|Special Topics in Cardiovascular Physiology|
|Instructor:||Dr. Darren Warburton|
|Office:||128 Osborne Unit 2|
|Important Course Pages|
Novel Recovery Strategies for Athletes
This wiki page was created to fulfill a requirement for a graduate level course, KIN 500: Special Topics in Cardiovascular Physiology. This page was created in collaboration with Dr. Darren Warburton. This page aims to address a variety of novel recovery strategies that athletes currently utilize in an attempt to maintain or improve future performance following training sessions. Based on the physiological and chemical stresses that exercise induces, there are a multitude of recovery strategies available for athletes. This section will focus on four methods; (1) normatec pneumatic compression device (2) compression garments (3) cold water immersion (4) cryotherapy chambers
- 1 Original Contributors - Date Published April 8th 2014
- 2 Background
- 3 Methods
- 3.1 Compression
- 3.1.1 Normatec Pneumatic Compression Device
- 18.104.22.168 Research
- 22.214.171.124 Technology/Mechanism
- 126.96.36.199 Recommendations
- 3.1.2 Compression Garments
- 3.1.1 Normatec Pneumatic Compression Device
- 3.2 Cryotherapy
- 3.1 Compression
- 4 References
Original Contributors - Date Published April 8th 2014
- Lauren Buschmann
- Josh Robertson
- James Thompson
- Holly Wollmann
Exercise causes a spectrum of stresses on the body, primarily metabolic stress which involves high rates of aerobic energy transformation and heat generation. These two sub-stressors contribute to an increase in reactive oxidative species (ROS) which denature proteins, lipids and nucleic acid which breaks down muscle cell structure (excitation-contraction coupling). This damage alters muscle kinetics thus reducing the capacity to generate force and reducing performance, commonly referred to as exercise induced muscle damage (EIMS). Alongside the increases of ROS, muscles fibers become more permeable due to the accumulation of metabolites in the cell which cause swelling or oedema. This increased muscle oedema impairs O2 delivery and removal of other wasteful metabolic by-products causing delayed onset muscle soreness (DOMS).
During muscle contractions, myofibrils are disrupted. This disruption initiates a local inflammatory response, which is characterized by leukotrienes shuttling to the site of inflammation  The presence of leukotrienes increases the vascular permeability, which allows neutrophils (white blood cells) to shuttle to the injury site (where the inflammation has occurred due to myofibril disruption). The increase in neutrophils results in the production of free radicals. This process is an underlying mechanism for exercise induced muscle damage.
To measure the effect of EIMS the most commonly assessed markers in literature were; muscle power, muscle strength, creatine kinase and perceived muscle soreness. Muscle power included anything that required explosive movement of the muscles; 5m sprint, vertical jump and the countermovement jump. Muscular strength was commonly measured using either; isometric/isokinetic/isotonic movements. DOMS was commonly measured from either the creatine kinase level from a capillary or venous sample or assessing the perceived muscles soreness using an analogy Likert type scale.
Based on the physiological and chemical stresses that exercise induces, there are a multitude of recovery strategies available for athletes. This section will focus on four methods; (1) normatec pneumatic compression device (2) compression garments (3) cold water immersion (4) cryotherapy chambers.
The two main compression recovery strategies currently used are pneumatic compression devices and compression garments. Having developed the idea from stockings used in clinical settings to aid circulatory and inflammatory disorders, manufacturers have introduced upper and lower limb alternatives into the sporting market with the aim to aid recovery and performance. The theory behind this technology is that the compression is applied intermittently to limbs (arms, legs, or both) in order to mimic the skeletal muscle pump and improve venous return. Compression has also been hypothesized to be effective for removing the metabolites and oedema that occur in the limbs following strenuous high intensity exercise. However, despite the anecdotal use by many athletes as a recovery mechanism, there is actually very little scientific evidence to support its use .
Normatec Pneumatic Compression Device
The Normatec pneumatic compression device is widely used by athletes as a means of accelerating recovery, however, this device is mainly supported via anecdotal reports. Very little evidence currently exists regarding the use of the Normatec recovery device as an effective (or ineffective) means of aiding recovery following high intensity eccentric exercise. The current research available largely investigates a variety of intermittent pneumatic compression devices, with only a few studies specifically addressing Normatec and its impact on recovery following exercise . Available literature suggests that Normatec is effective in improving blood lactate clearance following Wingate testing, and that it may be an effective recovery option for elite athletes . The Normatec website references their methodology and technology, however, they do not provide specific journal articles or studies supporting these claims. Normatec does provide links to magazine articles and books that reference the use of Normatec as an effective recovery mechanism. One such item references the peristaltic compression and ability to remove oedema (the common mechanisms that the MVP recovery device targets to promote recovery) . However, this item provided by Normatec offers up anecdotal reports from athletes, and no scientific methods to support these claims. There is still much controversy and contradiction in regards to effective recovery mechanisms, and whether intermittent pneumatic compression can be effective in healthy, athletic populations.
Pneumatic compression devices such as the Normatec MVP/Pro recovery devices have been studied recently as a means of accelerating limb haemodynamics, in an effort to increase venous return, and consequently facilitate the removal of metabolic waste that results from high-intensity exercise . Metabolic waste such as creatine kinase, lactic acid, lactate dehydrogenase, as well as oedema, often accumulate near muscles following heavy eccentric exercise.. Most studies have been contradicting in regards to the effectiveness of IPC and specifically the Normatec recovery devices in accelerating recovery following high intensity eccentric exercise. Eccentric exercises are largely studied as they have been identified as most effective in inducing fatigue and muscle damage.
This physiological occurrence is what drives most theories regarding recovery supplements and recovery mechanisms. By administering compression on the limbs, an increase in interstitial pressure occurs, which subsequently causes fluids and metabolic waste products to re-enter circulation.  The addition of sequential compression allows for the clearance of these metabolites and oedema from the limbs, aiding in recovery. As is the aim of most other recovery devices, by facilitating blood flow, the Normatec recovery device aims to mobilize free radicals (PC and TBARS), Interleukin-6, C-reactive protein, uric acid, blood lactate and other markers of inflammation, oxidative stress and free radical production. It is believed that by mobilizing the metabolic waste products away from the muscle site, inflammation response will not occur (ie. production of free radicals), which will consequently promote recovery. By minimizing the inflammation response, and removing waste products, there is the reduced possibility of soft tissue damage.
There have been conflicting reports on the effectiveness of intermittent pneumatic compression devices. One of the few available studies regarding the Normatec Recovery Device and it’s effectiveness as a recovery device post-exercise, failed to demonstrate findings that support the use of intermittent pneumatic compression devices as a recovery mechanism following high intensity eccentric exercise. It has been suggested by these experimenters that while intermittent pneumatic compression is an effective treatment for the prevention of deep vein thrombosis and other venous abnormalities, the same theory may not apply to apparently healthy populations, such as athletes. Furthermore, studies investigating the use of modified intermittent sequential pneumatic devices failed to demonstrate changes in blood levels of circulating metabolites following maximal aerobic capacity (VO2 max) tests.
There is some evidence suggesting that pneumatic compression could be effective in facilitating recovery for athletes following heavy eccentric loading. In one of the few known studies available investigating the effectiveness of the Normatec MVP recovery device, it was reported that the Normatec device was more effective in reducing blood lactate concentrations following Wingate testing, when compared to passive recovery. It has been suggested that it may be the time of application of the treatment that impacts the recovery process and reduces oedema from the affected limbs . Reports indicate that the greatest impact intermittent pneumatic compression devices can have on localized swelling post-exercise is approximately two days following eccentric exercise which is consistent with the timeframe commonly understood for delayed onset muscle soreness (DOMS). Furthermore, One study reported that investigators were unable to detect any changes in circulating blood metabolite levels, however there was a 45% improvement in performance in the second maximal aerobic capacity test .This indicates that there could be other underlying mechanisms not currently understood regarding this topic, but also further demonstrates the contradiction that exists amongst the literature currently.
In the past, the intermittent compression has been applied sequentially, in which constant compression, at a pre-determined intensity, is established for a specified amount of pulse time (approximately 30 seconds on, 30 seconds off for 20-30 minutes). Researchers attempted to identify the underlying mechanisms causing the effectiveness of intermittent pneumatic compression on the vascular system . It was concluded that the compression resulting from the device increases blood flow forward and away from where the compression is being applied. The vasodilation that occurs following the increase in blood volume, results in a strain force within the vessels, while a subsequent shear force is caused by an increase in the velocity of the blood flow, as it it pushed away from the site of compression . This demonstrates that there is considerable increase in the venous return as blood is being pushing away from the compressed limb and back towards the heart.
Commercially available devices: technology
More recently, intermittent compression devices have taken a non-sequential approach to compression, in which the compression/pressure is held in one of the chambers (typically starting at the distal limb). Pressure then continues to inflate in other chambers up the limb, until all of the pressure is released at the same time. According to current literature, intermittent pneumatic compression devices typically range in pressures of 65-120 mmHg .
Normatec Recovery Device
The Normatec recovery device is an intermittent pneumatic compression device that is promoted to be a recovery device for athletes of all sports and skill levels. A key difference of the Normatec recovery device from other commercially available intermittent pneumatic compression devices in that the patented technology designed by Normatec, Sequential Pulse Technology, differs from the traditional sequential and non-sequential compression that has been used in the past . Sequential Pulse Technology is designed to mimic the body’s skeletal muscle pump in order to induce venous return, while also preventing backflow of the materials that are being shuttled back through the veins to the heart.
Sequential Pulse Technology
Sequential pulse technology starts by a chamber at the distal end of the limb inflating, and increasing with pressure. While this chamber is inflating, and compression is being applied underneath the chamber, there is a pulsing component within the chamber . The pulsing component is a key feature of Normatec’s design strategy, as it is intended to mobilize the blood and oedema at the site of compression, and shuttle it upwards towards the heart through venous return. When a sequential application of pressure (as little as 50 mmHg) to the limbs is applied, the mobilization of blood flow that results can cause increases in blood flow velocity upwards of 200% in the vessels near the site of compression . Furthermore, the use of sequential compression was suggested to be the most effective method for venous emptying back towards the heart, due to this increase in blood flow mobilization.
The process of sequential chambering inflating, and pulsing within the chamber, continues up the limb. However, the Normatec recovery systems have a notable difference from other commercially available intermittent pneumatic compression devices. In Normatec devices, while the second chamber is inflating and increasing in pressure, the previous chamber remains constant and inflated, which is typical of intermittent pneumatic compression devices . However, unlike most compression devices, when a third chamber begins to inflate, the previous two chambers holds constant pressure, while the third chamber gradually inflates and pulses. Once the third chamber fully inflates, the most distal of the chambers releases pressure. This process continues up the limb and re-cycles back through, so that only two chambers are sequentially inflating, pulsing, and holding compression at any given time. Normatec believes that this compression is adequate to prevent the backflow of metabolites and blood backflow the valves and towards the distal end of the limb (where they were originally shuttled away from). Deflation of the chamber compression in one area while another chamber is inflating also allows for blood to flow back to the muscles that were previously compressed. This promotes the mobilization of metabolites and oedema that may still be present around the muscles, which is the main purpose for the Normatec device’s use . This design is believed to mimic the peristaltic compression wave that occurs in the lymphatic vessels .
Normatec recovery devices have been promoted for use after exercise to facilitate blood flow to the muscles and/or shuttle metabolites that occur post-exercise away from the muscles and back towards the heart . Normatec claims that there are no adverse effects to wearing the compression sleeves and undergoing treatment for any amount of time. Treatment commonly lasts 20-60 minutes following exercise .
There are a variety of options when using the Normatec recovery device in regards to programs and compression available. There are three options when setting up a program: Recovery flush (most commonly used, can select length of time), pre-programmed options, or a customized program. The system is designed to provide up to 100 mmHg of compression, which can be selected based on the intensity level set in each mode (recovery, pre-programmed, customized).
- Chamber 1 (Distal end of the limb): Pressure of 70mmHg, :30 seconds of inflation
- Chamber 2 : Pressure of 80mmHg, :30 seconds of inflation
- Chamber 3: Pressure of 80mmHg, :30 seconds of inflation
- Chamber 4: Pressure of 80mmHg, :30 seconds of inflation
- Chamber 5: Pressure of 60 mmHg, :30 seconds of inflation
- Rest period: No pressure (0 mmHg), :30 seconds of rest
Since the introduction of compression garments into the market there has been a constant increase in the variety of models available to recreational and elite athletes. Following a run or cycle compression clothing such as; knee length socks, knee length shorts or full length tights are most commonly used. Upper body or full body compression garments may be used following maximal strength or power exercises which involved the upper torso, for example a baseball player. With compression decreasing from distal to proximal the mechanism for improved recovery involves a number of factors.
The inflammatory response, which follows tissue damage, creates an increase in tissue osmotic pressure, which sensitizes nociceptors, resulting in sensations of pain and soreness . It has been suggested by applying garments immediately post exercise creates an external pressure gradient that can theoretically attenuate change in osmotic pressure and reduce the space available for swelling, haemorrhage and haematoma formation . Whilst it is still an area under great debate among literature it has been suggested this mechanism is due to an increase in the lymphatic outflow and transport of the profuse fluid from the interstitium of the muscle back into circulation . This transport of fluid should decrease intra-compartmental pressure, therefore decreasing pain and reducing the severity of DOMS .
Improved venous haemodynamics have been suggested to result in increased end-diastolic filling of the heart, increasing stroke volume and cardiac output . It is thought by compressing the superficial veins coupled with an improved muscle pump function and capillary filtration allows more blood to be shunted through deep veins  . This allows for an improved clearance of metabolites and enhanced repair of the muscle  .
Similar to the improvements in venous haemodynamics the application of compression clothing has been shown to increase arterial inflow. As the pressure of the compression garment is transmitted into the deep tissue, the vessels transmural pressure gradient decreases. The response leads to vasodilatation and favours arterial inflow . Like venous return this will enhance clearance of metabolites and supply of nutrients.
It has been suggested that compression garments provide some degree of mechanical support. The compression garments are believed to decrease oscillatory of the leg muscles and reduce the number of recruited fibres for a given movement. Therefore there is a decrease in energy expenditure and perceived exertion which could contribute to a reduction in perceived soreness .
It is evident that the majority of research focuses on investigating the effects of compression garments both during and following exercise . The wide variation in methodological design combined with differences in; timing and duration of application, exercise and training status of the population, has contributed to many investigators describing the findings as ‘equivocal’, . Currently there has been two reviews summarizing the findings of the application of compression garments post exercise as a recovery technique  . Both reviews base their conclusions on the statistical evidence available and are in agreeance with respect to the actual benefits and myths of wearing compression garments as a recovery technique.
The reviews agree on the fact that compression garments can lead to an improved recovery of various power and torque measurements following the application of compression clothing for 12 -24 hours post exercise. Vertical and countermovement jump height were two of the more commonly used jump tests which showed an improvement following compression garment application  . It seemed to be acceptable that compression garments provided some relief 24-48 hours post exercise, with perceived soreness repeatedly showing significant data of being lower  . However, the reviews were also quick to conclude that the compression garments produced mixed results for markers of muscle damage and inflammation 24 – 48 hours post exercise .
While there is a common consensus among investigators that there is still much to explore in terms of the specific models, application and prescription of compression garments , results indicate that when compression garments are worn after intense exercise for at least 12- 24 hours, participants could experience a moderate reduction in severity of DOMS, reduced decrements in strength and power and a reduced concentration of creatine kinase in the serum . It is with these results that many athletes choose to use compression garments as a recovery mechanism and a way to enhance performance.
Compression garments should be applied for at least 12 to 24 hours immediately post exercise . The fit should be tight but not to the extent where they are preventing movement and leading to great restriction . If the compression garment is applied and the area under the garment starts; feeling numb, cold or turns blue, discontinue its use immediately. On the contrary, if a garment is too loose and unable to provide a suitable level of compression it will simply not provide any of the benefits listed above .
For lower body compression, circumference of the thigh and calf should be taken as well as measuring the length of the leg (Hip - Ankle). Upper body, the chest, arm and waist should be measured . While there are slight differences in values according to the make/ model, commercially available compression clothing rarely applies pressure exceeding 25 mmHg. Before purchasing a particular brand it would be advised to carry out some background research on their results, as there are many brands claiming false benefits and technological advancements.
Cryotherapy is widely accepted as a treatment for musculoskeletal injury for athletes in combination with applied compression, elevation and rest.Athletes and professionals use cryotherapy to treat micro traumas in the muscle when visible trauma is not present. This application of cryotherapy is used to speed the healing process and reduce inflammation within muscle tissue. Post-exercise cryotherapy allows athletes to recover quickly and increase workload volume. Cooling injured tissue by methods of cryotherapy has shown to decrease cell metabolism and increase vasoconstriction. Cryotherapy accentuates the inflammatory response to exercise by allowing chemical mediators more time to repair muscle tissue and by limiting ischemic injury to peripheral cells by slowing their metabolic rate. Multiple cryotherapy treatments are readily available to athletes. Among these treatments are ice baths, ice application, cryo-cuffs, vapocoolant sprays, and cryo-chambers.
Cold Water Immersion
High intensity exercise is associated with metabolic and mechanical stressors that lead to a reduction in performance ability of skeletal muscles along with increased soreness and inflammation. The use of cryotherapy in particular cold-water immersion (CWI) has been shown to be a beneficial tool in the recovery of muscles.
Cold water immersion relies on the physiological change in the reduction of tissue temperature which results in vasoconstriction of blood flow, reduction in cell oedema and the flushing out of negative metabolites in the muscle. Systemically CWI causes a reduction of core temperature (Tc) alongside cardiovascular changes . The use of CWI immediately after exercise is thought to prevent the reduction in muscle performance and reduce the onset of DOMS. Cold water is widely acknowledged as a temporary anti-inflammatory, speeding up the healing time by reducing the activation of secondary pathways (ROS and inflammation) that cause muscle damage in the post-exercise recovery period
There are 2 main areas in which CWI is shown to have positive effects; decreases in local blood flow & muscle oedema reduction, and cardiovascular efficiency changes.
Blood Flow and Oedema
CWI has been shown to cause reflexive vasoconstriction and is thought to positively influence the anti-inflammatory process during recovery. Oedema that is caused by increased permeability of the muscle sarcolemma, is associated with decreases in functional muscular capacity, increased pain/DOMS and impaired O2 delivery. CWI reduces the blood flow to the affected muscle through vasoconstriction thus decreasing the swelling of the muscle cells  During immersion, the hydrostatic pressure of water acts on the body’s fluid distribution, moving fluid from the muscle extravascular spaces into the vascular compartments thus reducing exercise induced increases in muscle volume and inflammation. The hydrostatic pressure changes in combination with vasoconstriction from CWI reduce muscle oedema and inflammation.Compressive forces commonly combined with cold therapy (i.e. wraps, bags) limit cell swelling and fluid accumulation and increase the facilitation of waste removal
CWI has been shown to alter neural activity of the heart, restore central blood volume and enhance cardiac preload. The blood volume increases during immersion is redistributed through the body increasing cardiac output, preload and overall blood flow through the body. All of these changes have been suggested to improve recovery post-exercise. CWI causes increased cardiac output which helps with the enhancement blood flow, nutrient distribution and waste removal all which have been shown to be beneficial to increased recovery time. Many studies have shown the positive effects of CWI on reducing fatigue, improving heart rate recovery and increased performance ability in a second bout of exercise.These increases in cardiac efficiency help improve recovery without expending extra energy as is done in active recovery.
There have been multiple studies conducted on the effects of CWI for reducing DOMS and increasing recovery time after stressful exercise. However, a major issue with the literature is the inconsistency between methods and mechanisms that investigate the physiological changes. The general overview of CWI benefits remains unclear due to the contradictory results that have been found. Potential benefits have been reported, but there are also reports in which no benefit has been found.
The major finding of CWI shows the positive correlation between CWI when ice therapy is applied intermittently and to a larger surface area. Of the potential benefits that have been reported, the main factor relies on the theory that “the muscles will cool and relax after a few minutes in the bath. At the end of the bath the body will experience a strong flush of blood circulating through the muscles that were submerged. This sudden increase in circulation speeds up and improves the quality of muscle recovery by quickly flushing out the lactic acids that have built up in the tired muscle
The Cochrane Survey systematic review in 2012 found evidence that suggested CWI had a minimal effect of reducing DOMS within 96 hours after exercise that CWI lowered fatigue levels and CWI was reported to speed up muscle recovery by 28%. The review looked at seventeen studies which included 366 subjects in the comparison of CWI against resting and no recovery technique after a stressful bout of exercise. Of the research proposed, there are consistent beneficial findings which include; injury prevention, recovery time increased, reduction in DOMS, reduction of inflammation, less muscle pain and stiffness, and helps in the treatment of heat-related illness (heat stroke). The potential negative side effects that accompany CWI include: painful sensation of the ice water, breathing difficulty risks and potential medical risks such as frostbite and hypothermia.
Use of CWI varies in methodology but a general consensus involves the theory that skin temperature drops within 1-3 minutes and reaches a minimum temperature at 8-9 minutes. Deep layered muscle takes longer to cool down thus the recommended time for CWI should last no longer than 15 minutes to avoid frostbite to the superficial layer of skin. Water temperature should be around 15 degrees Celsius, but can be reduced to 9-10 degrees but it is not recommended for water temperature to go below 9 degrees in order to avoid potential medical risks. Submersion of the body up to the neck is recommended but not allowing the head to be submerged for any period of time to avoid severe hypothermia and frostbite. 30-60 minutes Post-CWI, it is recommended to shower in warm water to encourage blood flow and warming of the core temperature.
Whole Body Cryotherapy
Whole body cryotherapy (WBC) is a form of air-chilled cryotherapy used in sports medicine and performance recovery settings. Whole body cryotherapy has been used in experimental trials to reduce exercise-induced inflammation and to alleviate the effects of delayed-onset-muscle-soreness and to relieve symptoms of pain disorders such as fibromyalgia. Treatment types include and are not limited to alternate-temperature controlled chambers, localized treatment, and cryo-cabin treatments. Duration for these treatments ranges between 20-180seconds. This range seems suitable to provide beneficial effects, but there has not been any concrete evidence to support optimal time ranges for recovery in elite athletes. Some authors suggest that longer-term exposure could increase pro-inflammatory mediators such as tumor necrosis factor-α,  [8, 9] which would suggest that time exposure to Whole Body Cryotherapy is crucial to determine beneficial or detrimental results. Temperatures between these treatments vary from -60°C to -195°C
Cryotherapy accentuates mechanisms during the inflammatory response to exercise . Cold exposure to injury sites during recovery has been shown to reduce oedema formation by reducing pooling of blood and interstitial liquid  and to decrease cell metabolism allowing neighboring cells of the injury site to survive hypoxia due to oedema . Reducing temperature in target areas with cryotherapy can also reduce nerve conduction speed and in turn reduce pain . Enzymatic activity during Whole body cryotherapy treatment is often measured as an indicator of inflammation and tissue damage reduction. In particular, Whole body cryotherapy causes beneficial changes in enzymatic activity for ΔInterleukin1β, C-reactive protein, ΔInterleukin1ra , creatine kinase 
Vasoconstriction, a natural acute response during inflammation, is accelerated during Whole body cryotherapy. Whole body cryotherapy treatment targets the entire body and reduces core temperature rapidly causing more rapid and systemic vasoconstriction and decreasing vessel permeability to immune cells. Rapid reduction in core temperature and minimal cold exposure time are notable differences between typical cold therapy treatments such as ice massage or ice bath. Whole body cryotherapy does not appear to have any detrimental effects on cardiac function ,immunological parameters
Localized treatment Localized treatment is more commonly used to treat injury related to trauma or post-surgery. However, it has been used to treat exercised induced muscle damage. Localized treatment is administered at a higher temperature (-30 to -78) and has been suggested to be less effective in treating exercise related tissue damage since localized treatment fails to lower core body temperature and exposure time is too fast to reach deep tissues to reap the benefits of cryotherapy.
Many trials with Whole body cryotherapy use a cooling technique involving two alternate temperature chambers of -60°C and -100°C.During this protocol, subjects walk in a familiarization room of -10°C and proceed through the two colder rooms after a short duration. Subjects wear protective clothing on their extremities and a bathing suit. Timing during this protocol never surpasses 3 minutes. Another protocol used is a single exposure cryo-cabin; a temperature controlled standing chamber with temperatures between -140°C and -195°C
Whole body cryotherapy used on athletes   to treat exercise induced muscle damage has shown multiple beneficial results. Whole body cryotherapy has been proven more effective form of treatment in highly trained runners compared to passive and infrared techniques Anti-inflammatory effects have been shown in runners with application of Whole body cryotherapy, including a decrease in magnitude of interleukin-1β and C-reactive protein . Creatine kinase levels have been shown to drop after Whole body cryotherapy treatment in elite rugby players . However, trials with Whole body cryotherapy are often subject to a difficult measure of individual efforts during the exhaustion protocol to induce delayed onset muscle soreness and exercise induced muscle damage. Individual response to exercise induced muscle damage, training status and protocol have a large influence on inflammatory markers.
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