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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
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FIGURE 1. Outline of experiment 2. Mth, muscle thickness; 1RM, 1-repetition maximum; 30% to failure is test of muscle endurance.
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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.
Experiment 2.
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.
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441
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).
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.
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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)
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.
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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
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