INFLUENCE OF RELATIVE BLOOD FLOW RESTRICTION PRESSURE ON

MUSCLE ACTIVATION AND MUSCLE ADAPTATION

BRITTANY R. COUNTS, BS,1 SCOTT J. DANKEL, BS,1 BRIAN E. BARNETT, BS,1 DAEYEOL KIM, MS,2
J. GRANT MOUSER, BS,2 KIRSTEN M. ALLEN, BS,2 ROBERT S. THIEBAUD, PhD,3 TAKASHI ABE, PhD,1
MICHAEL G. BEMBEN, PhD,2 and JEREMY P. LOENNEKE, PhD1
1

Kevser Ermin Applied Physiology Laboratory, Department of Health, Exercise Science, and Recreation Management, University of
Mississippi, P.O. Box 1848, University, Mississippi 38677, USA
2
Department of Health and Exercise Science, Neuromuscular Research Laboratory, University of Oklahoma, Norman, Oklahoma, USA
3
Department of Kinesiology, Texas Wesleyan University, Fort Worth, Texas, USA
Accepted 30 June 2015
ABSTRACT: Introduction: The aim of this study was to investigate the acute and chronic skeletal muscle response to differing
levels of blood flow restriction (BFR) pressure. Methods: Fourteen participants completed elbow flexion exercise with pressures from 40% to 90% of arterial occlusion. Pre/post torque
measurements and electromyographic (EMG) amplitude of
each set were quantified for each condition. This was followed
by a separate 8-week training study of the effect of high (90%
arterial occlusion) and low (40% arterial occlusion) pressure on
muscle size and function. Results: For the acute study,
decreases in torque were similar between pressures [15.5
(5.9) Nm, P 5 0.344]. For amplitude of the first 3 and last 3
reps there was a time effect. After training, increases in muscle
size (10%), peak isotonic strength (18%), peak isokinetic torque
(1808/s 5 23%, 608/s 5 11%), and muscular endurance (62%)
changed similarly between pressures. Conclusion: We suggest
that higher relative pressures may not be necessary when exercising under BFR.
Muscle Nerve 53: 438445, 2016

Low-load resistance exercise [20%30% concentric 1-repetition maximum (1RM)] in combination

with blood flow restriction (BFR) increases muscle
size and strength in a variety of populations.13
When applied appropriately, this stimulus has
been found to provide a safe and effective stimulus
in the absence of measurable muscle damage.4,5
The mechanisms behind these beneficial effects
are not completely known, but metabolic accumulationinduced fatigue may be playing an influential role in the muscle adaptations observed after
this type of exercise. To illustrate, metabolic accumulation in combination with a reduced oxygen
environment may increase recruitment of higher
threshold (type II) muscle fibers.6,7 This suggests
that higher pressures, resulting in a greater reduction in oxygen and subsequent increase in metabolic accumulation,8 may augment muscle fiber
Abbreviations: 1RM, 1-repetition maximum; ANOVA, analysis of variance; bSBP, brachial systolic blood pressure; EMG, electromyography;
FR, blood flow restriction; MVC, maximal voluntary contraction
Additional Supporting Information may be found in the online version of
this article.
Key words: arterial occlusion; hypertrophy; KAATSU; perceptual
response; resistance training; vascular occlusion training
Correspondence to: J.P. Loenneke; e-mail: jploenne@olemiss.edu
C 2015 Wiley Periodicals, Inc.
V

Published online 2 July 2015 in Wiley Online Library (wileyonlinelibrary.com).

DOI 10.1002/mus.24756

438

Relative BFR Pressure

recruitment with low-load resistance exercise in

combination with BFR. Muscle fiber recruitment
may be important, as it has been previously suggested that increased recruitment is related to
some degree with changes in muscle protein synthesis.9 To illustrate, lower body low-load exercise
to volitional fatigue results in high levels of muscle
activation,1012 and has also been found to produce muscle protein synthetic13 and muscle hypertrophic responses similar to higher load resistance
training.14,15
We recently observed that higher relative pressures (pressures based on individual limb circumference) may not augment muscle activation in the
lower body.12 However, due to the lack of statistical
power to compare across groups, only qualitative
analyses could be completed across pressures
(40%60% estimated arterial occlusion). Furthermore, no published study to date has compared the
hypertrophic responses of BFR training under different occlusion pressures. Thus, the purpose of
this study was 2-fold. First, we sought to determine,
using a within-subject design, whether or not higher
relative pressures provide an increase in muscle activation over lower pressures. We hypothesized that
muscle activation would not be augmented to a
large degree with higher pressures. Second, based
on the acute muscle activation data, we sought to
determine whether differences in muscle adaptation
would be observed after 8 weeks of resistance training with either high or low pressures applied.
Although similar muscle activation was reported
across pressures, we hypothesized that exercising
with higher relative pressures may attenuate some
of the gains in muscle mass due to the reduction in
total exercise volume observed with higher pressures from the acute study.
METHODS
Participants.

For experiment 1, 14 physically active

participants (10 men, 4 women) were recruited.
Physically active was defined as being active 3 or
more days per week with an upper body resistance
training component 2 or more days per week for at
least the previous 3 months. Physically active
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participants were used to better reflect the actual acute

responses to different exercise and limit the possibility
of a training effect due to repeated testing. For experiment 2, a total of 8 nonresistance-trained men
(n 5 5) and women (n 5 3) volunteered to participate
in this study. One man enrolled but dropped out
before the first visit, therefore analysis was conducted
on the remaining 7 participants. Participants were
excluded if they had at least 1 risk factor for thromboembolism. The experiments were approved by the
universitys institutional review board, and each
participant gave written informed consent before
participation.
Experiment 1 Study Design. During the initial visit
participants had standing arterial occlusion pressure determined and were then tested on each
arm for the unilateral dumbbell elbow flexion 1repetition maximum (1RM). Participants were
then familiarized with the BFR stimulus and maximal voluntary contraction (MVC) testing. Next,
participants were scheduled for the first of 3 testing visits with a minimum of 5 and a maximum of
10 days between visits. Participants completed all
of the exercise conditions in random order (1 condition per arm) across 3 separate visits (2 conditions per visit). The exercise bouts within each day
were separated by 10 min of rest. For each condition, the participants were instructed to complete
1 set of 30 repetitions followed by 3 sets of 15 repetitions at 30% of their concentric 1RM at 40%,
50%, 60%, 70%, 80%, or 90% of their standing
arterial occlusion pressure. All conditions were separated by 30-s rest periods between sets. A metronome was used to ensure that the participants
held the cadence of 1 s for the concentric muscle
action and 1 s for the eccentric muscle action during the unilateral elbow flexion exercise. If the
participant could not maintain the cadence during
a particular set, the set was stopped, and the participant rested for 30 s until the next set. Muscle activation was measured at pre-exercise (no BFR) and
during each set of exercise (with BFR). The elbow
flexor MVC was performed on an isokinetic dynamometer pre- and post-exercise to determine
fatigue. All testing sessions were completed before
the participant exercised for that day, and each
visit was completed at least 24 h after the last
upper body workout.
Electromyography and Isometric Fatigue. Electromyographic (EMG) signals were recorded from the
biceps brachii of the arm during exercise. Electrodes were placed on a line between the medial acromion and the antecubital fossa at a distance of
one-third from the antecubital fossa. The skin was
shaved, abraded, and cleaned with alcohol wipes.
Bipolar electrodes were placed over the muscle
Relative BFR Pressure

belly with an inter-electrode distance of 20 mm.

The ground electrode was placed on the seventh
cervical vertebrae at the neck. The surface electrodes were connected to an amplifier and digitized
(Biopac Systems, Inc., Goleta, California). The signal was filtered (low-pass filter 500 HZ, high-pass
filter 10 HZ), amplified (1,0003), and sampled at
a rate of 1 kHZ. Before the exercise bout, the participant performed 2 isometric MVCs with the
biceps brachii at a joint angle of 908 with a 30-s
rest between MVCs on an isokinetic dynamometer.
The EMG was recorded continuously from the
biceps brachii during each exercise bout. LabView
7.1 (National Instrument Corp., Austin, Texas)
computer software was used to analyze the data.
EMG amplitude (root mean square, RMS) was analyzed from the average of the first 3 repetitions
and the average of the last 3 repetitions for each
set and expressed relative to the highest preexercise MVC (%MVC).
Experiment 2 Study Design. Based on findings
from the acute study, we sought to determine
whether the acute changes would translate to
chronic muscle adaptation. Thus, participants completed 8 weeks of low-load unilateral elbow flexion
training with 1 arm exercising at low pressure
(40% arterial occlusion) and the other arm exercising at higher pressure (90% arterial occlusion).
The participants visited the laboratory for a total
of 26 visits. The first 2 pre-training visits consisted
of paperwork and baseline measurements, followed
by 22 separate training sessions and 2 post-training
visits (4872 h after last training session) that
measured changes caused by the exercise intervention (Fig. 1). Participants trained 2 times per week
for the first 2 weeks followed by 3 training sessions
per week for weeks 38. A similar number of training sessions has previously been shown to produce
measurable changes in muscle size and
strength.16,17 The goal reps for each exercise protocol included 1 set of 30 repetitions followed by 3
sets of 15, with 30-s rest periods between sets. Exercise was completed to a metronome with 1 s for
the concentric and 1 s for the eccentric portion of
the exercise. Participants were stopped before
completing the goal number of repetitions, when
they were unable to lift the load with proper form
or keep to the beat of the metronome. Training
load was adjusted every 2 weeks to maintain 30%
of 1RM. A non-BFR control condition was not
included, as previous studies have consistently
shown that repetition-matched protocols without
BFR do not lead to meaningful changes in muscle
size and strength.1
Determination of 1RM. For experiments 1 and 2,
the maximum load that could be lifted for the
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439

FIGURE 1. Outline of experiment 2. Mth, muscle thickness; 1RM, 1-repetition maximum; 30% to failure is test of muscle endurance.

unilateral dumbbell curl through a full range of

motion with proper form was assessed and
recorded as the concentric 1RM. Briefly, participants completed 5 reps of light weight (3.41 kg)
as a warm-up, and then weight was progressively
increased until the load could not be lifted successfully through a full range of motion.18 Each arm
was tested in a random order, and all participants
reached their 1RM within 5 attempts. To ensure
strict form, participants completed their concentric
1RM with their back and heels against a wall and
with feet shoulder width apart.
Determination of Arterial Occlusion Pressure. For
experiments 1 and 2, a narrow (5-cm-wide bladder) nylon cuff was applied to the most proximal
part of the arm. Pressure was regulated using a
cuff inflator system (E 20 Rapid Cuff Inflator;
Hokanson, Bellevue, Washington). The pulse at
the wrist (arterial blood blow) was detected using a
hand-held bidirectional Doppler probe placed on
the radial artery. The cuffs were inflated to 50 mm
Hg and quickly raised to the participants previously measured systolic blood pressure. Pressure
was then slowly increased until the arterial flow
was no longer detected during inflation. Arterial
occlusion pressure was recorded to the nearest
1 mm Hg as the lowest cuff pressure at which a
pulse was not present.

For experiment 2, muscle size

was estimated by B-mode ultrasound (SSD-500 with
a 5-MHZ probe; Aloka). Ultrasound measurements
of the biceps brachii were taken halfway between
the acromion process and lateral epicondyle and
10 cm proximal to the lateral epicondyle. Muscle
size of the anterior forearm was measured at 30%
proximal between the styloid process and the head
of the ulna. Three images were taken at each site,
printed, and analyzed by an investigator who was
blinded to the arms condition. The average of the
3 measurements was used for final analysis. Muscle
Muscle Thickness.

440

Relative BFR Pressure

thicknesses of the deltoid and triceps were also

measured to demonstrate stability of the measurement across time, as those muscle groups were not
expected to change with strict elbow flexion exercise. The minimal difference (i.e., reliability)
needed to be considered real for the anterior portion of the upper and lower arm was calculated to
be 0.2 cm.
Muscle Endurance. Participants completed as
many repetitions of unilateral elbow flexion exercise as they could to a metronome with 1 s for the
concentric and 1 s for the eccentric portion of the
lift. The load used was 30% of the predetermined
1RM for that test day. All participants kept their
back and heels against a wall with their feet
shoulder width apart to ensure strict form throughout testing.
Isokinetic Elbow Flexion Strength. Isokinetic torque
was measured using an isokinetic dynamometer
(Quickset System 4; Biodex) Measurements were
taken on both arms in random order. First, participants completed 2 sets of 3 at 1808/s separated by
90 s of rest. This was then repeated at 608/s. All
values were gravity corrected. The minimal differences needed for changes to be considered real
were calculated as 5 Nm for 1808/s and 3 Nm for
608/s.
Ratings of Discomfort. Ratings of discomfort were
quantified using the Borg discomfort scale
(CR101) before each exercise bout and after each
set for all training sessions, Methods have been
described in detail previously.19
Statistical Analyses. All data were analyzed using
SPSS 22.0 software (SPSS, Inc., Chicago, Illinois)
with variability represented as standard deviation
(SD). For experiment 1, there were no baseline
differences in MVC, thus a 1-way analysis of variance (ANOVA) was completed for the MVC
change scores (mean decrease from baseline) and
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overall exercise volume to determine whether differences existed between conditions. For EMG, a 6
(condition) 3 4 (time) repeated-measures ANOVA
was used. A significant result from the repeatedmeasures ANOVA was followed by a 1-way ANOVA
to determine where the difference occurred across
time within each visit and within each time-point
across visits. Statistical significance was set at an
alpha level of 0.05.
For experiment 2, a 2 (condition) 3 3 (time)
repeated-measures ANOVA was completed for muscle thickness, maximal isotonic strength, and exercise volume. A significant result from the repeatedmeasures ANOVA was followed by a 1-way ANOVA
to determine where the difference occurred across
time within each pressure, and a paired-sample ttest was used to determine where the differences
occurred between pressures within each timepoint. A 2 (condition) 3 2 (time) repeatedmeasures ANOVA was completed for isokinetic
strength. Follow-up tests included paired sample ttests across time within each pressure and across
pressures within each time-point. For ratings of discomfort, Wilcoxon-related samples non-parametric
tests determined differences between pressures
within each set of exercise. Statistical significance
was set at an alpha level of 0.05.
RESULTS
Experiment 1.

Participants. Participants (n 5 14),

on average, were 24 6 3 years old, 174 6 7 cm in
height, 79.7 6 11.3 kg in weight, and had a 1RM for
the right arm of 18 6 6 kg and a 1RM for the left
arm of 19 6 6 kg, and had a standing arterial occlusion pressure of 140 6 14 mm Hg for the right arm
and 143 6 17 mm Hg for the left arm.
Maximal Voluntary Contraction. There were no
significant differences across arterial occlusion
pressures in the MVC change scores from baseline
(P 5 0.344). The grand mean decline in torque
from baseline was 215.5 6 5.9 Nm.
Exercise Volume. There were significant differences in exercise volume across pressures, with less
volume being completed at the highest pressures
(P < 0.001; Fig. 2B).
EMG. There was no significant interaction
with amplitude of the first 3 repetitions (P 5 0.456;
Table 1). In addition, there was no significant
main effect for condition (P 5 0.850), but there
was for time (P < 0.001), with amplitude increasing
from the first set. For the last repetitions, there
was no significant interaction with EMG amplitude
(P 5 0.450; Table 1). In addition, there was no significant main effect for condition (P 5 0.881), but
there was for time (P 5 0.021).

Participants. Participants (n 5 7),

on average, were 23 6 3 years old, 169.6 6 9.5 cm

Experiment 2.

Relative BFR Pressure

FIGURE 2. Mean total exercise volume completed across pressures in the acute study (experiment 1). Conditions with different letters represent significant differences between conditions
(P  0.05). Variability is represented as standard deviations.

in height, 56.7 6 11.3 kg in weight, and had a

standing arterial occlusion pressure of 129 6 19
mm Hg for the high-pressure arm and 133 6 19
mm Hg for the low-pressure arm. Thus, the mean
pressure used during exercise was 116 6 17 mm
Hg and 53 6 7 mm Hg for the high- and lowpressure arms, respectively. Of the 22 training sessions, 2 participants missed 1 training session each,
translating into an overall completion rate of 99%.
Muscle Thickness. There was no significant
interaction with muscle thickness at the midupper
arm (P 5 0.258; Fig. 3A) or 10 cm above the elbow
joint (P 5 0.674; Fig. 3B). In addition, there was no
significant main effect for condition (P  0.151),
but there was for time (P < 0.001). With the forearm, there was no interaction (P 5 0.338) or main
effect of condition, but there was a main effect of
time (P 5 0.04). Follow-up tests for forearm muscle
size identified a significant increase from pre to
post [1.8 6 0.1 cm vs. 1.9 6 0.2 cm], but this difference did not exceed the error of our measurement.
In addition, no significant differences were
observed across time for the triceps or deltoid (data
not shown).
Muscle Strength. There was no significant interaction with muscle strength (P 5 0.909). In addition,
there was no significant main effect for condition
(P 5 0.409), but there was for time (P < 0.001). Maximal isotonic strength (1RM) increased from pre to
mid [11.2 6 5 kg vs. 12.2 6 5.5 kg] to post
[13.2 6 5.8 kg], with significant differences between
each time-point (P  0.006).
Isokinetic Torque. There was no significant interaction with isokinetic strength at 1808/s (P 5 0.480;
Fig. 3C) or 608/s (P 5 0.386; Fig. 3D). In addition,
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441

Table 1. Muscle activation from experiment 1.

EMG amplitude first 3 reps (%MVC)
Arterial occlusion
40%
50%
60%
70%
80%
90%

Set 1
33 (9)
38 (13)
43 (31)
36 (20)
37 (13)
36 (20)

Arterial occlusion
40%
50%
60%
70%
80%
90%

Set 1
53 (16)
62 (27)
71 (45)
62 (43)
61 (26)
57 (35)

Set 2
Set 3
46 (19)
48 (18)
51 (17)
56 (21)
58 (32)
56 (30)
49 (26)
52 (26)
53 (23)
45 (15)
53 (37)
53 (39)
EMG amplitude last 3 reps (%MVC)
Set 2
Set 3
61 (22)
56 (23)
74 (34)
64 (38)
71 (37)
65 (39)
65 (37)
59 (30)
68 (41)
66 (48)
64 (53)
58 (49)

Time
Set 4
44 (14)
53 (23)
56 (28)
49 (23)
55 (31)
51 (33)

1 vs. 2, 3, 4

Set 4
49 (16)
63 (38)
60 (35)
55 (30)
61 (40)
56 (43)

2 vs. 3, 4; 3 vs. 4

Variability represented as standard deviations. Main effects of time are noted in the Time column at far right. The different numbers represent significant
differences between sets (P  0.05).

there was no significant main effect for condition

(P  0.633), but there was for time (P  0.014).
Muscle Endurance. There was no significant
interaction with muscle endurance (P 5 0.901). In
addition, there was no significant main effect for
condition (P 5 0.265), but there was for time
(P < 0.001). The number of repetitions completed
to failure increased from pre [37 (7) repetitions]
to post [60 (13) repetitions].
Rating of Discomfort. Ratings of discomfort
between pressures were statistically compared in
the first, eleventh, and last training sessions. Ratings of discomfort were significantly different

between pressures for most sets of exercise (Table

2). When plotted across time, the peak discomfort
was almost always higher in the high-pressure arm
(see Fig. S1 in the Supplementary Material, available online).
Exercise Volume. There was no significant interaction with the average repetitions completed in
the first set in weeks 1, 4, or 8 (P 5 0.08; Table 3).
In addition, there was no significant main effect
for condition (P 5 0.08) or time (P 5 0.10). For
the average repetitions completed in sets 24,
there was no significant interaction (P 5 0.416;
Table 3); however, there was a significant main

FIGURE 3. Mean changes across applied pressures in muscle thickness at the 10-cm site (A), muscle thickness of the mid-upper arm
(B), and isokinetic peak torque at 1808/s (C) and 608/s (D). Dagger () indicates a main effect of time. Time-points with different letters
represent significant differences between time-points in (A) and (B). Variability is represented as standard deviations. To maintain sufficient statistical power, only pre-exercise, day 11, and post-exercise were compared.
442

Relative BFR Pressure

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in exercise volume between pressures did not

appear to affect muscle adaptation.

Table 2. Ratings of discomfort from experiment 2.

Ratings of discomfort (0101)
Day 1
High
Low
Day 11
High
Low
Day 22
High
Low

Set 1
2 (0.52.5)
0.5 (0.32)
Set 1*
2 (1.53)
0.7 (0.51)
Set 1
1.5 (12)
1 (0.31.5)

Set 2*
3 (34)
1 (0.32.5)
Set 2*
2.5 (24)
1 (0.52)
Set 2*
2 (1.53)
1 (0.52)

Set 3*
3.5 (35)
2 (0.33)
Set 3*
3 (1.55)
1 (12)
Set 3*
3 (2.53)
1 (0.72)

Set 4*
4 (37)
2.5 (0.55)
Set 4*
3 (25)
1.5 (12)
Set 4*
3 (33)
1.5 (12.5)

Data presented as 50th percentile (25th75th percentiles).

*Significant differences between pressures for that set (P  0.05).

effect for condition (P 5 0.004) and time

(P < 0.001). For the average exercise volume completed in weeks 1, 4, or 8, a 2 3 3 repeatedmeasures ANOVA did not reveal a significant interaction (P 5 0.766) or main effect of condition
(P 5 0.127), but there was a main effect for time
(P < 0.001; Table 3).
DISCUSSION

These findings suggest that relatively high

pressures may not be needed to maximize the
acute or chronic response to BFR exercise. For
example, although a wide range of relative pressures were used in the acute experiment, the
increase in fatigue and muscle activation across
pressures was similar. Thus, we speculated that
lower pressures may produce similar changes in
muscle size and strength as higher pressures. To
provide further insight, we completed a smallscale training study to determine if differences in
muscle adaptation could be observed after exercise in combination with 2 different pressures
(40% vs. 90% arterial occlusion). Our chronic
data are in agreement with the acute experiment
and suggests that both relative pressures
increased muscle size and strength to a similar
extent after low-load training in combination with
BFR. Contrary to our hypothesis, the difference

Experiment 1. Previous studies in the upper body

have identified increases in EMG amplitude during
low-load resistance exercise in combination with
BFR.7,17,2023 The increase in EMG amplitude may
be due to a metabolic overload (i.e., depletion of
phosphocreatine stores and decrease in muscle
pH) induced fatigue within the muscle.6 The metabolic accumulation in concert with a reduced oxygen environment from the restriction of blood
flow may increase recruitment of higher threshold
fibers through stimulation of group III and IV
afferent fibers.7 The muscle activation of the last 3
repetitions marginally decreased in some of the
sets. This is likely due to the participant cheating
the weight up with muscles other than the biceps
brachii. This occurred despite our efforts to make
the exercise execution as strict as possible. To our
knowledge, only 1 other study21 has addressed
those changes across different pressures [80%,
100%, and 120% of brachial systolic blood pressure (bSBP)] in the upper body. In that study, the
authors observed that muscle activation increased
progressively in all groups. However, the amplitude
was significantly greater with 120% bSBP than a
work-matched non-BFR condition from the end of
30 repetitive contractions to the end of the second
set of 15 contractions. In addition, previous data
in the lower body suggested that EMG amplitude
is increased from 40% to 50% estimated arterial
occlusion, but no further increase was observed
when the pressure was increased to 60% estimated
arterial occlusion.12 Our finding of a lack of augmentation with increasing pressure is in contrast
to the 2 previous studies. Possible reasons for this
discrepancy may be related to the setting of restriction pressure. In our study we set the pressure relative to the actual cuff used during exercise, but the
aforementioned investigation by Yasuda et al.21 did
not. Second, the previous study in our laboratory
was completed with narrow cuffs in the lower

Table 3. Exercise volume from experiment 2.

First set
High
Low
Sets 24
High*
Low
Volume (kg)
High
Low

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

27 (3)
29 (1)
Week 1*
5 (2)
10 (4)
Week 1*
151.7 (88.5)
185. 5 (81.9)

28 (2)
29 (1)
Week 2
5 (2)
10 (4)
Week 2
155.5 (76)
186.1 (74)

28 (1)
30 (0)
Week 3
6 (2)
11 (3)
Week 3
171.9 (86)
207.7 (97.1)

30 (0)
30 (0)
Week 4
9 (4)
13 (3)
Week 4
203.7 (99.7)
229.3 (117.9)

30 (0)
30 (0)
Week 5
8 (3)
12 (2)
Week 5
212.8 (107.8)
252.7 (124.8)

30 (0)
30 (0)
Week 6
9 (4)
13 (2)
Week 6
221.2 (107.9)
257.4 (122.4)

30 (0)
30 (0)
Week 7
11 (4)
14 (1)
Week 7
250.3 (119.5)
282.5 (131.8)

30 (0)
30 (0)
Week 8
11 (4)
14 (1)
Week 8
254.7 (115.5)
283.7 (132.8)

Weeks with different symbols represents significant differences between weeks. Conditions with different symbols represent significant differences between
conditions. To maintain sufficient statistical power, only weeks 1, 4, and 8 were compared. Variability represented as standard deviation.

Relative BFR Pressure

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443

body,12 thus arterial occlusion could only be estimated.24 It is possible that the estimated value in
the lower body may have been less than 40% arterial occlusion. However, in the present study, we
were able to determine arterial occlusion in every
individual, thus we likely have a truer representation of 40% arterial occlusion in the upper body.
It may also be that there are intrinsic differences
between the upper and lower body musculature.
Experiment 2. Although research has shown that
low-load exercise with BFR increases muscle mass
and strength,1,3 it was unknown whether the applied
pressure affected the overall adaptive response. We
found no difference in muscle size, strength, or
endurance between pressures, despite differences in
exercise volume. It has been previously hypothesized
that one needs to surpass a certain volume threshold
to maximize the hypertrophic response9; however,
our results suggest that threshold may be lower than
the commonly prescribed 75-repetition protocol.
This finding coincides with a previous study suggesting that more volume does not always augment muscle size and strength.25 Given that both groups had
similar volumes of work in the first set, this may suggest that, in this population, the first set of approximately 30 repetitions may be the most important
with the following sets being of less importance,
assuming the muscle reaches maximal fatigue. However, we also cannot rule out the possibility that
high relative pressure has a physiologic effect on
muscle, making the overall exercise volume of less
importance.
It has been hypothesized that a hypothetical
range may exist for observing beneficial adaptations with low-load exercise in combination with
BFR, and higher pressures increase the possibility
of an adverse event.26 Our results show that muscle
adaptions were similar, but there was an overall
higher rating of discomfort during exercise with
the higher applied pressure. Although the differences in discomfort were small, these differences
were maintained throughout the training study.
Further, peak ratings of discomfort for each session were almost always greater with higher applied
pressures compared with lower applied pressures
(see Fig. S1 online). It is important to note that
our rating quantified discomfort during exercise
and not the rest periods. Most participants
reported anecdotally much greater discomfort during the rest period with high relative pressures,
which suggests that our measurement time-point
was inadequate to show the true differences
between pressures. Taken together, 40% arterial
occlusion may be all that is needed to maximize
the anabolic response to low-load BFR training
when compared with 90% arterial occlusion, with444

Relative BFR Pressure

out the greater discomfort that was observed with

90% arterial occlusion.
Limitations. In view of the results presented, this
study has some limitations. First, the training study
had a relatively small sample size. However, mean
changes in muscle size, strength, and endurance
were similar between arms, which suggests that the
similar change between pressures was unlikely due
to a statistical power issue. Further, the acute data
presented here, along with a previous study,12 corroborate the finding that higher relative pressures
may not augment muscle adaptation. Our estimate
of muscle growth was muscle thickness and not the
gold standard estimate from magnetic resonance
imaging, although previous studies indicated a
strong relationship between ultrasound estimates
and more sophisticated measures.2729 Regardless,
the significant increases in biceps brachii thickness
exceeded the error of our blinded tester (minimal
difference), which gives confidence to the results.
In addition, post-exercise muscle thickness measurements were taken 4872 h after exercise despite
previous data suggesting that swelling from upper
body exercise lasts less than 24 h.30 A final potential limitation could be the cross-education of
strength from one limb to the other; however, it
has been noted previously that the cross-education
effect is minimal or nonexistent when both limbs
are training with different protocols.14
In conclusion, these findings indicate that muscle activation is not affected to a large degree by
relative differences in applied pressure. Furthermore, we found that low-load exercise in combination with either 40% or 90% arterial occlusion
produced similar increases in muscle size, strength,
and endurance. In addition, the higher pressure
condition produced indicated higher ratings of discomfort throughout the training program. Based
on these preliminary data, we suggest that higher
relative pressures may not be necessary with lowload resistance training in combination with BFR.
REFERENCES
1. Loenneke JP, Wilson JM, Marin PJ, Zourdos MC, Bemben MG. Low
intensity blood flow restriction training: a meta-analysis. Eur J Appl
Physiol 2012;112:18491859.
2. Loenneke JP, Abe T, Wilson JM, Thiebaud RS, Fahs CA, Rossow LM,
et al. Blood flow restriction: an evidence based progressive model
(review). Acta Physiol Hung 2012;99:235250.
3. Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with
blood flow restriction: an updated evidence-based approach for
enhanced muscular development. Sports Med 2015;45:313325.
4. Loenneke JP, Wilson JM, Wilson GJ, Pujol TJ, Bemben MG. Potential
safety issues with blood flow restriction training. Scand J Med Sci
Sports 2011;21:510518.
5. Loenneke JP, Thiebaud RS, Abe T. Does blood flow restriction result
in skeletal muscle damage? A critical review of available evidence.
Scand J Med Sci Sports 2014;24:e415422.
6. Suga T, Okita K, Takada S, Omokawa M, Kadoguchi T, Yokota T, et
al. Effect of multiple set on intramuscular metabolic stress during
low-intensity resistance exercise with blood flow restriction. Eur J
Appl Physiol 2012;112:39153920.

MUSCLE & NERVE

March 2016

7. Yasuda T, Abe T, Brechue WF, Iida H, Takano H, Meguro K, et al.

Venous blood gas and metabolite response to low-intensity muscle
contractions with external limb compression. Metabolism 2010;59:
15101519.
8. Sugaya M, Yasuda T, Suga T, Okita K, Abe T. Change in intramuscular inorganic phosphate during multiple sets of blood flow-restricted
low-intensity exercise. Clin Physiol Funct Imaging 2011;31:411413.
9. Loenneke JP, Fahs CA, Wilson JM, Bemben MG. Blood flow restriction: the metabolite/volume threshold theory. Med Hypotheses 2011;
77:748752.
10. Cook SB, Clark BC, Ploutz-Snyder LL. Effects of exercise load and
blood-flow restriction on skeletal muscle function. Med Sci Sports
Exerc 2007;39:17081713.
11. Fahs CA, Loenneke JP, Thiebaud RS, Rossow LM, Kim D, Abe T, et
al. Muscular adaptations to fatiguing exercise with and without blood
flow restriction. Clin Physiol Funct Imaging 2015;35:167176.
12. Loenneke JP, Kim D, Fahs CA, Thiebaud RS, Abe T, Larson RD, et al.
Effects of exercise with and without different degrees of blood flow restriction on torque and muscle activation. Muscle Nerve 2015;51:713721.
13. Burd NA, West DW, Staples AW, Atherton PJ, Baker JM, Moore DR,
et al. Low-load high volume resistance exercise stimulates muscle
protein synthesis more than high-load low volume resistance exercise
in young men. PLoS One 2010;5:e12033.
14. Mitchell CJ, Churchward-Venne TA, West DW, Burd NA, Breen L,
Baker SK, et al. Resistance exercise load does not determine trainingmediated hypertrophic gains in young men. J Appl Physiol 2012;113:
7177.
15. van Roie E, Delecluse C, Coudyzer W, Boonen S, Bautmans I.
Strength training at high versus low external resistance in older
adults: effects on muscle volume, muscle strength, and force-velocity
characteristics. Exp Gerontol 2013;48:13511361.
16. Yasuda T, Fukumura K, Uchida Y, Koshi H, Iida H, Masamune K,
et al. Effects of low-load, elastic band resistance training combined
with blood flow restriction on muscle size and arterial stiffness in
older adults. J Gerontol A Biol Sci Med Sci 2015;70:950958.
17. Yasuda T, Loenneke JP, Thiebaud RS, Abe T. Effects of blood flow
restricted low-intensity concentric or eccentric training on muscle
size and strength. PLoS One 2012;7:e52843.
18. Baechle TR, Earle RW. Essentials of strength training and conditioning. Champaign, IL: Human Kinetics; 2000.

Relative BFR Pressure

19. Loenneke JP, Thiebaud RS, Fahs CA, Rossow LM, Abe T, Bemben
MG. Blood flow rest iction does not result in prolonged decrements
in torque. Eur J Appl Physiol 2013;113:923931.
20. Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N.
Effects of resitance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol 2000;88:2097
2106.
21. Yasuda T, Brechue WF, Fujita T, Sato Y, Abe T. Muscle activation
during low-intensity mucle contractions with varying levels of external
limb compression. J Sports Sci Med 2008;7:467474.
22. Yasuda T, Loenneke JP, Ogasawara R, Abe T. Influence of continuous or intermittent blood flow restriction on muscle activation during low-intensity multiple sets of resistance exercise. Acta Physiol
Hung 2013;100:419426.
23. Yasuda T, Fukumura K, Iida H, Nakajima T. Effect of low-load resistance exercise with and without blood flow restriction to volitional
fatigue on muscle swelling. Eur J Appl Physiol 2015;115:919926.
24. Loenneke JP, Fahs CA, Rossow LM, Thiebaud RS, Mattocks KT, Abe
T, et al. Blood flow restriction pressure recommendations: a tale of
two cuffs. Front Physiol 2013;4:249.
25. Martin-Hernandez J, Marin PJ, Menendez H, Ferrero C, Loenneke
JP, Herrero AJ. Muscular adaptations after two different volumes of
blood flow-restricted training. Scand J Med Sci Sports 2013;23:e114
120.
26. Loenneke JP, Thiebaud RS, Abe T, Bemben MG. Blood flow restriction pressure recommendations: the hormesis hypothesis. Med
Hypotheses 2014;82:623626.
27. Kawakami Y, Abe T, Fukunaga T. Muscle-fiber pennation angles are
greater in hypertrophied than in normal muscles. J Appl Physiol
1993;74:27402744.
28. Koskelo EK, Kivisaari LM, Saarinen UM, Siimes MA. Quantitation of
muscles and fat by ultrasonography: a useful method in the assessment of malnutrition in children. Acta Paediatr Scand 1991;80:682
687.
29. Dupont AC, Sauerbrei EE, Fenton PV, Shragge PC, Loeb GE,
Richmond FJ. Real-time sonography to estimate muscle thickness:
comparison with MRI and CT. J Clin Ultrasound 2001;29:230236.
30. Thiebaud RS, Yasuda T, Loenneke JP, Abe T. Effects of low-intensity
concentric and eccentric exercise combined with blood flow restriction on indices of exercise-induced muscle damage. Interv Med Appl
Sci 2013;5:5359.

MUSCLE & NERVE

March 2016

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