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ABSTRACT: Introduction: The aim of this study was to investi- recruitment with low-load resistance exercise in
gate the acute and chronic skeletal muscle response to differing combination with BFR. Muscle fiber recruitment
levels of blood flow restriction (BFR) pressure. Methods: Four-
teen participants completed elbow flexion exercise with pres- may be important, as it has been previously sug-
sures from 40% to 90% of arterial occlusion. Pre/post torque gested that increased recruitment is related to
measurements and electromyographic (EMG) amplitude of some degree with changes in muscle protein syn-
each set were quantified for each condition. This was followed
by a separate 8-week training study of the effect of high (90% thesis.9 To illustrate, lower body low-load exercise
arterial occlusion) and low (40% arterial occlusion) pressure on to volitional fatigue results in high levels of muscle
muscle size and function. Results: For the acute study, activation,1012 and has also been found to pro-
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 duce muscle protein synthetic13 and muscle hyper-
reps there was a time effect. After training, increases in muscle trophic responses similar to higher load resistance
size (10%), peak isotonic strength (18%), peak isokinetic torque training.14,15
(1808/s 5 23%, 608/s 5 11%), and muscular endurance (62%)
changed similarly between pressures. Conclusion: We suggest We recently observed that higher relative pres-
that higher relative pressures may not be necessary when exer- sures (pressures based on individual limb circumfer-
cising under BFR. ence) may not augment muscle activation in the
Muscle Nerve 53: 438445, 2016
lower body.12 However, due to the lack of statistical
power to compare across groups, only qualitative
analyses could be completed across pressures
Low-load resistance exercise [20%30% concen- (40%60% estimated arterial occlusion). Further-
tric 1-repetition maximum (1RM)] in combination more, no published study to date has compared the
with blood flow restriction (BFR) increases muscle hypertrophic responses of BFR training under dif-
size and strength in a variety of populations.13 ferent occlusion pressures. Thus, the purpose of
When applied appropriately, this stimulus has this study was 2-fold. First, we sought to determine,
been found to provide a safe and effective stimulus using a within-subject design, whether or not higher
in the absence of measurable muscle damage.4,5 relative pressures provide an increase in muscle acti-
The mechanisms behind these beneficial effects vation over lower pressures. We hypothesized that
are not completely known, but metabolic accumu- muscle activation would not be augmented to a
lationinduced fatigue may be playing an influen- large degree with higher pressures. Second, based
tial role in the muscle adaptations observed after on the acute muscle activation data, we sought to
this type of exercise. To illustrate, metabolic accu- determine whether differences in muscle adaptation
mulation in combination with a reduced oxygen would be observed after 8 weeks of resistance train-
environment may increase recruitment of higher ing with either high or low pressures applied.
threshold (type II) muscle fibers.6,7 This suggests Although similar muscle activation was reported
that higher pressures, resulting in a greater reduc- across pressures, we hypothesized that exercising
tion in oxygen and subsequent increase in meta- with higher relative pressures may attenuate some
bolic accumulation,8 may augment muscle fiber of the gains in muscle mass due to the reduction in
total exercise volume observed with higher pres-
Abbreviations: 1RM, 1-repetition maximum; ANOVA, analysis of var- sures from the acute study.
iance; bSBP, brachial systolic blood pressure; EMG, electromyography;
FR, blood flow restriction; MVC, maximal voluntary contraction
METHODS
Additional Supporting Information may be found in the online version of
this article. Participants. For experiment 1, 14 physically active
Key words: arterial occlusion; hypertrophy; KAATSU; perceptual participants (10 men, 4 women) were recruited.
response; resistance training; vascular occlusion training Physically active was defined as being active 3 or
Correspondence to: J.P. Loenneke; e-mail: jploenne@olemiss.edu
more days per week with an upper body resistance
C 2015 Wiley Periodicals, Inc.
V
Published online 2 July 2015 in Wiley Online Library (wileyonlinelibrary.com).
training component 2 or more days per week for at
DOI 10.1002/mus.24756 least the previous 3 months. Physically active
438 Relative BFR Pressure MUSCLE & NERVE March 2016
participants were used to better reflect the actual acute belly with an inter-electrode distance of 20 mm.
responses to different exercise and limit the possibility The ground electrode was placed on the seventh
of a training effect due to repeated testing. For experi- cervical vertebrae at the neck. The surface electro-
ment 2, a total of 8 nonresistance-trained men des were connected to an amplifier and digitized
(n 5 5) and women (n 5 3) volunteered to participate (Biopac Systems, Inc., Goleta, California). The sig-
in this study. One man enrolled but dropped out nal was filtered (low-pass filter 500 HZ, high-pass
before the first visit, therefore analysis was conducted filter 10 HZ), amplified (1,0003), and sampled at
on the remaining 7 participants. Participants were a rate of 1 kHZ. Before the exercise bout, the par-
excluded if they had at least 1 risk factor for throm- ticipant performed 2 isometric MVCs with the
boembolism. The experiments were approved by the biceps brachii at a joint angle of 908 with a 30-s
universitys institutional review board, and each rest between MVCs on an isokinetic dynamometer.
participant gave written informed consent before The EMG was recorded continuously from the
participation. biceps brachii during each exercise bout. LabView
7.1 (National Instrument Corp., Austin, Texas)
Experiment 1 Study Design. During the initial visit
computer software was used to analyze the data.
participants had standing arterial occlusion pres-
EMG amplitude (root mean square, RMS) was ana-
sure determined and were then tested on each
lyzed from the average of the first 3 repetitions
arm for the unilateral dumbbell elbow flexion 1-
and the average of the last 3 repetitions for each
repetition maximum (1RM). Participants were
set and expressed relative to the highest pre-
then familiarized with the BFR stimulus and maxi-
exercise MVC (%MVC).
mal voluntary contraction (MVC) testing. Next,
participants were scheduled for the first of 3 test- Experiment 2 Study Design. Based on findings
ing visits with a minimum of 5 and a maximum of from the acute study, we sought to determine
10 days between visits. Participants completed all whether the acute changes would translate to
of the exercise conditions in random order (1 con- chronic muscle adaptation. Thus, participants com-
dition per arm) across 3 separate visits (2 condi- pleted 8 weeks of low-load unilateral elbow flexion
tions per visit). The exercise bouts within each day training with 1 arm exercising at low pressure
were separated by 10 min of rest. For each condi- (40% arterial occlusion) and the other arm exer-
tion, the participants were instructed to complete cising at higher pressure (90% arterial occlusion).
1 set of 30 repetitions followed by 3 sets of 15 rep- The participants visited the laboratory for a total
etitions at 30% of their concentric 1RM at 40%, of 26 visits. The first 2 pre-training visits consisted
50%, 60%, 70%, 80%, or 90% of their standing of paperwork and baseline measurements, followed
arterial occlusion pressure. All conditions were sep- by 22 separate training sessions and 2 post-training
arated by 30-s rest periods between sets. A metro- visits (4872 h after last training session) that
nome was used to ensure that the participants measured changes caused by the exercise interven-
held the cadence of 1 s for the concentric muscle tion (Fig. 1). Participants trained 2 times per week
action and 1 s for the eccentric muscle action dur- for the first 2 weeks followed by 3 training sessions
ing the unilateral elbow flexion exercise. If the per week for weeks 38. A similar number of train-
participant could not maintain the cadence during ing sessions has previously been shown to produce
a particular set, the set was stopped, and the partic- measurable changes in muscle size and
ipant rested for 30 s until the next set. Muscle acti- strength.16,17 The goal reps for each exercise pro-
vation was measured at pre-exercise (no BFR) and tocol included 1 set of 30 repetitions followed by 3
during each set of exercise (with BFR). The elbow sets of 15, with 30-s rest periods between sets. Exer-
flexor MVC was performed on an isokinetic dyna- cise was completed to a metronome with 1 s for
mometer pre- and post-exercise to determine the concentric and 1 s for the eccentric portion of
fatigue. All testing sessions were completed before the exercise. Participants were stopped before
the participant exercised for that day, and each completing the goal number of repetitions, when
visit was completed at least 24 h after the last they were unable to lift the load with proper form
upper body workout. or keep to the beat of the metronome. Training
load was adjusted every 2 weeks to maintain 30%
Electromyography and Isometric Fatigue. Electro-
of 1RM. A non-BFR control condition was not
myographic (EMG) signals were recorded from the
included, as previous studies have consistently
biceps brachii of the arm during exercise. Electro-
shown that repetition-matched protocols without
des were placed on a line between the medial acro-
BFR do not lead to meaningful changes in muscle
mion and the antecubital fossa at a distance of
size and strength.1
one-third from the antecubital fossa. The skin was
shaved, abraded, and cleaned with alcohol wipes. Determination of 1RM. For experiments 1 and 2,
Bipolar electrodes were placed over the muscle the maximum load that could be lifted for the
Relative BFR Pressure MUSCLE & NERVE March 2016 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 thicknesses of the deltoid and triceps were also
motion with proper form was assessed and measured to demonstrate stability of the measure-
recorded as the concentric 1RM. Briefly, partici- ment across time, as those muscle groups were not
pants completed 5 reps of light weight (3.41 kg) expected to change with strict elbow flexion exer-
as a warm-up, and then weight was progressively cise. The minimal difference (i.e., reliability)
increased until the load could not be lifted success- needed to be considered real for the anterior por-
fully through a full range of motion.18 Each arm tion of the upper and lower arm was calculated to
was tested in a random order, and all participants be 0.2 cm.
reached their 1RM within 5 attempts. To ensure
Muscle Endurance. Participants completed as
strict form, participants completed their concentric
many repetitions of unilateral elbow flexion exer-
1RM with their back and heels against a wall and
cise as they could to a metronome with 1 s for the
with feet shoulder width apart.
concentric and 1 s for the eccentric portion of the
Determination of Arterial Occlusion Pressure. For lift. The load used was 30% of the predetermined
experiments 1 and 2, a narrow (5-cm-wide blad- 1RM for that test day. All participants kept their
der) nylon cuff was applied to the most proximal back and heels against a wall with their feet
part of the arm. Pressure was regulated using a shoulder width apart to ensure strict form through-
cuff inflator system (E 20 Rapid Cuff Inflator; out testing.
Hokanson, Bellevue, Washington). The pulse at
Isokinetic Elbow Flexion Strength. Isokinetic torque
the wrist (arterial blood blow) was detected using a
was measured using an isokinetic dynamometer
hand-held bidirectional Doppler probe placed on
(Quickset System 4; Biodex) Measurements were
the radial artery. The cuffs were inflated to 50 mm
taken on both arms in random order. First, partici-
Hg and quickly raised to the participants previ-
pants completed 2 sets of 3 at 1808/s separated by
ously measured systolic blood pressure. Pressure
90 s of rest. This was then repeated at 608/s. All
was then slowly increased until the arterial flow
values were gravity corrected. The minimal differ-
was no longer detected during inflation. Arterial
ences needed for changes to be considered real
occlusion pressure was recorded to the nearest
were calculated as 5 Nm for 1808/s and 3 Nm for
1 mm Hg as the lowest cuff pressure at which a
608/s.
pulse was not present.
Ratings of Discomfort. Ratings of discomfort were
Muscle Thickness. For experiment 2, muscle size
quantified using the Borg discomfort scale
was estimated by B-mode ultrasound (SSD-500 with
(CR101) before each exercise bout and after each
a 5-MHZ probe; Aloka). Ultrasound measurements
set for all training sessions, Methods have been
of the biceps brachii were taken halfway between
described in detail previously.19
the acromion process and lateral epicondyle and
10 cm proximal to the lateral epicondyle. Muscle Statistical Analyses. All data were analyzed using
size of the anterior forearm was measured at 30% SPSS 22.0 software (SPSS, Inc., Chicago, Illinois)
proximal between the styloid process and the head with variability represented as standard deviation
of the ulna. Three images were taken at each site, (SD). For experiment 1, there were no baseline
printed, and analyzed by an investigator who was differences in MVC, thus a 1-way analysis of var-
blinded to the arms condition. The average of the iance (ANOVA) was completed for the MVC
3 measurements was used for final analysis. Muscle change scores (mean decrease from baseline) and
440 Relative BFR Pressure MUSCLE & NERVE March 2016
overall exercise volume to determine whether dif-
ferences existed between conditions. For EMG, a 6
(condition) 3 4 (time) repeated-measures ANOVA
was used. A significant result from the repeated-
measures 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 mus-
cle thickness, maximal isotonic strength, and exer-
cise volume. A significant result from the repeated-
measures ANOVA was followed by a 1-way ANOVA
to determine where the difference occurred across
time within each pressure, and a paired-sample t-
test was used to determine where the differences FIGURE 2. Mean total exercise volume completed across pres-
sures in the acute study (experiment 1). Conditions with differ-
occurred between pressures within each time- ent letters represent significant differences between conditions
point. A 2 (condition) 3 2 (time) repeated- (P 0.05). Variability is represented as standard deviations.
measures ANOVA was completed for isokinetic
strength. Follow-up tests included paired sample t- in height, 56.7 6 11.3 kg in weight, and had a
tests across time within each pressure and across standing arterial occlusion pressure of 129 6 19
pressures within each time-point. For ratings of dis- mm Hg for the high-pressure arm and 133 6 19
comfort, Wilcoxon-related samples non-parametric mm Hg for the low-pressure arm. Thus, the mean
tests determined differences between pressures pressure used during exercise was 116 6 17 mm
within each set of exercise. Statistical significance Hg and 53 6 7 mm Hg for the high- and low-
was set at an alpha level of 0.05. pressure arms, respectively. Of the 22 training ses-
RESULTS sions, 2 participants missed 1 training session each,
Experiment 1. Participants. Participants (n 5 14), translating into an overall completion rate of 99%.
on average, were 24 6 3 years old, 174 6 7 cm in Muscle Thickness. There was no significant
height, 79.7 6 11.3 kg in weight, and had a 1RM for interaction with muscle thickness at the midupper
the right arm of 18 6 6 kg and a 1RM for the left arm (P 5 0.258; Fig. 3A) or 10 cm above the elbow
arm of 19 6 6 kg, and had a standing arterial occlu- joint (P 5 0.674; Fig. 3B). In addition, there was no
sion pressure of 140 6 14 mm Hg for the right arm significant main effect for condition (P 0.151),
and 143 6 17 mm Hg for the left arm. but there was for time (P < 0.001). With the fore-
Maximal Voluntary Contraction. There were no
arm, there was no interaction (P 5 0.338) or main
significant differences across arterial occlusion
effect of condition, but there was a main effect of
pressures in the MVC change scores from baseline
time (P 5 0.04). Follow-up tests for forearm muscle
(P 5 0.344). The grand mean decline in torque
size identified a significant increase from pre to
from baseline was 215.5 6 5.9 Nm.
post [1.8 6 0.1 cm vs. 1.9 6 0.2 cm], but this differ-
Exercise Volume. There were significant differ-
ence did not exceed the error of our measurement.
ences in exercise volume across pressures, with less
volume being completed at the highest pressures In addition, no significant differences were
(P < 0.001; Fig. 2B). observed across time for the triceps or deltoid (data
EMG. There was no significant interaction not shown).
with amplitude of the first 3 repetitions (P 5 0.456; Muscle Strength. There was no significant inter-
Table 1). In addition, there was no significant action with muscle strength (P 5 0.909). In addition,
main effect for condition (P 5 0.850), but there there was no significant main effect for condition
was for time (P < 0.001), with amplitude increasing (P 5 0.409), but there was for time (P < 0.001). Maxi-
from the first set. For the last repetitions, there mal isotonic strength (1RM) increased from pre to
was no significant interaction with EMG amplitude mid [11.2 6 5 kg vs. 12.2 6 5.5 kg] to post
(P 5 0.450; Table 1). In addition, there was no sig- [13.2 6 5.8 kg], with significant differences between
nificant main effect for condition (P 5 0.881), but each time-point (P 0.006).
there was for time (P 5 0.021).
Isokinetic Torque. There was no significant inter-
Experiment 2. Participants. Participants (n 5 7), action with isokinetic strength at 1808/s (P 5 0.480;
on average, were 23 6 3 years old, 169.6 6 9.5 cm Fig. 3C) or 608/s (P 5 0.386; Fig. 3D). In addition,
Relative BFR Pressure MUSCLE & NERVE March 2016 441
Table 1. Muscle activation from experiment 1.
EMG amplitude first 3 reps (%MVC) Time
Arterial occlusion Set 1 Set 2 Set 3 Set 4 1 vs. 2, 3, 4
40% 33 (9) 46 (19) 48 (18) 44 (14)
50% 38 (13) 51 (17) 56 (21) 53 (23)
60% 43 (31) 58 (32) 56 (30) 56 (28)
70% 36 (20) 49 (26) 52 (26) 49 (23)
80% 37 (13) 53 (23) 45 (15) 55 (31)
90% 36 (20) 53 (37) 53 (39) 51 (33)
EMG amplitude last 3 reps (%MVC)
Arterial occlusion Set 1 Set 2 Set 3 Set 4 2 vs. 3, 4; 3 vs. 4
40% 53 (16) 61 (22) 56 (23) 49 (16)
50% 62 (27) 74 (34) 64 (38) 63 (38)
60% 71 (45) 71 (37) 65 (39) 60 (35)
70% 62 (43) 65 (37) 59 (30) 55 (30)
80% 61 (26) 68 (41) 66 (48) 61 (40)
90% 57 (35) 64 (53) 58 (49) 56 (43)
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 between pressures for most sets of exercise (Table
(P 0.633), but there was for time (P 0.014). 2). When plotted across time, the peak discomfort
Muscle Endurance. There was no significant was almost always higher in the high-pressure arm
interaction with muscle endurance (P 5 0.901). In (see Fig. S1 in the Supplementary Material, avail-
addition, there was no significant main effect for able online).
condition (P 5 0.265), but there was for time Exercise Volume. There was no significant inter-
(P < 0.001). The number of repetitions completed action with the average repetitions completed in
to failure increased from pre [37 (7) repetitions] the first set in weeks 1, 4, or 8 (P 5 0.08; Table 3).
to post [60 (13) repetitions]. In addition, there was no significant main effect
Rating of Discomfort. Ratings of discomfort for condition (P 5 0.08) or time (P 5 0.10). For
between pressures were statistically compared in the average repetitions completed in sets 24,
the first, eleventh, and last training sessions. Rat- there was no significant interaction (P 5 0.416;
ings of discomfort were significantly different 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 suffi-
cient statistical power, only pre-exercise, day 11, and post-exercise were compared.
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.