Blood Flow Restriction Training for Muscle Mass

Maintenance:
A Special Interview With Dr. Jim Stray-Gundersen
By Dr. Joseph Mercola

JM: Dr. Joseph Mercola

JS: Dr. Jim Stray-Gundersen

JM: Welcome, everyone. This is Dr. Mercola, helping you take control of your health. Today
we’re going to talk about what is, without a doubt, the most exciting innovation in exercise training
I’ve ever encountered in my 50 years of exercise. To help us walk through this exercise innovation
is one of the experts in this area, Dr. Jim Stray-Gundersen, who is a physician, a M.D. He also has
an interest in exercise physiology so he’s studied deeply the science of this, sports performance
and training. He trains a lot of elite and professional athletes and Olympic athletes. He hangs out
in Park City, Utah. Welcome and thank you for joining us today.

JS: Thank you for having me.

JM: Alright. I didn’t mention it, but what we’re going to talk today about is blood flow restriction
(BFR) training, which was developed by Dr. Yoshiaki Sato, out of Japan, I think in 1966 or so. I
believe you’ve actually met him and worked with the organization, KAATSU Global, for a while.
Maybe you can describe your experience with this. Certainly in this description, also articulate
what BFR training is, and then we’ll go into some of the intriguing mechanisms on why it works
and the unbelievable potential it has for one of the greatest threats to longevity that I perceived,
which is sarcopenia. Why don’t you lead us down that journey?

JS: Very well. Dr. Sato had an epiphany in 1966. He was busy attending a funeral service. He
ended up having to sit in a certain position where we would say our legs fell asleep. This reminded
him – When he tried to get up, his legs didn’t work very well. This reminded him of when he really
would exhaust himself with heavy weightlifting. That just kind of stuck in his mind. Then over the
next couple of years, he was trying a few things.

But in 1973, he had a ski accident. He ended up in a full-length leg cast. As most physicians know,
these full-length leg casts produce lots of atrophy. He had been, in a way, just playing around with
this idea of BFR, but this was an occasion where he could try this out for himself. What he did was
he took a judo belt and he wrapped it several times around the top of his thigh, above the cast. And
then he did isometric exercises in the cast.

In those days, the cast were routinely changed at six weeks, because there typically had been so
much atrophy that the cast was now loose and really wouldn’t hold a fracture in the proper location.
When he reported to the physicians to change the cast, it turned out that he really didn’t have much
atrophy at all. His ankle fracture and his knee injury were now not tender. Instead of getting another
cast put on for another six weeks, he basically just walked out of the clinic. That was really the
point for him to say, ‘Hey there’s really something here.”
Really, for the next 30 years, he literally experimented with himself and his fellow bodybuilders,
trying to understand the ins and outs of what they were calling a occlusion training at the time.
And then in the middle of the ‘90s, in a decade, he had learned a number of things over these
intervening 30 years. He realized he needed an elastic band. He realized he needed a relatively
narrow band. He realized that he could have very good control of a situation if he had developed
a kind of pneumatic bladder in which he could control the pressure that was applying this blood
flow restriction.

And then the first paper came out in the English literature in about 1998, and another one in 2000,
where he and his group conclusively demonstrated that this was effective for increasing muscle
strength and muscle hypertrophy. Kind of at the same time, his group had been involved in
bodybuilding and was now doing this at international shows in the beginning to just get a good
pump for their show. Their European competitors and American competitors would see what they
were doing but they really didn’t have the language skills nor were the Japanese really interested
in sharing what this knowledge was about.

Around 2000, maybe a little bit later, the West started trying to reproduce what he was already
doing. But they didn’t have the benefit of this 30 years of experience of figuring out what worked
and what didn’t work, what was safe, what was effective. This is when BFRs kind of got going in
Europe and North America. Go ahead.

JM: No. I was going to ask. So about 2000, less than 20 years. I’m wondering what your initial
exposure to it was and how you got interested.

JS: Well in my particular case, I’ve had a career in human performance and kind of elite
performance. I’ve worked with Winter Olympians from cross-country skiers, alpine skiers, speed
skaters and hockey players, pretty much all the different types. In the Sumer Olympics, runners,
swimmers, cyclists, triathletes, manly focused on endurance sports, but then also soccer to a large
extent.

Through all these years – And then my day job was a professor at the med school at the University
of Texas Southwestern in Dallas. Through all these years, I always had my eyes out for things that
could improve athletes’ performance, as well as be very useful for the population in general. In
2011, I happened to run into a colleague at the American College of Sports Medicine Annual
Meeting, who told me about KAATSU. KAATSU is what Dr. Sato calls his form of BFR training.
My colleague was busy telling me about how great this was and that you could get improvements
in strength in as little as two weeks.

I was quite skeptical at first. Most of the physiology that I knew about to make significant gains in
strength and muscle size. You needed about six weeks. This didn’t quite make sense to me. But
the short story is I ended up checking it out and ended up contacting KAATSU Global and Steve
Munatones. From there, getting to spend some time with Dr. Sato and learning the ins and outs of
KAATSU, which, in Japan, Dr. Sato treats it a little bit like a martial art. He’s got his – what’s the
right word – group of disciples. It takes you several years to really learn the ins and outs of all this.
In the meantime, you scrub floors and do a lot of things. That’s kind of a lot of fun.
Being an American, we skipped a lot of that kind of stuff and went right to learning about it. It’s
actually quite fantastic. It’s really a big paradigm shift in how we will think about training and
how to think about, really, antiaging medicine or using exercise as a medicine for health and
fitness. It’s really – It will change the way we train.

JM: Well, it should. There’s no question. It’s the greatest innovation in exercise therapy I’ve ever
seen. I’ve been fascinated with exercise ever since ’68, which is probably about the time you
started, because we’re about the same age. Interestingly, we’re in a similar neighborhood. We’re
very close to each other actually.

My parents passed away about two years ago. I’m very grateful that I was able to mentor them
through the system so they never have to die from a medial mistake because that’s a significant
reason why people die, from medical mistakes.

[-----10:00-----]

JS: Absolutely.

JM: But they didn’t. Instead, I believe they largely died from frailty. I’m really disappointed in
myself that I never understood how to treat it. I could never help them. They had sarcopenia.
Sarcopenia is massively prevalent – 20% to 25% of 60-year-olds and like 60% of 80-year-olds.
It’s not just cosmetics or frailty, but it’s 50% of your tissue is muscle. It’s actually a metabolic
organ, an endocrine organ. It makes cytokines and myokines. It actually is a great deposit of
glucose. That’s the primary reason I’m so motivated about it. It’s because of the ability to really
effectively address the sarcopenia issue like no other training.

Now, as you mentioned earlier, your experience and the traditional experience with gaining muscle
mass is conventional strength training, which is anywhere from 60%, 70% to 85% of your one rep
max. When you do that intensely, maybe six to eight reps a few times a week, because you can’t
do much more than that because you’re digging a hole and you’ve got to recover.

JS: Right.

JM: But KAATSU is completely different. It just turns everything upside down. Why don’t you
discuss the differences between them? Because I think that’s the most radical innovation.

JS: Yeah. I would say that, succinctly, that what KAATSU does is it allows you to get the same
benefits you get from heavy standard lifting with very light weights, 20% to 30% of one rep max
and this BFR training. What the BFR is, that may sound a little weird or not normal, but really,
what we’re doing is we’re limiting the venous outflow out of an extremity and creating a situation
in the working muscle where it’s not getting enough oxygen to sustain or to rebuild the energy
stores that are used up in the course of that work.

So you set up this metabolic crisis where you’re not making enough ATP to replace the ATP that
you’re using. The consequence of that is you get a disturbance of homeostasis, which is just like
the disturbance of homeostasis you get with very heavy lifting. The difference is that we’re doing
it by modulating and impeding the blood flow as opposed to doing very hard work, which actually
does damage to the tissue at the same time.

One of the reasons why you get these effects much sooner than typically is because we have altered
the time scale by not doing the damage. Therefore, we’re getting the benefits of this exercise in
very short order. Really, we’ve tapped into starting to understand what the real adaptation to
exercise is. It’s creating that stress or that disturbance of homeostasis that the body then reacts to
in a systemic way and tries to move the body forward. At the same time, it has to repair the damage
that was done during the course of the exercise or whatever the pervasion was.

What’s really nice about KAATSU, which I would generically characterize as an elastic,
pneumatic, relatively narrow BFR training, is that we provide an anabolic stimulus very early on
through this systemic effect.

Now, one of the things that other papers have shown is it’s not just the muscle that’s getting better.
It’s the bone. It’s the blood vessels. There’s even a study showing that the neural transmission
from a motor nerve to a motor fiber is improved by BFR training. This whole thing, if you take a
step back, we kind of know that regular exercise helps us all to maintain as much function as we
can. But as we age, we become unable to do those same kinds of workouts that it took to recreate
this stuff in the first place. Now we have the ability to do this with very light, easy exercises that
anybody can do. Therefore, get the benefits of this anti-aging medicine.

JM: Okay. Let’s dive deeper. But before we do, let’s just agree to maybe just call it generically
“BFR,” because there are so many different variants of this. That would include KAATSU and
probably half a dozen others or more.

JS: One of the things to say though is that I think –

JM: We’ll go into the differences though. I mean that definitely is a part of this.

JS: Okay.

JM: Just to communicate it, just generic. Because I definitely have a lot of questions for you about
the differences and the most significant dangers, which is the surgical occlusive approaches. I just
found out recently that many physical therapists are using it. Anyway, I was beyond intrigued
when I was introduced to you. Actually, I first heard your stem cell talk years ago. I just never
implemented it. For some reason, there was a KAATSU exhibitor at the Bulletproof Conference I
was attending. I purchased a unit and I just was blown away with the results I was getting. I didn’t
necessarily believe that people in the company, what they were saying, because it just didn’t seem
to have a sound scientific basis.

I said, ‘Listen. I’ve got the tools. I’m going to research the literature.” I looked up a few hundred
references and wrote a 25-page paper on it, which you were kind enough to review. We’re going
to discuss some of these here. But I couldn’t believe the mechanism. It was just beyond
extraordinary.
What I learned, and what I’d like to discuss now is what you alluded to, with the difference between
or the inability of most elderly, which is an ever-growing population, of course, to engage in this
high-intensity exercise, so they can do that. They can physically do it with the lower weights. But
even if, for some reason, they were extraordinarily fit individuals – and many 60-, 70- or 80-year-
olds are, and can do conventional training – if they don’t integrate some other form of BFR, BFR
training, their physiology is going to limit them from getting the benefits.

The reason is – this is an important distinction and what I learned after reviewing this – that your
microcirculations tend to decrease with age. Your capillary growth is just diminished. That is an
absolute essential to supply the blood flow to the stem cells, specifically the Type II muscle fiber
stem cells. If they don’t have enough blood flow, even though they’re getting the signal from the
conventional strength training, they’re not going to grow. You’re not going to get muscle
hypertrophy and strength.

But BFR does that in spades because of the hypoxia that is created, the relatively local hypoxia is
going to stimulate HIF1A, which is hypoxia-inducible factor-1 alpha, and then secondarily, VEGF,
which is vascular endothelial growth factor, fertilizer for your blood vessels, which allows those
stem cells to actually function the way that they were designed to when they were younger. I’m
wondering if you can address that in your perspective because I think it’s really the primary
characteristic that distinguishes this and makes it such an unbelievably phenomenal exercise.

JS: You’re really touching on a good point with respect to those of us who are over 60. That is we
just can’t do the kind of hard work that we used to be able to do without risking injury or
aggravating chronic injuries or that sort of stuff. What’s super about BFR training is that the loads
are light that anybody can do. We get to that adaptation signal by restricting the blood flow to the
working muscle.

What’s really needed about that is if you’re thinking about really heavy lifting, you have to recruit
pretty much all the motor units in a particular muscle or a particular group of muscles to be able
to do the lift. It’s that that gets into stimulating the Type II fibers. If the stimulus is hard enough,
the satellite cells are also stimulated to develop and to make bigger and stronger muscles, which
addresses this sarcopenia issue that you rightly point out is a very important problem for seniors.

Now, what happens is also because of hypoxia, essentially, the body recognizes it’s not getting
enough blood flow to the tissues that are exercising. You have things like vascular endothelial
growth factor and HIF1A that are secreted that enhance the capillarization of the muscle and
perhaps the veins in the arteries as well.

[-----20:00-----]

What’s really exciting about that is that now all of a sudden, we have something that can repair
and build endothelium. And that is, endothelium is the first order of business when we’re talking
about the ravages of atherosclerosis. One of the big applications in Japan is with cardiac
rehabilitation patients and stroke patients, where they do BFR training with these people, because
they can. Even if they have some hemiparetic problem or difficulty walking, they can always do
some sort of exercise that stimulates the fibers that are still intact.
This whole thing is a way to recruit as many motor units as possible in a body or a human. That,
in turn, then is a very powerful stimulus for reversing sarcopenia or building muscle and building
better blood vessels. All of these things are related. We’re kind of tapping into the normal ways
that the body gets bigger, but it’s just that we can’t do those normal ways anymore. Essentially,
Dr. Sato found a way to do these things with relatively light and easy exercises and get the same
effects that he can get out of standard heavy lifting.

JM: Yes. Thank you for bringing that up because it alludes to this systemic or crossover effect.
Because even though you’re restricting the blood flow to your extremities, once you release those
bands, these metabolic variables get generated and they flow into your blood – lactate being one
of them. We’ll talk about that in a moment.

But it goes and it spread all this metabolic magic throughout your entire system, so rehabbing heart
patients and stroke patients. Because this VEGF, which is literally fertilizer for your blood vessels,
gets transferred systemically throughout your whole body, so it could be a very powerful way to
not only treat strokes, but probably be proactive as a powerful tool in preventing Alzheimer’s
disease, which is, of course, in epidemic proportions, but also helping you reduce your risk for
heart disease, which is another major killer of all of us. The systemic benefit is crazy.

JS: One of the ways I think about this is I consider BFR training as Drano for the arteries. We’re
only as young as our arteries.

JM: Right.

JS: The whole thing turns around and we can get those arteries in shape, and capillaries and veins
also. Off we go.

JM: Yeah. It’s really tremendous. That’s one of the major ways, because you’re in agreement that
we’re able to increase the blood flow to these important satellite stem cells and facilitate muscle
hypertrophy and strength. But there are a few other mechanisms that seem to be corollary and also
beneficial. That is – Most of us know that there are two types of muscle fibers, primarily Type I
and Type II, and there’s Type IIa and Type IIx. But the Type I are the slow fibers. They’re
endurance fibers and they require oxygen to function. But when you deprive the oxygen, these
Type I fibers, they fail pretty quickly and you have to rely on the Type II, which are larger.
Especially IIx, they don’t use oxygen. They use a form of energy generation called glycolysis. One
of the byproducts of that is lactate.

Lactate is not going anywhere if you’re restricting your blood flow. It builds up to high
concentrations and the water has to flow into those cells, which actually gives you this pump,
which is why the Japanese were using it. But you can get an inch, 2 inches. I’m not sure if you’ve
seen even a greater increase in muscle size as soon as you take the bands off. It’s just phenomenal.
But that lactate increases – But the lactate is a waste product, but that’s the way it used to be
viewed, but now, we view it as a pseudohormone. That hormone has such powerful benefits. I’m
wondering if you could speak to some of these, like going to the brain, crossing the blood-brain
barrier through a monocarboxylate transporter and stimulating brain-derived neurotrophic factor
(BDNF). Address that and some of the other things, like myostatin, then we’ll talk about it.

JS: It’s not just lactate in my view.

JM: Okay.

JS: There’s a whole series of things that are produced when you disturb the homeostasis on a
working fiber. One of them is lactate. We tend to think of these things as local mechanisms,
whether it’s lactate or the hypoxia or a drop in pH. These things stimulate local protein synthesis.
We’re already doing stuff to build more and better blood vessels. But in addition, these factors can
go to other cells in the area and help them. But the big deal is that we recognize this disturbance
of homeostasis in our brains. Our brains end up saying, “Wow. Our muscles are feeling fatigued
or they’re running out of gas.” It’s the same thing that we’re constantly doing.

Let’s say we’re running marathons that I know you’ve done. Basically we’re kind of listening to
our body all the time to see how it’s going. We use that same sensory system to see how it’s going
with BFR training. The ultimate message is that our muscles are in trouble. They’re not getting
them out of oxygen. They’re not regenerating the amount of adenosine triphosphate (ATP) that
they need to do this. This is happening now in all the fibers, both the Type I fibers at the beginning,
but they drop out, and then they recruit the Type II, and let’s say the Type IIx, and stimulate the
stem cells to differentiate into satellite cells and build new muscle fibers. But now this message
has gotten into the brain and the brain reacts to it by putting out a neurohumoral systemic response.
This has been well characterized by an increase in circulating growth hormone in the 15 to 30
minutes after an effective BFR session.

What growth hormone does is – One of the things it does is it goes to the liver and stimulates
insulin growth factor 1 (IGF-1), which also is an anabolic hormone. But the growth hormone also
goes to fat cells and starts to break down fat to produce substrates so it’s lipolytic, which is also a
good thing in general if you have to build new fibers. All this is essentially – It’s not just growth
hormone. There’s basically an anabolic hormonal milieu that is created that amplifies all these
local processes.

Now, whatever lactate was stimulating, the upregulation and the protein synthesis, now this is
happening again to a greater extent because there’s growth hormone around to help it do this. You
end up getting adaptation everywhere, not just the muscles that were used in the exercise. A way
to think of this is that, really, there’s a systemic process. For example, let’s say we’re doing bench
presses. We’re using some muscles, like our triceps, for example, that may be distal to the band.
But we’re also using our pectoralis major muscles, their blood flow is just fine, thank you very
much, and normal because the bands don’t get in the way of it. But they also get the benefit. The
whole bench press gets stronger or lifts more and so do all the muscles that are involved in that.
Both muscles, proximal and distal to the bands, end up benefiting.

JM: Okay. So a few questions on that because there seems to be a bit of a disagreement or a lack
of uniformity, at least in the studies I reviewed with respect to growth hormone. Some of the
studies suggest that it’s increased quite significantly, maybe 900%, nine times above normal or
even more. But then others suggest it’s not much of an issue and that the growth hormone, IGF-1,
increase may not be responsible for it. I’m wondering if you could address that. Well, address that
and then we could talk about the second.

JS: Okay. One of the things I say about that is the studies that do show that benefit, they also had
groups doing control exercise or the same absolute workloads of exercise, but without the bands
in place. They did not see any increase in growth hormone or IGF-1 or vascular endothelial growth
factor. It’s pretty clear that the combination of light exercise and BFR training is able to induce a
significant growth hormone response out of the brain.

[-----30:00-----]

JM: Okay. That’s secondarily because it’s stimulating an anabolic benefit. I haven’t seen any
literature on this but it would seem that in some way that it would be useful to interact with the
mammalian target of rapamycin (mTOR) pathway. I just haven’t seen anything like that because
most of the literature, first the mTOR being activated by insulin or branched-chain amino acids,
but not necessarily exercise.

JS: One of the things that happens, one of these local reactions, is self-surface receptors for growth
hormone and for insulin and for a variety of anabolic hormones are upregulated, so there’s an
increase in receptor density on the surface of these cells – any cells that were used in the course of
this exercise, for example, the pecs and the triceps. Now this growth hormone comes along and it
binds into these receptors and that stimulates – it’s pretty well worked out now – that that
stimulates the mTOR pathway to upregulate protein synthesis.

JM: Okay.

JS: That’s where you get this amplification effect. It’s not that the growth hormone is stimulating
mTOR. It’s just that the hypoxia and the acidosis and the lactate acidosis in the cells have
stimulated not only protein synthesis locally, but also the cell membrane receptors so that there’s
a greater receptor density and whatever growth hormone comes along ends up getting bound and
amplifying the effect.

JM: Thank you very much for that clarification. I’d like to delve into – Hopefully we’ve got people
excited about this incredible exercise. I’d like to go and dive deep into some of the details of how
that’s implemented because there’s a bit of controversy out there. You and I are biased, of course,
because my perspective is in training this with KAATSU. I think rightfully so. I mean he’s the
innovator. He figured this thing out over 50 years ago.

JS: It took him 30 years of trial and error to do so.

JM: Yeah. That shouldn’t be discounted. These Johnny-come-latelys who’ve done it for less than
20 years – in most cases less than 15 years – thinking they know better, you have to be suspicious
of it. Anyway, let me just break it down. There is the essentially KAATSU camp, which uses very
narrow bands, elastic bands that control pressures, and then there’s another camp, which I didn’t
realize was relatively large, primarily physical therapy-based, who use surgical – but other
researchers too – the surgical occlusion bands. They actually call it blood flow occlusion, which
is if you’ve read the KAATSU literature, you’d just like hit your head and say, “What are they
doing?” Because –

JS: Yes. That’s the only way to hurt yourself. It’s if you occlude the arterial inflow.

JM: Why don’t we talk about that because the size of the cuffs too, the width of the cuffs, which
is another important variable?

JS: Right.

JM: And the dangers of doing this.

JS: Right. All serious complications with BFR training happen if you happen to occlude the arterial
inflow into an extremity. The wider the cuff or the band, the easier it is to do that. If the cuff is
rigid, as opposed to elastic, the easier it is to do that. Those are the two main factors. These groups
who have tried to use surgical tourniquets or blood pressure cuffs to do this, they first read Dr.
Sato’s paper and were very excited but couldn’t get a hold of the KAATSU equipment at the time.
As a result of that, ended up just picking up something that they thought would do the same thing.
Unfortunately, they really didn’t quite understand what Dr. Sato was up to. But it still can work.
It’s just –

JM: Yeah.

JS: You just have a very narrow window where you need to get some level of BFR. But if you get
too much, then all of a sudden you’re including the arteries. So there’s a very narrow band of, let’s
say, pressure or flow that is safe and effective, where when you’re using something that is
relatively narrow and elastic, then you have a much bigger window in which you can get enough
BFR to be effective and still be safe throughout the time period where you’re doing this.

There’s one of the secrets, if you will, to this. It’s that the way that BFR training works is – The
first order of business when you first put on the band, whether it’s rigid, wide, narrow, elastic or
whatever, is you really want to clean up down on the venous outflow from the extremity, while at
the same time, allowing the artery to continue to pump blood in. But at some point, that gets stuck.
There’s only so much blood you can put into an extremity before something has to get led out.

Now one of the really important things that we have is we have what we call the muscle pump.
Anytime you do any exercise, the working muscles, they contract and they usually get a stiffer and
a bigger cross-sectional area where, let’s say, fatter, and that then forces the blood out through the
venous channels past through the venous blockade. So you’ve changed the venous flow from one
in which you can think of as a lazy river where the venous flow was continually going back towards
the heart, to one in which there are intermittent obstructions or occlusions of that venous flow with
a periodic pulsatile, high flow states. This ends up equaling the arterial inflow.

Usually, when you get into this kind of sweet spot of the right amount of BFR, you have decreased
arterial inflow a little bit. But really, the big thing is you’ve change the character or the venous
outflow. You really can’t do that as well with a rigid system as you can with an elastic system,
because when you have the muscles pumping this big amount of blood past the venous obstruction,
if there’s a rigid outer casing, there’s just nowhere to go. The muscles are getting thicker. It takes
a tremendous amount of pressure to push any blood past this venous obstruction. Where if you
have an elastic situation, now that elasticity can accommodate the increase in cross-sectional area
and this increasing amount of venous flow.

What happens is while the rigid, wide systems can be made to work, there’s a very narrow window
where they’re both safe and effective. On the other hand, with the elastic relatively narrow ones,
there’s a much larger window to get the pressures right and get the situation right for the
participants.

JM: Okay. Thank you for explaining that. We’ve established that the safer and effective way is
not to do the occlusion therapy and to get that sweet spot. Help us understand how the best way to
get that sweet spot is and maybe go over the ways to test for capillary profusion by checking your
thenar eminence.

JS: One of the – Again, going back to that first rule of safety, you’d want to make sure that arterial
inflow is preserved. You can do that a number of ways. One is you could feel a pulse distal to the
bands. You could feel your radial pulse in your wrist. But actually, a lot of non-medical people
have trouble finding their pulse in their wrist. One way that is very effective is to just push in on
your thenar eminence and then release it. What happens is you see that that it goes from white to
kind of reddish or pinkish in a relatively short order, a matter of seconds. If that’s the case, then
you know the arteries are open.

JM: I’m wondering how you do that. Because typically, you require far less pressure to get that
sweet spot in the arm than you do the leg – sometimes maybe twice as much pressure. If you can
generate that much pressure in your leg, what’s to stop that from causing damage to the arm?
Because it’s so much higher.

[-----40:00-----]

JS: Well, the main thing – and this is really what our group has come up with – is we’ve made a
situation where at a certain – I might show you with one of our systems. I don’t know if you can
kind of see this on the –Basically there’s a series of –

JM: That’s the leg band.

JS: Yeah. This is just one of our leg bands. You can see right here there’s a little kind of cylinder
that goes from one side to the other. In that thing, it starts out being flat. And then when we inflate
it with air –

JM: So you’ve got multiple bladders in there.

JS: Right. There are multiple – Let’s see if we can show this.

JM: Yeah.

JS: So, there it is.

JM: Yeah. You can see it that way. Yeah.

JS: So what’s happening is –

JM: A bunch of pillows lined together.

JS: There you go. We call them barrels. But basically, when there’s no air in there or no pressure
in there, they’re basically two flat sheets of material. When we do put the pressure in there, they
become more cylinder-like. There’s a limit to how big that cylinder can get. That’s the key.

JM: Okay.

JS: No matter how much pressure we put in there, there’s that limit that we found out over time
with a variety of experimentation and looking at blood flow things that up to the maximum pressure
of our pumps, we can’t occlude the arteries.

JM: Okay.

JS: That’s a really nice safety factor for all the people to use at home.

JM: Which isn’t in the KAATSU bands. Because I believe the KAATSU just has one bladder that
runs the longitudinal distance of the arm.

JS: Yeah. That is correct. With KAATSU, it’s still possible to occlude the artery, but at very high
pressures. KAATSU is very safe compared to the surgical tourniquets or blood pressure cuffs.

JM: Yeah.

JS: Putting bands on around the neck is not a good idea.

JM: Not a good idea. Let’s get into some of the general parameters for the training, because it
would be the same for both systems and that, at least with the KAATSU, I’m not sure what your
recommendations, they recommend restricting the time of occlusion or actually BFR to 15 minutes
on the arms and 20 minutes on the legs. And then during that time, engaging in these exercises,
typically – Well, there’s a wide range.

I definitely want to get your feedback on this because you’ve been doing it for eight years with
some very good athletes. You probably got enormous experience as a result of that. But the
traditional recommendation is like 30 times 3 or 30-25-20, with a 15-second rest for the arms and
maybe 30 seconds for the legs. Why don’t you share with us your strategy for implementing BFR?
JS: The main thing that we’re trying to do is we’re trying to create fatigue in the working muscle.
We found, over time, three or four sets of a particular exercise will do that for you. We want that
first set to last somewhere around 30 to 45 seconds. Then we want what we call 30 to 45 seconds
of pseudo-rest. Because now, if you remember, we talked about the muscle pump pushing blood
past the venous obstruction when you’re exercising. That increases the flow through the system.

Now when you’re resting or pseudo-resting, now you don’t have that muscle pump to help you
with the flow, so the actual environment in the muscle fibers that’s working deteriorates even
more. That’s why we generally use three or four sets with a specific amount of recovery in
between, where the person thinks they’re recovering or resting, but really, the situation, the
metabolic situation is getting worse in the fiber. It’s all about creating this disturbance of
homeostasis and this fatigue feeling.

And so, we have a number of variables to play with. We have the pressure in the bands. We have
the kind of exercises that we’re doing. We have the weight load, the weights that we’re using,
which generally we’d want to keep very low. And we have the number of reps in a particular set,
and then the number of sets for a given exercise. And then we also have a series of exercises, so
that when we’re done with this whole thing, we’ve exercised pretty much of the body’s muscle
mass as we can. Generally, that takes, for arms and legs, somewhere around 30 minutes. Out of
the abundance of caution, we just wanted to say that the bands should be in that order of business,
this 30 to, let’s say, maximum 45 minutes worth of exercise. We start out –

JM: That’s under continuous occlusion or occlusion by restriction? Because that contradicts what
KAATSU teaches in all their manuals. It’s just like no longer than 15 minutes on the arms, and
then release the bands, and then 20 minutes on the legs.

JS: In many ways, because their system can occlude under some circumstances and out of an
abundance of caution, they limit the time just so that you are not doing that. We don’t really have
that restriction for our system, because we’ve designed it so it can’t occlude. But at the same time,
we don’t want people to, let’s say, wear them around for 24 hours or go to sleep with them. And
we also want people to go about business of doing this exercise session. If they’re doing it right,
generally by the time they’ve done 15 minutes with their arms or 20 minutes with their legs,
they’ve fatigued themselves and they’ve gotten the point of the session, so it’s time for it to be
over.

JM: The beautiful aspect of this training is that their recovery time is so short, as we alluded to
earlier. So much so that, I found personally – and I carefully monitor my recovery status – but I
could do it every day pretty comfortably, unless I’m pushing it to high extremes with respect to
closer to 30% to 35%, maybe 40% one rep max. But that’s a little bit too much, and then I do dig
up to myself. But if I stick to the 20% to 30%, I can easily do it every day. So I’m wondering what
your experience is. Is it based on their capacity?

JS: Yeah. There’s an age dynamic to this where the 20-something or 30-something athlete could
probably do twice a day, two a day on these sorts of things. With some injured athletes, we end up
doing three workouts a day. And where we could never get away with that was standard weights.
Generally, one of the things that we say is that with standard heavy lifting, maybe twice a week or
at the most every other day, is the most that even the 20-year-olds can tolerate. But with this, we
can do this instead of twice a week, we can do it twice a day.

JM: Yeah.

[-----50:00-----]

JS: When you get to being our age and if I just break things up into, let’s say, 20 to 40, 40 to 60,
and include us in the 60-year-olds, because we’re young for our age, and then 60 to 60 and on,
generally the 20 to 40 crowd can tolerate one day a week or five workouts a week. Generally, the
40 to 60 can tolerate three workouts a week. The greater than 60 ends up being twice a week.

JM: Interesting. With BFR? Really?

JS: Mm-hmm. It also depends on what other things you’re doing.

JM: Yeah. Because for these elderly who are essentially wheelchair-bound, they’re not going to
be using weights. All they’re doing is body movements. That’s it.

JS: Right. And getting up and out of their wheelchairs.

JM: Right.

JS: Our experience has been that – I might take my parents as an example. My dad’s 90 – I don’t
know. Let’s say 93.

JM: How long has he been doing BFR?

JS: About five years.

JM: Yes.

JS: But he’s an ex-jock. He gets a little grin on his face when he gets that good fatigue signal. But
for the life of me, I can’t get my mother to do this. There are social battles going on in terms of
what you can get away with. We basically try to help everybody to the extent that we can. Some
people like this better than others. I would say that those who are used to it, who have been
exercising throughout their lives, take to it quite readily. Ones where exercise is something new
for them don’t do it quite as often or are not as quite as compliant as we would like to see.

JM: We have been primarily focusing on the muscle strength benefits and addressing sarcopenia
and frailty. But you also alluded to the fact that it also is good for bone density. I’m wondering
what your personal experience has been and what you’ve seen over the years.

JS: Well.
JM: With respect to people who have documented osteoporosis or osteopenia try the BFR.

JS: We have one couple who were 67 and 68 at the time when they did this. But they were in the
habit of getting dual-energy X-ray absorptiometry (DEXA) scans every two to three years on
themselves. They had the very common experience of their bone mineral density decreasing with
age. They were vigorous. They ate a good diet. They were not taking any kind of osteoporosis
medicines at this point. But they had one scan in November of 2015, I think it was. And then that
following February of 2016, they started a program, where they pretty much did a two- to three-
times-a-week for the next eight months.

That following October, they got another DEXA scan. Instead of the steady decrease in bone
marrow density over the years, now all of a sudden in one year or 11 months, they had a 5% and
6%, in the other case, increase in bone mineral density, without doing it, with continuing their
normal diet, continuing their normal exercise, but just adding a workout. Now, it’s a case report.
It’s an NF2, but it’s very promising that. There are other sorts of examples, particularly in the
KAATSU literature where we heal fractures faster and we do a lot of things that make bone turn
over quicker and better with this BFR. But this is a personal example where it’s really, really
helped.

JM: Well, there’s a number of studies that point out the increased bone turnover, but I’ve never
seen anything published that shows an improvement of bone density via DEXA. I would encourage
you to assign someone on your staff to write that case study up because it would be a significant
contribution to further validate that this is working.

JS: Alright. And be a very effective pilot data for some osteoporotic clinic to give this a try on a
regular basis with a lot more people.

JM: Yeah. No question. With respect to optimizing muscle hypertrophy and strength, what would
you suggest is the best parameters within the framework that we’ve discussed? There are some
suggestion – Well, the universal suggestion seems to be to push towards failure or fatigue. I mean
if you’re not pushed to that level, you’re not going to generate the responses. But even within that
level, you can go to 20% versus 30% of the maximum one rep max. It seems there’s a trend to go
into the higher side of the 30% to get more of a hypertrophy benefit. What’s your experience been?
Are you getting the same results with even the lower ones?

JS: Yeah. I have not systematically looked at 15%, 20%, 25% or 30% of one rep max. In terms of
which is more effective in our view – Firstly, many of the exercise that we have, we don’t know –
What’s the one rep max for pushups? Most of our exercises are some form of calisthenics, maybe
with a little extra weight. But I think the take-home message is that it is otherwise easy trivial
weight that is used to cause the fatigue, that then causes the adaptation.

One of the things that we go by in our sessions is we want the individual to feel that they’ve gotten
fatigue. If they are able to do the same exercise and they’re not getting the fatigue, then we increase
something. We may increase the number of reps, the number of sets, maybe the weight a little bit,
or we may increase the pressure that we’re using for them in particular. We play with these
variables we have, but the common denominator is that feeling of fatigue. Now, the other dynamic
is what an 80-year-old feels as fatigue is not the same thing that a 20-year-old feels as fatigue.
With the 20-year-olds, we can get them so they just can’t do one more pushup. But with the 80-
year-olds, when they say they’re getting tired, then that’s enough. They’re still seeing the benefit.

JM: Excellent. Alright. Thank you for that. I think the other issue I wanted to address is your
equipment is really good at doing these things, but there’s another version of BFR training that Dr.
Sato developed, which he called cycling. That really can’t – I guess you could do it manually, but
it would be really tedious and certainly not convenient – where there’s a mechanical compressor.
It costs more.

KAATSU, just to give a brief rundown, has three levels of equipment now. One is their Master
Training, which is 5,000 dollars; the other is a Nano, which is like half the price at 2,000 dollars;
and then this new one, this is the Cycle 2.0, which comes at 800 dollars. These are all automated.
The program has got a computer chip and pumps in there. With these automated systems, you can
have a cycle. So the pressure will go up for 20 seconds, and then down for five. You do that for
about eight sessions. And he’s very persistent in claiming this might even be superior to what he
calls KAATSU training or the traditional BFR training, where you have the continuous pressure.
I’m wondering if you can comment on your experience with that, because I’m sure you’ve looked
at both.

JS: Yeah. I’m not as enthralled as Dr. Sato is with this cycling idea. But there has not really been
any publications that has demonstrated convincingly that it works. At the same time, we’ve had
some good discussions about it. There is a reasonable theoretical basis why it might work. That is
that part of BFR training is this business of distending and then emptying the vasculature. You can
do that without exercise by cycling the stimulus. In many ways, you do it with exercise by having
a contraction of the muscle, and then relaxation of the muscles. You’re getting kind of that
distention and relaxation at the same time that way. Where Dr. Sato has primarily used cycling –
or at least when I was with him – has been in people who really can’t do exercises or much
exercises. They’re bed-ridden.

[-----1:00:00-----]

JM: Or quadriplegic.

JS: Yeah. And so, maybe that’s definitely better than nothing if they can’t do it. But very quickly,
you get to being able to do some sort of exercise. And, you’re right, if you try to do cycling with
our manual systems, it would take two pumps and you’re sitting there pumping them up at the
same time. You’re then letting the pressure out to try to do that sort of thing. But –

JM: Theoretically possible, but not convenient.

JS: Yeah. The comparison of all these different systems and that sort of thing. One of the things
is that we want to make our systems very affordable. We wanted to make them eminently safe.
We’ve done that with our design and then our manual system. If we sacrifice the idea of cycling
as a result of that, we think that’s still a pretty good deal for the individual.
JM: Okay. Great. Another question I had was on high-intensity training. Several years ago, Phil
Campbell I connected with. He trained a lot of NFL players with some high-intensity sprint work,
primarily cardio work, and he called it Sprint 8. We think he changed this to Peak 8 or Peak Fitness
exercises. I did those for a while but I stopped doing them because I thought they were somewhat
dangerous.

But in the process, you go through this really – and I’m sure you’re familiar with this – this really
intense workout for 20 to 30 seconds and then you relax for a minute or two, and you just repeat
cycles of that. The process, of course, is you’re sweating profusely. I believe the theory was you’re
stimulating the Type IIa and IIx fibers. This is the sweating and the complete exhaustion of that
seemed to be the two characteristics. I’m wondering if you would qualify, from a scientific basis,
the BFR as high-intensity training.

JS: Yeah. I’d sign onto that. But one of the things that we do is we put the bands on for high-
intensity training or the HIIT training. That’s just really – For those athletes looking for something
that fatigues them, this really does the trick. It accentuates all the things that you talked about.
There’s profuse sweating. There’s a great fatigue signal. Those are the kinds of things that help
you adapt. The only difference would be is you don’t have to do as many of them when you put
the bands on, because you just can’t.

JM: Yeah. I have a personal question for you with respect to someone who’s truly grounded in
the physiological sciences and exercise like you are. What is that sweating a result of? Why are
you sweating so intensely? Because it’s far more than you would anticipate.

JS: Right. That is a good example of this disturbance of homeostasis and this communication of
the disturbance of homeostasis up to the CNS. The CNS, one of the things that we talked about is
it puts out this growth hormone response. But the other thing it does is it activates the sympathetic
nervous system. The sympathetic nervous system causes you to sweat, causes you to breathe
harder, causes your blood pressure to go up a little bit, your heart rate to go up a little bit. And so
really, what this indicates is this inappropriately large amount of sweating is a good marker of
getting a good fatigue signal in the muscle that has now caused a sympathetic activation of the
autonomic nervous system.

JM: Interesting, interesting. So do you use that clinically when you’re training your clients?

JS: Mm-hmm.

JM: Do you look for that increased sweating?

JS: Right. What we do is we look for increased sweating and inappropriately heavy breathing, that
sort of thing. If they happen to have a heart rate monitor on and having a little higher heart rate
than they would otherwise have for the work and that feeling of fatigue in the muscle. When you
have those things, you know you have had a good session.

JM: Excellent, excellent. You’ve had quite some extraordinary results. I think you’ve been a real
asset and catalyst for many people winning Olympic golds.
JS: You know, one of the really neat things about this is our typical experience is that people get
stronger and their muscles may get a little bit bigger. But they also get leaner because of the athletic
effect of the growth hormone. For so many of our sports, weight is a penalty. Particularly with our
distance runners and our ski jumpers and a variety of other athletes where weight is just such a
huge penalty, they’re very pleased to notice that they become very lean and as well as strong. For
our ski jumpers, that just helps them fly.

JM: Yeah. There you go. One other strategy that’s recommended by the KAATSU people is
something they call KAATSU walking, where you put the bands on. It could be in the cycling
mode, but it certainly could be in the training mode too, where there’s just continuous pressure,
and then you go on walking for 20, 30 or 40 minutes in your case.

JS: Right.

JM: What’s your experience with that?

JS: We do a similar sort of thing. We can do it with four bands with rowing, cross-country skiing,
cycling or jogging. We do that and basically, 15 to 30 minutes of any of those activities is you’ve
had enough. In the case of running, it decreases the amount of pounding you get in return for
getting in shape, and then we get the same sort of thing. That whole thing would be kind of an
aerobic basis for BFR training. That’s well established. The other is more of a strength training or
a power training thing where you’re lifting weights or doing calisthenics or push-ups or whatever.

JM: Time efficiency is a very important part.

JS: Yes. Particularly for us, and maybe the kind of, let’s say, the baby boomer group, where we’ve
got kids to worry about, we’ve got a job to worry about that’s busy. This kind of activity allows
us to get in a really good workout in a short amount of time. Call it 30 minutes. We can even do it
at our desks. I’ve got cuffs right here that we can try to put on. You don’t need to drive to the
health club. You don’t need to change things.

JM: Yeah, yeah. We’ll let you demo that in a moment. But I think one of my last questions is on
the safety, which we briefly discussed earlier. When I was reviewing the literature, I had a section
on the safety of BFR. And then I was thinking there was really the risk and then if you compared
the risk of high blood pressure events, it’s significant in people who are using conventional strength
training. I mean, there are reported cases of people getting a stroke. If you have uncontrolled high
blood pressure, you have to be careful. And then I looked at the literature and I said, “Oh my gosh.
BFR can cause this. But even worse.”

And then when I contacted you about this by email, you helped me understand that this was more
artifact of the wrong type of bands. Why don’t you talk about the hypertensive response risk? But
also in the same discussion, also the risk of DVTs, deep vein thrombosis, which anyone with a
simple amount of training is going to realize is a concern, or if they do not, they should realize the
concern. We should address those, because those are the two primary issues that people have with
it.
JS: Deep vein thrombosis, DVTs, or blood clots in the veins, in the extremity can be deadly. It’s
a problem associated – Typically we see it post-operatively in surgery. But there was a Dr. Rudolf
Virchow back in the 1800s, or something like that, who identified that there were three conditions
that were necessary. One was venous stasis. If you don’t have arterial occlusion, you don’t get
venous stasis. If you’re doing the exercises where the muscle pump is pushing the venous blood
past and the arterial is backfilling into this space, then you never get stasis.

One of the things about being safe is never occlude the arteries. That way, you never get venous
stasis. That way, you don’t get deep venous thrombosis. The other aspect or another one-third of
the Virchow’s triad is endothelial damage that you of course get when you’re using a scalpel or a
bovie to cut and cauterize blood vessels in the operation room. But with normal BFR training, you
don’t injure those vessels at all. You also don’t get this endothelial damage that can start a clotting
cascade.

[-----1:10:00-----]

JM: You get the reverse with VEGF. You get endothelium improvement.

JS: Exactly. There was a study done, again, by Dr. Sato, where he looked at a large number of
people. I think it was 12,462 people or 12,642 people who have been doing KAATSU of which
22% had been hospitalized. In Japan, the incidence of DVTs is about 1 in 100 in those hospitalized
populations. It worked that they had about 1 in 2,000 DVTs in the same kind of hospitalized people.
There was actually a lower incidence of DVTs in those people who have been doing KAATSU in
this case.

JM: Dramatically lower.

JS: The same cannot be said for these wide, rigid systems where they’re what are used in the
operating room and basically have a pretty high incidence of DVTs associated with them. Now,
the other thing that you mentioned was hypertension. That ends up being a very interesting thing.
The contraindications in the surgical tourniquet world, say if you have somebody who has
uncontrolled hypertension is an absolute contraindication to using these things. It is a real and
important consideration when you’re using the wide, rigid systems. Also the wide, rigid systems,
when the muscles contract, as I said before, there’s kind of nowhere to go. That induces ischemia
and potentially damage to the exercising muscle. This causes a reflex exercise pressure response
that can manifest as increasing hypertension.

Now, as it happens, one of my sons who’s doing a Ph.D. at University of Texas at Austin just did
a thesis on looking at the difference in hypertensive response to walking with narrow, elastic bands
versus wide, rigid tourniquet system. He found that the wide, rigid cuffs ended up causing a very
robust hypertensive response that nearly doubled the double product or the myocardial oxygen
above the control exercise. Where when he used the narrow, elastic bands, that ended up being no
different. In fact, slightly less than just walking on the treadmill by itself without any bands on it.
I think it relates to this idea of a relatively narrow elastic setup that doesn’t elicit this kind
hypertensive risk that the wider systems and rigid systems do.
JM: Okay. Last question before we let you show how you put your bands on. There are those who
can’t afford your system or the KAATSU system, of course. There are less expensive alternatives
that you can get online that causes as little as 15 dollars for a set of bands that you can put in your
arms that do meet the requirements that have – They’re not very wide. They’re only 1 inch. They’re
elastic, which is, I think, two of the key variables: the width size and elasticity. They seem to
generate enough pressure. I use those. I like to travel with them. You can fold them up and put
them in the palm of your hand. They’re so small. They only weight a few ounces. They’re easy to
travel with.

Obviously – You can pretty much know and get a consistent reading when you reapply them, so
you can have a consistency in the training

JS: We feel we have struck a middle ground, an abundance of caution to make sure we’re as safe
as possible and still allow us to have some control over the situation with the inflatable portion.

JM: Yeah. It’s still not terribly expensive when you consider the cost of most exercise equipment.
I mean, gosh, compared to almost any treadmill that people would get, which, I think – you
probably have a different opinion – but I think they’re a waste of time. I mean there are so many
better things to do to get yourself fit than waste your time on a treadmill.

JS: It’s much nicer to be outdoors. That’s for sure.

JM: Yeah. Absolutely. I mean it’s a fraction of the cost of the treadmill. Why don’t you show us
your system and how easy it is to setup on your arms?

JS: Yeah. Here we go. This comes in a nice case.

JM: Yes.

JS: The case ends up having a pump, a set of armbands and a set of leg bands. Literally, to put
these things on, you just put them through the ramp. You put them up. We want to put the armbands
up high on the arm. We’re basically –

JM: At the base of the bicep, right? Where you see the depression.

JS: On the top of the bicep and the base of the deltoid.

JM: Okay.

JS: And then you just touch the pump. And then we have – When people are starting out, we just
go to 200 millimeters of mercury (mmHg) on our pump.

JM: Just to get people an idea. Even though for most people, that’s higher. They’re hopefully
higher than their systolic blood pressure. This is not equating to systolic blood pressure.
JS: Right. This pressure is pressure that’s in our barrels.

JM: Right.

JS: It’s got nothing to do with a person’s blood pressure.

JM: Right.

JS: There we go. I’m ready to exercise. I’ll put either just both armbands on or both leg bands on,
but it happens in very short order.

JM: Yeah. It takes a minute or two.

JS: Yeah.

JM: I can assure you that it’s a lot more comfortable if you have clothing under those bands. The
likelihood of pinching – Because it can pinch a little bit on bare skin.

JS: It can. I would say that most people – Normally, I wouldn’t have my little sweater on over
this. I would generally use a t-shirt. Sometimes the band goes directly on my skin, sometimes over
the t-shirt. For the legs, basically some tights, exercise shorts or something like that are called for.
Generally with the legs, it’s almost always over some sort of material. It’s hard to have short
enough shorts so that the –

JM: Because they go pretty high up. Yeah. I noticed you didn’t really put a lot of extra pressure
on there as you tightened it. I mean, what’s your rule for figuring out the initial pressure that you
tighten the band with?

JS: There are a number of ways of going about this. But basically, I just put these things on so
they’re firm, so that the barrels or the inner layer is right on my shirt or skin. That’s really all there
is to it. The word I use is “firm.” I put them on so it’s firm.

JM: Okay. As you mentioned, that’s another way you can increase the pressure. It’s put that initial,
make it much tighter.

JS: Yeah. Although at least with our system, that is true of KAATSU. With our system, if you
have all the air evacuated out of these barrels in the first place, then there’s just a limit.

JM: Okay. It’s more of a restriction. Okay.

JS: Yeah. There’s only so far –

[-----1:20:00-----]

JM: Because the way the band is constructed because you’ve got stitching vertically that limits its
stretchability. Okay. That makes sense. Alright.
JS: One thing that can happen is you can put it on too loose. But the way you know that that
happens is if you can just slip it down.

JM: Not a good idea.

JS: Yeah.

JM: What do you gradually increase up to? What would you progress up to?

JS: For example –

JM: For a 20-year-old vs. a 60-year old.

JS: Yeah. Our initial pressure settings for these red bands. Let me back up and say that the bigger
the cross-sectional area of the extremity, the higher the pressure you generally need. Also, the
older the person or the closer to 20 to 30 years old they are, the higher the pressure they need. So
the older they get or literally the younger they get, the less pressure that you do. At one point, I
wrote a very complicated algorithm taking those things and some other things into consideration.
But over time, we found that the easiest way to do this is we just make four different-sized bands.
We have our – Let’s see. We have our No. 1 bands, which are green; No. 2 bands, which are red;
No. 3, which are blue; and No. 4, which are yellow.

Basically, they’re just bigger bands. The pressures you use are partial to those bands. We have a
series of initial pressures to use for our bands. And then beyond that, the intensity is chosen by the
feelings of fatigue. If you’re getting good feelings of fatigue, the exercises you’re doing and the
pressures you’re using are just fine. You don’t really have to change anything. Over time, usually
those pressures creep up to give you an idea. I’ve been doing this for quite a number of years.
Where the initial pressures with the red bands is supposed to be 200, I generally am at 300 with
my arm exercises. I would say the same thing for legs. I’m a blue, No. 3, on my legs. That calls
for a pressure of 250 initially. I would say that I’m at 350 to 400 on my legs routinely.

JM: Four hundred is the upper limit, right?

JS: Our pumps go up to 500.

JM: Oh. Five hundred. Okay. Alright. This is great. Anything else you’d like to add?

JS: No. Just that really, on one hand, we have to give a lot of credit to Dr. Sato for hanging in there
for 30 years, doing trial and error and experimenting with this thing. He had identified something
that he thought was special and he’s pursued it. I think this is a way for all of us to get our anti-
aging medicine in. It’s done in an easy way to comply with a regular exercise program.

JM: I like to pick your brain now because I’m in absolute agreement with you. I think it’s one of
the most important components of an effective anti-aging strategy. But can you just share with us
why you believe that’s so?
JS: I would say because of the results I’ve seen in our center here where we’ve had people of all
sorts of ages. They’ve had dramatic improvements in fitness and function. We haven’t killed
anybody yet, so onward they go.

JM: Yeah. To me, it seems it’s the missing part of the equation for most longevity protocols. They
superficially acknowledge exercise but never really get into the details, and certainly never address
this issue of maintaining optimal muscle mass as a viable endocrine organ.

JS: I think the big contribution when you get right down to it is that this provides doable exercises
that pretty much anybody can do from just getting up and out of your chair and sitting back down
to getting a glass of water off of a shelf as forms of activities of daily living that can be turned into
exercise as where you can get a significant fitness improvement for when you’re suing BFR bands.

JM: Yeah.

JS: And where the normal kinds of workouts that it would take to get those benefits in exercise
are just not really possible as we age.

JM: Yeah. Well, thank you for your time and sharing your wisdom with us in this incredibly
powerful innovation in exercise therapy that essentially should be done by just about everyone.
There are very few people who wouldn’t benefit from it, even competitive athletes. I mean, they
shouldn’t use this exclusively, but it would certainly be part of the routine.

JS: We’re on the brink of a revolution. It’s about to take off.

JM: Yeah. I agree. Thanks again.

JS: Thank you so much.

[END]