitions performed to muscle fatigue - not by increasing weights / loads.

"Dietary intake was recorded during the first and final week of supplementation and resistance training to assess differences in total energy and macronutrient composition between groups. Participants used a 3 day food booklet to record food intake for two weekdays and one weekend day. Participants were instructed to record all food items, including portion sizes consumed for the three designated days" (Joannesmeyer. 2016).

Next to body composition, strength and the training loads, the scientists also tested the levels of 3-methylhistidine (3-MH), an indicator of muscle protein breakdown which is (obviously) of particular importance for potentially catabolic elderly muscle.

Figure 2: Lean mass (kg) and protein breakdown (3MH) before and after the 12 week study (Johannesmeyer. 2016).

That this protein catabolism was lower than the exercise-induced anabolism for both groups becomes obvious when you look at the lean mass changes in Figure 2.

Goto et al.'s 2004 study is the only one showing a sign. lean mass advantage when comparing regular strength training (5 x 90%1RM; 3 min rest) to the same training plus a single extra-set at only 50% 1RM that was performed 30 s after the last of the 90%1RM sets. What is important to remember is that this advantage existed only in the strength phase of the linear periodization cycle Goto et al. choose, yet not when the subjects did nine sets of exercises at 80-40% of their 1RM in the hypertrophy phase.

What can other studies tell us about the efficacy of dropsets? Well, I've discussed this question only recently based on a study by Fisher et al. (2016) who were unable to confirm extra-gains in response to drop-sets in a much younger subject group. In contrast to the dropset protocol you are probably doing, the protocols in the Fisher study were however chosen "to allow parity between training load (the BD and CON groups both used the same relative load to begin; permitting 8–12 repetitions) and repetition volume (the HLBD and CON groups both performed a total of ~8 to 12 repetitions)" (Fisher. 2016). Thus the researchers eliminated the (probably) only relevant advantage of doing drop sets, i.e. a sign. increase in training volume, so that it is not really surprising that they didn't record sign. inter-group differences - after all, increasing the training volume was exactly what Sarah Johannsmeyer et al. had in mind when they combining heavy loads with light loads for their latest paper in Experimental Gerontology.

This doesn't change the fact that there's only little evidence that drop sets work: Goto et al. (2003) who had initially observed a sign. increase in GH when they had their subjects to extra low-intensity sets (50% of 1RM) immediately after the performance of a high-intensity sets, for example, observed in a follow up study (Goto. 2004) that drop setting resulted in a significant increase in the muscle CSA as opposed to doing the standardized baseline strength training program, alone. In contrast to the Fisher study, the training volume was not controlled for by Goto et al. (2004), though. Eventually it's thus not unlikely that it all came back to the benefits of an increased training volume - an advantage of which the Goto study also suggests that it exists only if the volume is rather low (strength phase vs. hypertrophy phase in the figure above).

A figure that also tells you that the "addition of creatine to drop-set resistance training significantly increased body mass (p = 0.002) and muscle mass (p = 0.007) compared to placebo" (Johannesmeyer. 2016).

Figure 3: Muscle strength (1-RM) for t (Johannesmeyer. 2016).t, chest press and lat pull down exercise and endurance measurements (repetitions to volitional fatigue with 80% baseline 1-RM for leg press and 70% baseline 1-RM for chest press) before and after 12 weeks of supplementation and high-low resistance training (Johannesmeyer. 2016).

That's in contrast to the data in Figure 3, which indicates that the changes in muscle strength (1-RM) for the leg press, hack squat, chest press and lat pull down exercise and endurance measurements (repetitions to volitional fatigue with 80% baseline 1-RM for leg press and 70% baseline 1-RM for chest press) before and after 12 weeks of supplementation and high-low resistance training did not differ sign. when the scientists compared the placebo (PLA) to the creatine (CR) group.

Table 1: Total calorie (kcal/day) and macronutrient (g/day) content of the CR and PLA group for 3 days during the first and final week of supplementation and resistance training (Johannesmeyer. 2016).

Whether the existing inter-group difference in total and lean mass gains, as well as the likewise significant sex-differences which indicate that males benefit more from creatine, strength-wise (lat pull-down only) than women have anything do do with the protein intake of the subjects (see Tablel 1) is merely speculative. If you do the math, you will realize that both groups consumed almost the same relative amount of protein with 1.28 g/kg in the creatine and 1.11 g/kg in the placebo group... thus, it seems very unlikely that the protein intake mattered.

Figure 4: Unfortunately, there's nothing you can learn about the efficacy of dropsets in 50-y+ agers from a study with only two experimental groups differing only by creatine supple-mentation (Johannsmeyer. 2016). For that we need the few existing studies that had these groups (see red box + discussion in the bottom line)

One thing's missing... eventually, even two things, namely a non-dropset PLA and CRE group that would allow us to modify the scientists conclusion that "[t]he addition of creatine to drop-set resistance training augments the gains in muscle mass from resistance training alone" with reference to the individual effects of doing dropsets.

Accordingly, the study at hand shows that drop sets won't burn old muscle and confirm that creatine at a dosage of ~7-8g/day will sign. improve the lean mass gains of men and women in their late 50s. What it does not do, however, is to give us any clue whether the subjects would have gained less than the 3kg of lean mass if they hadn't done dropsets. Previous studies in younger people (discussed in this SV Classic | Fisher. 2016) appear to refute that - if they don't contribute to sign. increases in training volume. If this increase occurs, as in the strength period of the Goto Study, however, things look good for dropsets | Comment!

References:

• Bubbico, Aaron, and Len Kravitz. "Muscle hypertrophy: New insights and training recommendations." IDEA Fitness Journal 2326 (2011).
• Fisher, James P., Luke Carlson, and James Steele. "The Effects of Breakdown Set Resistance Training on Muscular Performance and Body Composition in Young Men and Women." The Journal of Strength & Conditioning Research 30.5 (2016): 1425-1432.
• Goto, K., K. Sato, and K. Takamatsu. "A single set of low intensity resistance exercise immediately following high intensity resistance exercise stimulates growth hormone secretion in men." Journal of sports medicine and physical fitness 43.2 (2003): 243.
• Goto, Kazushige, et al. "Muscular adaptations to combinations of high-and low-intensity resistance exercises." The Journal of Strength & Conditioning Research 18.4 (2004): 730-737.
• Johannsmeyer, Sarah, Candow, Darren G., Brahms, C. Markus, Michel, Deborah, Zello, Gordon A.  "Effect of creatine supplementation and drop-set resistance training in untrained aging adults." Experimental Gerontology (2016) - Published ahead of print on Aug 11 (doi: 10.1016/j.exger.2016.08.005).

Cupping for Pain, Health & Performance | Must Be Good, if Phelps Does it, Right? Let's See What the 100+ Studies Say

The "cups" come in various forms and sizes... and no, there's no meta-analysis yet that can tell you what the optimal size and form for the treatment of a given disease / problem would be ;-)

"If Phelps does it, it must be good!" I am pretty sure that SuppVersity readers don't think like that this is why I'd like to invite you to join my brief research review on cupping, i.e. the use of cups that are sucked to specific acupuncture points on your back via a simply physics trick: After being heated with fire, the air in the cup expands rapidly only to decrease by the same extent after the pre-heated cup is placed on your back. The rapid reduction of the volume of air in the cup will will create a vacuum that will not just glue the cup to your skin, but literally suck some of your skin into the cup and the capillaries in the skin to rupture - no wonder Phelp's body was plastered with red "cup marks" during the Olympic games ;-)

With Phelps strongly believing in the practice, it is quite obvious that it would have worked its alleged recovery magic irrespective of whether the increased blood flow to the cupped area has any local or systemic health effects whic allegedly range from anti-viral therapy to blood pressure management - you call that "placebo effect".

Read previous True or False!? Articles at the SuppVersity

You Cannot Consume too Much Whey?!

Caffeine and Creatine Don't Mix, do They?!

Creatine is Better Taken After Workouts!?

Low Fat for Lean, Low Carb for Fat Individuals!?

Protein Timing Really Doesn't Matter!?

Nicotine Gums Will Help Fat Loss!?

From a science perspective, though, there is some preliminary evidence that Phelps' trust is / was not totally misplaced, though - here's an overview of what we know...

• Initial evidence of cupping to treat chronic neck pain (Lauche. 2013) - Chronic neck pain is a major public health problem with very few evidence-based complementary treatment options.
  
  It would thus be great, if the positive results of a 2013 study that tested the efficacy of 12 weeks of a partner-delivered home-based cupping massage, and compared it to the same period of progressive muscle relaxation in patients with chronic non-specific neck pain, could be reproduced in a more tightly controlled  setting.
  

  

  Figure 1: Cupping vs. PMR home-treatment in a 12-week study in patients w/ chronic neck pain (Lauche. 2013).

  Primary outcome measure was the current neck pain intensity (0-100 mm visual analog scale; VAS) after 12 weeks. Secondary outcome measures included pain on motion, affective pain perception, functional disability, psychological distress, wellbeing, health-related quality of life, pressure pain thresholds and adverse events. Sixty one patients (54.1±12.7 years; 73.8%female) were randomized to cupping massage (n = 30) or progressive muscle relaxation (n = 31).
  
  After treatment, both groups showed significantly less pain compared to baseline however without significant group differences. Significant effects in favor of cupping massage were only found for wellbeing and pressure pain thresholds.
  
  "In conclusion, cupping massage is no more effective than progressive muscle relaxation in reducing chronic non-specific neck pain. Both therapies can be easily used at home and can reduce pain to a minimal clinically relevant extent. Cupping massage may however be better than PMR in improving well-being and decreasing pressure pain sensitivity but more studies with larger samples and longer follow-up periods are needed to confirm these results" (Lauche. 2013), the Lauche and colleagues from the University of Duisburg-Essen conclude.
• Preliminary evidence of a reduction of symptoms of osteoarthritis (Teut. 2012) - Scientists from the Charité University Medical Center in Berlin investigated the effectiveness of cupping in relieving the symptoms of knee osteoarthritis (OA) in a two-group, randomized controlled exploratory pilot study.
  
  

  

  Image 1: Much in contrast to most other studies, the osteoarthritis didn't use "cups" and heating, but this adaptable silicone cup at the knee (Teut. 2012).

  Patients with a clinically and radiological confirmed knee OA (Kellgren-Lawrence Grading Scale: 2-4) and a pain intensity > 40 mm on a 100 mm visual analogue scale (VAS) were included. 40 Patients were randomized to either 8 sessions of pulsatile dry cupping within 4 weeks or no intervention (control). Paracetamol was allowed on demand for both groups. Outcomes were the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the pain intensity on a VAS (0 mm = no pain to 100 mm = maximum intensity) and Quality of Life (SF-36) 4 and 12 weeks after randomization.
  
  In addition, the subjects' use of Paracetamol was documented within the 4-week treatment period. Analyses were performed by analysis of covariance adjusting for the baseline value for each outcome.
  

  

  Figure 2: Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score and Visual Analogue Scale (VAS) for pain intensity after 4 and 12 weeks of cupping or control (Teut. 2012).

  21 patients were allocated to the cupping group (5 male; mean age 68 ± SD 7.2) and 19 to the control group (8 male; 69 ± 6.8). After 4 weeks the WOMAC global score improved significantly more in the cupping group with a mean of 27.7 (95% confidence interval 22.1; 33.3) compared to 42.2 (36.3; 48.1) in the control group (p = 0.001). After 12 weeks the WOMAC global score were still significantly different in favor for cupping (31.0 (24.9; 37.2) vs. 40.8 (34.4; 47.3) p = 0.032), however the WOMAC subscores for pain and stiffness were not significant anymore. Significantly better outcomes in the cupping group were also observed for pain intensity on VAS and for the SF-36 Physical Component Scale compared to the control group after 4 and 12 weeks. No significant difference was observed for the SF-36 Mental Component Scale and the total number of consumed Paracetamol tablets between both groups (mean 9.1, SD ± 20.0 vs. 11.5 ± 15.9).
  
  "In this exploratory study dry cupping with a pulsatile cupping device relieved symptoms of knee OA compared to no intervention. Further studies comparing cupping with active treatments are needed," Teut et al. conclude and forget to mention that everything could be placebo... after all, simply not doing anything is not a valid / significant "treatment" to evaluate the effects of cupping. This and the fact that the dosage of pain-killers are things you should keep in mind when evaluating the study results. 

"Wet" = bloody cupping - Geez!

"Wet cupping" is gorier than you'd expect: What doesn't sound like much is in fact a completely different way of cupping. While the previously described procedure (see introduction) may be a bit painful, it is totally non-invasive. That's in contrast to the so-called "wet-cupping" process aka "Hijamat bilshurt" in Unani medicine, which involves "the incising of skin either before the cup is placed or during the process of suctioning with needles placed at the base of the cup being used" (Akhtar. 2008). Overall a rather gory practice as the image to the left is one of the rather harmless photos you will find online.

• Promising effects in chronic low back pain, systematic review says (Huang. 2016) - It's just published as a letter, but the systematic review Huang and colleagues from Taiwan argue that "the research results show that cupping therapy is promising for pain control and improvement of quality of life, and minimises the potential risks of treatment" (ibid.). Huang et al. base this assessment on their review of one randomised controlled trial (RCT, level I evidence), six non-RCTs (level II evidence), 20 case reports (level IV evidence) and two mechanism-based reasoning studies (see Table 1):
  

  

  Table 1: Overview of studies with levels I and II evidence Huang et al. (2016) included in their review.

  In the RCT, the effective rate of the wet-cupping (see red box!) group was similar to that of the waiting-list group (p>0.05). Interventions in both groups decreased pain, disability and acetaminophen dosage, but a significant decrease in pain intensity according to the McGill pain questionnaire (p<0.01) and reduced consumption of acetaminophen (p=0.09) were seen in the wet-cupping group. Similarly promising were the results of the six non-RCTs: one showed that the visual analogue scale (VAS) score and the Oswestry disability index in the balance-cupping group were significantly lower than in the group with cupping with retention and diclofenac (p<0.05), but there was no difference between the cupping with retention group and the diclofenac-only group (p>0.05). The other studies individually showed that the effectiveness of cupping in decreasing VAS,  reducing recurrence rate and improving quality of life, was better than Western medication.
  
  It should not be forgotten, though, that the evidence is rather preliminary than water-tight. Accordingly, Huang et al. are 100% right, when they demand that "further studies are needed to determine the potential role of cupping therapy in the treatment of low back pain" (Huang. 2016).

Table 2: Estimate effect of cupping for pain management (all types of diseases) from 16 included trials (Cao. 2014).

Pain management appears to be the best proven area of application (Cao. 2014) - As the overview of studies from Cao et al.'s 2014 review in Table 2 indicates, the effect of cupping for pain management (regardless of type of diseases) from 16 included trials is mostly, but not exclusively positive (meaning the pain was reduced), albeit not always significant and in many cases potentially influenced by confounding factors / treatments and thus far from being convincing evidence.

• A plethora of additional possible benefits (Cao. 2012) - While pain management appears to be the closest to being a proven benefit of cupping, the literature that was reviewed among others by Cao, Li and Liu lists other purported benefits.
  
  The scientists from the University of Western Sydney and the Beijing University of Chinese Medicine managed to identify the impressive number of 135 RCTs published from 1992 through 2010; studies that were generally of low methodological quality, but investigated diseases ranging from herpes zoster, facial paralysis (Bell palsy), cough and dyspnea, over acne, lumbar disc herniation, to cervical spondylosis.
  

  

  Figure 3: Types of cupping therapy used in the studies in the meta-analysis (Cao. 2012).

  Unlike Phelps, most researchers used the "bloody" wet cupping - when all is said end done, not without negative effects as Cao et al. point out: "Meta-analysis showed cupping therapy combined with other TCM treatments was significantly superior to other treatments alone in increasing the number of cured patients with herpes zoster, facial paralysis, acne, and cervical spondylosis" (Cao. 2012 | check out the Figures for free). 

Figure 3: While it turned out to be a failure in this follow up study (data from Aleyeidi. 2015), wet, i.e. bloody, cupping aka "Hijama" is traditionally used in Indian medicine to treat hypertension (=elevated blood pressure), too - and guess what: initial evidence from other studies suggested that it works (Lee. 2010; Zarai. 2012).

Bottom line: Thanks to the placebo effect and its very likely effects on practitioners pain threshold, it does not seem appropriate to laugh about Michael Phelps or anyone else who uses (dry!) cupping to promote recovery and/or control back, knee or whatever other pain (cf. Cao. 2014).

In the absence of bulletproof evidence from sensibly controlled human trials, it would yet be similarly misguided to think of cupping as a decisive factor in Phelps' recent Olympia success and/or a traditional medicine technique that doesn't just cure pain but also high blood lipid levels, which was the goal of an inaccessible doctoral thesis Abeer Mohammed Kawthar announced at the King Abdulaziz University - for blood pressure, Kawthar, this time working with Aleyeidi & Aseri has, after all, only recently failed to replicate the results of previous studies that suggested a blood pressure lowering effect of wet, i.e. bloody, cupping (Aleyeidi. 2015) | Comment!

References:

• Akhtar, Jamal, and M. Khalid Siddiqui. "Utility of cupping therapy Hijamat in Unani medicine." Indian J Trad Knowl 7.4 (2008): 572-4.
• Cao, Huijuan, Xun Li, and Jianping Liu. "An updated review of the efficacy of cupping therapy." PLoS One 7.2 (2012): e31793.
• Cao, Huijuan, et al. "Cupping therapy for acute and chronic pain management: a systematic review of randomized clinical trials." Journal of Traditional Chinese Medical Sciences 1.1 (2014): 49-61.
• Huang, Chia-Yu, Mun-Yau Choong, and Tzong-Shiun Li. "Effectiveness of cupping therapy for low back pain: a systematic review." Acupuncture in Medicine (2013): acupmed-2013.
• Kawthar, Abeer Mohammed. "Effect of compining antilipids drugs with wet cupping on lipid blood level." (2007).
• Lauche, Romy, et al. "Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain—A randomized controlled trial." PloS one 8.6 (2013): e65378 [FFT]
• Lee, Myeong Soo, et al. "Cupping for hypertension: a systematic review." Clinical and experimental hypertension 32.7 (2010): 423-425.
• Teut, Michael, et al. "Pulsatile dry cupping in patients with osteoarthritis of the knee–a randomized controlled exploratory trial." BMC complementary and alternative medicine 12.1 (2012): 1.
• Zarei, Mohammad, et al. "The efficacy of wet cupping in the treatment of hypertension." ARYA Atheroscler (2012): S145-S148.