EFFECT OF COMPRESSION STOCKINGS ON PHYSIOLOGICAL RESPONSES AND RUNNING PERFORMANCE IN DIVISION III COLLEGIATE CROSS-COUNTRY RUNNERS DURING A MAXIMAL TREADMILL TEST BRIAN C. RIDER,1,2 ADAM M. COUGHLIN,3 TAMARA D. HEW-BUTLER,1 1 3
AND
BRIAN R. GOSLIN1
School of Health Science, Oakland University, Rochester, Michigan; 2University of Tennessee, Knoxville, Tennessee; and Human Performance Lab, Adrian College, Adrian, Michigan
ABSTRACT Rider, BC, Coughlin, AM, Hew-Butler, TD, and Goslin, BR. Effect of compression stockings on physiological responses and running performance in division III collegiate cross-country runners during a maximal treadmill test. J Strength Cond Res 28(6): 1732–1738, 2014—There is a growing trend for runners to use compression stockings (CS) to improve performance. The purpose of this study was to determine the effect of CS on physiological variables associated with running performance. Participants were 10 NCAA division III cross-country runners. The study used a randomized, crossover design with 2 conditions (with CS and without CS). Both conditions consisted of a maximal treadmill test that involved 3-minute stages of increasing speed and incline, separated by a minute and one-half walking recovery stage. Seven days later, the participants repeated the maximal test but switched CS condition. Heart rate, blood lactate (BLa), blood lactate threshold, maximal oxygen consumption (V_ O2max), respiratory exchange ratio, rating of perceived exertion, and time to fatigue were measured. Before and during the maximal treadmill tests, the variables showed no significant difference (p # 0.05) between the CS conditions. Blood lactate was lower while wearing CS when measured during recovery at the 1-minute (CS = 13.3 6 2.9 mmol$L21, non-CS = 14.8 6 2.8 mmol$L 21, p = 0.03) and the 5-minute (CS = 11.0 6 2.7 mmol$L 21, non-CS = 12.8 6 2.8 mmol$L 21, p = 0.02) periods. Time to fatigue was longer without CS (CS = 23.570 6 2.39 minutes, nonCS = 23.93 6 2.49 minutes, p = 0.04). These findings suggest that CS may not improve running performance, but Address correspondence to Brian C. Rider, [email protected]. 28(6)/1732–1738 Journal of Strength and Conditioning Research Ó 2014 National Strength and Conditioning Association
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could lend credence to certain manufacturers’ claims of improved recovery through lower BLa values after exercise.
KEY WORDS recovery, blood lactate, lactate threshold, running, compression garments, lactate INTRODUCTION
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ompression stockings (CS) have traditionally been designed for and used by populations suffering from venous return insufficiency (VI) secondary to a number of diseases or disabilities (20,22) or at risk for developing deep vein thrombosis (23). Compression stockings enhance the skeletal muscle pump function thereby increasing blood circulation back to the heart from the limbs. Lower extremity CS act on the calf muscle pump (capable, in healthy individuals, of generating pressures of greater than 200 mm Hg) and promote even greater venous return than normal conditions (4). Numerous studies have illustrated the benefits of CS in rehabilitation settings and among those suffering from VI (6,19). However, there is a relatively new interest in using CS in athletics. Compression stockings and other compression garments have been tested among a diverse population of athletes (10–12,15,16). Some CS manufacturers claim that similar benefits of CS experienced among chronic disease and/or disability patients (improved venous return, improved circulation, decrease in leg soreness, and swelling) can be of use to athletes, particularly endurance runners (24). Consequently, CS have been marketed as a way to reduce lactic acid buildup in the legs during exercise while improving energy, performance, and recovery (24). Despite manufacturers’ claims and the growing popularity among runners, there have been few studies examining the effect of CS on running performance specifically (8,15). These studies have examined both standard (8) and graduated CS (15). Whereas standard CS exert constant pressure, graduated CS exert varying levels of compression. Typically,
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TABLE 1. Participant characteristics.* Age (y)
Height (cm) Weight (kg) Body mass index (kg$m22) Collegiate personal record (min:s)
Men (n = 7) 21 6 1.3 172.8 6 4.2 68.7 6 9.7 Women (n = 3) 18.7 6 0.6 162.9 6 4.7 56.7 6 3.3
23.0 6 2.7 21.4 6 0.3
26:37 6 00:56† 19:04 6 00:39
*Data are represented as mean 6 SD. Personal records of men based on 8-km distance. Personal records of women based on 5-km distance. †One male subject failed to provide his personal record based on 8-km distance.
greater pressure will be applied distally (in or towards the ankle) with less pressure applied towards the calf. This is done to reduce blood pooling in the lower extremities and enhance venous blood return towards the heart. Many factors affect running performance and, historically, one of the more controversial and misunderstood factors has been blood lactate (BLa) and the concept of the lactate threshold (LT) (13). Various training techniques and plans have centered on the premise of delaying the onset of the LT to improve running performance. Previous studies exploring the relationship between CS and exercise have shown modest improvements in performance and other physiological variables (1,5,8,15,27), however, only one found a significant difference in BLa levels (5). Also, none of the previous studies examined a group of highly trained runners with a homogenous training regimen to help limit variability between runners. If CS were shown to lower BLa levels and delay the LT, their use as an ergogenic aid among professional, amateur, and recreation runners would be substantial. However, currently the literature on the effect of CS on BLa and LT remains unclear, and when considering truth in marketing of CS to runners, ample research and investigation of manufacturers’ claims should be well documented. Therefore, the purpose of this study was to determine whether wearing below-the-knee graduated CS with a minimum of 15 mm Hg of pressure during a maximal treadmill run would induce physiological changes among collegiate cross-country runners. The main outcome variable examined was BLa levels and the corresponding LT. Secondary variables that were assessed were: maximal oxygen consumption (V_ O2max), rating of perceived exertion (RPE), heart rate (HR), respiratory exchange ratio (RER), and time to fatigue (TTF). It was our hypothesis that the CS would decrease BLa accumulation, and as a result improve performance during a maximal treadmill test.
performance in Division III collegiate cross-country runners. This within-group subject study design let each participant serve as his/her own control. Subjects
Ten Division III cross-country runners were recruited, (men; n = 7) for this study. All participants were at least 18 years of age, were current members of their collegiate cross-country team, had competed in the previous cross-country season, and all were medically cleared for participation in crosscountry competition. None of the female participants reported that they were pregnant. Testing was completed in June and all of the participants were involved in the cross-country off-season conditioning program. All participants were cleared using the American College of Sports Medicine absolute or relative contraindications to testing and criteria for stopping an exercise test (26). All study participants gave written informed consent, and the study was approved by the university institutional review board. Procedures
The study used a randomized, crossover design with half of the subjects completing condition 1 first. All participants
METHODS Experimental Approach to the Problem
This study used a randomized crossover design to determine the effect of wearing beneath-the-knee graduated CS on BLa, LT, and other physiological markers and running
Figure 1. Posterior view of participant wearing compression stockings during maximal treadmill test.
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Compression Stockings and Physiological Responses a specific prerace meal, but were asked to eat a similar (if not identical) meal before each test. Participants were allowed to hydrate ad libitum before testing. Additionally, participants were asked to wear the same clothing and running shoes for each visit. Before beginning the test, a number of pre-exercise measures were taken. Participants’ height and weight were measured using a standard stadiometer and physician beam balance (Table 1). The participants then were seated for 5 minutes during which time the Figure 2. Blood lactate (BLa) levels before/during exercise, 1- and 5-minute recovery in compression stockings “6–20 RPE Borg” scale (7) (CS) and non-CS conditions. *p # 0.05. was explained to them. The participants were informed that if they needed to stop for any reason during the test, were asked to report to the laboratory for 2 visits, which to grab onto the treadmill handrails. This would serve as the were exactly 7 days apart. During visit 1, participants were volitional sign to end the test. Each participant was fitted randomized to group 1 or group 2. Group 1 wore the CS with Hans Rudolph (Hans Rudolph Inc.) valve and a Polar during their first visit, whereas the group 2 wore CS for visit heart rate monitor (Polar USA, Lake Success, NY, USA) and 2. Athletic Recovery Graduated Compression Stockings either CS or no CS (depending on their condition order). from SIGVARIS Inc. (Peachtree City, GA, USA) were used. Expired gases were collected and analyzed to calculate oxyThey were made up of 67% dri-release polyester, 26% nylon, gen consumption using a ParvoMedics True One system and 7% spandex. Each CS was manufactured to provide (Sandy, UT, USA) (3). The metabolic measurement system a minimum of 20 mm Hg pressure (ankle) to 15 mm Hg was used to compute V_ O2 and RER, and data were consolpressure (calf ), when properly fitted (Michael Leonard, idated and reported in 30-second increments. personal communication, October 8, 2010). The fitting scale After 5 minutes of seated measurements, the participant corresponded to each participant’s shoe size. then stepped onto the treadmill and began a walk at All participants reported at the same time of the day for 80.4 m$min21 with a 0% incline. While walking at each of the 2 test days, which varied by individual. This was 80.4 m$min21, HR and RPE were recorded. The BLa was a performance test and, as such, the participants were measured through finger stick using the Accutrend analyzer instructed to prepare as they would for a race. To best (Hawthorne, NY, USA) (coefficient of variance, 2.8–5.0). control for nutrition, the participants were not restricted to These values constituted the “pre-exercise” measurements. This study used a discontinuous ramped treadmill protoTABLE 2. Physiological measurements between the 2 CS conditions.* col. Each stage lasted for 3 minutes, with up to a 90Variable (units) CS (mean 6 SD) Non-CS (mean 6 SD) second active rest period (walking at 80.4 m$min21 at 198.6 6 7.7 200.9 6 7.4 Peak HR (b$min21) V_ O2max (ml$kg21$min21) 63.1 6 6.0 64.9 6 7.0 previous stage grade) between Maximum RPE (Borg’s scale 6–20) 19.0 6 0.9 19.5 6 0.5 stages. Heart rate was recorded Maximum RER 1.2 6 0.06 1.2 6 0.1 10 seconds before each stage LT (stage #) 3.0 6 1.0 3.0 6 1.0 ended through telemetry. The Performance (TTF) (min) 23.6 6 2.4 23.9 6 2.5† RPE and BLa were measured *CS = compression stockings; HR = heart rate; RPE = rating of perceived exertion; RER = during active rest. The metarespiratory exchange ratio; LT = lactate threshold; TTF = time to fatigue. bolic measurement system †p # 0.05. was used to compute V_ O2 and RER in 30-second increments.
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participants repeated the maximal test but switched CS condition. All blood samples were taken by the same investigator, in the same manner, for all of the participants, using the same BLa analyzer (2). Statistical Analyses
Microsoft Excel for Windows 7 and SPSS Version 20 (IBM Corp., Armonk, NY, USA) were used to analyze the data. Mean values and SD (mean 6 SD) were calculated for all descriptive measures. Repeated-measures analyses of variance were used Figure 3. Relationship between 1-minute Blood lactate (BLa) change and total time to fatigue (TTF) change (nonto assess the differences in BLa, compression stocking [CS] minus CS values). _ O2, RER, RPE, and HR across V testing stage and condition. Paired t-tests were used to anaFor the first stage, all participants ran at 160 m$min21 and lyze the maximum values between the conditions using an a 0% grade. For the second stage, all participants ran at 160 alpha level set a priori at p # 0.05. Linear regression analysis m$min21 and a 5% grade. Each subsequent stage increased was used to analyze the TTF as it related to BLa. by 26.8 m$min21 and 1% grade until the participant reached RESULTS volitional exhaustion. For the purpose of this study, LT was There were no differences in the physiological responses defined as the point at which the participant’s lactate levels measured in this study under the CS and non-CS conditions reached 4 mmol or greater (25). other than BLa and recovery TTF. After noticeable differences Once the participant reached their volitional physical in BLa between conditions at 1 and 5 minutes post-test were limit, indicated by them grabbing the handrails, the treadmill was reduced to 80.4 m$min21 and 0% incline, the mouthfound, paired t-tests were run and showed that BLa was sigpiece and headgear were removed, and they walked for nificantly lower while wearing CS when measured during a 5-minute cool down. At 1 and 5 minutes post-exercise, recovery from the treadmill test at 1-minute (CS = 13.3 6 BLa, HR, and RPE were recorded. Seven days later, the 2.9 mmol$L21, non-CS = 14.8 6 2.8 mmol$L21, p = 0.03) and the 5-minute (CS = 11.0 6 2.7 mmol$L21, non-CS = 12.8 6 2.8 mmol$L21, p = 0.02) periods (Figures 1 and 2). Paired t-tests revealed that TTF was modestly, but significantly longer without CS (CS = 23.570 6 2.39 minutes, nonCS = 23.93 6 2.49 minutes, p = 0.04) (Table 2). To determine whether this had any effect on the recovery BLa levels, a linear r2 analysis was used to determine any significance and was plotted on a line graph. (Figures 3 and 4). The results indicated that the differences in TTF between the 2 trials accounted for 49% Figure 4. Relationship between 5-minute blood lactate (BLa) change and total time to fatigue (TTF) change (noncompression stocking [CS] minus CS values). of the variation in BLa for 1-minute recovery data and VOLUME 28 | NUMBER 6 | JUNE 2014 |
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Compression Stockings and Physiological Responses 63% of the variation in BLa 5-minute recovery data. Therefore, not all of the differences in postexercise BLa levels can be attributed to the CS/non-CS conditions. However, this indicates that the CS were responsible for part of the other 51 and 37%, respectively. Paired sample t-tests showed no significant difference for order effect between the first and second treadmill tests (first = 23.8 6 2.5 minutes, second = 23.7 6 2.3 minutes, p = 0.06). Before and during the submaximal stages of the maximal treadmill test, HR, RER, V_ O2, RPE, and LT were not significantly different between CS conditions. _ O2max, max RER, and max RPE showed no Peak HR, V differences between conditions either (Table 2).
DISCUSSION The most important finding of this investigation was the increase in TTF in the non-CS condition. Time to fatigue was significantly longer without CS (CS = 23.570 6 2.39 minutes, non-CS = 23.93 6 2.49 minutes, p = 0.04). These findings are in agreement with a previous study that examined the effect of CS on athletes during sprint workout (9). Decreased TTF when wearing CS goes against the manufacturers’ claims of the benefits of wearing the CS (24). The decrease in TTF while wearing the CS could hypothetically be explained in several ways. First, this study did not have a protocol for recording anecdotal data. Participants were not asked their opinion of the CS nor could they list any discomfort or feelings, positive or negative, relating to the CS. It is possible that some of the subjects did not like running in the CS. If the subjects had any negative perceptions of the stockings (e.g., too itchy, hot, or restrictive), then this may have affected their performance. Second, the CS may have added weight to the runners, especially as the test went on and sweat made the CS heavier. However, it is unlikely that the weight of the fabric was significantly changing based on the materials that made up the CS. Order effect could help explain this study’s lack of improvement in TTF among the runners in comparison to similar studies. Kemmler et al. (15) observed an increase in TTF with their subjects wearing the CS. Their data illustrated that running performance determined by time under load (36.44 6 3.49 vs. 35.03 6 3.55 minutes, effect size [ES], 0.40) and total work (422 6 78 vs. 399 6 77 kJ, ES, 0.30) were significantly higher with the CS. However, Kemmler et al. (15) used a different population focusing on recreational runners with a greater age range (25–60 years vs. 18–22 years) and lower mean V_ O2max (52.0 vs. 64.1) for their study. Kemmler et al. (15) did not report statistical analysis of testing order. If they did not complete this analysis, it is not unreasonable to hypothesize that some sort of change in performance could have occurred as a result of the order in which the subjects ran their tests. This study accounted for order effect by randomizing the testing. It also found no statistical significance when examining for order effect, but it is unclear whether other studies examined their data post hoc for order effect as well. One would not expect
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collegiate runners, with a homogenized training level, to perform significantly better/worse on a treadmill test over the course of 1 week. The CS appeared to have a significant effect on BLa levels after 1- and 5-minute active recoveries, with BLa levels in recovery from exercise being higher for the non-CS conditions (Figures 3 and 4) defined by augmented capacity to remove BLa. This may lend credence to certain manufacturers’ claims of improved recovery after exercise (24). There is also the possibility that the lower BLa levels observed in the CS condition were the result of the decrease in TTF displayed by the CS group. Less time spent running would result in decreased BLa levels. This would further suggest that CS decreased performance. The proposed mechanism behind CS is that they improve oxidation of the muscle through increasing venous return via the calf muscle pump (28). Previous studies have found the use of compression garments of varying length and compression to reduce soreness after bouts of eccentric exercise and other activities (16–18). Specifically, as a study conducted by Kraemer et al. (18) on the effect of commercial hosiery with various levels of graduated compression found that all were effective at attenuating lower leg swelling and venous pooling among normal healthy women. This was followed by a reduction in lower leg discomfort (18). Although this study did not ask participants how they felt after the run between conditions, the previous research does strengthen the idea of CS in recovery from exercise. Kraemer et al. (18) noted that the lower leg swelling was the result of increased creatine kinase (CK) activity in the blood stream after 8 hours of standing, and that CS with even a modest level of compression (15.4 mm Hg ankle, 8.4 mm Hg calf, 8.6 mm Hg thigh) decreased CK activity (18). This study did not measure CK activity between conditions. Also, it is important to note that any benefits from increased muscle pump may not lead to increased BLa buffering in subjects with already highly developed muscle pump function. The effects of endurance training on the body are well established. However, studies examining training effect on calf muscle pump function in healthy populations are lacking. The available literature focuses on subjects with VI (14,21). Padberg et al. (21) looked at patients suffering from VI and found calf muscle pump function and dynamic calf muscle strength were improved after a 6-month program of structured exercise. Based on these results, it stands to reason that training (running) would result in improved muscle pump function among healthy subjects, and that the runners in this study would have well-developed calf muscle pump function. Aerobically trained improvements in calf muscle pump function might leave little room for improvement because of CS when considering venous return. The results of this study appear to support this contention. Other than TTF and recovery BLa, there were no differences in the physiological responses measured in this study under the CS and non-CS conditions. There was no
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Journal of Strength and Conditioning Research difference in BLa levels before or during exercise between CS and non-CS conditions. The CS did not reduce the levels of BLa at each stage between conditions nor did they delay the onset of the LT. Berry et al. (5) did observe decreased BLa levels in the CS trial. They postulated increased retention of lactate in the muscle bed resulted in lower BLa levels from the CS. Although this is physiologically possible, it is untested (5). To further test that hypothesis, more invasive testing of the muscle properties would need to be performed. A maximal test does not closely resemble a traditional race protocol. Presumably, this may not limit performance if the mechanism that limited maximum TTF does not come into play at race pace. Additional studies could employ a testing protocol that more closely mirrors a typical long distance race, where time is examined as closely as intensity. Further research should also examine whether the level of training will influence the possible effects that CS might have on them. It would be appropriate to examine whether wearing the CS immediately after exercise causes the same decrease in BLa during recovery as in this study. If, in fact, CS decreases TTF, as this study indicates, it needs to be examined whether putting the socks on immediately after exercise would provide the same benefits observed on BLa levels in recovery without negatively affecting the runner’s maximal performance. Previous studies have also monitored their participants for longer periods of time after the exercise bout, and had participants provide information on their perceived level of soreness (9,17,18). Had this study inquired about lower extremity soreness after the 2 treadmill tests, it is possible some better anecdotal recovery data could have been gleaned. Previous CS research used CS with “slightly degressive” pressure from the ankle of 24 mm Hg (15) and 15–22 mm Hg (27). These pressure ranges are comparable to those in the CS used in this study. Therefore, differences observed in performance and physiological markers are most likely related to other variables, such as participant characteristics/fitness level and test design. Unfortunately, this study had a non-blind limitation. The subjects were aware when they were wearing the stockings and when they were not. Use of a placebo might have helped eliminate any bias (consciously or subconsciously) that may have existed.
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from maximal exercise. Therefore, we cannot recommend their use as an ergogenic aid in this population participating in a maximal treadmill test. Accordingly, coaches, trainers, and runners searching for a legal “edge” should exercise caution when using CS during competition. This study demonstrates that although CS did not appear beneficial for a maximal exercise test, they may prove beneficial after exercise. When examining the effects of a purported ergogenic aid, a lack of significant findings is often as critical as significant differences in assessing the validity of the manufacturer’s claims. Perhaps, the findings of this study will lead to further examination of the claims made by CS manufacturers to better educate the coaches, trainers, and athletes, both professional and recreational, who use them.
ACKNOWLEDGMENTS The assistance of Dr. Kevin Darr, Cary Springer (statistical assistance) Jennifer Flynn, and Dr. Scott Conger is gratefully acknowledged. The authors thank Judith Brannan at Sigvaris for donating compression stockings for the study. The authors declare no professional relationship with Sigvaris and state that the results of this study do not constitute an endorsement of the product.
REFERENCES 1. Ali, A, Caine, MP, and Snow, BG. Graduated compression stockings: physiological and perceptual responses during and after exercise. J Sports Sci 25: 413–419, 2007. 2. Baldari, C, Bonavolonta, V, Emerenziani, GP, Gallotta, MC, Silva, AJ, and Guidetti, L. Accuracy, reliability, linearity of Accutrend and Lactate Pro versus EBIO plus analyzer. Eur J Appl Physiol 107: 105–111, 2009. 3. Bassett, DR Jr, Howley, ET, Thompson, DL, King, GA, Strath, SJ, McLaughlin, JE, and Parr, BB. Validity of inspiratory and expiratory methods of measuring gas exchange with a computerized system. J Appl Physiol (1985) 91: 218–224, 2001. 4. Bermudez, K, Knudson, MM, Morabito, D, and Kessel, O. Fasciotomy, chronic venous insufficiency, and the calf muscle pump. Arch Surg 133: 1356–1361, 1998. 5. Berry, MJ and McMurray, RG. Effects of graduated compression stockings on blood lactate following an exhaustive bout of exercise. Am J Phys Med 66: 121–132, 1987. 6. Best, AJ, Williams, S, Crozier, A, Bhatt, R, Gregg, PJ, and Hui, AC. Graded compression stockings in elective orthopaedic surgery. An assessment of the in vivo performance of commercially available stockings in patients having hip and knee arthroplasty. J Bone Joint Surg Br 82: 116–118, 2000.
PRACTICAL APPLICATIONS
7. Borg, G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Human Kinetics, 1998.
The practical applications of this study appear to demonstrate that CS are not beneficial to highly trained collegiate cross-country runners unaccustomed to wearing CS during a treadmill run to maximal volitional exhaustion. The runners fatigued faster when wearing CS. Accordingly, BLa during recovery was significantly lower due, in part, to the shorter TTF when wearing the CS. Based on the results of this study, it is unknown whether decreased BLa during recovery benefits physiological recovery
8. Bringard, A, Perrey, S, and Belluye, N. Aerobic energy cost and sensation responses during submaximal running exercise–positive effects of wearing compression tights. Int J Sports Med 27: 373–378, 2006. 9. Davies, V, Thompson, KG, and Cooper, SM. The effects of compression garments on recovery. J Strength Cond Res 23: 1786– 1794, 2009. 10. Doan, BK, Kwon, YH, Newton, RU, Shim, J, Popper, EM, Rogers, RA, Bolt, LR, Robertson, M, and Kraemer, WJ. Evaluation of a lower-body compression garment. J Sports Sci 21: 601–610, 2003. VOLUME 28 | NUMBER 6 | JUNE 2014 |
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Compression Stockings and Physiological Responses 11. Duffield, R, Cannon, J, and King, M. The effects of compression garments on recovery of muscle performance following highintensity sprint and plyometric exercise. J Sci Med Sport 13: 136–140, 2010. 12. Duffield, R and Portus, M. Comparison of three types of full-body compression garments on throwing and repeat-sprint performance in cricket players. Br J Sports Med 41: 409–414, 2007. discussion 414. 13. Faude, O, Kindermann, W, and Meyer, T. Lactate threshold concepts: How valid are they? Sports Med 39: 469–490, 2009. 14. Jones, NA, Webb, PJ, Rees, RI, and Kakkar, VV. A physiological study of elastic compression stockings in venous disorders of the leg. Br J Surg 67: 569–572, 1980. 15. Kemmler, W, von Stengel, S, Kockritz, C, Mayhew, J, Wassermann, A, and Zapf, J. Effect of compression stockings on running performance in men runners. J Strength Cond Res 23: 101– 105, 2009. 16. Kraemer, WJ, Bush, JA, Bauer, JA, Triplett-McBride, NT, Paxton, NJ, Clemson, A, Koziris, LP, Mangino, LC, Fry, AC, and Newton, RU. Influence of compression garments on vertical jump performance in NCAA Division I volleyball players. J Strength Cond Res 10: 180–183, 1996. 17. Kraemer, WJ, Flanagan, SD, Comstock, BA, Fragala, MS, Earp, JE, Dunn-Lewis, C, Ho, JY, Thomas, GA, Solomon-Hill, G, Penwell, ZR, Powell, MD, Wolf, MR, Volek, JS, Denegar, CR, and Maresh, CM. Effects of a whole body compression garment on markers of recovery after a heavy resistance workout in men and women. J Strength Cond Res 24: 804–814, 2010. 18. Kraemer, WJ, Volek, JS, Bush, JA, Gotshalk, LA, Wagner, PR, Gomez, AL, Zatsiorsky, VM, Duarte, M, Ratamess, NA, Mazzetti, SA, and Selle, BJ. Influence of compression hosiery on physiological responses to standing fatigue in women. Med Sci Sports Exerc 32: 1849–1858, 2000.
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19. Morris, RJ and Woodcock, JP. Effects of supine intermittent compression on arterial inflow to the lower limb. Arch Surg 137: 1269–1273, 2002. 20. O’Donnell, TF Jr, Rosenthal, DA, Callow, AD, and Ledig, BL. Effect of elastic compression on venous hemodynamics in postphlebitic limbs. JAMA 242: 2766–2768, 1979. 21. Padberg, FT Jr, Johnston, MV, and Sisto, SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: A randomized trial. J Vasc Surg 39: 79–87, 2004. 22. Rimaud, D, Calmels, P, Roche, F, Mongold, JJ, Trudeau, F, and Devillard, X. Effects of graduated compression stockings on cardiovascular and metabolic responses to exercise and exercise recovery in persons with spinal cord injury. Arch Phys Med Rehabil 88: 703–709, 2007. 23. Sachdeva, A, Dalton, M, Amaragiri, SV, and Lees, T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev CD001484, 2010. 24. Sigvaris website: http://www.sigvaris.com/en/sigvaris-sports/ sigvaris-sports-line/better-performance-faster-recovery. Accessed June 24, 2013. 25. Sjodin, B and Jacobs, I. Onset of blood lactate accumulation and marathon running performance. Int J Sports Med 2: 23–26, 1981. 26. Thompson, WR, Gordan, NF, and Pescatello, LS. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins, 2010. 27. Varela-Sanz, A, Espana, J, Carr, N, Boullosa, DA, and EsteveLanao, J. Effects of gradual-elastic compression stockings on running economy, kinematics, and performance in runners. J Strength Cond Res 25: 2902–2910, 2011. 28. Zajkowski, PJ, Proctor, MC, Wakefield, TW, Bloom, J, Blessing, B, and Greenfield, LJ. Compression stockings and venous function. Arch Surg 137: 1064–1068, 2002.
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AND
BRIAN R. GOSLIN1
School of Health Science, Oakland University, Rochester, Michigan; 2University of Tennessee, Knoxville, Tennessee; and Human Performance Lab, Adrian College, Adrian, Michigan
ABSTRACT Rider, BC, Coughlin, AM, Hew-Butler, TD, and Goslin, BR. Effect of compression stockings on physiological responses and running performance in division III collegiate cross-country runners during a maximal treadmill test. J Strength Cond Res 28(6): 1732–1738, 2014—There is a growing trend for runners to use compression stockings (CS) to improve performance. The purpose of this study was to determine the effect of CS on physiological variables associated with running performance. Participants were 10 NCAA division III cross-country runners. The study used a randomized, crossover design with 2 conditions (with CS and without CS). Both conditions consisted of a maximal treadmill test that involved 3-minute stages of increasing speed and incline, separated by a minute and one-half walking recovery stage. Seven days later, the participants repeated the maximal test but switched CS condition. Heart rate, blood lactate (BLa), blood lactate threshold, maximal oxygen consumption (V_ O2max), respiratory exchange ratio, rating of perceived exertion, and time to fatigue were measured. Before and during the maximal treadmill tests, the variables showed no significant difference (p # 0.05) between the CS conditions. Blood lactate was lower while wearing CS when measured during recovery at the 1-minute (CS = 13.3 6 2.9 mmol$L21, non-CS = 14.8 6 2.8 mmol$L 21, p = 0.03) and the 5-minute (CS = 11.0 6 2.7 mmol$L 21, non-CS = 12.8 6 2.8 mmol$L 21, p = 0.02) periods. Time to fatigue was longer without CS (CS = 23.570 6 2.39 minutes, nonCS = 23.93 6 2.49 minutes, p = 0.04). These findings suggest that CS may not improve running performance, but Address correspondence to Brian C. Rider, [email protected]. 28(6)/1732–1738 Journal of Strength and Conditioning Research Ó 2014 National Strength and Conditioning Association
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could lend credence to certain manufacturers’ claims of improved recovery through lower BLa values after exercise.
KEY WORDS recovery, blood lactate, lactate threshold, running, compression garments, lactate INTRODUCTION
C
ompression stockings (CS) have traditionally been designed for and used by populations suffering from venous return insufficiency (VI) secondary to a number of diseases or disabilities (20,22) or at risk for developing deep vein thrombosis (23). Compression stockings enhance the skeletal muscle pump function thereby increasing blood circulation back to the heart from the limbs. Lower extremity CS act on the calf muscle pump (capable, in healthy individuals, of generating pressures of greater than 200 mm Hg) and promote even greater venous return than normal conditions (4). Numerous studies have illustrated the benefits of CS in rehabilitation settings and among those suffering from VI (6,19). However, there is a relatively new interest in using CS in athletics. Compression stockings and other compression garments have been tested among a diverse population of athletes (10–12,15,16). Some CS manufacturers claim that similar benefits of CS experienced among chronic disease and/or disability patients (improved venous return, improved circulation, decrease in leg soreness, and swelling) can be of use to athletes, particularly endurance runners (24). Consequently, CS have been marketed as a way to reduce lactic acid buildup in the legs during exercise while improving energy, performance, and recovery (24). Despite manufacturers’ claims and the growing popularity among runners, there have been few studies examining the effect of CS on running performance specifically (8,15). These studies have examined both standard (8) and graduated CS (15). Whereas standard CS exert constant pressure, graduated CS exert varying levels of compression. Typically,
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TABLE 1. Participant characteristics.* Age (y)
Height (cm) Weight (kg) Body mass index (kg$m22) Collegiate personal record (min:s)
Men (n = 7) 21 6 1.3 172.8 6 4.2 68.7 6 9.7 Women (n = 3) 18.7 6 0.6 162.9 6 4.7 56.7 6 3.3
23.0 6 2.7 21.4 6 0.3
26:37 6 00:56† 19:04 6 00:39
*Data are represented as mean 6 SD. Personal records of men based on 8-km distance. Personal records of women based on 5-km distance. †One male subject failed to provide his personal record based on 8-km distance.
greater pressure will be applied distally (in or towards the ankle) with less pressure applied towards the calf. This is done to reduce blood pooling in the lower extremities and enhance venous blood return towards the heart. Many factors affect running performance and, historically, one of the more controversial and misunderstood factors has been blood lactate (BLa) and the concept of the lactate threshold (LT) (13). Various training techniques and plans have centered on the premise of delaying the onset of the LT to improve running performance. Previous studies exploring the relationship between CS and exercise have shown modest improvements in performance and other physiological variables (1,5,8,15,27), however, only one found a significant difference in BLa levels (5). Also, none of the previous studies examined a group of highly trained runners with a homogenous training regimen to help limit variability between runners. If CS were shown to lower BLa levels and delay the LT, their use as an ergogenic aid among professional, amateur, and recreation runners would be substantial. However, currently the literature on the effect of CS on BLa and LT remains unclear, and when considering truth in marketing of CS to runners, ample research and investigation of manufacturers’ claims should be well documented. Therefore, the purpose of this study was to determine whether wearing below-the-knee graduated CS with a minimum of 15 mm Hg of pressure during a maximal treadmill run would induce physiological changes among collegiate cross-country runners. The main outcome variable examined was BLa levels and the corresponding LT. Secondary variables that were assessed were: maximal oxygen consumption (V_ O2max), rating of perceived exertion (RPE), heart rate (HR), respiratory exchange ratio (RER), and time to fatigue (TTF). It was our hypothesis that the CS would decrease BLa accumulation, and as a result improve performance during a maximal treadmill test.
performance in Division III collegiate cross-country runners. This within-group subject study design let each participant serve as his/her own control. Subjects
Ten Division III cross-country runners were recruited, (men; n = 7) for this study. All participants were at least 18 years of age, were current members of their collegiate cross-country team, had competed in the previous cross-country season, and all were medically cleared for participation in crosscountry competition. None of the female participants reported that they were pregnant. Testing was completed in June and all of the participants were involved in the cross-country off-season conditioning program. All participants were cleared using the American College of Sports Medicine absolute or relative contraindications to testing and criteria for stopping an exercise test (26). All study participants gave written informed consent, and the study was approved by the university institutional review board. Procedures
The study used a randomized, crossover design with half of the subjects completing condition 1 first. All participants
METHODS Experimental Approach to the Problem
This study used a randomized crossover design to determine the effect of wearing beneath-the-knee graduated CS on BLa, LT, and other physiological markers and running
Figure 1. Posterior view of participant wearing compression stockings during maximal treadmill test.
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Compression Stockings and Physiological Responses a specific prerace meal, but were asked to eat a similar (if not identical) meal before each test. Participants were allowed to hydrate ad libitum before testing. Additionally, participants were asked to wear the same clothing and running shoes for each visit. Before beginning the test, a number of pre-exercise measures were taken. Participants’ height and weight were measured using a standard stadiometer and physician beam balance (Table 1). The participants then were seated for 5 minutes during which time the Figure 2. Blood lactate (BLa) levels before/during exercise, 1- and 5-minute recovery in compression stockings “6–20 RPE Borg” scale (7) (CS) and non-CS conditions. *p # 0.05. was explained to them. The participants were informed that if they needed to stop for any reason during the test, were asked to report to the laboratory for 2 visits, which to grab onto the treadmill handrails. This would serve as the were exactly 7 days apart. During visit 1, participants were volitional sign to end the test. Each participant was fitted randomized to group 1 or group 2. Group 1 wore the CS with Hans Rudolph (Hans Rudolph Inc.) valve and a Polar during their first visit, whereas the group 2 wore CS for visit heart rate monitor (Polar USA, Lake Success, NY, USA) and 2. Athletic Recovery Graduated Compression Stockings either CS or no CS (depending on their condition order). from SIGVARIS Inc. (Peachtree City, GA, USA) were used. Expired gases were collected and analyzed to calculate oxyThey were made up of 67% dri-release polyester, 26% nylon, gen consumption using a ParvoMedics True One system and 7% spandex. Each CS was manufactured to provide (Sandy, UT, USA) (3). The metabolic measurement system a minimum of 20 mm Hg pressure (ankle) to 15 mm Hg was used to compute V_ O2 and RER, and data were consolpressure (calf ), when properly fitted (Michael Leonard, idated and reported in 30-second increments. personal communication, October 8, 2010). The fitting scale After 5 minutes of seated measurements, the participant corresponded to each participant’s shoe size. then stepped onto the treadmill and began a walk at All participants reported at the same time of the day for 80.4 m$min21 with a 0% incline. While walking at each of the 2 test days, which varied by individual. This was 80.4 m$min21, HR and RPE were recorded. The BLa was a performance test and, as such, the participants were measured through finger stick using the Accutrend analyzer instructed to prepare as they would for a race. To best (Hawthorne, NY, USA) (coefficient of variance, 2.8–5.0). control for nutrition, the participants were not restricted to These values constituted the “pre-exercise” measurements. This study used a discontinuous ramped treadmill protoTABLE 2. Physiological measurements between the 2 CS conditions.* col. Each stage lasted for 3 minutes, with up to a 90Variable (units) CS (mean 6 SD) Non-CS (mean 6 SD) second active rest period (walking at 80.4 m$min21 at 198.6 6 7.7 200.9 6 7.4 Peak HR (b$min21) V_ O2max (ml$kg21$min21) 63.1 6 6.0 64.9 6 7.0 previous stage grade) between Maximum RPE (Borg’s scale 6–20) 19.0 6 0.9 19.5 6 0.5 stages. Heart rate was recorded Maximum RER 1.2 6 0.06 1.2 6 0.1 10 seconds before each stage LT (stage #) 3.0 6 1.0 3.0 6 1.0 ended through telemetry. The Performance (TTF) (min) 23.6 6 2.4 23.9 6 2.5† RPE and BLa were measured *CS = compression stockings; HR = heart rate; RPE = rating of perceived exertion; RER = during active rest. The metarespiratory exchange ratio; LT = lactate threshold; TTF = time to fatigue. bolic measurement system †p # 0.05. was used to compute V_ O2 and RER in 30-second increments.
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participants repeated the maximal test but switched CS condition. All blood samples were taken by the same investigator, in the same manner, for all of the participants, using the same BLa analyzer (2). Statistical Analyses
Microsoft Excel for Windows 7 and SPSS Version 20 (IBM Corp., Armonk, NY, USA) were used to analyze the data. Mean values and SD (mean 6 SD) were calculated for all descriptive measures. Repeated-measures analyses of variance were used Figure 3. Relationship between 1-minute Blood lactate (BLa) change and total time to fatigue (TTF) change (nonto assess the differences in BLa, compression stocking [CS] minus CS values). _ O2, RER, RPE, and HR across V testing stage and condition. Paired t-tests were used to anaFor the first stage, all participants ran at 160 m$min21 and lyze the maximum values between the conditions using an a 0% grade. For the second stage, all participants ran at 160 alpha level set a priori at p # 0.05. Linear regression analysis m$min21 and a 5% grade. Each subsequent stage increased was used to analyze the TTF as it related to BLa. by 26.8 m$min21 and 1% grade until the participant reached RESULTS volitional exhaustion. For the purpose of this study, LT was There were no differences in the physiological responses defined as the point at which the participant’s lactate levels measured in this study under the CS and non-CS conditions reached 4 mmol or greater (25). other than BLa and recovery TTF. After noticeable differences Once the participant reached their volitional physical in BLa between conditions at 1 and 5 minutes post-test were limit, indicated by them grabbing the handrails, the treadmill was reduced to 80.4 m$min21 and 0% incline, the mouthfound, paired t-tests were run and showed that BLa was sigpiece and headgear were removed, and they walked for nificantly lower while wearing CS when measured during a 5-minute cool down. At 1 and 5 minutes post-exercise, recovery from the treadmill test at 1-minute (CS = 13.3 6 BLa, HR, and RPE were recorded. Seven days later, the 2.9 mmol$L21, non-CS = 14.8 6 2.8 mmol$L21, p = 0.03) and the 5-minute (CS = 11.0 6 2.7 mmol$L21, non-CS = 12.8 6 2.8 mmol$L21, p = 0.02) periods (Figures 1 and 2). Paired t-tests revealed that TTF was modestly, but significantly longer without CS (CS = 23.570 6 2.39 minutes, nonCS = 23.93 6 2.49 minutes, p = 0.04) (Table 2). To determine whether this had any effect on the recovery BLa levels, a linear r2 analysis was used to determine any significance and was plotted on a line graph. (Figures 3 and 4). The results indicated that the differences in TTF between the 2 trials accounted for 49% Figure 4. Relationship between 5-minute blood lactate (BLa) change and total time to fatigue (TTF) change (noncompression stocking [CS] minus CS values). of the variation in BLa for 1-minute recovery data and VOLUME 28 | NUMBER 6 | JUNE 2014 |
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Compression Stockings and Physiological Responses 63% of the variation in BLa 5-minute recovery data. Therefore, not all of the differences in postexercise BLa levels can be attributed to the CS/non-CS conditions. However, this indicates that the CS were responsible for part of the other 51 and 37%, respectively. Paired sample t-tests showed no significant difference for order effect between the first and second treadmill tests (first = 23.8 6 2.5 minutes, second = 23.7 6 2.3 minutes, p = 0.06). Before and during the submaximal stages of the maximal treadmill test, HR, RER, V_ O2, RPE, and LT were not significantly different between CS conditions. _ O2max, max RER, and max RPE showed no Peak HR, V differences between conditions either (Table 2).
DISCUSSION The most important finding of this investigation was the increase in TTF in the non-CS condition. Time to fatigue was significantly longer without CS (CS = 23.570 6 2.39 minutes, non-CS = 23.93 6 2.49 minutes, p = 0.04). These findings are in agreement with a previous study that examined the effect of CS on athletes during sprint workout (9). Decreased TTF when wearing CS goes against the manufacturers’ claims of the benefits of wearing the CS (24). The decrease in TTF while wearing the CS could hypothetically be explained in several ways. First, this study did not have a protocol for recording anecdotal data. Participants were not asked their opinion of the CS nor could they list any discomfort or feelings, positive or negative, relating to the CS. It is possible that some of the subjects did not like running in the CS. If the subjects had any negative perceptions of the stockings (e.g., too itchy, hot, or restrictive), then this may have affected their performance. Second, the CS may have added weight to the runners, especially as the test went on and sweat made the CS heavier. However, it is unlikely that the weight of the fabric was significantly changing based on the materials that made up the CS. Order effect could help explain this study’s lack of improvement in TTF among the runners in comparison to similar studies. Kemmler et al. (15) observed an increase in TTF with their subjects wearing the CS. Their data illustrated that running performance determined by time under load (36.44 6 3.49 vs. 35.03 6 3.55 minutes, effect size [ES], 0.40) and total work (422 6 78 vs. 399 6 77 kJ, ES, 0.30) were significantly higher with the CS. However, Kemmler et al. (15) used a different population focusing on recreational runners with a greater age range (25–60 years vs. 18–22 years) and lower mean V_ O2max (52.0 vs. 64.1) for their study. Kemmler et al. (15) did not report statistical analysis of testing order. If they did not complete this analysis, it is not unreasonable to hypothesize that some sort of change in performance could have occurred as a result of the order in which the subjects ran their tests. This study accounted for order effect by randomizing the testing. It also found no statistical significance when examining for order effect, but it is unclear whether other studies examined their data post hoc for order effect as well. One would not expect
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collegiate runners, with a homogenized training level, to perform significantly better/worse on a treadmill test over the course of 1 week. The CS appeared to have a significant effect on BLa levels after 1- and 5-minute active recoveries, with BLa levels in recovery from exercise being higher for the non-CS conditions (Figures 3 and 4) defined by augmented capacity to remove BLa. This may lend credence to certain manufacturers’ claims of improved recovery after exercise (24). There is also the possibility that the lower BLa levels observed in the CS condition were the result of the decrease in TTF displayed by the CS group. Less time spent running would result in decreased BLa levels. This would further suggest that CS decreased performance. The proposed mechanism behind CS is that they improve oxidation of the muscle through increasing venous return via the calf muscle pump (28). Previous studies have found the use of compression garments of varying length and compression to reduce soreness after bouts of eccentric exercise and other activities (16–18). Specifically, as a study conducted by Kraemer et al. (18) on the effect of commercial hosiery with various levels of graduated compression found that all were effective at attenuating lower leg swelling and venous pooling among normal healthy women. This was followed by a reduction in lower leg discomfort (18). Although this study did not ask participants how they felt after the run between conditions, the previous research does strengthen the idea of CS in recovery from exercise. Kraemer et al. (18) noted that the lower leg swelling was the result of increased creatine kinase (CK) activity in the blood stream after 8 hours of standing, and that CS with even a modest level of compression (15.4 mm Hg ankle, 8.4 mm Hg calf, 8.6 mm Hg thigh) decreased CK activity (18). This study did not measure CK activity between conditions. Also, it is important to note that any benefits from increased muscle pump may not lead to increased BLa buffering in subjects with already highly developed muscle pump function. The effects of endurance training on the body are well established. However, studies examining training effect on calf muscle pump function in healthy populations are lacking. The available literature focuses on subjects with VI (14,21). Padberg et al. (21) looked at patients suffering from VI and found calf muscle pump function and dynamic calf muscle strength were improved after a 6-month program of structured exercise. Based on these results, it stands to reason that training (running) would result in improved muscle pump function among healthy subjects, and that the runners in this study would have well-developed calf muscle pump function. Aerobically trained improvements in calf muscle pump function might leave little room for improvement because of CS when considering venous return. The results of this study appear to support this contention. Other than TTF and recovery BLa, there were no differences in the physiological responses measured in this study under the CS and non-CS conditions. There was no
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Journal of Strength and Conditioning Research difference in BLa levels before or during exercise between CS and non-CS conditions. The CS did not reduce the levels of BLa at each stage between conditions nor did they delay the onset of the LT. Berry et al. (5) did observe decreased BLa levels in the CS trial. They postulated increased retention of lactate in the muscle bed resulted in lower BLa levels from the CS. Although this is physiologically possible, it is untested (5). To further test that hypothesis, more invasive testing of the muscle properties would need to be performed. A maximal test does not closely resemble a traditional race protocol. Presumably, this may not limit performance if the mechanism that limited maximum TTF does not come into play at race pace. Additional studies could employ a testing protocol that more closely mirrors a typical long distance race, where time is examined as closely as intensity. Further research should also examine whether the level of training will influence the possible effects that CS might have on them. It would be appropriate to examine whether wearing the CS immediately after exercise causes the same decrease in BLa during recovery as in this study. If, in fact, CS decreases TTF, as this study indicates, it needs to be examined whether putting the socks on immediately after exercise would provide the same benefits observed on BLa levels in recovery without negatively affecting the runner’s maximal performance. Previous studies have also monitored their participants for longer periods of time after the exercise bout, and had participants provide information on their perceived level of soreness (9,17,18). Had this study inquired about lower extremity soreness after the 2 treadmill tests, it is possible some better anecdotal recovery data could have been gleaned. Previous CS research used CS with “slightly degressive” pressure from the ankle of 24 mm Hg (15) and 15–22 mm Hg (27). These pressure ranges are comparable to those in the CS used in this study. Therefore, differences observed in performance and physiological markers are most likely related to other variables, such as participant characteristics/fitness level and test design. Unfortunately, this study had a non-blind limitation. The subjects were aware when they were wearing the stockings and when they were not. Use of a placebo might have helped eliminate any bias (consciously or subconsciously) that may have existed.
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from maximal exercise. Therefore, we cannot recommend their use as an ergogenic aid in this population participating in a maximal treadmill test. Accordingly, coaches, trainers, and runners searching for a legal “edge” should exercise caution when using CS during competition. This study demonstrates that although CS did not appear beneficial for a maximal exercise test, they may prove beneficial after exercise. When examining the effects of a purported ergogenic aid, a lack of significant findings is often as critical as significant differences in assessing the validity of the manufacturer’s claims. Perhaps, the findings of this study will lead to further examination of the claims made by CS manufacturers to better educate the coaches, trainers, and athletes, both professional and recreational, who use them.
ACKNOWLEDGMENTS The assistance of Dr. Kevin Darr, Cary Springer (statistical assistance) Jennifer Flynn, and Dr. Scott Conger is gratefully acknowledged. The authors thank Judith Brannan at Sigvaris for donating compression stockings for the study. The authors declare no professional relationship with Sigvaris and state that the results of this study do not constitute an endorsement of the product.
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PRACTICAL APPLICATIONS
7. Borg, G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Human Kinetics, 1998.
The practical applications of this study appear to demonstrate that CS are not beneficial to highly trained collegiate cross-country runners unaccustomed to wearing CS during a treadmill run to maximal volitional exhaustion. The runners fatigued faster when wearing CS. Accordingly, BLa during recovery was significantly lower due, in part, to the shorter TTF when wearing the CS. Based on the results of this study, it is unknown whether decreased BLa during recovery benefits physiological recovery
8. Bringard, A, Perrey, S, and Belluye, N. Aerobic energy cost and sensation responses during submaximal running exercise–positive effects of wearing compression tights. Int J Sports Med 27: 373–378, 2006. 9. Davies, V, Thompson, KG, and Cooper, SM. The effects of compression garments on recovery. J Strength Cond Res 23: 1786– 1794, 2009. 10. Doan, BK, Kwon, YH, Newton, RU, Shim, J, Popper, EM, Rogers, RA, Bolt, LR, Robertson, M, and Kraemer, WJ. Evaluation of a lower-body compression garment. J Sports Sci 21: 601–610, 2003. VOLUME 28 | NUMBER 6 | JUNE 2014 |
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Compression Stockings and Physiological Responses 11. Duffield, R, Cannon, J, and King, M. The effects of compression garments on recovery of muscle performance following highintensity sprint and plyometric exercise. J Sci Med Sport 13: 136–140, 2010. 12. Duffield, R and Portus, M. Comparison of three types of full-body compression garments on throwing and repeat-sprint performance in cricket players. Br J Sports Med 41: 409–414, 2007. discussion 414. 13. Faude, O, Kindermann, W, and Meyer, T. Lactate threshold concepts: How valid are they? Sports Med 39: 469–490, 2009. 14. Jones, NA, Webb, PJ, Rees, RI, and Kakkar, VV. A physiological study of elastic compression stockings in venous disorders of the leg. Br J Surg 67: 569–572, 1980. 15. Kemmler, W, von Stengel, S, Kockritz, C, Mayhew, J, Wassermann, A, and Zapf, J. Effect of compression stockings on running performance in men runners. J Strength Cond Res 23: 101– 105, 2009. 16. Kraemer, WJ, Bush, JA, Bauer, JA, Triplett-McBride, NT, Paxton, NJ, Clemson, A, Koziris, LP, Mangino, LC, Fry, AC, and Newton, RU. Influence of compression garments on vertical jump performance in NCAA Division I volleyball players. J Strength Cond Res 10: 180–183, 1996. 17. Kraemer, WJ, Flanagan, SD, Comstock, BA, Fragala, MS, Earp, JE, Dunn-Lewis, C, Ho, JY, Thomas, GA, Solomon-Hill, G, Penwell, ZR, Powell, MD, Wolf, MR, Volek, JS, Denegar, CR, and Maresh, CM. Effects of a whole body compression garment on markers of recovery after a heavy resistance workout in men and women. J Strength Cond Res 24: 804–814, 2010. 18. Kraemer, WJ, Volek, JS, Bush, JA, Gotshalk, LA, Wagner, PR, Gomez, AL, Zatsiorsky, VM, Duarte, M, Ratamess, NA, Mazzetti, SA, and Selle, BJ. Influence of compression hosiery on physiological responses to standing fatigue in women. Med Sci Sports Exerc 32: 1849–1858, 2000.
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19. Morris, RJ and Woodcock, JP. Effects of supine intermittent compression on arterial inflow to the lower limb. Arch Surg 137: 1269–1273, 2002. 20. O’Donnell, TF Jr, Rosenthal, DA, Callow, AD, and Ledig, BL. Effect of elastic compression on venous hemodynamics in postphlebitic limbs. JAMA 242: 2766–2768, 1979. 21. Padberg, FT Jr, Johnston, MV, and Sisto, SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: A randomized trial. J Vasc Surg 39: 79–87, 2004. 22. Rimaud, D, Calmels, P, Roche, F, Mongold, JJ, Trudeau, F, and Devillard, X. Effects of graduated compression stockings on cardiovascular and metabolic responses to exercise and exercise recovery in persons with spinal cord injury. Arch Phys Med Rehabil 88: 703–709, 2007. 23. Sachdeva, A, Dalton, M, Amaragiri, SV, and Lees, T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev CD001484, 2010. 24. Sigvaris website: http://www.sigvaris.com/en/sigvaris-sports/ sigvaris-sports-line/better-performance-faster-recovery. Accessed June 24, 2013. 25. Sjodin, B and Jacobs, I. Onset of blood lactate accumulation and marathon running performance. Int J Sports Med 2: 23–26, 1981. 26. Thompson, WR, Gordan, NF, and Pescatello, LS. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins, 2010. 27. Varela-Sanz, A, Espana, J, Carr, N, Boullosa, DA, and EsteveLanao, J. Effects of gradual-elastic compression stockings on running economy, kinematics, and performance in runners. J Strength Cond Res 25: 2902–2910, 2011. 28. Zajkowski, PJ, Proctor, MC, Wakefield, TW, Bloom, J, Blessing, B, and Greenfield, LJ. Compression stockings and venous function. Arch Surg 137: 1064–1068, 2002.
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