Episode #387: The Valsalva Maneuver- Blood Pressure & Safety in Lifting

28:00right and you're you're able to consciously make your own decisions i think you can exercise there's probably a way for you to exercise yeah if any of those things are compromised you probably need to be in a you know in some sort of observatory unit uh in a medical facility because you're impending surgery uh for some sort of emergent condition agree all right well let's look at the opposite opposite side that was looking at this issue through the lens of somebody who's very concerned about risks so what does the science say it's easy to look at the blood pressure numbers like 480 over 350 and assume a blowout is imminent.

28:33But focusing solely on the internal blood pressure ignores the most important variable in vascular safety, transmural pressure. A blood vessel doesn't fail just because the pressure inside of it is high. It tends to fail when the pressure inside significantly exceeds the pressure on the outside of the vessel. So if you have 400 millimeters of mercury pushing out, but 390 millimeters of mercury pushing back in, the actual stress on the arterial wall is pretty much negligible at that point. And in the gym, we do in fact create a high pressure environment that surrounds and supports, maybe even cradles, the vascular system.

29:10Austin, this concept of a pressure gradient, the transmural pressure across the blood vessel wall or any space in the body really, that's very important. Can you break that down for our listeners? Yeah, I think you actually did a perfectly fine job of describing it already, pressure gradients are how things move. That's the same way as I described of how we breathe, for example. We generate a pressure gradient between the outside environment and our lungs. And so air rushes in. And then when we're ready to breathe out, we increase pressure in our chest and air goes back out. The same way our heart generates blood flow, increases the pressure, squeezes down, blood flows out, lowers the pressure by relaxing, blood fills it back up again.

29:50So pressure gradients is a very important part of life and so transmural is just a fancy way of saying across the wall and so the pressure difference across the wall of a blood vessel is the physiologic parameter that we're that we're talking about here that is of interest when having this type of conversation it doesn't need to be too much more complicated than that at least for our purposes here today yeah all right so let's look at some evidence on this transmural pressure gradient. So one study had dudes do leg presses again. It seems to be a very common exercise amongst the exercise scientists.

30:22It was pretty heavy too. 80 % and 100 % of their one rep max while using an ultrasound to watch their heart during the Valsal maneuver while they were exercising. And while blood pressure skyrocketed, the stress on the heart walls remained stable or decreased if they measured it by ultrasound. Why did this happen? Well, the high pressure inside of the chest actually pushes back against the walls of the heart. So it's the walls of the heart, wall that is contracting, are trying to, you know, go outwardly, but you've got this high pressure system on the other side that prevents that from becoming too great.

30:56There's also direct measurements that show the intrathoracic pressure surrounding the aorta. That's the major blood vessel coming off of your heart. That increases one-to-one with its internal pressure, preventing the vessel from over expanding. In the brain, we talk about external pressure protecting the brain. Well, we're really talking about cerebrospinal fluid or CSF. You can think of your brain as an object kind of floating in a bath of clear fluid. And this fluid surrounds the brain and every single blood vessel inside your head. On the other side, you have your skull. This is rigid bony box.

31:29It doesn't expand, at least we hope not. And the volume inside of your skull is therefore fixed. If you try to cram more stuff or more anything into that box, the pressure of the fluid has to go up. So when you perform a Valsalva, the high pressure in your chest acts like a dam. It makes it harder for the blood to drain out of your head through your jugular veins. And this causes a momentary resistance to flow of the blood that's inside your skull. Because that fluid has nowhere to go, the pressure inside the skull, the intracranial pressure, goes up, which gets passed on to the cerebral spinal fluid.

32:03Again, that's the fluid surrounding your brain and its blood vessels. And this is the pushback. You have blood pressure pushing out from the inside of the artery, but you have an equal spike in the fluid pressure pushing back from the outside. And the result, when it's measured, is that your cerebral perfusion pressure remains remarkably stable with the Valsalv maneuver, which has been directly investigated. Also using some fancy technology called transcranial Doppler, this looks at blood flow. Researchers observed that cerebral blood flow is well maintained during the initial phases of a valsalva maneuver.

32:35A significant drop in flow only occurs if the strain is held long enough to reach this late phase two. Effectively, you're holding a valsalva maneuver for like 15 seconds, 20 seconds, something like that, where cardiac output finally begins to fall. And this is really where we see some of that syncope risk start to come up. There is some nuance here when you release the air, particularly if it's done quickly. Intracranial pressure and intrathoracic pressure drop to zero or very low almost instantly. And so there can be an overshoot, which Austin talked about earlier. Your systemic blood pressure stays high because the heart is suddenly pumping a huge volume of blood into the still constricted blood vessels.

33:15You have this high internal pressure and low external support. Theoretically, that would be the highest risk of something bad happening because that transmural pressure could be higher. But again, where are the bodies? Hey, Austin, most people have seen the meme of you deadlifting with your eyes popping out. Can you explain this based on the mechanisms that we've talked about so far? Yeah, I mean, that's kind of the image that I had in my mind when you were describing increases in intracranial pressure. And obviously, it's very fortunate that we have this kind of balancing mechanism to maintain relatively stable cerebral perfusion pressure as a very important variable.

33:51That is basically a fancy physiologic term that describes the ability of blood flow to get into your brain and keep you awake and conscious. And this is why during those very high intensity efforts is not when we tend to see quite as much of the syncopal episodes and things like that. But also the eyes and everything, they're all kind of in very close neighborly proximity to these other structures and pressure can get transmitted in all sorts of different ways. And so, yeah, I think that I might have a little bit of an above average tendency to have some of that proptosis as a way we can describe it.

34:25My eyes bulging out a little bit more when under that degree of pressure. And fortunately, they go back in afterwards when I when I release things. I seem to recall an episode of you. I believe you were deadlifting, but you might have been squatting. I don't know if this is revisionist history. And you had contacts in you actually like jettisoned a contact from your eyeball. Yeah, that's happened a handful of times, actually, over the years. And I remember one of my earlier powerlifting meets that I did, I think it was after the first time I moved to San Antonio for residency training now over a decade ago at this point, that I actually did the whole meet wearing regular like eyeglasses instead of contacts because I was worried that in the middle of the meet, I was going to pop a contact out.

35:03And that was in a powerlifting gym, not going to be a contact that I chose to pick up off the ground and put back into my eyes. So I just wore eyeglasses for the whole meet. Would have been a great case study. you know, what weird infection do you get in your eyeball from? Polymicrobial is what I would say. 100%. Yeah. So that that's the sort of pressurized suit defense that we're going to keep referencing. But there's also some thought that doing the Valsalva is bad for your heart, can't be good for you, you know, due to the increase in blood pressure that occurs with all exercise, but markedly with resistance training.

35:35And then it's even higher with the Valsalva maneuver. Perhaps This causes left ventricular hypertrophy or LVH, and that theoretically could be avoided if you didn't do the Valsal maneuver when you lifted weights. So left ventricular hypertrophy is the thickening and stiffening of the heart's main pumping chamber, your left ventricle, which would reduce its efficiency and can lead to heart failure, arrhythmias, heart attack, or stroke. Now, the heart does change relatively quickly in response to training. That's been well characterized for years. However, historically, there's been some weird data around this.

36:11We covered this in our extreme exercise hypothesis podcast. I think it was episode 215. I'll link that in the show notes. But there's this thought that the changes at the level of the heart were markedly different between endurance training and resistance training. Endurance training caused all four chambers of the heart to grow kind of equally, and resistance training only caused a handful of the chambers to get thicker and not necessarily grow in size. This eccentric versus concentric hypertrophy difference. Yeah, that was just based on faulty analyses and not as sophisticated imaging techniques.

36:46techniques. And so what we see now in high quality studies, they don't really support the idea that lifting alone causes this pathological thick walled, small chamber, left ventricle or left ventricular hypertrophy that you see most commonly in folks with chronic undertreated or untreated hypertension. That's like the biggest risk factor here. Instead, what you see is a similar level of remodeling and similar style of remodeling that happens with endurance training, unless the individual happens to be using androgenic anabolic steroids, which there are a number of not only small case studies, case control studies, but also case reports of individuals using anabolic steroids at high doses in particular, that should be stated, where they end up developing this left ventricular hypertrophy and potentially heart failure from that.

37:36It's not from the Valsalva. It's not from resistance training. And it just seems to be an effect of taking anabolic steroids at high doses. So Austin, we have extreme blood pressure numbers when lifting and using the Valsal maneuver, but we don't have a trail of dead lifters. We also have good data that lifting heavy, which requires the use of a Valsal maneuver, even if it's reflexive, we have good data that that reduces resting blood pressure, which suggests against some sort of mechanism of developing left ventricular hypertrophy. And we also know that the body's vascular system is highly adaptable like other biological systems.

38:12So if you were having a peer-to-peer conversation with another physician who thought the Valsalva maneuver was dangerous during exercise and was telling their patients as much, how would you approach that conversation? As I do with many conversations, try to figure out where their belief is coming from and assess their kind of epistemology around it. What's their level of confidence in that claim and kind of what is it coming from? What are they most afraid of, right? And then just kind of gently poke at that if there is a willingness to engage on the topic. I find it super plausible and reasonable to think that, you know, high intensity chronic resistance exercise versus cardiorespiratory aerobic endurance exercise will lead to divergent cardiovascular adaptations.

38:55And that is related to them having somewhat unique and divergent cardiovascular demands, right? So that is very plausible to me. But as we've talked about before, one of our favorite phrases is it matters how you got there in the sense that somebody with chronic resting hypertension, pathologic hypertension by whatever underlying mechanism, the heart is having a very different experience in working against that chronic high resting blood pressure compared with somebody who might not have hypertension, who has a healthy resting blood pressure, or maybe who is even training as a part of a way to improve their resting blood pressure, who lowers it yet is only having a handful of brief periodic increases fluctuations in their blood pressure during the course of routine resistance training and then for the remaining 23 hours of the day and 365 days of the year they are not experiencing that same level of thing those are different ways and different demands and different adaptations that should result and so yeah i see a lot of heart failure that is related to pathological you know cardiac remodeling and things like that, I have seen precisely zero cases of somebody who squatted, bench-pressed, and deadlifted themselves into heart failure as an end state.

40:13So similar to the question of where are the bodies. So I remain very open and actually in support of the idea that there are different adaptations that you can get from these things as a justification, in fact, in our mind to like, people ought to do both. This is why we recommend both strength and conditioning if health is the primary goal, right? It doesn't need to be all of one or all of the other. But if I was talking to a clinician who's deliberately telling people that the Valsalva maneuver is dangerous and they should never do it, it's just like, what are you afraid of and what's it based on and how confident are you?

40:42Are you open to like reconsidering this and things like that? Because I think that your patients might do better if we can get them to do more things, some of which may actually involve doing this type of maneuver. Yeah, and you can slide into Austin's DMs if you are a healthcare professional and he will go through this with you. Probably not, but yeah, good luck. All right, let's pivot here. After the break, we're going to come back and talk about special populations, specifically our individuals at an increased risk of stroke or a ruptured aneurysm. And what about individuals during pregnancy?

41:13Can they do the Valsal maneuver? All that and more after the break. Quick break from our podcast because I want to mention today's sponsor, Caraway. Now, I've been going through the process of moving into a new house, and I've been finding a lot of things that I'm ready to replace. and that includes stuff that I cook with in the kitchen. Enter Carraway. Carraway has gained a lot of traction for their non-toxic ceramic coating. From a materials perspective, these are designed to be third-party tested and manufactured without the use of forever chemicals like PFAS. Now, while the long-term clinical data on the cumulative exposure to some of these compounds is still an area of active research, many people, myself included, prefer to simply minimize exposure whenever possible.

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44:10We can think of a blood vessel like a high-pressure garden hose. In that context, an aneurysm is essentially like a blister or a thin spot in the wall of that hose. And over time, or due to genetics, that specific section of the wall becomes stretched out and weak. In the brain, these are often called berry aneurysms because they look like a small fruit hanging off the vessel. The fear is that with the Valsalva, if you suddenly crank the pressure up inside that hose to 400 millimeters of mercury, that thin, weak blister will finally give way and burst. This is the pop that everyone is afraid of.

44:42This is called a hemorrhagic stroke, where blood escapes the vessel and enters the brain tissue or the space surrounding it. It's a plumbing failure, where the pipe bursts under pressure. There's another type of stroke called an ischemic stroke, which is from a blockage. This is much more common in daily life. About 87 % of strokes are ischemic. And this is where a clog or a piece of debris, like a plaque, breaks loose and blocks the flow of the blood to the brain. The concern here is that the turbulence of the breath hold and release might shake a piece of plaque loose. The link between Valsalva maneuver and stroke is largely based on theoretical speculation, mostly mechanistic type reasoning.

45:21When we look at actual outcomes, the incidence of cerebrovascular accidents in lifters is exceedingly low. Most evidence here comes from isolated case reports, and these almost exclusively involve people with undiagnosed vascular malformations like Barry aneurysms. And again, we have that transmural protection. The fear of having a pop assumes that the high internal pressure against low external pressure. But in reality, the cerebrospinal fluid pressure rises nearly instantly to offset that internal spike in pressure. So, Austin, based on the available data regarding strokes occurring during exercise and maybe more generally, it seems like a focus on acute changes in blood pressure misses the forest for the trees.

46:03Instead, people should focus on chronic risk factors, right? I mean, if we look at the most compelling risk factor data for the incidence of stroke, chronic hypertension is number one, two, three, four, five on that list of risk factors as the thing that we need to spend the most time addressing. It's interesting, you know, for all the kind of biohacker optimization space and how much interest there is for them, for example, in like wearing continuous glucose monitors and minimizing glucose spikes, how wearing a continuous ambulatory blood pressure monitoring or something like that has not taken off in that space and keeping their blood pressure as low as possible for as long as possible.

46:43I think that people, you know, obviously there's the visual evidence when you're doing a hard valve salva against a heavy load, like seeing the face, the contortions, the discomfort. I think people would be very surprised if they were to learn the degree of fluctuations that can be physiologic, normal, or sometimes abnormal that they experience, but never know about just in their day-to-day life. you know blood pressure spike that happens while you are maybe you're in traffic and you have a near miss or a near accident or somebody passes you and pisses you off while you're on the road or other forms of life stress work stress all sorts of other things as you mentioned when you're on the toilet i just think that people would be surprised and um to know that their blood pressure fluctuates minute to minute throughout the day a lot more than they probably think and yet focusing on this as a unique risk factor, mainly based on fear and like facial evidence of strain.

47:40It is an interesting phenomenon. I understand how we got here. I understand how this happens. But recognizing like the bigger picture here of like chronic resting hypertension is the thing that we ought to spend probably the most time worrying about. The situations where these acute fluctuations become more concerning are the situations that we alluded to earlier, where it's like, you probably ought to be in an ICU and like impending surgery or something like that. Right. And that's just so uncommon compared with the proportion of people out there who stand to benefit from doing these types of activities that, yep, it's going to require a bit of blood pressure increase if you want to support some exercise.

48:17And to whatever extent there may or may not be some risk associated with that. Again, we're not seeing the trails of bodies. And instead, we see very ample evidence of benefit from people being able to participate in these things over long periods of time. Yeah. In fact, it'd be a huge red flag if you were to initiate exercise and your blood pressure couldn't go up, you know, like same thing as if your heart rate can't go up, we, you know, this sort of a relationship is a huge red flag in practice. So yeah, I, again, I get why, how we got here and I get the theoretical concerns, but then immediately we should look at, all right, well, what is the outcome data?

48:53And it's like, oh, well, I guess I just have to reject that hypothesis. Perhaps it was incomplete logic. Yeah. I think that's the story on strokes and aneurysms. What about the pelvic floor? Get this thought out there that, look, if you do a valsal maneuver, particularly if you're a woman, well, that's going to cause stress urinary incontinence. You know, it's going to wreck your pelvic floor. Obviously, there's some stuff on social media. You can see this happening, right? Women who have leakage during a lift, usually a heavy lift for the most part. And usually that's co-occurring with those sort of distorted faces, as you were talking about.

49:27So there's just this assumption. All right, they're doing a Valsalva, they're lifting heavy, stress urinary incontinence, it's all, it's causal, right? The rooster crows, sun comes up, rooster causes sun to grow, to come up. It's missing a few important things that happen. One is a reflexive co-activation. Pelvic floor muscles contract prior to and during the rise of intra-abdominal pressure. It's the sort of feed forward mechanism designed to counteract the downward force of the Valsalva maneuver on the pelvic organs. There's also a weightlifters paradox. Powerlifters, this has been studied, often have lower rates of incontinence than high impact athletes like gymnasts and runners, suggesting that the impact of landing or that sort of impulse is a bigger driver of dysfunction than the pressure of a three second brace.

50:15Also, there's chronic straining when you're on the toilet, particularly for long durations. That's much more strongly linked with something like a prolapse than intentional straining during a heavy squat. We don't really see pelvic organ prolapse there because the Valsalva maneuver is wrecking your pelvic floor musculature. And also, by the way, the pelvic floor is adaptable, just like other muscle tissue, other tissues in the body. And it does adapt. High intra-abdominal pressure is a stimulus for adaptation, not just a risk of breaking the floor. Again, we're not really like cars. We do adapt to what we're exposed to or not exposed to.

50:50There's no real evidence here of a Valsalva maneuver during exercise worsening pelvic floor dysfunction, but it may be provocative. And I think that's what people are mostly noticing. Individuals who are susceptible to, whether it's stress and urinary incontinence or some sort of pelvic floor dysfunction that may crop up when they're lifting heavier. And again, since the Valsalva maneuver is reflexive anyway, like this may all kind of go together in their sort of lived experience, but saying that it's causal and then further that you should avoid it. Again, I think that's really just incompatible with exercise.

51:19What do you think about that? Yeah, I think that's a fair take. This is fortunately, you know, something that I think that is not something that I am encountering routinely in day-to-day medical practice. I think we probably encounter a bit more in like coaching practice. But there are folks who can, you know, help in these situations, whether through coaching kind of cues and programming methods with some deliberate guidance on that front, as well as things like pelvic floor physical therapy. Yeah, yeah. We also have a podcast that I will link in the show notes on stress urinary incontinence.

51:52You can hear that if you are so inclined. All right. This was the most fun part of the podcast for me when I was doing the research because this is near and dear to my heart, not because I am an individual experiencing pregnancy, but just because I feel charged to take this up. Okay. Well, I think that, you know, pregnancy is one of those periods of time that women have the most interaction with healthcare professionals. Right. And so to me, there's like a lot of, you know, opportunity to do good there. And exercise is underdosed, underdelivered, underutilized in pregnancy. And I'm just like, why?

52:27You know, and I think it just comes back to fears surrounding many different aspects of exercise with respect to not only baby, but also mom. And that extends to the Valsalva maneuver. Look, there's going to be harm to baby by compromising blood flow if you use the Valsalva maneuver when you exercise during pregnancy. And if you combine that with the knowledge that this is really an unavoidable reflex at heavier loads, then if you were to attempt to avoid it, that might actually, you know, decrease the utility or the efficacy of the training stimulus, which there are known benefits to exercise to mom and baby during exercise and known risks of insufficient activity.

53:05activity. And so for people to avoid that, that would be problematic because we know exercise works better for health if it actually works to make you fitter. So when we look at actual evidence on things like uterine blood flow, for example, the maternal presser response, that's a fancy way of saying the rise in blood pressure during exercise, actually helps maintain the pressure gradient needed to keep blood moving through the placenta. There's actually a study monitoring individuals who are pregnant lifting up to 90 % of their 10 rep max using a Valsalva maneuver. There was no evidence of fetal distress.

53:41Fetal heart rates stayed stable and umbilical blood flow metrics remain normal. Another study involving 48 pregnant athletes performing heavy barbell training like sumo deadlifts, for example, at about 76 % of their one rep max, there was only one transient case of fetal bradycardia, which is a reduction in heart rate, But it resolved quickly and did not meet clinical criteria of concern. The study concluded that heavy resistance training is generally well tolerated. Although this study did not explicitly record breathing techniques, the researchers noted that given the heavy loads, many participants likely used the Valsal maneuver instinctively.

54:18And then there's survey data that indicates that women who maintained their high-intensity training levels, including the use of the Valsal maneuver, until delivery, Well, they had reduced odds of pregnancy and delivery related complications compared to those who reduced their training intensity. This is all captured in ACOG by ACOG, the American College of Obstetrics and Gynecology, who they've moved away from like heart rate limits on exercise towards RPE, rate of perceived exertion. And they support strength training, although they don't explicitly say, and you can hold your breath when you do it.

54:51That would be the that's their final form. Right. I just think that the historical recommendation for pregnant individuals to avoid the Valsal maneuver and straining, it's largely based on, again, vibes, theoretical concerns regarding uterine blood flow, pelvic floor integrity, fetal heart rate, stuff like that. The clinical data just doesn't seem to support that. instead current evidence seems to suggest that for healthy uncomplicated pregnancies brief bouts of increased intra-abdominal pressure during resistance training during resistance training with the valsov maneuver is well tolerated and uh hasn't been shown to be the primary driver of dysfunction compared to the cumulative load of pregnancy and the mode of delivery especially with respect to like the pelvic floor does that all make sense to you do you feel like i'm selling this.

55:35I think you did a fine job putting that together. And I, and I think the wrong message to take away would be to say, ah, well, nothing about training fundamentally needs to change when somebody is proceeding through pregnancy. Of course, the nature of the training, the programming, perhaps the exercise selection, just based on how people feel, maybe the, you know, intensity, proximity to failure may need to change, but that's much more based on an individual level, not just based on the binary of pregnant versus non-pregnant. The, you know, the training will necessarily need to evolve, but that's more with the person rather than just that binary of the pregnant state.

56:12Yeah, I think this goes back to just exercise prescription and kind of our view on this in general. It's not that the person is pregnant that connotes, you know, necessitates a change prophylactically. It's like, okay, now they are preferring different exercises. These certain exercises are uncomfortable. They don't want to do whatever. It's, again, based on the individual, which is independent of pregnancy by and large, because this can happen outside of pregnancy, obviously. So if we were coming up with like a pregnancy template, like how would it look different than our beginner prescription, for example, beginner template?

56:41It would just have more options. Probably, you know, that that's what I'm thinking about. Just more options for people to pick and choose from rather than like you can't squat. You can't hold your breath. You can't lift. Yeah. And it's like that doesn't seem to be an evidence based position to hold. Yeah. The last thing I want to talk about is, you know, for performance. It's a Barbell Medicine podcast. We got to talk about lifting. So Austin, in your view, when you think about the Valsalva maneuver, particularly doing an intentional Valsalva maneuver, do you think there's like a performance benefit compared to just the reflexive component or reflexive part of a Valsalva maneuver?

57:16I think so. I, you know, there's, I think ample just personal experience, our own experience as athletes, as lifters, as well as, as, as coaches that sometimes even just observing a lifter when they're moving through these exercises, particularly at higher intensities, there are times when we actually will coach or cue the way that they are bracing in a more deliberate fashion. If it was purely the reflex, then it would never be something that needs attention or coaching or cueing. You could just like trust that the reflex is going to do its thing and that it would always lead to kind of like a quote unquote optimal brace and maximum performance.

57:54But that doesn't actually seem to be the case. Yes, it is reflexive. It is automatic to some degree. But that doesn't mean that there isn't room for doing it in certain different ways that might lead to better or worse performance outcomes. And so that's something that we've probably experimented with our own bracing strategy. coaching other people. Sometimes we watch people and it's like, oh, when they brace, it seems like they look like they're like holding all this pressure in their face instead of in their thorax or their trunk or their abdomen. It's like, and it's also subtly different compared with how you might do a Valsalva to like have a bowel movement.

58:24Like that's not actually what you want to be doing when you're trying to lift a heavy load, the nature of the brace and kind of like, I know this is going to be anatomic heresy, but it's kind of like where in your body you feel it is a little bit different when you're doing it for a heavy lift compared with a bowel movement, compared with delivering a baby, compared with a sneeze, compared with a cough. You know, these things are subtly different and sometimes require some degree of like volitional or conscious kind of cueing, coaching modification. Yeah. Yeah. I don't view this like, oh, we got to fix your brace or we got to, you know, optimize your ball saw maneuver to be like the key to unlocking somebody's performance.

58:58But I do think there's an efficiency bump that's possible there, especially if someone is doing it like really wrong, you know, or really in an inefficient manner. It's just an opportunity for improved performance. Yep. Agree. All right. Perhaps a more medically interesting part of this podcast for you, Dr. Baraki, contraindications to the Valsalv maneuver. Can you imagine if I just put you at 60 seconds on the clock, what are all the absolute contraindications to Valsalv maneuver? Let's see how many of them I got, and then you can see if there's any more. Most medical contraindications for the Valsalv maneuver are rooted in mechanistic theory, the fear of the spike in pressure, rather than actual clinical outcome data.

59:36And so absolute contraindications are rare. They almost exclusively involve short-term unstable conditions where a sudden pressure spike or the overshoot at the end of a Valsalv maneuver poses an immediate threat to some sort of compromised anatomical structure, for example. So these would be things like an aortic aneurysm or dissection that is like large or newly discovered, typically greater than like five centimeters, for example. I think, again, at that point, if you've been recently diagnosed with that, again, unlikely you just casually go into the gym and wondering, should I do a Valsalva or not?

1:00:13I think about if there are times where an acute intracranial pressure spike is contraindicated. indicated. So recent head injury, recent neurosurgery, symptomatic brain masses. In these cases, the pushback from the cerebral spinal fluid might actually lead to like herniation theoretically of the brain. That'd be unusual. I'd look for case reports, did not find any, fortunately. So that is a fear I no longer have to think about for me. If somebody had recent like ocular surgery or retinal detachment, it's another sort of theoretical risk, especially in the early preoperative phase, like after cataract surgery, uh, could disrupt delicate sutures or compromise the healing, um, after an acute cardiovascular event.

1:00:55So like right after a heart attack or during unstable angina chest pain before that has been stabilized or, and or revascularized in the case of a heart attack. I think though, in most of these cases, you can correct me if I'm wrong, exercise would be restricted anyway. So it's not like people like, Hey, look, you can do any exercise you want, but just don't do a Valsalva maneuver. Yeah. You got this huge aortic aneurysm just hanging out, like carry on. Yeah. I think that that's generally the case. I think the, the gray areas here involve not so much the acute things, but when there is a clear risk factor that has been identified for one of these things.

1:01:30So what if somebody has an established diagnosis of an aortic aneurysm that maybe doesn't meet immediate surgical criteria? What do you do in that situation? And I got to tell you, I'm don't have an answer. You know, I don't think that many of us do. And so many people will err certainly on what they perceive to be a more cautious side. I've had patients, for example, who had a known aortic aneurysm, didn't need a immediate or urgent surgery. And yet they were like, well, I really like training for powerlifting and setting one rep max PRs. Would it be better if I trained for sets of 10 instead?

1:01:59And I'm like, maybe. It might make you feel better. I don't know how much of a quantitative difference in risk there might be. There's also the question of like, well, what's our proximity to failure here? Does that play a role? Maybe. I also don't have evidence on this stuff. So, you know, I wish I had all the answers and I wish I had strong evidence to base this on, but we just don't really have that. And so it seems plausible to me that maybe there is some spectrum or gradation in risk. And sometimes I try to put myself in that situation and imagine like if I were diagnosed with this aneurysm, how might I go about training if I really, really wanted to?

1:02:33and it can still be a hard question to answer because I'm still imposing some of my own, you know, conscious, unconscious biases and preferences on it that may not be applicable to another person. So there are certainly gray areas where people may have to, you know, deal with advice that they don't like and decide what they want to do with it in their own kind of individual risk calculation to the extent that can even be calculated. Yeah, that's the whole thing. It's like, seems like a lot of unknown risk, but these acute settings are probably, to your point, maybe not the major sort of talking point.

1:03:01Rather, it's like if somebody's got stable coronary artery disease, so some long lasting stuff, is it OK for them to do a Valsalva maneuver? Like we know we have data, ultrasound related data showing that, oh, look, the pressure gradient across the wall of the heart actually is either stabilized or goes down when people do the Valsalva and they're lifting heavy weights. And also the new American Heart Association guidelines on resistance training don't mention anything about avoiding the Valsalva maneuver. And so it's like, should we encourage the Valsalva maneuver? Should we just take it on a case-by-case basis?

1:03:34And then if so, what are our recommendations? They're just vibes-based? I don't know. Yeah, stable coronary artery disease does not really get me terribly worked up here. Now, if somebody has anginal symptoms with it, like chest pain with exertion that reliably gets better with rest, there's going to necessarily be some exercise modifications that get put into place there. But we also see evidence that there is still adaptive capacity. So for example, when patients who have limb claudication, meaning they get like pain in their legs when they walk because of problem blockages in blood flow. When you put them on like high intensity walking programs and things like that, they actually tend to improve their walking distance and their capacity and pain goes down.

1:04:10And that's probably a result of like kind of subacute to chronic kind of revascularization, neovascularization that happens, collateral blood flow, various other things that can happen in the adaptive process. So yeah, this, you know, stable atherosclerosis is something that is also massively prevalent and often undiagnosed in many people. Like tons of people out there have it and are just like going about their life and even exercising, lifting weights, doing all sorts of things. And there's a big spectrum in what, you know, coronary disease means and atherosclerosis, big spectrum of what that is.

1:04:42But, you know, stable disease gets me much less concerned in that context, especially if the person has no symptoms. Yeah. There's also this thought you got to avoid the Valsal maneuver if you're at risk or you have an inguinal or abdominal hernia. You can't strain. You know that. Except for hernias are usually the result of like chronic pressure and genetics, not like a three second brace underneath the squat, for example, or deadlift. Although it certainly can be provocative. But again, it wasn't really the cause. It was just like the, you know, the straw that broke the camel's back, for example.

1:05:15um i think in these cases though i wouldn't necessarily ban lifting that'd be very challenging for me to say you can't lift right you can otherwise live your life but you can't lift that'd be challenging i don't know that i would also ban the valsalva maneuver again at least the reflexive components of it i can probably figure out a program where somebody be unlikely to do much in the way of reflexive valsalva in but i don't know that i could create an effective exercise program where it's completely eliminated. It's just like the nature of exercise requires you to transmit force in a somewhat efficient manner.

1:05:50And if it gets hard enough to work, you're going to probably do some Valsalva, whether that's intentional or not. Yeah, I agree. Are there any other cases where you think that exercise is not restricted, you can do whatever you want, but you have to, you can't do a Valsalva? Yeah, it's a tough one. You know, the way that I tend to organize things is by organ system. If I really wanted to go through we've talked a lot about like brain central nervous system stuff one area we didn't talk a ton about is like the the ear and vestibular system and so there are sometimes things relating to the vestibular system in the inner ear like semicircular canal disease dehiscence certain other conditions where it's like there can certainly be like some pressure impacts there that may impact recommendations around valsalvas if particularly if it tends to be provocative of symptoms but that's not subtle like somebody would know if doing a valsalva like sends them into a fit of vertigo, for example.

1:06:43That's what I'm saying. Like not terribly subtle. How's a person active if they have active vertigo? Right, yeah, yeah. We talked a lot about the cardiovascular system, the heart, the aorta, the valves, the coronaries. With respect to the lungs, you know, I can envision scenarios, maybe if somebody is at uniquely high risk of pneumothorax or if they're recovering from a pneumothorax where pressure changes can be potentially problematic that might impact recommendations. And then beyond that, You touched on the hernia question, but really outside of that, there's not a ton more like below the diaphragm that would get me super concerned.

1:07:18We've talked a little bit about organ prolapse, whether, you know, pelvic organ prolapse in women or if somebody's prone for whatever reason to like rectal prolapse and things like that. That's something that generally people are going to want to get fixed, you know, before they move on with the rest of their life doing these things. So those are just some of the other things that we hadn't touched on that kind of came across my mind that I might be, you know, discussing with a patient if there may be some relationship. But again, not subtle things that they probably would identify before I did.

1:07:45Yeah, yeah, I agree. All right. Well, look, we spent the episode debunking gym folklore and talking about the protective pressurized suit. Now, how do we actually apply this for the person under the bar or the clinician in the office? Once again, we go back to one of our age old sayings. The body isn't fragile. There's multiple, redundant, adaptable mechanisms in place to not only tolerate the Valsava, but also make it more efficient. For healthy populations, I think we both agree that the Valsava maneuver is a safe and, in some cases, necessary tool to exercise. So for the trainee, we would say treat bracing as a skill.

1:08:21Don't wait for the reflexive Valsava maneuver to kick in, but learn to consciously brace before the rep starts, usually during the unrack period to create a stable platform for force production and force transfer. Beginners should learn the intentional Valsalva maneuver early. This ensures they have the skill ready as the weights increase rather than being surprised later on. I would say the duration should be controlled. So you're not doing a Valsalva maneuver for, you know, five seconds, seven seconds, 10 seconds at a time prevents the significant drop in cardiac output that occurs with prolonged Valsava maneuvers also would avoid hyperventilating before a lift.

1:08:59Generally unhelpful. Yeah. Yeah. If you want to psych yourself up, just make sure that you're breathing. Okay. And then if you regularly experience lightheadedness after a rep, that's something that happens to you. You feel like I'm talking about you right now. You can hiss on the way out to let your air out. That can be useful, particularly after a rep. For the clinician, I think we would both agree that reassurance for worried patients, you know, suggesting you perform reflexive mini-Valsavas daily, when you cough, when you sneeze, when you stand up from a low chair, the system is designed for this.

1:09:35So for a patient that's worried about the Valsava maneuver, overly concerned, some reassurance is usually useful here. Would also focus on chronic changes in something like blood pressure, not acute changes. if somebody were to come into your office and say, look, Austin, I wanna exercise. I hear all your stuff, I should exercise. But look, this blood pressure thing freaks me out. You're telling me that my blood pressure can get into the 300s if I do a leg press or in the 200s if I'm doing a one-arm biceps curl? I think you would just focus on the chronic changes to their blood pressure rather than what's happening during exercise.

1:10:09It matters more what happens during the other 23 hours of the day than the one hour per day that you lift weights. And again, that sort of safety valve strategy, if people are at high risk for some sort of unwanted event from a valsalva or perhaps a syncopal event passing out afterwards, or for people that are apprehensive, this active exhalation or hiss during the concentric phase can be useful. Like actively cueing a grunt can also work for folks if they can't quite get the hiss or the active exhalation. But again, the valsalva is going to happen regardless. The point is, are you going to dump the air immediately right afterwards?

1:10:48Do you need to have a slower release or something of that nature? And then you want to get the most out of it by doing an intentional one. And lastly, for individuals experiencing pregnancy, look, without contraindication, you should be exercising at sufficient intensity, sufficient dose of exercise to see improvements in fitness, strength, cardiovascular fitness, etc. And the Valsalva maneuver is going to be part of that. It's reflexive. You may experience some discomfort with the Valsalva as fetal size increases. So again, transitioning to this hiss during either the concentric phase or near the end of the rep can improve that for folks who are training and experiencing discomfort due to the size of the fetus as it increases during pregnancy.

1:11:37But the reality is there's no statistical evidence that Valsalva during resistance training is more dangerous for vascular health than when it's performed reflexively in daily life. The pressurized suit logic holds up. The internal spike is matched by the external cradle of support. So for the healthy individual, the Valsalva is a performance-enhancing reflex that protects the spine, the vascular system, and the brain simultaneously. For the clinician, the goal should be to empower the individual over avoiding the Valsava. Teach patients to manage the pressure rather than fear it. Austin, any closing notes on the Valsava maneuver?

1:12:13over reasonable take and if people are uh concerned about a particular medical condition that they have uh for example among that long list of potential contraindications that we talked about earlier that's where just super individualized advice might need to come into play even if we recognize that some of that advice is not based on super compelling super strong evidence it might be based on your personal risk tolerance or lack thereof and that's okay too you get to make these choices. Yep. Yeah. Well said. All right. Well, that is a wrap on the Valsalva maneuver with Barbell Medicine. Special shout out to Dr.

1:12:46Austin Baraki for joining me on the podcast. Before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance in health and fitness. Again, I'm Dr. Jordan Weigenbaum. We'll catch you next week and every week right here on the Barbell Medicine Podcast.