This thesis details four consecutive research investigations which were designed to examine the effect of age on the pulmonary oxygen uptake (VO2)and muscle oxygenation (mOxy) responses to exercise in well-trained cyclists. (Abridged)

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Doctor of Philosophy / In this thesis, three experiments were conducted to monitor: (i) muscle oxygenation and electromyographic activity of the biceps brachii after exercise-induced muscle damage (ii) muscle oxygenation after downhill walking-induced muscle damage, and, (iii) muscle oxygenation following a bout of vigorous concentric exercise. Maximal eccentric exercise (EE) of biceps brachii resulted in significantly increased mean resting oxygen saturation and decreased deoxyhaemoglobin. During isometric contractions at 50% and 80% of subjects’ maximum voluntary torque (MVT), oxygen desaturation and resaturation kinetics and volume were significantly decreased after EE, and these declines were significantly prevalent over the following 6 days. Additionally, a significant shift in median frequency intercept (measured by electromyography; EMG) towards lower frequencies was observed during isometric contractions at both 50% and 80% MVT after EE in the exercised arm. After an exhaustive session of downhill walking, another form of EE, resting total haemoglobin and oxyhaemoglobin decreased. Furthermore, during isometric contractions at 30%, 50% and 80% of MVT, prolonged and significant increases were observed in oxygen desaturation and resaturation kinetics and volumes after ambulatory EE. In contrast to the two EE experiments, concentric contractions did not evoke any prolonged changes in muscle oxygenation. Collectively, the findings of this thesis revealed significant and prolonged changes in muscle oxygenation at rest and during exercise, following sessions of strenuous eccentric exercise. Although not clear, the possible mechanism responsible for the changes in muscle oxygenation after EE could be increased resting muscle oxygen utilization due to probable muscle damage and a subsequent requirement of energy demanding repair processes. Concentric exercise resulted in fatigue, but it did not affect muscle oxygenation. Although a prolonged reduction in EMG median frequency intercept was observed after EE, this was not closely time-associated with the biochemical, anthropometric or functional markers of muscle damage.

The prevalence of work-related muscle pain (WRMP) is large in the general population in the industrialized world. Despite significant advances over recent years in some research areas, the mechanisms of why WRMP occurs and the pathophysiological mechanisms behind the disorders are still unclear. One suggested explanation is that WRMP is caused initially by a limitation of the local muscle circulation and oxidative metabolism. There is a lack of objective methods to gauge the development and diagnosis of WRMP. Near infrared spectroscopy (NIRS) is a non-invasive technique that allows for determinations of oxygenation and blood flow. The purpose of this thesis was to evaluate NIRS (1) as a method for measuring muscle oxygenation and hemodynamics for the extensor carpi radialis (ECR) and trapezius descendens muscles (TD), and (2) to investigate whether variables measured by NIRS differed between patients diagnosed with WRMP and healthy subjects. Several variables of NIRS were produced and investigated. These included muscle oxygenation (StO2%), changes during contractions (ΔStO2%) and StO2% recovery (Rslope), total hemoglobin (HbT) as an indication of blood volume and its changes during contractions (ΔHbT). In addition, for the ECR, by applying an upper arm venous occlusion (VO) HbTslope increase as a surrogate of blood flow, and for both VO and arterial occlusion (AO) HHbslope increase (i.e. deoxyhemoglobin slope) as a surrogate of oxygen consumption were variables of interest. A first objective was to determine how StO2% and HbT responded to various contraction forces and how it related to muscle activation measured by electromyography (EMG). For both muscles isometric contractions of 10, 30, 50 and 70% of maximal voluntary contraction (MVC) were maintained for 20 s each by healthy males and females; additionally a 10% MVC contraction was sustained for 5 min. For the different contraction levels, predictable relationships were seen between ΔStO2% and force, and between ΔStO2% and EMG RMS amplitude. The general trend was a decrease in ΔStO2% with increasing force and increasing EMG. Females showed a tendency for a higher oxygen use (i.e., drop in StO2%) for the ECR over force levels than males and a higher RMS% MVC for the TD. For the 10% MVC contraction sustained for 5 min gender specific changes over time for HbT and RMS for the ECR, and for StO2% for the TD muscle were seen. A second objective was to determine the day-to-day reliability of NIRS variables for the ECR and TD muscles at group level (Pooled data) and at gender level (males and females). Measurements were performed on two occasions separated by 4-6 days and intraclass correlation coefficients (ICC) and limits of agreement (LOA) were determined as reliability and reproducibility indicators, respectively. Variables tested were ΔStO2% during submaximal isometric contractions of 10, 30, 50 and 70% MVC and StO2% recovery (Rslope) after contractions and after AO. For the ECR, HbTslope as an indication of blood flow (using VO) and HHbslope as a surrogate of oxygen consumption for both VO and AO were computed. For ΔStO2% for the ECR the highest ICC was at 30% MVC for both the pooled data and at gender level. For the TD ICCs were comparably high for 30, 50, 70 % MVC (for both muscles the ΔStO2% at 10% MVC showed the lowest ICC). Further, females showed a higher ICC than males for contraction levels of 50 and 70% MVC. For both muscles, LOA for ΔStO2% was lowest at 10% and highest at 50 and 70% MVC. For the ECR Rslope ICCs were high for all contraction levels, but was lower for AO; LOA was lowest at 70% MVC. For the TD, Rslope ICCs were also high for all contraction levels and LOA was lowest at 30 % MVC. ICC for HbTslope was the lowest of all variables tested. For HHbslope ICC was higher for AO than for VO, and LOA was lower for AO. A third objective was to determine if there were differences between healthy subjects and patients diagnosed with WRMP in ΔStO2% and ΔHbT responses during varying submaximal contractions (10, 30, 50 and 70% MVC), and StO2% recovery (Rslope) immediately after contractions and AO. Additional variables tested in the ECR at rest were HHbslope to indicate oxygen consumption (using AO) and HbTslope as an indication of blood flow. There were no differences between groups in ΔStO2% and ΔHbT variables during the contractions or Rslope in the recovery after contractions or AO. Furthermore, HbTslope was not different between groups However, oxygen consumption for the ECR and StO2% for the TD at rest were significantly greater for healthy subjects compared to patients. A fourth objective was to determine if there were differences in StO2% and HbT between healthy subjects and WRMP patients during a 12 min sustained contraction of 15 % MVC. In addition, the protocol included a recovery period of 30 min. Prior to contraction, as well as during the recovery period, HbTslope as a surrogate of blood flow was determined for the ECR. Neither the ECR nor the TD exhibited significant differences between groups for StO2% and HbT during the contraction. For the TD patients showed a lower StO2% value at rest and throughout the contraction than healthy subjects. For the ECR HbT during the sustained contraction the general trend was an initial decrease with gradual increase throughout the contraction for both groups. For HbTslope no differences were seen between patients and healthy subjects before the sustained contraction and during the recovery period for both muscles. NIRS is deemed a suitable technique for assessing physiological measurements of the upper extremity, including for day-to-day testing. NIRS was not able to distinguish between the patients with WRMP and controls. A concern in the thesis is the characteristics of the patient group in being equally active in recreational sports, actively working, and similar in muscle strength as controls. Thus, applying NIRS for studying a more severe patient group could yield different results.

Doctor of Philosophy / In this thesis, three experiments were conducted to monitor: (i) muscle oxygenation and electromyographic activity of the biceps brachii after exercise-induced muscle damage (ii) muscle oxygenation after downhill walking-induced muscle damage, and, (iii) muscle oxygenation following a bout of vigorous concentric exercise. Maximal eccentric exercise (EE) of biceps brachii resulted in significantly increased mean resting oxygen saturation and decreased deoxyhaemoglobin. During isometric contractions at 50% and 80% of subjects’ maximum voluntary torque (MVT), oxygen desaturation and resaturation kinetics and volume were significantly decreased after EE, and these declines were significantly prevalent over the following 6 days. Additionally, a significant shift in median frequency intercept (measured by electromyography; EMG) towards lower frequencies was observed during isometric contractions at both 50% and 80% MVT after EE in the exercised arm. After an exhaustive session of downhill walking, another form of EE, resting total haemoglobin and oxyhaemoglobin decreased. Furthermore, during isometric contractions at 30%, 50% and 80% of MVT, prolonged and significant increases were observed in oxygen desaturation and resaturation kinetics and volumes after ambulatory EE. In contrast to the two EE experiments, concentric contractions did not evoke any prolonged changes in muscle oxygenation. Collectively, the findings of this thesis revealed significant and prolonged changes in muscle oxygenation at rest and during exercise, following sessions of strenuous eccentric exercise. Although not clear, the possible mechanism responsible for the changes in muscle oxygenation after EE could be increased resting muscle oxygen utilization due to probable muscle damage and a subsequent requirement of energy demanding repair processes. Concentric exercise resulted in fatigue, but it did not affect muscle oxygenation. Although a prolonged reduction in EMG median frequency intercept was observed after EE, this was not closely time-associated with the biochemical, anthropometric or functional markers of muscle damage.

La drépanocytose est une hémoglobinopathie aux formes et aux sévérités cliniques très hétérogènes qui affectent de nombreux organes chez les patients touchés. Pour cette raison le terme de syndrome drépanocytaire majeur est généralement employé. Tous les syndromes drépanocytaires majeurs ont en commun une mutation ponctuelle du gène β-globine appelée mutation βs . Cette mutation βs conduit à la synthèse de la protéine d'hémoglobine S (HbS) caractérisée par sa capacité à polymériser dans sa forme désoxygénée. La polymérisation de l'HbS est l'élément déclencheur de la falciformation du globule rouge et conduit à de nombreuses altérations hématologiques et hémorhéologiques. Ces dernières sont à l'origine de troubles de l'hémodynamique, de l'oxygénation sanguine et de la perfusion tissulaire en oxygène. Il en résulte de nombreuses complications aigues (crise vaso-occlusive, accident vasculaire cérébral, syndrome thoracique aigu etc.) et/ou chroniques (glomérulopathie, ostéonécrose de la tête fémorale etc.) causés par un défaut d'oxygénation des tissus. / Sickle cell anemia is a hemoglobinopathy forms and severities very heterogeneous clinical affecting many organs in affected patients. For this reason the term major sickle cell syndrome is generally used. All major sickle cell syndromes have a common point mutation in the gene called β-globin mutation βs. This βs mutation leads to the synthesis of the protein hemoglobin S (HbS) is characterized by its ability to polymerize in its deoxygenated form. The polymerization of HbS is the trigger for the sickling of red blood cells and leads to many Hematological and hemorheological. These are at the origin of disorders hemodynamics, blood oxygenation and tissue perfusion with oxygen. This results in many acute complications (vaso-occlusive crisis, stroke, acute chest syndrome, etc..) And / or chronic (glomerulopathy, osteonecrosis of the femoral head etc.). Caused by a defect of tissue oxygenation.

Stress and monotonous work contribute substantially to the development of chronic musculoskeletal disorders. Yet, the pathophysiological mechanisms underlying the process, particularly the involvement of autonomic regulation, remain unclear. It has been suggested that altered motor control resulting from distorted sensory information from fatigued muscles may be an important component in the development of musculoskeletal disorders. Animal studies have shown that sympathetic nervous system activation exerts actions in skeletal muscles, such as vasoconstriction and modulation of afferent information from muscle spindles. However, few attempts have been made to address this issue in humans. Therefore, the first aim of the thesis was to investigate the impact of repetitive computer work with and without additional stressors on muscle oxygenation and position sense in the upper extremity. Assuming an important role of stress in the development of chronic musculoskeletal symptoms, one may expect open or latent manifestations of such symptoms in patients with non-specific stress-related illnesses. It is possible that sympathetic activation may influence pain perception, and that treatments aimed at reducing stress may also affect the pain experience. Thus, the second aim of the thesis was to evaluate the effects of a cognitive-behavioral training program and a physical activity program for patients with stress-related illnesses on autonomic reactivity, pain, and perceived health. First, a laboratory model of computer mouse use was characterized in terms of biomechanical exposure of the wrist, and wrist position sense was determined before and after 45 minutes of continuous mouse use. Then, the effects of performing the computer mouse work under time pressure and precision demands were determined. Autonomic activity and muscle oxygenation in the upper extremity were measured during the work, and wrist position sense was assessed before and after the work. When patients with stress-related illnesses were compared to healthy individuals in autonomic reactivity to functional tests, pressure-pain thresholds, and ratings of health, indications of a relation between autonomic reactivity and symptoms of pain was found. Hence, in a subsequent evaluation of a cognitive-behavioral training program and a physical activity program for patients with stress-related illnesses, post intervention effects on autonomic reactivity to functional tests, pressure-pain thresholds, ratings of health and return-to-work were studied during a period of 12 months after the intervention. The main findings were the following. 1) Wrist kinetics data obtained during the computer mouse work showed similarities to previously presented data for mouse-operated design tasks. 2) When time pressure and precision demands were added to the computer work, increased autonomic activity paralleled with decreased muscle oxygenation in the upper extremity was found. Wrist position sense accuracy, however, did not decrease after the work as it did when the work was performed without the additional demands. The result is intriguing, as it does not appear to be in concordance with previous animal studies. 3) Patients with stress-related illnesses showed higher autonomic reactivity to cognitive and physical laboratory tests than healthy control subjects. They also had substantially lower pressure-pain thresholds in the back, and rated poorer health and health-related behavior than the control subjects. 4) We found little difference in effect of cognitive-behavioral training and physical activity, compared to usual care, for patients with stress-related illnesses. Patients in the control group showed an improvement of about the same magnitude as in the treatment groups over the 12-month follow-up period. The present findings indicate a non-additive relation between autonomic activity during repetitive work and position sense inaccuracy. Furthermore, patients with stress-related illnesses often reported pain in the neck, shoulders, and lower back. This was associated with lower pressure-pain thresholds in the back and a modest increase in sympathetic reactivity to physical and mental tests, which might suggest a potential use of these methods in the clinical examination and rehabilitation of patients with stress-related illnesses.

Submitted by Livia Mello (liviacmello@yahoo.com.br) on 2016-10-05T18:24:22Z No. of bitstreams: 1 DissTMPCB.pdf: 1589921 bytes, checksum: 09e871d1565d828344ed4b2819fe9a86 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-20T18:50:10Z (GMT) No. of bitstreams: 1 DissTMPCB.pdf: 1589921 bytes, checksum: 09e871d1565d828344ed4b2819fe9a86 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-20T18:50:17Z (GMT) No. of bitstreams: 1 DissTMPCB.pdf: 1589921 bytes, checksum: 09e871d1565d828344ed4b2819fe9a86 (MD5) / Made available in DSpace on 2016-10-20T18:50:24Z (GMT). No. of bitstreams: 1 DissTMPCB.pdf: 1589921 bytes, checksum: 09e871d1565d828344ed4b2819fe9a86 (MD5) Previous issue date: 2016-04-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Local hypoxia (i.e. intramuscular) resulting from resistance training (RT) contributes to ions H+ accumulation and decreased muscle pH (i.e. metabolic stress). It has been suggested that the accumulation of these metabolites promotes an increase in the motor units (MU) recruitment and consequent increase in cross-sectional area (CSA) and muscle strength. Nevertheless, it remain sunknown whether the level of local hypoxia can affect the magnitude of these adaptations. Objective: The objective of the study was to analyze and compare the effect of local hypoxia during low-intensity resistance training with blood flow restriction (LI-BFR: 3-4 x 20/20% of one repetition maximum [1-RM] / 60% total pressure of occlusion), high-intensity resistance training (HI-RT: 3-4 x 10/80% of 1RM) and high-intensity resistance training with blood flow restriction (HI-BFR: 3-4 x 10/80% 1-RM / 60% total occlusion pressure) on muscle activation, strength, mass and architecture in young individuals. Methods: Thirty young men were selected and each leg allocated to three experimental conditions through unilateral knee extension in randomized order and counterbalanced after ranking by strength level (1- RM) and vastus lateralis (VL) muscle CSA quartiles. The dynamic maximum force was measured by 1-RM test and CSA acquisition, muscle thickness (MT), pennation angle (PA) and VL fascicle length (FL) was performed through ultrasound images. The training program consisted of 10 weeks with a minimum interval of 72 hours between training sessions and the measurement of muscle activation by surface electromyography (EMG) and deoxyhemoglobin ([HHb]) and oxyhemoglobin ([HbO2]) concentrations through near-infrared espectroscopy (NIRS) of VL, performed during the training session with relative load obtained after the 1-RM, before (T1), after five (T2) and ten weeks (T3) training. Results: The training total volume (TV) was greater for HI-RT and HI-BFR compared to LI-BFR. There was no difference between the groups in regarding the increase of 1-RM, CSA, MT and AP. However, the FL showed higher increase for HI-BFR compared to HI-RT and LI-BFR. Regarding the magnitude of the EMG, the HI-BFR group showed higher values than HI-RT and LI-BFR. On the other hand, [HHb] were higher for HI-BFR and LI-BFR, however there was no difference between groups on the reduction of [HbO2].Conclusion: The level of local hypoxia does not influence the magnitude of the increase of muscle activation, strength, mass and architecture changes after resistance training. However, the addition of local hypoxia seems to have a greater contribution to the adjustments resulting from the low-intensity resistance training compared to high intensity. / A hipóxia local (i.e. intramuscular) decorrente do treinamento força (TF) contribui para o acúmulo de íons H+ e diminuição do pH muscular (i.e. estresse metabólico). Sugere-se que o acúmulo desses metabólitos promove aumento no recrutamento de unidades motoras (UM) e consequente aumento da área de secção transversa (AST) e força muscular. Embora isso seja sugerido, ainda não se sabe se o nível de hipóxia local pode afetar a magnitude dessas adaptações. Objetivo: O objetivo do estudo foi analisar e comparar o efeito da hipóxia local durante o treinamento de força de baixa intensidade com restrição do fluxo sanguíneo (TFBI-RFS: 3-4 x 20 / 20% de uma repetição máxima [1-RM] / 60% pressão total de oclusão), treinamento de força de alta intensidade (TFAI: 3-4 x 10 / 80% de 1-RM) e treinamento de força de alta intensidade com restrição do fluxo sanguíneo (TFAI-RFS: 3-4 x 10 / 80% de 1-RM/ 60% pressão total de oclusão) na ativação, força, massa e arquitetura muscular em indivíduos jovens. Métodos: Trinta homens jovens foram selecionados e cada membro inferior alocado nas três condições experimentais de TF de extensão unilateral de joelho em ordem aleatorizada e contrabalanceada após ranqueamento em quartis, para nível de força (1-RM) e AST muscular do músculo vasto lateral (VL). A força máxima dinâmica foi mensurada por meio do teste de 1-RM e a aquisição da AST, espessura muscular (EM), ângulo de penação (AP) e comprimento do fascículo (CF) do VL foi realizada por meio de imagens de ultrassonografia. O programa de treinamento foi composto por 10 semanas com intervalo mínimo de 72 horas entre os treinos. A mensuração da ativação muscular foi realizada por eletromiografia de superfície (EMG) e das concentrações de desoxihemoglobina ([HHb]) e hemoglobina oxigenada ([HbO2]), por meio do near-infrared espectroscopy (NIRS) do VL durante a sessão de treinamento com carga relativa obtida após o teste de 1-RM, antes (T1), após cinco (T2) e dez semanas (T3) do programa de treinamento. Resultados: O volume total (VT) do treinamento foi maior para TFAI e TFAI-RFS comparado ao TFBI-RFS. Não houve diferença entre os grupos em relação ao aumento da 1-RM, AST, EM, AP. Porém, o CF apresentou maior aumento para TFAI-RFS comparado ao TFAI e TFBI-RFS. Em relação à amplitude da EMG, o grupo TFAI-RFS apresentou maiores valores que o TFAI e TFBI-RFS. Por outro lado, as [HHb] foram maiores para o TFAI-RFS e TFBI-RFS, entretanto não houve diferença entre os grupos na redução das [HbO2 ]. Conclusão: O nível de hipóxia local não influência a magnitude do aumento da ativação, força, massa muscular e alterações na arquiteura muscular decorrente do treinamento de força. Entretanto, a adição da hipóxia local parece ter uma maior contribuição para as adaptações decorrentes do treinamento de força de baixa em relação ao de alta intensidade.

Title: Application of blood flow restriction by a sport training of climbers - an innovative training method for sportsmen? Author: Tomáš Javorský BSc. Department: Department of Physiology Supervisor: doc. Jiří Baláš, Ph.D. Abstract: The most common injuries of performance climbers include tendon injuries of finger flexors. This kind of injury can leave a sportsman unable to follow his training programme for several months, which can have a crucial impact on his peak season. The thesis comprised a comparison of a high-intensity training performed at 70% of muscle strength maximum, with a blood flow restriction training performed at a 30% muscle load, and also the physiological and functional aspects of the training. Objectives: The presumption is, that the combination of a low muscle load with an ischemy will achieve the same results as a high-intensity training. We also presume, that the alterations in muscle oxygenation remain the same despite different amounts of performed muscle work. Methods: 13 participants finished the experiment performed in the form of a crossover study. During the experiment the muscle oxidative capacity and the extent of the muscle deoxygenation were measured by spectroscopy. The maximum force, critical force, impulse and the impulse above the critical force point were measured...

Aim: To examine local muscle oxygen kinetics when performing wrist extensions till failure in an occluded versus non-occluded state, to compare the perceived ratings of pain and local muscle exertion, and analysing presence of gender differences. Methods: Twenty-one healthy individuals (mean age 25,6±3.2, 10 females) performed wrist extensions at 30% of peak isometric strength till failure. The order in which the states was performed was randomized. The oxygen kinetics in the m. extensor digitorum was analysed using Near-infrared spectroscopy continuously. Ratings of perceived pain and local muscle exertion were collected before exercise, when reaching failure and post exercise recovery. Result: No difference was identified in tissue oxygen saturation (TOI) at the exercise plateau (-24.0±18.3% vs -23.5±13.9%, p=0.609). TOI at rest was lower for the occluded state (64.2±4.5% vs 57.2±5.9%, p<0.001). During the second minute of recovery, there was a greater increase in TOI for the occluded state (0.01±0.01%/sec vs 0.04±0.03/sec, p<0.001). A higher rating of perceived pain was found for the occluded state during baseline (0.0±0.0 vs 0.7±0.9, p=0.005) and first minute of recovery post exercise (2.3±2.0 vs 3.3±2.1, p=0.011). No clinically relevant gender differences were found. Conclusion: Venous occlusion during low-intensity dynamic wrist extensions affects the local oxygen kinetics in the muscle before and after exercise. The oxygenation kinetics does not differ when exercise plateau is reached when both regimes are performed till failure. This suggests that performing low-load dynamic wrist extensions in a no-relaxation manner, may have the same effects no matter whether occlusion is used or not. / Syfte: Att undersöka den lokala syreomsättningen i muskeln när handledsextensioner utförs till failure i ockluderat tillstånd jämfört med icke-ockluderat tillstånd, samt att jämföra den skattade upplevda smärtan och lokala muskelansträngningen, och eventuella skillnader mellan könen. Metod: Tjugoen friska individer (medelålder 25.6±3.2, 10 kvinnor) utförde handledsextentioner på 30 % av maximal isometrisk styrka till failure. Ordningen av ocklusion och icke-ocklusion var randomiserad. Nära-infraröd spektroskopi användes för att undersöka syreomsättningen lokalt i m. extensor digitorum. Skattning av upplevd smärta och lokal muskelansträngning samlades in före träning, vid failure och vid återhämtning efter träning. Resultat: Ingen skillnad identifierades i vävnadssyremättnad (TOI) vid uppnådd träningsplatå (-24.0±18.3% vs -23.5±13.9%, p=0.609). TOI i vila var lägre för det ockluderade tillståndet (64.2±4.5% vs 57.2±5.9%, p <0.001). Under den andra återhämtningsminuten var det en större ökning av TOI för det ockluderade tillståndet (0.01±0.01%/sek vs 0.04±0.03/sek, p <0.001). En högre skattning av upplevd smärta sågs för det ockluderade tillståndet under den första vilominuten (0.0±0.0 vs 0.7±0.9, p=0.005) och första minuten av återhämtning (2.3±2.0 vs 3.3±2.1, p=0.011). Inga kliniskt relevanta skillnader mellan könen hittades. Slutsats: Ocklusion under lågintensiva dynamiska handledsextensioner påverkar den lokala syreomsättningen i muskeln före och efter träning. Den muskulära syreomsättningen skiljer sig däremot inte när träningsplatå uppnås när båda regimerna utförs till failure. Detta tyder på att utförande av dynamiska handledsextensioner på låg belastning utan att muskeln tillåts att slappna av, kan ge samma effekter oberoende av om ocklusion appliceras eller inte.