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Clin Physiol Funct Imaging (2017) doi: 10.1111/cpf.12416

The acute muscular response to blood flow-restricted

exercise with very low relative pressure
Matthew B. Jessee, Kevin T. Mattocks, Samuel L. Buckner, J. Grant Mouser, Brittany R. Counts,
Scott J. Dankel, Gilberto C. Laurentino and Jeremy P. Loenneke
Department of Health, Exercise Science, and Recreation Management, Kevser Ermin Applied Physiology Laboratory, The University of Mississippi, University, MS,
USA

Summary

Correspondence
Jeremy P. Loenneke, Kevser Ermin Applied
Physiology Laboratory, Department of Health,
Exercise Science, and Recreation Management,
The University of Mississippi, 231 Turner Center,
University, MS 38677, USA
E-mail: jploenne@olemiss.edu
Accepted for publication
Received 4 November 2016;
accepted 22 December 2016
Key words
EMG amplitude; muscle hypertrophy; muscle
thickness; occlusion training, arterial occlusion
To investigate the acute responses to blood flow-restricted (BFR) exercise across
low, moderate and high relative pressures. Muscle thickness, maximal voluntary
contraction (MVC) and electromyography (EMG) amplitude were assessed follow-
ing exercise with six different BFR pressures: 0%, 10%, 20%, 30%, 50% and 90%
of arterial occlusion pressure (AOP). There were differences between each time
point within each condition for muscle thickness, which increased postexercise
[+0
47 (0
40, 0
54) cm] and then trended towards baseline. For MVC, higher
pressures resulted in greater decrements than lower pressures [e.g. 10% AOP:
20
7 (15
5, 25
8) Nm versus 90% AOP: 24 (19
1, 28
9) Nm] postex-
ercise. EMG amplitude increased from the first three repetitions to the last three
repetitions within each set. When using a common BFR protocol with 30% 1RM,
applying BFR does not seem to augment acute responses over that of exercise
alone when exercise is taken to failure.

muscle activation (Yasuda et al., 2010) caused by metabolite-

Introduction
Resistance training with low loads, such as 20–30% of con-
centric one-repetition maximum (1RM), while under the
application of blood flow restriction (BFR) produces an
increase in muscle mass and strength similar to traditional
high-load (i.e. >70% 1RM) resistance training (Laurentino
et al., 2012; Martin-Hernandez et al., 2013; Vechin et al.,
2015). Many BFR studies involving the upper (Jessee et al.,
2016) and lower (Loenneke et al., 2012b,c) body have used
absolute pressures, which could be problematic as the stimu-
lus may not be the same for all participants. Although some
researchers have applied a restrictive stimulus based on bra-
chial systolic blood pressure measurements, it has been sug-
gested that the application of pressure be made relative to the
cuff used for BFR and to the individual, in order to ensure a
similar stimulus for each participant (Loenneke et al., 2013).
By measuring the arterial occlusion pressure (AOP) with the
cuff actually used during the BFR protocol, then applying the
stimulus as a percentage of that value, this ensures that the
methodology is replicable, and allows investigators to com-
pare various combinations of load and relative restriction pres-
sures (Loenneke et al., 2013).
The exact process by which BFR training works to increase
muscle size remains unclear. However, several potential mech-
anisms such as an increased muscle protein synthetic response
via muscle swelling (Yasuda et al., 2012) or an increased
induced fatigue (Sugaya et al., 2011) may be responsible for
muscle adaptation when training with BFR. Few studies have
investigated these muscular responses to BFR while using dif-
ferent combinations of the load being lifted and different rela-
tive restriction pressures applied (Loenneke et al., 2015, 2016;
Counts et al., 2016). In the lower body, acute muscle swelling
appears to be similar after exercising with 30% 1RM to fail-
ure, a traditional high-load (70% 1RM) protocol, and a com-
mon BFR protocol using moderate restrictive pressures (40,
50, and 60% of AOP), which suggests that muscle swelling in
the lower body is not further augmented by increasing the
load above 30% or applying a BFR stimulus (Loenneke et al.,
2016). Additionally, neither torque nor muscle activation
observed while exercising with 30% 1RM seems to be aug-
mented by applying restrictive pressures above 50% of AOP
(Loenneke et al., 2015). Thus, it seems when using 30% 1RM
with BFR, only moderate relative restrictive pressures (i.e. 40–
50% AOP) seem necessary to elicit acute muscular responses
indicative of a muscle hypertrophic stimulus. In support of
this, a training study, using a within-subject design, found
that BFR using either a high (90% of AOP) or a moderate
(40% AOP) relative pressure resulted in similar muscle size
and strength adaptations following 8 weeks of resistance train-
ing with 30% of 1RM (Counts et al., 2016). Thus, with
respect to skeletal muscle, it seems more beneficial to use a
moderate rather than a high restriction pressure, as higher

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 1
2 Lowest effective pressure, M. B. Jessee et al.
levels of restriction could potentially increase the chances of
adverse cardiovascular responses and increase participant dis-
comfort (Rossow et al., 2012). Even though BFR pressures
ranging from moderate (40% of AOP) to high (90% of AOP)
have been shown to result in similar muscular adaptation, it
remains unknown whether there is a lower threshold of
restriction pressure that would be necessary to elicit the same
adaptations. As previous acute studies have not investigated
pressures below 40% of AOP, and it is currently unknown
how BFR exercise using lower relative restriction pressures
(i.e. <40% AOP) influences the acute muscular response to
resistance exercise with 30% 1RM, the purpose of this study
was to compare the acute muscular response to upper body
exercise using a low load (30% 1RM) in combination with
various low (0%, 10%, 20%, 30% AOP), moderate (50%
AOP) and high (90% AOP) BFR pressures. We hypothesized
that elbow flexion exercise in combination with BFR would
elicit greater acute muscular responses compared to exercise
alone (0% of AOP), but there would be no difference in these
muscular responses between the BFR conditions (10%, 20%,
30%, 50%, 90% of AOP).
Materials and methods
Participants
Twenty-nine participants (22 males and seven females) with
resistance training experience in the upper body (at least two
times per week for the previous 6 months) volunteered to
participate in the study. Exclusion criteria included the follow-
ing: being outside the age range of 18–35 years, use of
tobacco, BMI > 30, exercise in the previous 24 h, caffeine in
the previous 8 h, food in the previous 2 h, alcohol consump-
tion in the previous 24 h and any orthopaedic injury prevent-
ing exercise. Participants were also excluded if they met two
or more of the following risk factors for thromboembolism:
currently taking birth control, diagnosed with Crohn’s disease,
past fracture of hip, pelvis or femur, major surgery within the
last 6 months, varicose veins, family or personal history of
deep vein thrombosis, or family or personal history of pul-
monary embolism (Motykie et al., 2000). In total, three partic-
ipants were excluded from the study. One participant used
tobacco, another answered yes to a question on the PAR-Q,
and the third participant did not complete all testing visits due
to reasons unrelated to the study. Thus, the data presented are
for 26 participants (20 males and six females). The Univer-
sity’s Institutional Review Board approved this study. Addi-
tionally, participants were informed of all experimental
procedures as well as any potential risks associated with the
study before giving written informed consent.
Study design
Participants visited the laboratory four times, with each visit
separated by 5–10 days. The first visit was a familiarization
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
visit, and the next three were testing visits. On visit 1, partici-
pants completed paperwork, were measured for height and
body mass, standing arterial occlusion pressure (AOP), and
then elbow flexion 1RM was determined for both arms. After-
wards, participants were familiarized in both arms to isomet-
ric strength testing using a maximal voluntary contraction
(MVC) followed by BFR elbow flexion exercise (one set of 15
repetitions using 30% 1RM and 40% of AOP). At the conclu-
sion of visit 1, the order of experimental relative arterial
occlusion pressures (0%, 10%, 20%, 30%, 50% and 90% of
AOP) was randomized for each participant. For visits 2–4,
both arms performed BFR exercise and were tested for AOP,
muscle thickness, torque and electromyography (EMG) ampli-
tude. Similar to a previous study (Counts et al., 2016), all
exercise and testing were completed in the first arm (random-
ized between right or left) with one of the predetermined
pressures, and after a 5-min quiet rest period, the testing pro-
tocol was completed using the opposite arm using the appro-
priate predetermined pressure. Each testing protocol consisted
of the following measurements in order: AOP, muscle thick-
ness (pre), EMG skin preparation and electrode placement,
MVC (pre), BFR exercise, then muscle thickness and MVC
immediately after exercise (00 ), 15 min after exercise (150 )
and 30 min after exercise (300 ).
Arterial occlusion pressure
Upon arrival at the laboratory, participants were seated in a
quiet room for a 10-min rest period. After the rest period,
participants were asked to stand slowly, and a 5-cm nylon cuff
(SC5, Hokanson, Bellevue, WA, USA) was placed around the
most proximal portion of their upper arm. Next, a Doppler
probe (MD6, Hokanson) was placed at the radial artery of the
arm being tested to give an auditory indication of blood flow
distal to the cuff. The cuff was then slowly inflated using an
E20 Rapid Cuff Inflator (Hokanson). The lowest inflation pres-
sure at which a pulse was no longer detected by the Doppler
probe was deemed to be the AOP. After determining AOP, the
cuff was immediately deflated and removed.
One-repetition maximum
One-repetition maximum was determined to be the greatest
load a participant could properly lift through the concentric
portion of elbow flexion. To ensure strict form, the participant
began by standing with their feet shoulder width apart, and
their heels and back against a wall. The testing was preceded
by a warm-up of approximately five repetitions using a load
estimated to be close to 30% of the participant’s 1RM. Next,
the participant performed one repetition with a load around
60–75% 1RM, and then, the load progressively increased until
the participant failed to lift a load one time with proper form.
Each arm performed the test in an alternating fashion with 3–
5 min of rest in between each attempt. One-repetition maxi-
mum was usually achieved within five attempts.

Muscle thickness
Muscle thickness was measured using B-mode ultrasonography
(Aloka SSD-550; 5 MHz probe) in the standing position to
give an indication of acute muscle swelling. The site to be
measured for muscle thickness of the anterior arm was
marked by measuring 10 cm proximal to the lateral epi-
condyle of the humerus and tracing a line anteriorly over the
midline of the biceps muscle belly. An ultrasound probe was
coated with water-soluble transmission gel and then placed
over the site in a medial–lateral orientation at a perpendicular
angle to the arm. Care was taken to exert minimal pressure to
the skin in order to achieve the most accurate measurement.
Muscle thickness was determined to be the distance between
the muscle–bone interface and the muscle–fat interface. Mus-
cle thickness was measured prior to exercise, immediately
after exercise, as well as 15 and 30 min after exercise. Two
images were taken at each time point and averaged for analy-
sis. All muscle thickness measurements were performed prior
to MVC measurements with the exception of the 00 time
point, which required MVC to be performed first to minimize
recovery time. The minimal difference for muscle thickness
was calculated to be 0
2 cm.
Maximal voluntary isometric contraction
Maximal voluntary isometric contractions of the elbow flexors
were performed at a 60-degree angle on a dynamometer (Bio-
dex Quickset System 4, Biodex Medical Systems, Shirley, New
York, USA) to give an indication of fatigue. The participant
was properly fitted and secured in the chair of the
dynamometer, and then, the limb was weighed at 30° of
elbow flexion to correct for gravity. Afterwards, the lever arm
was moved to 60°, and the participant was instructed to pull
against the fixed lever arm as hard as possible for 3-s. After
observing a 60-s rest period, another 3-s MVC was completed.
The highest torque measurement from the two MVCs was
used for analysis. Torque was measured immediately prior to,
immediately post and 15 and 30 min postexercise.
Surface electromyography
Surface EMG activity was recorded from the biceps brachii
during the initial torque measurement and during exercise to
give an indication of muscle activation. While the elbow was
flexed and held at a 90-degree angle, a mark was made dis-
tally at two-thirds of the distance from the acromion process
to the crease of the antecubital fossa (Hermens et al., 1999).
This area of the skin as well as the area over the 7th cervical
vertebrae was shaved, abraded and then wiped with alcohol.
Two bipolar surface electrodes were placed using an interelec-
trode distance of 20 mm, and a ground electrode was placed
over the 7th cervical vertebrae. The surface electrodes were
connected to an amplifier and digitized (iWorx, Dover, NH,
USA). The signal was filtered (low-pass filter 500 kHz; high-
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Lowest effective pressure, M. B. Jessee et al. 3
pass filter 10 kHz), amplified (10009) and sampled at a rate
of 1 kHz. Computer software (Lab Scribe 2) was used to anal-
yse the data. Electromyography amplitude (root mean square,
RMS) was analysed using the average of the first three repeti-
tions and an average of the last three repetitions for each set
and expressed relative to the first three repetitions of set 1.
Our original intent was to normalize to the baseline MVC, but
due to EMG equipment malfunction during MVC in some of
the visits, we normalized to the first set in order to maintain a
sufficient sample size.
Blood flow restriction protocols
While standing, the participant had a 5-cm nylon cuff (SC5,
Hokanson, Bellevue, WA) applied to the proximal portion of
the exercise arm. The cuff was then inflated to one of the six
relative target inflation pressures investigated (0%, 10%, 20%,
30%, 50% and 90% of AOP). Once the cuff was inflated, the
participant began elbow flexion exercise with a load equal to
30% of their predetermined 1RM. The goal repetitions were
30, 15, 15 and 15 for sets 1–4, respectively, and 30 s of rest
was observed between each set. Upon completion of the final
repetition of the last set, the cuff was deflated and removed.
Each set was determined to be complete when the participant
performed all goal repetitions, they were unable to lift the
load or they could not lift the load to the pace of a metro-
nome which was set at 1-s for the concentric and 1-s for the
eccentric portion of the lift.
Statistical analyses
All data (means, 95% confidence intervals) were analysed using
the SPSS 22.0 statistical software package (IBM, Chicago, IL,
USA). To detect an interaction effect between condition and
time, a 6 (condition) 9 4 (time) repeated-measures ANOVA
was used for muscle thickness, MVC and repetitions, and a 6
(condition) 9 7 (time) repeated-measures ANOVA was used
for EMG amplitude. If there was a significant interaction, a one-
way repeated-measures ANOVA was performed across condi-
tions within each time point and across time points within each
condition to determine where the differences occurred. All sta-
tistical significance was set at an alpha level of 0
05.
Results
Participants
Descriptive statistics for the participants can be found in
Table 1.
Muscle thickness
A 6 9 4 repeated-measures ANOVA revealed a significant con-
dition x time interaction for muscle thickness (Fig. 1,
P = 0
024). A follow-up one-way ANOVA revealed no
4 Lowest effective pressure, M. B. Jessee et al.

Table 1 Participant characteristics.

EMG
Variable Mean Lower 95% Upper 95% A 6 9 7 repeated-measures ANOVA revealed no significant
Age (years) 22 21 23 condition x time interaction (Fig. 2, P = 0
458). Further, a
Height (cm) 175
3 171
2 179
4 one-way ANOVA revealed no main effect for condition
Body mass (kg) 78
7 73
4 84
1 (P = 0
724), but there was a main effect of time with ampli-
1RM left (kg) 22
6 19
9 25
4 tude increasing from the first three repetitions to the last three
1RM right (kg) 22
9 20
1 24
6
repetitions within each set (P≤0
003).
1RM, one-repetition maximum.
Repetitions
significant differences between conditions for each time point A 6 9 4 repeated-measures ANOVA revealed a significant
(pre: P = 0
339; 00 post: P = 0
585; 150 post: P = 0
798, 300 condition x time interaction for repetitions (Table 3,
post: P = 0
604). However, there were significant differences P<0
001). A one-way ANOVA across conditions revealed sig-
between each time point (P<0
001) within each condition with nificant differences in repetitions with fewer repetitions typi-
muscle thickness increasing postexercise and then trending back cally being completed using higher pressures (P<0
05). A
towards baseline (Fig. 1). Mean changes in muscle thickness one-way ANOVA within each condition across time points
from pre to 00 with 95% confidence intervals can be found in revealed significant differences between conditions with the
Figure S1. number of repetitions completed decreasing across time
(Table 3, P<0
001).
Maximal voluntary isometric contraction
A 6 9 4 repeated-measures ANOVA revealed a significant
Discussion
condition x time interaction for MVC (Table 2, P = 0
012). Overall, the current study suggests that there are no meaning-
Follow-up tests found significant differences across time ful differences in several acute muscular responses to exercise
within each individual condition (P<0
001). Torque decreased with 30% 1RM alone (0% AOP), or in combination with low
from pre- to postexercise and remained below baseline at 300 (10%, 20%, 30% AOP), moderate (50% AOP) or high (90%
post within all conditions. When looking across conditions AOP) relative BFR pressures when using a common set and
within each time point, there were significant differences only repetition protocol found within the BFR literature (Loenneke
at post (P = 0
015) with higher pressures resulting in greater et al., 2012c). Thus, when using such a protocol with a load
torque decrements than lower pressures (Table 2). Mean equal to 30% 1RM, applying BFR does not appear to augment
changes in torque from pre to post with 95% confidence acute muscle swelling, EMG amplitude or postexercise decre-
intervals can be found in Figure S2. ments in torque to a large degree. However, the conditions

Figure 1 Muscle thickness measurements taken immediately before exercise (pre), immediately after exercise (00 ), 15 min after exercise (150 ),
and 30 min after exercise (300 ) (P<0
05).

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
 Lowest effective pressure, M. B. Jessee et al. 5

Table 2 Maximal voluntary isometric contraction (Nm)

Condition Pre 00 Post 150 Post 300 Post Time

0% 66
7 (57
1, 76
3) 48
7 (41
7, 55
6) a

54
8 (45
8, 63
7) 56
9 (48
1, 65
8) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300 ;
150 versus 300
10% 66
6 (58
1, 75
1) 45
9 (40
0, 51
8)ab 56
0 (48
2, 63
8) 56
6 (48
6, 64
5) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300
20% 65
3 (56
1, 74
4) 46
8 (40
6, 53
1)a 53
8 (45
5, 62
1) 55
2 (46
9, 63
5) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300
30% 67
9 (58
0, 77
7) 47
9 (39
6, 56
1)a 56
2 (47
2, 65
3) 58
8 (49
4, 68
2) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300 ;
150 versus 300
50% 65
1 (56
0, 74
1) 43
7 (37
5, 49
9)b 53
8 (45
5, 62
0) 53
9 (45
7, 62
1) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300
90% 65
9 (56
1, 75
6) 41
8 (35
5, 48
1)b 54
7 (46
0, 63
4) 57
3 (48
6, 66
0) Pre versus 00 , 150 , 300 ; 00 versus 150 , 300 ;
150 versus 300

Data presented as means and 95% confidence intervals. Different letters indicate significant differences across conditions, within a particular time
point (P<0
05). If at least one letter is the same, those conditions are not significantly different. Simple effects of time are noted in the far right
column corresponding with each specific condition (P<0
05). Pre: immediately before exercise; 00 post: immediately after exercise; 150 : 15 min
after exercise; 300 : 30 min after exercise.

Figure 2 Average electromyography ampli-

tude of the first three repetitions and last
three repetitions of each set collapsed across
conditions. All values (n = 19) were made
relative to the first three repetitions of set 1.
Different letters indicate significant differences
between time points (P<0
05). If at least one
letter is the same, those conditions are not
significantly different.

Table 3 Repetitions per set for each condition.

Condition Set 1 Set 2 Set 3 Set 4 Time

0% 30 (30, 30)a 13 (12, 14)ab 11 (10, 12)ab 10 (9, 12)a 1 versus 2, 3, 4; 2 versus 3, 4
10% 29 (29, 30)ab 13 (12, 14)a 11 (10, 13)b 11 (9, 12)a 1 versus 2, 3, 4; 2 versus 3, 4; 3 versus. 4
20% 30 (30, 30)a 13 (12, 14)ac 11 (10, 13)ab 10 (9, 12)a 1 versus 2, 3, 4; 2 versus 3, 4
30% 30 (30, 30)a 12 (11, 13)bcd 11 (9, 12)ab 10 (8, 12)a 1 versus 2, 3, 4; 2 versus 3, 4; 3 versus 4
50% 29 (29, 29)bc 12 (11, 13)d 10 (8, 12)a 10 (8, 11)a 1 versus 2, 3, 4; 2 versus 3, 4
90% 29 (28, 30)ac 9 (7, 11)e 6 (4, 7)c 5 (3, 7)b 1 versus 2, 3, 4; 2 versus 3, 4

Data presented as means and 95% confidence intervals. Different letters indicate significant differences across conditions, within each particular set
(P<0
05). If at least one letter is the same, those conditions are not significantly different. Simple effects of time are noted in the far right column
corresponding with each specific condition (P<0
05).

applying BFR resulted in a lower overall number of repetitions skeletal muscle adaptation (Yasuda et al., 2012; Counts et al.,
completed, which became increasingly lower with an increas- 2016), this seems to suggest there would be no long-term
ing relative pressure. As the acute muscular responses investi- difference in muscle growth when training with 30% 1RM
gated within this study have been associated with long-term alone, or in combination with a variety of relative BFR

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
6 Lowest effective pressure, M. B. Jessee et al.
pressures, assuming the load is great enough to obtain failure
within the established protocol. However, such differences
should be investigated with long-term training studies, as
acute indirect markers of muscle growth may not necessarily
translate into long-term adaptations.
Acute muscle swelling
The acute change in muscle thickness following an exercise
protocol may indicate an extracellular fluid shift into the mus-
cle cell (Yasuda et al., 2012; Mart
ın-Hern
andez et al., 2013).
In turn, this increased fluid volume within the cell has been
suggested to start a signalling cascade to activate mTORC1 in
rats, eventually leading to an anabolic response in skeletal
muscle (Nakajima et al., 2016). In fact, previous associations
have been observed between acute muscle swelling and hyper-
trophy following BFR training, suggesting that a stimulus
resulting in a larger swelling response immediately after exer-
cise is associated with a greater overall hypertrophic response
following training (Yasuda et al., 2012). In the lower body, a
protocol using 30% 1RM to failure had similar acute muscle
thickness changes to that observed with BFR exercise protocols
using 40%, 50% and 60% of AOP (Loenneke et al., 2016).
Alongside the current study, there appears to be a lack of dif-
ference regarding acute changes in muscle swelling when
exercise is taken to failure, with no augmentation through the
application of BFR. This finding is in agreement with previous
data that show no difference in acute muscle swelling of the
elbow flexors following exercise to exhaustion, either with or
without BFR (Yasuda et al., 2015). Taken together, if acute
muscle swelling is in fact important for long-term muscle
growth, we would predict similar adaptations across all condi-
tions, as has been shown when low-load exercise with or
without BFR is taken to failure (Farup et al., 2015). It is
important to note, however, that although swelling is associ-
ated with muscle growth, it may not be a sufficient stimulus
alone, as BFR in the absence of exercise induces acute changes
in muscle thickness, but does not result in long-term muscle
growth (Loenneke et al., 2012a).
EMG amplitude
Exercise with BFR induces an accumulation of various metabo-
lites within the working muscle and could eventually result in
a fatiguing stimulus that may increase the stimulation of group
III and IV afferents, consequently leading to an increased
recruitment of higher threshold motor units in order to main-
tain voluntary performance of the desired muscle action
(Yasuda et al., 2010; Brandner et al., 2015). Acute decrements
in torque due to fatigue from exercise have been shown to be
similar following a traditional high-load (70% 1RM) protocol,
low load (30% 1RM) to failure or 30% 1RM in combination
with BFR (40%, 50% and 60% of AOP) (Loenneke et al., 2015)
and thus may increase muscle activation comparably. Indeed,
the current study found similar exercise-induced fatigue and
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
EMG amplitude, regardless of the BFR condition. In contrast, a
previous study found that the change in EMG amplitude and
fatigue following BFR exercise was dependent upon the level
of the cuff inflation pressure (Fatela et al., 2016). The discrep-
ancy in findings between studies may be attributed to several
methodological differences. In the current study, muscular
responses were examined in a trained population exercising
with 30% 1RM, whereas Fatela et al. studied untrained partici-
pants exercising with a lower relative load (20% 1RM), which
suggests that either training status or the load being used in
combination with BFR may play a role in mediating the mus-
cular response to varying degrees of restrictive pressure. A BFR
study comparing EMG amplitude between moderate (40%,
50% and 60% of AOP) relative BFR pressures using 30% 1RM
has shown that amplitude may be increased from 40% to 50%
AOP, but not further augmented when applying 60% of AOP
(Loenneke et al., 2015). However, this study was carried out in
the lower body, using a between-subject design, and only
investigated qualitative differences between conditions,
whereas an acute study carried out in the upper body using a
within-subject design found no differences in EMG amplitude
between conditions using 30% 1RM in combination with
either 40%, 50%, 60%, 70%, 80% or 90% of AOP (Counts
et al., 2016). Additionally, training of the elbow flexors for
8 weeks using 30% 1RM in combination with either a moder-
ate (40% of AOP) or high (90% of AOP) BFR pressure resulted
in similar muscle growth (Counts et al., 2016). Thus, the lack
of differences found in EMG amplitude in the current study
may suggest that using 30% 1RM is sufficient to induce a
hypertrophic stimulus and applying BFR would not augment
the response.
Exercise to fatigue
The lack of differences in acute muscular responses found in
the current study is most likely due to the load and repetition
protocol inducing fatigue, regardless of the relative pressure
applied. This can be supported by the inability of the partici-
pants to perform all of the goal repetitions (Table 3 and Fig-
ure S3) and the lack of meaningful differences (higher
pressure resulted in a larger decrement only at 00 post) in
exercise-induced torque decrements observed between condi-
tions. The importance of exercise to failure may be illustrated
best when comparing high and low loads. Mixed and myofib-
rillar protein fractional synthetic rate 4 h postexercise was
comparable between a condition using a high percentage of
1RM (90%) performed to failure and a condition performing
30% 1RM to failure; however, a 30% 1RM work-matched
condition (to 90%), although increased above baseline, was
significantly lower than the failure conditions (Burd et al.,
2010). In fact, knee extension training for 10 weeks elicited
similar muscle growth in the quadriceps when using either a
high (80%) or low (30%) load provided the protocol is taken
to failure (Mitchell et al., 2012). Adding BFR to a failure pro-
tocol even with low loads would not augment hypertrophy,
 Lowest effective pressure, M. B. Jessee et al. 7

as performing knee extensions to volitional fatigue, using
30% 1RM alone or with BFR, elicited similar increases in
muscle thickness (Fahs et al., 2015). It should be noted that
the participants in the current study had a moderately high
1RM, and when considering the absolute load being lifted
during exercise (even at 30% of maximum), they may have
reached fatigue more quickly than previous studies imple-
menting the repetition protocol 30-15-15-15. In fact, previ-
ous research has shown that the endurance differences
between men and women are related to differences in the
absolute load being lifted, even at a low percentage (20%) of
maximum intensity (Hunter & Enoka, 2001). It could there-
fore be argued that, in a weaker population, 30% 1RM alone
may not be a sufficient load to reach volitional fatigue, and
the addition of BFR could potentially augment muscle adapta-
tion over 30% 1RM alone. It should not be overlooked, how-
ever, that BFR might induce fatigue quicker, in turn reducing
the overall workload, which may be beneficial in certain pop-
ulations.
Limitations
The current study is not without limitation. The responses
investigated were only acute, investigated in trained partici-
pants, only performed in the upper body, and BFR was
applied using only a narrow cuff. Muscular responses of exer-
cise were investigated due to various studies showing that
acute changes in muscle thickness, EMG amplitude and muscle
fatigue are associated with long-term hypertrophic adaptations
(Yasuda et al., 2012, 2015; Counts et al., 2016). Thus,
researchers can infer with a reasonable amount of confidence
how a muscle might respond to a long-term training stimulus
based on the aforementioned acute responses to different
exercise stimuli. To avoid the effects of the exercise stimulus
being novel, trained participants were studied, and in addi-
tion, most participants in this study had a fairly high 1RM.
Thus, the absolute load being lifted at 30% 1RM is likely
higher than what most populations would be using for BFR
exercise. The acute responses to various relative BFR pressures
was investigated in the upper body only and may not neces-
sarily be relevant to the lower body. However, given that the
results of previous studies completed in the lower body are
quite similar to those found in the upper body, we are confi-
dent the responses may not be different, although a long-term
training study would be necessary to confirm such. Finally,
the relative restrictive pressures investigated in the current
study were applied only using a narrow (5 cm) cuff, and it is
possible the muscular response may be different when using a
wider cuff (Kacin & Strazar, 2011; Ellefsen et al., 2015); how-
ever, Laurentino et al. (2016) suggested that the response in
the upper body is similar when the restrictive pressure is
made relative to the AOP of the cuff being used for BFR.
Conclusion
The results of the current experiment suggest that when exer-
cising with a load equal to 30% of 1RM taken to volitional
fatigue, applying BFR does not augment various acute muscu-
lar responses indicative of a hypertrophic stimulus. Therefore,
training with 30% 1RM alone may be sufficient in stronger
populations to induce long-term muscle adaptations. How-
ever, this may not necessarily be true of lower relative exer-
cise loads, or weaker individuals. Thus, future research should
investigate the effect of BFR on acute muscular responses
using lower relative loads.
Acknowledgments
This study was supported in part by the BioLayne foundation
(SJD and JPL).
Conflict of interests
The authors declare no conflict of interest.

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Figure S1. The mean pre-post change in muscle thickness
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