Blood Flow Restriction Exercise in Sprinters

and Endurance Runners

SHINGO TAKADA1, KOICHI OKITA2,3, TADASHI SUGA1, MASASHI OMOKAWA2, NORITERU MORITA3,4,
MASAHIRO HORIUCHI3, TOMOYASU KADOGUCHI2, MASASHIGE TAKAHASHI1, KAGAMI HIRABAYASHI1,
TAKASHI YOKOTA1, SHINTARO KINUGAWA1, and HIROYUKI TSUTSUI1
1
Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, JAPAN;
2
Graduate School of Program in Lifelong Learning Studies, Hokusho University, Hokkaido, JAPAN; 3Northern Regions
Lifelong Sports Research Center, Hokkaido, JAPAN; and 4Department of Sports Education, Hokkaido University of Education,
Hokkaido, JAPAN

ABSTRACT
TAKADA, S., K. OKITA, T. SUGA, M. OMOKAWA, N. MORITA, M. HORIUCHI, T. KADOGUCHI, M. TAKAHASHI, K.

BASIC SCIENCES
HIRABAYASHI, T. YOKOTA, S. KINUGAWA, and H. TSUTSUI. Blood Flow Restriction Exercise in Sprinters and Endurance
Runners. Med. Sci. Sports Exerc., Vol. 44, No. 3, pp. 413–419, 2012. Purpose: We demonstrated that blood flow restriction (BFR)
remarkably enhances muscular metabolic stress in resistance exercise, although there is a wide range of individual differences in the
responses. It is possible that these differences could be due to training status and muscular physiological characteristics. We investigated
intramuscular metabolic responses during low-intensity resistance exercise with BFR between two different types of track athletes.
Methods: Twelve age-matched male track athletes (sprinter group, n = 6; endurance runner group, n = 6) were recruited and performed
unilateral plantarflexion (30 repetitions per minute). The exercise protocols were as follows: low-intensity exercise at 20% of one-
repetition maximum (1RM) (L), high-intensity exercise at 65% 1RM without BFR (1.3 times of systolic blood pressure), L with BFR for
2 min (L-BFR), and prolonged exercise time in L-BFR for 3 min (prolonged BFR). Metabolic stress, defined as phosphocreatine and
intramuscular pH decrease, and muscle fiber recruitment were evaluated using 31P magnetic resonance spectroscopy. Results: Endurance
runners showed higher peak oxygen uptake and lower muscle strength than sprinters. Phosphocreatine decreases in endurance runners
during exercise with BFR protocols were significantly greater than those in sprinters (P G 0.05), although those occurring during L were
significantly lower than those in sprinters (P G 0.05). The changes in intramuscular pH and the incidence of fast-twitch fiber recruitment
did not show a statistical difference between the two groups. Phosphocreatine decreases in L-BFR were significantly correlated with peak
oxygen uptake (P G 0.05). Conclusions: The effects of low-intensity resistance exercise with BFR are greater in endurance runners
according to higher aerobic capacity. Key Words: CHEMICAL STRESS, ISCHEMIA, INDIVIDUAL DIFFERENCE, TRAINING,
MUSCLE HYPERTROPHY

T
o increase muscle bulk and strength, high-intensity
resistance training must be performed with a mechan-
ical load greater than 65% of one-repetition maxi-
mum (1RM) (17). However, such intensive loads cannot often
be applied for frail participants or for deconditioned or injured
athletes in a clinical setting (24).
In recent years, several lines of study have provided
compelling data showing that resistance exercise with blood
flow restriction (BFR), which has been widely applied as an
exercise prescription for sports athletes, results in favorable
Address for correspondence: Koichi Okita, M.D., Ph.D., Graduate School of
Program in Lifelong Learning Studies, Hokusho University, 23 Bunkyodai,
Ebetsu 069-8511, Hokkaido, Japan; E-mail: okitak@hokusho-u.ac.jp.
Submitted for publication February 2011.
Accepted for publication July 2011.
0195-9131/12/4403-0413/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2012 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e31822f39b3
and short-term training effects despite using a lower work-
load (1,2,21,28). This training method could be performed
safely (2,21) and has even seemed effective in early reha-
bilitation after an injury or surgery in athletes and clinical
cases (18,20,25,29).
Several studies have demonstrated that stimulation of me-
tabolism with muscle contraction in response to BFR exercise
is important to obtain muscle bulk and increases in strength
(4,12,26,27). However, we have previously observed that a
considerable number of participants could not get sufficient
muscular stress during low-intensity resistance exercise with
BFR. There was a wide range of individual differences in
the muscular metabolic responses to this type of exercise
(26,27). It could be speculated that those differences might be
due to training status and muscular physiological character-
istics. We therefore hypothesized that BFR exercise might
not provide the same effects in different types of athletes,
specifically sprinters and endurance runners. The purpose of
the present study was to compare physiological responses
during low-intensity resistance exercises with BFR between
sprinters and endurance runners by 31P magnetic resonance

413

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 spectroscopy (MRS), which can elucidate intramuscular en-
ergetic metabolism and muscle fiber recruitment.
METHODS
Participants. Twelve trained male participants (sprinters,
n = 6; endurance runners, n = 6) took part in the study. The
average personal best times for the sprinters in the 100-m
sprint, 110-m hurdle, and 400-m sprint were 10.90, 14.82,
and 48.29 s, respectively. The average personal best time for
the endurance runners in the 5-km run was 15 min 45 s. All
participants were healthy and without orthopedic or cardio-
vascular diseases. Informed consent was obtained from all
participants. The study was approved by the ethics committee
of Hokusho University (HOKUSHO-SPOR: 200704).
Anthropometric measurements were performed in all par-
ticipants after participants abstained from exercise training
BASIC SCIENCES
and vigorous physical activities of for at least 24 h. The
measurement was performed from 6:00 to 8:00 p.m. Blood
pressure was evaluated at sitting rest, and the average levels
of two sequential measurements were used. The muscle
cross-sectional area (MCA) of the plantar flexor group, which
is composed of the medial gastrocnemius, lateral gastrocne-
mius, soleus, flexor hallucis longus, tibialis posterior, flexor
digitorum longus, peroneus longus, and peroneus brevis, was
evaluated by magnetic resonance imaging (9).
Exercise procedures. All participants performed a uni-
lateral plantarflexion exercise under four conditions: two re-
sistance exercises without BFR and two BFR protocols. The
two resistance exercises without BFR were low-intensity
exercises at 20% of 1RM (L) and high-intensity exercises
at 65% of 1RM for 2 min (H). The 2 BFR protocols were as
follows: 20% of 1RM with BFR for 2 min (L-BFR), and
prolonged exercise in L-BFR for 3 min (prolonged BFR). The
exercise intensities used in the present study have been
assigned to the level of low-intensity resistance training. The
plantarflexion exercises were carried out at 30 repetitions per
minute, and the weight was lifted 5 cm above the ground.
Throughout the experiments, we carefully monitored the lift-
ing height (5 cm) and repetitions (30 per minute) using a ruler
and metronome, respectively, to avoid variance within and
between participants. The 1RM was determined to be a suc-
cessful concentric-only contraction on the same plantarflexion
apparatus equipped with a magnetic resonance device. Par-
ticipants were instructed to lift the load through the range of
motion to prevent assistance from any other body part (e.g.,
the thigh). The 1RM trials were designed using increments of
10 kg until 60%–80% of the perceived maximum. The load
was then gradually increased by 1- to 5-kg weights until lift
fail, during which the participant was not able to maintain
proper form or to completely lift the weight. The last accept-
able lift with the highest possible load was determined as
1RM. BFR pressure was set as 130% of resting systolic blood
pressure (6,26,27). Participants performed exercises under
all four conditions in random order, on 2 d separated by at
least 1 wk. Before each protocol, we confirmed the recovery
414 Official Journal of the American College of Sports Medicine
Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
in altered intramuscular phosphocreatine (PCr) and pH to
baseline levels. BFR was carried out using a pneumatic rapid
inflator (E-20 rapid cuff inflator; Hokanson, Bellevue, WA)
with an 18.5-cm–wide pressure cuff placed around the right
thigh. The cuff was inflated for 10 s before the exercise protocol
and promptly released after the exercise was completed. The
real-time cuff pressure was monitored digitally and precisely
maintained during exercise.
31
P MRS. Participants lay in the supine position on an
original apparatus equipped with a magnetic resonance de-
vice, and the right foot was attached to the pedal by a Velcro
strap. 31P MRS was performed using a 55-cm-bore 1.5-T
superconducting magnet (Magnetom Vision VB33G; Sie-
mens, Erlangen, Germany). An 80-mm surface coil was
placed under the muscle belly of the right gastrocnemius.
Shimming was adjusted using the proton signal from water.
Spectra of high-energy phosphate were acquired at a pulse
width of 500 Hs, a transmitter voltage of 20 V, and a repe-
tition time of 2000 ms. The spectra were obtained at rest
and every 30 s during exercise. Each spectrum consisted
of an average of eight scans during 16 s before each time
point. For the spectral postprocessing procedure, the stan-
dard software package (LUISE; Siemens) was applied. After
Fourier transformation, Gauss filtering in the time domain,
and phase and baseline correction of the spectral raw data,
the peaks were identified and semiautomatically fitted for
the integrals under the curve in the frequency domain. The
intramuscular PCr millimolar concentration assumed that
PCr millimolar concentration + creatine concentration =
42.5 mM (13) and supposed that the inorganic phosphate (Pi)
concentration is equal to the creatine concentration (16).
Intramuscular pH was calculated from the chemical shift of
Pi relative to PCr. When distinct Pi splitting was shown, the
pH was calculated by standardizing the obtained individual
pH on the basis of peaks corresponding to each Pi (19).
Near-infrared spectroscopy. Calf muscle oxygena-
tion was assessed by near-infrared spectroscopy (NIRS) us-
ing a tissue oximeter (NIRO-200; Hamamatsu Photonics,
Hamamatsu, Japan) during L and L-BFR in six randomly se-
lected participants (sprinters = 3, endurance runners = 3). The
theory behind the NIRS approach and the reliability to mea-
sure tissue O2 saturation has been reported (22). The NIRO-
200 provides tissue O2 saturation data as tissue oxygenation
index (TOI = oxyhemoglobin (HbO2)/total hemoglobin,
expressed in percentage). The TOI value reflects predomi-
nantly the mean of arteriolar, capillary, and venular O2
saturations, with a minor contribution from myoglobin (22).
After exercise begins, HbO2 saturation is depleted from the
stable baseline (100%) and then reaches a plateau (0%) in-
dicating the balance of oxygen demand and supply in muscle
tissue. After exercise is completed, the HbO2 saturation
increases until it reaches a plateau. Data sampled every 1 s
were fed into a personal computer and saved as a file, and this
result showed an average of 5 s.
Measurement of peak oxygen uptake. Peak oxy-
gen uptake (peak V̇O2) was determined with participants
http://www.acsm-msse.org
TABLE 1. Physical and physiological characteristics. Statistical analysis. The values are presented as means T
Sprinters Endurance Runners SE in the table, text, and figures. Intergroup comparisons
(n = 6) (n = 6) P
of a single measurement were performed using the Student’s
Age (yr) 20.8 T 0.6 20.5 T 0.4 0.707
Height (cm) 175.3 T 2.3 172.1 T 2.9 0.379
unpaired t-test in sprinters and endurance runners. Compar-
Weight (kg) 66.3 T 1.5 60.9 T 2.2 0.042 isons of metabolic measures at the end of exercise among
BMI (kgImj2) 21.6 T 0.7 20.6 T 0.6 0.245 protocols were examined by one-way ANOVA. Interaction
SBP (mm Hg) 116.2 T 2.5 116.2 T 1.8 1.000
BFRP (mm Hg) 151.0 T 3.2 151.2 T 2.3 0.970 effects (group  time) were examined by two-way ANOVA
MCA (cm2) 73.4 T 3.3 67.5 T 1.4 0.189 with repeated measures. Post hoc comparisons were exam-
1RM (kg) 60.3 T 1.5 51.8 T 1.4 0.003
20% 1RM (kg) 12.1 T 0.3 10.5 T 0.3 0.003 ined by the Bonferroni test. The relationship between var-
65% 1RM (kg) 39.3 T 1.0 33.8 T 0.9 0.004 iables was examined by linear regression analysis by the
1RM/MCA (kgIcmj2) 0.83 T 0.07 0.77 T 0.03 0.239
Peak V̇O2 (mLIkgj1Iminj1) 62.7 T 1.7 74.2 T 2.4 0.002
Pearson test. The comparisons of split Pi appearance among
AT (mLIkgj1Iminj1) 31.4 T 1.0 36.1 T 1.2 0.020 exercise conditions were performed by a W2 test. The level of
Peak R 1.30 T 0.03 1.25 T 0.01 0.173 significance was set at P G 0.05. All statistical tests were
HRmax (bpm) 194.7 T 4.4 190.2 T 3.5 0.510
Run time (s) 564.7 T 21.4 722.2 T 34.8 0.002 performed using SPSS 17 (SPSS 17.0 for Windows soft-
Training status ware, Chicago, IL).
Training history (yr) 9.5 T 1.1 6.7 T 0.4 0.059
Main training time (hIwkj1) 13.6 T 1.7 14.7 T 1.9 0.658
Training frequency 4.8 T 0.4 6.7 T 0.4 0.002
RESULTS

(times per week)
Resistance training time 3.3 T 1.0 0.5 T 0.4
(hIwkj1)
Values are the means T SE. P values by t-test denote level of significance between
sprinters and endurance runners.
BMI, body mass index; SBP, systolic blood pressure; BFRP, BFR pressure (1.3 times of
SBP); R, RERYR, gas exchange ratio.
exercising on a treadmill using a modified Bruce protocol.
Peak V̇O2 was identified by satisfying more than two con-
ditions, as follows: HRmax (bpm) is 220 j age T 10, respi-
ratory gas exchange ratio is more than 1.2, and leveling off
is observed. Respiratory gas analysis was performed with
a breath-by-breath apparatus (Vmax; SensorMedicsÒ, Yorba
Linda, CA). The anaerobic threshold (AT) was determined
by the V-slope method (3).
As an index of perceived effort, the RPE was evaluated
with the modified Borg 10-point scale. The RPE was taken
immediately after the exercises were finished.
BASIC SCIENCES
0.039
The 1RM in sprinters was significantly greater than that in
endurance runners, and the loads of 20% and 65% of 1RM
in sprinters were greater than those in endurance runners, but
no differences between the two groups were observed in
MCA or 1RM/MCA. Peak V̇O2 and AT in endurance run-
ners were significantly greater than those in sprinters. The
training frequency per week in endurance runners was sig-
nificantly greater than that in sprinters. The resistance train-
ing time per week for sprinters was significantly greater than
that for endurance runners (Table 1).
Intramuscular energetic metabolism during BFR
exercises. Figure 1 shows the time courses of PCr during
exercises carried out under L and L-BFR conditions. There
was no significant difference in the average intramuscular
PCr or pH levels at rest in any of the protocols (PCr = 38.0 T
0.2 mM (sprinters) vs 37.6 T 0.2 mM (endurance runners),
pH = 7.01 T 0.00 vs 7.00 T 0.00). PCr in L was significantly

FIGURE 1—Time courses of change in PCr of rest during L (A) and L-BFR (B) in sprinters (h) and endurance runners (Ì). Values are the means T SE.
†PCr decrease was significantly greater in sprinters than in endurance runners, P G 0.05. *PCr decrease was significantly greater in endurance runners
than in sprinters, P G 0.05.

DIFFERENT RESPONSES IN OCCLUSION EXERCISE Medicine & Science in Sports & Exercised 415

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 FIGURE 2—Time courses of intramuscular pH during L (A) and L-BFR (B) in sprinters (h) and endurance runners (Ì). Values are the means T SE.
BASIC SCIENCES

lower in sprinters than in endurance runners (Fig. 1A), prolonged BFR tended to be greater than that in L-BFR in
whereas in L-BFR, that in endurance runners was signifi- sprinters (P = 0.051). PCr decreases might be enhanced by
cantly lower than that in sprinters (Fig. 1B). Also, there increasing exercise time in both groups.
were significant interactions in the L and L-BFR conditions Fast-twitch fiber recruitment at the end of exer-
(P G 0.001). Although PCr in H tended to be lower in cises. Although recruitment of fast-twitch (FT) fibers, as
sprinters compared with endurance runners, the difference evaluated by Pi splitting (19), was observed during L-BFR,
was not statistically significant (25.7% T 4.1% vs 32.7% T H, and prolonged BFR, none was observed during L. The
3.3%). There was not a significant interaction under the H incidence of Pi splitting was greater in H and prolonged
condition. Similarly, PCr at the end of prolonged BFR ex- BFR than in L-BFR in all participants (L-BFR = 33.3% vs
ercise in endurance runners tended to be lower than that in H = 100% and prolonged BFR = 83.3%, P G 0.01). Sprinters
sprinters (32.0% T 3.2% vs 24.6% T 1.4%, P = 0.062). There and endurance runners showed a similar incidence of Pi
was a significant interaction under the prolonged BFR con- splitting in each comparable protocol (L-BFR = 33.3% vs
dition (P G 0.001). The time courses of intramuscular pH 33.3%, H = 100% vs 100%, prolonged BFR = 83.3% vs
were very similar to those of PCr. However, the difference 83.3%).
between the two groups did not reach statistical signifi- Oxygenation levels in calf muscle. Averaged TOI
cance in any condition possibly because of the wide indi- as oxygenation levels in calf muscles during exercises
vidual variation and large SD (Fig. 2). Interestingly, under for the last 30 s in L tended to be greater in sprinters than
the L-BFR protocol, the decrease in PCr at the end of ex- in endurance runners (80.1% T 7.9% vs 96.2% T 2.7%,
ercise was positively correlated with peak V̇O2 in all par- P = 0.188), whereas in L-BFR, these values were similar
ticipants (Fig. 3), whereas the PCr decrease at the end of
exercise under the L protocol was not significantly corre-
lated with peak V̇O2 (r = j0.357, P = 0.255). There were no
correlations between the degree of metabolic response and
the 1RM or BFR pressure.
We next examined metabolic responses under various
conditions for each of the groups (Fig. 4). Intragroup com-
parisons showed PCr decreases at the end of all exercise
protocols in both sprinters (Fig. 4A) and endurance runners
(Fig. 4B). In both groups, PCr decreases in L-BFR, H, and
prolonged BFR were significantly greater than those in L.
Although endurance runners showed similar PCr decreases
in H and L-BFR, in sprinters, the decreases were signifi-
cantly greater in H than in L-BFR. In endurance runners,
PCr decreases in prolonged BFR were significantly greater
than those in L-BFR. Moreover, those in prolonged BFR
tended to be greater than those in H (P = 0.093). In contrast,
PCr decreases in sprinters during the long-duration proto- FIGURE 3—Correlation between peak V̇O2 and PCr decrease at the
cols were less than those in H. Furthermore, PCr decrease in end of the L-BFR condition in all participants.

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 BASIC SCIENCES
FIGURE 4—PCr decrease from rest in sprinters (A, solid bar) and endurance runners (B, open bar) at the end of the variable exercise protocols.
Values are the means T SE. *P G 0.01 versus L; †P G 0.01 versus L-BFR.

between sprinters and endurance runners (11.8% T 1.7% vs ways. First, there is a difference in aerobic capacity between
14.8% T 4.7%). There was a significant interaction in L sprinters and endurance runners. Endurance runners natu-
(P G 0.001), whereas there was not a significant interaction rally have a higher aerobic capacity than sprinters. Higher
in L-BFR. Therefore, the degree of BFR in exercising mus- aerobic capacity is associated with higher oxygen delivery to
cle was similar in both athletes (Fig. 5). the exercising muscle, which might mean a larger blood flow
RPE. No significant differences in RPE at the end of dependence in endurance runners. Therefore, there might be
exercise between sprinters and endurance runners were ob- a greater disturbance of BFR in energetic metabolism during
served under any of the conditions used (L = 2.7 T 0.3 vs exercise in endurance runners compared with sprinters. In fact,
2.3 T 0.6, L-BFR = 6.5 T 0.7 vs 8.0 T 0.5, H = 8.3 T 0.5 vs a strong correlation was found between PCr decrease and peak
8.5 T 0.5, prolonged BFR = 9.2 T 0.4 vs 8.8 T 0.5). V̇O2 in the present study (Fig. 3). Concordantly, Clark et al.
(5) have suggested that the higher the endurance capacity
with natural blood flow, the greater the reduction in endur-
DISCUSSION ance time with BFR.
Major findings. We elucidated the intramuscular ener-
getic metabolism during resistance exercises with a BFR
protocol in sprinters and endurance runners. The results
showed that muscular metabolic stress as indicated by PCr
and intramuscular pH decrease during exercises with BFR is
significantly greater in endurance runners than in sprinters.
In addition, the muscular stress during low-intensity BFR
exercises was found to be equal or superior to that during
high-intensity exercise without BFR in endurance runners
but not in sprinters; in contrast, during exercises without BFR,
sprinters showed greater muscular metabolic stress than en-
durance runners. These results indicate that endurance run-
ners could more effectively be subjected to muscular stress
by applying BFR during resistance exercise than could
sprinters. Although this training method has been used for
various athletes in rehabilitation after injury and surgery, a
uniform procedure might not have the same successful effects
in all individuals, especially in sprint-type athletes.
The different response of intramuscular metabolic stress
FIGURE 5—Time courses of change in relative oxygenation from rest
during resistance exercise with BFR between sprinters and in L in sprinters (h) and endurance runners (Ì) and in L-BFR in
endurance runners could be explained in several different sprinters () and endurance runners ()). Values are the means T SE.

DIFFERENT RESPONSES IN OCCLUSION EXERCISE Medicine & Science in Sports & Exercised 417

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 The second possible explanation is the different muscular
histological properties of the two different athlete groups.
Endurance runners have more slow-twitch (ST) fibers
(7,10,11), which results in a higher volume of mitochondria
and oxidative enzymes (e.g., citrate synthase, succinate de-
hydrogenase), a higher capillary density (7,14,30), and
higher myoglobin levels (8,31) compared with sprinters, also
leading to higher oxygen dependence. In contrast, sprinters
have more FT fibers, which have more glycolytic enzymes
(e.g., lactate dehydrogenase, phosphofructokinase) (7), and
can carry out multifaceted anaerobic adenosine triphosphate
productions even under the BFR condition. Similarly,
Ingemann-Hansen et al. (15) have reported that a higher ST
fibers ratio was associated with a greater decline of muscle
strength under an ischemic condition.
In the present study, there was no difference in the FT
fiber recruitment as detected by splitting Pi between the two
BASIC SCIENCES
groups. As mentioned above, sprinters with a greater percent
of FT fiber might show a greater incidence of splitting Pi
during resistance exercise. On the other hand, endurance
runners were more stressed during resistance exercise with
BFR compared with sprinters, which led to accelerated Pi
splitting. Thus, both factors could conflictingly contribute to
no significant difference in Pi splitting.
Limitations. The present study has some limitations.
First, we did not examine the muscle fiber type composition
by muscle biopsy. However, we carefully selected the par-
ticipants by their typical competition records and training
status. It is well known that elite sprinters have a predomi-
nance of FT fibers, whereas endurance runners have a pre-
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between sprinters and endurance runners. Supplementation
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creating an effective prescription in resistance exercise with
BFR (Fig. 4).
This work was supported by grants from the Hokusho University
Northern Regions Lifelong Sports Research Center, the Meiji Yasuda
Life Foundation of Health and Welfare, and the Descente and Ishimoto
Memorial Foundation for the Promotion of Sports Science.
The authors thank Dr. Takayuki Sako, Japan Women’s University,
for help with advisement and technical assistance in NIRS mea-
surement. They also thank Mr. Takayuki Kosuge and Mr. Takashi
Sato, Hokusho University, for assistance in data collection. The
authors also thank the study participants.
The authors have no disclosures to declare.
The author contributions are as follows: S.T., T.S., M.O., T.K.,
N.M., M.H., T.Y., K.H., and M.T. performed the experiments; S.T. and
K.O. designed and planned the study; S.T., K.O., T.S., N.M., and
M.H. prepared the article; S.K. and H.T. supervised the study; and all
authors interpreted data.
The results of the present study do not constitute endorsement
by the American College of Sports and Medicine.
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