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The Perceptual Responses to Occluded Exercise

Article in International Journal of Sports Medicine December 2010

DOI: 10.1055/s-0030-1268472 Source: PubMed

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The Perceptual Responses to Occluded Exercise
Authors
Aliation
Key words
RPE
pain
hypertrophy
muscle
protein synthesis
accepted after revision
October 24, 2010
Bibliography
DOI http://dx.doi.org/
10.1055/s-0030-1268472
Published online:
December 16, 2010
Int J Sports Med 2011; 32:
181184 Georg Thieme
Verlag KG Stuttgart New York
ISSN 0172-4622
Correspondence
Jeremy Paul Loenneke
Southeast Missouri State
University
Health, Human Performance
and Recreation
One University Plaza
63701 Cape Girardeau
United States
Tel.: +1/573/450 2952
Fax: +1/573/651 5150
J. P. Loenneke, A. Balapur, A. D. Thrower, J. T. Barnes, T. J. Pujol
Southeast Missouri State University, Health, Human Performance and Recreation, Cape Girardeau, United States
Abstract
lyzed using paired sample t-tests with an alpha
The purpose was to determine repetitions to
failure and perceptual responses to exercise
with and without occlusion. 15 subjects partici-
pated in a randomized crossover study of 3 trials.
The first determined one repetition maximum
(1RM) on the leg extension. Subjects were then
assigned to an occlusion (OCC) or control (CON)
group. After trial 2, subjects crossed over to the
opposite trial. Knee wraps (KW) were placed
around the upper thigh of each leg during OCC.
Subjects completed 2 sets of leg extensions to
failure at 30 % 1RM, with 30 s rest between sets.
Ratings of perceived exertion (RPE) and pain (P)
Introduction
The American College of Sports Medicine (ACSM)
recommends lifting a weight of at least 70 % of
ones one repetition maximum (1RM) to achieve
muscular hypertrophy under normal conditions,
and it is believed that anything below this inten-
sity rarely produces substantial muscle hypertro-
phy or strength gains [2]. However, many
populations are unable to withstand the high
mechanical stress placed upon the joints during
heavy resistance training, for example, the elderly
and rehabilitating athletes. Therefore, profes-
sionals have sought lower intensity alternatives
for such individuals.
One such alternative is vascular occlusion train-
ing, also known as KAATSU training. Vascular
occlusion training, as the name implies, involves
decreasing blood flow to a working muscle, by
application of a wrapping device, such as a blood
pressure cu. Evidence indicates that this unique
style of training can be beneficial in clinical set-
tings, as it produces positive training adaptations
equivalent to the physical activity of daily life
(1030 % of maximal work capacity) [1]. Muscle
Loenneke JP et al. The Perceptual Responses to Occluded Int J Sports Med 2011; 32: 181184
Training & Testing 181
were taken following each set. Data were ana-
level of 0.01. OCC repetitions were lower for the
first and second set compared to CON (p = 0.001).
Total work completed was significantly lower
with OCC compared to CON (p = 0.001). OCC RPE
were higher for both the first (p = 0.01) and sec-
ond set (p = 0.003) compared to CON. P was not
dierent following one set but was higher with
OCC over CON following the second (p = 0.009).
In conclusion, KW provide an OCC stimulus
allowing failure to occur sooner. However, the
higher perceptual responses with OCC may limit
its application to the highly motivated.
hypertrophy has recently been shown to occur
during exercise as low as 20 % 1RM with moder-
ate vascular occlusion (~100 mmHg) [24]; which
can be beneficial to athletes [19], patients in post
operation rehabilitation (specifically ACL inju-
ries), cardiac rehabilitation patients, and the
elderly [18, 20]. Some research indicates that vas-
cular occlusion training might also be beneficial
for astronauts while in a zero gravity environ-
ment [12, 18].
Previous literature has discussed the proposed
mechanisms of vascular occlusion training in
depth [11, 13, 14]. The stimulation of muscle pro-
tein synthesis is one mechanism involved in
skeletal muscle hypertrophy and research dem-
onstrates that vascular occlusion training stimu-
lates MPS at rates similar to high intensity
resistance training. Interestingly, muscle protein
synthesis, when exercising at 30 % 1RM with nor-
mal blood flow to failure, has been shown to
occur at rates equal to heavy resistance training
to failure [5]. Additionally, Burd et al. [6] have
demonstrated that 3 sets of resistance exercise
performed to muscular failure produces a greater
amplitude and duration in MPS than 1 set of the
182 Training & Testing
same exercise to failure, highlighting an importance of resist-
ance exercise volume, however 1 set to muscular failure did sig-
nificantly elevate muscle protein synthesis. Low intensity
exercise to muscular failure forces a recruitment of the fast
twitch (FT) fibers, however, a low load protocol requires more
repetitions to stimulate muscle protein synthesis, and individu-
als with lower limb injuries or the elderly may be incapable of
sustaining the mechanical stress necessary to reach muscular
failure.
Researchers have shown that vascular occlusion using a curved
pneumatic tourniquet cu allows fewer repetitions to be com-
pleted until muscular failure is reached when compared to low
intensity exercise using the same load (30 %1RM). These findings
suggest that vascular occlusion training using a pneumatic tour-
niquet cu allows muscular failure to occur after an overall
lower volume of work (repetitions load) since low intensity
exercise required more repetitions to be completed. Further-
more, vascular occlusion training research has demonstrated
through integrated electromyography (iEMG) [15, 19, 21] and
inorganic phosphate splitting [16], that recruitment of the higher
threshold motor units (containing FT fibers) does occur with
lower intensity exercise despite this reduced volume, likely from
the reduction in oxygen and subsequent metabolic accumula-
tion [13].
Despite the observed benefits with vascular occlusion training,
potential perceptual limitations to performing such exercise
have been previously investigated with pneumatic tourniquet
cus. Previous research has not observed dierences in ratings
of perceived exertion (RPE) [22, 23], but ratings of pain (P) with
vascular occlusion training remain contradictory. One study
observed increased P when compared to low intensity exercise
without vascular restriction [22], however another observed no
dierences [23]. The perceptual response to exercise is of impor-
tance because electromyography (EMG) signals have been shown
to parallel the perceived workload [10]. Additionally, if RPE and
P are perceived to be greater when vascular occlusion is applied,
then the activity of stress hormones (e. g. cortisol) could possibly
be altered as well [8]. Repetitions to failure for 2 sets of bilateral
leg extensor exercise and the perceptual responses for both RPE
and P have yet to be investigated using practical occlusion from
elastic knee wraps (KW).
Materials and Methods
Experimental approach to the problem
The purpose of this investigation was to examine the perceptual
(RPE and P) responses to 2 sets of bilateral low intensity (30 %
1RM) knee extensor exercise to muscular failure with and with-
out practical occlusion from KW.
Subjects
15, recreationally active, healthy men (n = 9) and women (n = 6)
participated in this study. Subjects indicated in a pre-study
screening interview that they had no known symptoms of
impaired endothelial function or known risk factors for cardio-
vascular or metabolic diseases. Their strength levels were con-
sidered relatively steady state, and no dramatic changes in their
strength could be expected during the 3 week time course of the
study. Alcohol was restricted for 24 h and caeine was restricted
for 12 h before each test. Subjects were informed about the pro-
cedures and potential risks of the tests before their informed
Loenneke JP et al. The Perceptual Responses to Occluded Int J Sports Med 2011; 32: 181184
consent was obtained. The universities institutional review
board approved this study, which was performed in accordance
with the ethical standards of the International Journal of Sports
Medicine (IJSM) as presented by Harris and Atkinson [7].
Strength-testing procedures
Subjects bilateral knee extensor strength was tested using a
selectorized leg extension machine (CG5512, California Gym,
Pomona, CA, USA). Prior to testing, subjects performed low
intensity aerobic exercise on a treadmill, walking at 2.5 mph for
10 min to warm up their leg musculature. After treadmill walk-
ing, subjects were instructed to perform 810 repetitions of the
leg extension exercise. Following a rest period of 90 s, the weight
was increased, and subjects were instructed to perform 46 rep-
etitions. Following a rest of 90 s, the weight was increased again
and subjects were instructed to perform 1 repetition. Weight
was progressively increased until 1RM was determined. All
1RMs were achieved within 5 attempts. 1RM was defined as the
most weight that could be lifted through a controlled, full range
of motion (ROM). Full ROM was visually defined as completing a
repetition from the starting angle of 90 to a full lockout at
180 . The speed of movement was kept constant using a 1 s con-
centric and 1 s eccentric contraction, a cadence previously used
with vascular occlusion training [19, 22].
Vascular occlusion and control testing procedures
Testing trials were separated by at least 7 days and no more than
8 days. Trials were randomized with subjects completing 2 sets
of bilateral leg extensions with 30 % 1RM to muscular failure
with 30 s rest between sets under normal conditions (CON) and
the other trial completing the same protocol while occluded
(OCC). For the OCC trial, KW (Harbinger Red-Line, 76 mm wide)
were applied to the upper thigh, as described and depicted by
Loenneke and Pujol [11], immediately before the exercise bout
and were removed following the second set of exercise.
Repetitions and perceptual responses
Repetitions to muscular failure were determined by the number
of repetitions completed through a full range of motion RPE and
P were determined following each set of muscular failure using
the Borg CR10 scale, as described by Hollander et al. [8]. RPE was
defined as the sense of eort experienced while performing
physical work and pain was defined as an unpleasant sensation
produced from the independent variables [4].
Subjects were visually shown the RPE and P scale prior to exer-
cise and after each set of exercise. In addition, subjects received
verbal instruction on rating both RPE and P prior to the start of
each trial, similar to those used by Hollander [8]. For RPE,
subjects were told, We want you to rate your perception of
exertion, that is, how heavy and strenuous the exercise feels to
you. The perception of exertion depends mainly on the strain
and fatigue in your muscles and on your feeling of breathlessness
or aches in the chest. We want you to use this scale from 010
and (Absolute Maximum), where 0 means no exertion at all
and 10 means extremely strong, that is the maximal exertion
you have previously experienced. There may be a level of exer-
tion that is still stronger than your 10; you will say 11 or 12. If it
is much stronger, for example, 1.5 times Extremely Strong you
will say 15.
For P, subjects were quoted, What are your worst experiences of
pain? Maximum pain is your main point of reference; it is
anchored by your previously experienced worst pain. The worst

Table 1 Mean Values of RPE and P following 2 sets to muscular failure with
and without occlusion. *indicates a significant dierence between OCC and
CON (p .01). All values are expressed as means SD.
RPE P
SET OCC CON OCC CON
1 5.53 2.06* 4.36 1.23 5.00 2.58 4.20 1.97
2 6.46 2.35* 5.10 0.43 6.43 2.63* 4.93 2.59
Ratings of Perceived Exertion (RPE); Pain (P); Occlusion (OCC); Control (CON)
pain that you have ever experienced, the Maximum Pain may
not be the highest possible level of pain. There may be a level of
pain that is still stronger than your 10; you will say 11 or 12. If it
is much stronger, for example, 1.5 times Maximum Pain you
will say 15, any questions?.
Statistical analysis
Dierences between trials were determined by analyzing repeti-
tions, repetitions load (total work), RPE, and P using paired
sample t-tests. Alpha levels for all tests were set at 0.01 to
account for the lack of interindividual variability. Mean values
are represented as SD.
Results
Subject characteristics were age 21.7 2.18 yr, height 171.9
9.14 cm, body mass 78.3 21.84 kg. The number of repetitions
until failure were significantly lower with practical OCC com-
pared to CON for both the first (p = 0.001) [OCC 20.6 4.68 vs.
CON 27.86 6.12] and second set (p = 0.001) [OCC 4.26 1.66 vs.
CON 11.33 2.12] of exercise. Total work was significantly lower
with practical OCC compared to CON (p = 0.001) [OCC
619.86 276.18 vs. CON 962.25 344.14]. RPE responses were
significantly higher with practical OCC compared to CON for
both the first (p = 0.01) and second set (p = 0.003) of exercise
(
Table 1). P responses were not dierent between OCC and
CON following the first set to muscular failure (p = 0.15) but were
significantly higher with practical OCC following the second set
(p = 0.009) (
Table 1).
Discussion
In this study, practical vascular occlusion with KW provided a
stimulus for decreasing the time to failure for 2 sets of exercise,
compared to low intensity exercise under normal conditions.
Decreasing the time to muscular failure is significant as muscle
protein synthesis is stimulated to a similar level, independent of
exercise intensity, as long as exercise is taken to muscular failure
[5]. KW, provide a mode to increase the intensity of low-load
exercise, resulting in muscular failure occurring at an overall
lower volume of work (repetitions load) since low intensity
exercise under normal conditions required more repetitions to
be completed. Furthermore, research has demonstrated through
integrated electromyography (iEMG) [15, 19, 21] and inorganic
phosphate splitting [16], that recruitment of the higher thresh-
old motor units (containing FT fibers) does occur with low load
vascular occlusion training, likely from the reduction in oxygen
and subsequent metabolic accumulation [13].
Another significant finding was the perceptual responses for
both RPE and P were altered with OCC, which is in agreement
Loenneke JP et al. The Perceptual Responses to Occluded Int J Sports Med 2011; 32: 181184
Training & Testing 183
with Hollander et al. [9] who demonstrated partial occlusion
with a low load (30 %1RM) altered perceptual changes similarly
to higher intensity exercise (70 %1RM). RPE was significantly
higher following both sets of exercise with OCC, which is in dis-
agreement with Wernbom [22], who reported no dierences
between vascular occlusion training and regular low intensity
exercise for RPE. P ratings were significantly higher after the sec-
ond set of exercise with OCC, which is in agreement with one
study [22], and is in disagreement with another [23].
The disparity could be due to the OCC stimulus used. Wernbom
[23] used a curved tourniquet cu of 135 mm in width with a
100 mm wide pneumatic bag inside of it, which was connected
to a surgical tourniquet system with automatic regulation of the
pressure. The KW used in this study were only 76 mm wide, so
the pressure applied to the upper thigh was likely greater than
the 100 mm HG of pressure applied to the width of 135 mm used
in the latter Wernbom study. In an earlier Wernbom study which
found dierences [22], a pressure of 200 mm HG was used, which
might explain the dierence between their more recent findings
and their previous study.
Another possibility might include dierences in research design.
Subjects in their earlier study completed 4 sets to muscular fail-
ure with 45 s of rest between sets, while their later study com-
pleted 3 sets. RPE and P ratings were measured following the
completion of exercise, whereas our subjects completed only 2
sets to muscular failure, with 30 s rest and, RPE and P were meas-
ured immediately after both sets of exercise. The dierences in
perceptual responses with KW may prove to be important, as
the higher ratings of both RPE and P with OCC might limit its
application to individuals who are highly motivated. The per-
ceptual responses were similar to or slightly lower than those
observed previously with higher intensity exercise with both
RPE [8, 17] and pain [8, 9, 17].
Although increases in muscle hypertrophy, strength, and endur-
ance have been observed with vascular occlusion training, the
application of this type of training is limited by the high cost and
technical skills needed to operate pneumatic tourniquets. Thus,
a need exists for a more practical way to occlude blood flow (e. g.
elastic knee wraps). Future research should focus on both the
acute and chronic eects of KW as a mode of practical occlusion.
In this study, both exercise bouts were taken to muscular failure,
so it was assumed that the higher threshold motor units were
recruited. However, this study did not measure iEMG activity,
but future investigations should quantify the degree of high
threshold motor unit activity with practical occlusion. Burd et al.
[5], found that muscle protein synthesis rates were similar for
resistance training, independent of intensity, as long as exercise
is taken to muscular failure. In this study, muscle protein synthe-
sis rates were not measured, so investigations should compare
the rates of practical occlusion to both traditional training and
occlusion with a KAATSU Master Apparatus. In addition, one can-
not ignore the increased perceptual responses of OCC. Although,
cortisol was not measured in this study, previous reports have
shown a relationship between perceptual responses and stress
hormones levels [3, 4]. Future studies should identify if this rela-
tionship exists with practical occlusion, and further examine
what, if any limitations this may present in its application.
In conclusion, knee extensor exercise with practical occlusion
from KW, provides a stimulus for decreasing the time to failure
for 2 sets of exercise, compared to low intensity exercise under
normal conditions. Furthermore, perceptual responses for both
RPE and P were higher with OCC compared to CON even though
184 Training & Testing
less work was completed. The higher acute P rating with practi-
cal OCC may limit its application to the highly motivated, but
may serve as a stimulus to increase intensity for populations in
which high intensity exercise is contraindicated, or those who
cannot sustain the mechanical stress of low intensity exercise
with normal blood flow which requires more total work to be
completed to muscular failure (e. g., early rehabilitation after a
sports injury).
References
1 Abe T, Kearns CF, Sato Y. Muscle size and strength are increased fol-
lowing walk training with restricted venous blood flow from the leg
muscle, Kaatsu-walk training. J Appl Physiol 2006; 100: 14601466
2 ACSM. American College of Sports Medicine position stand. Progres-
sion models in resistance training for healthy adults. Med Sci Sports
Exerc 2009; 41: 687708
3 Adler GK. Exercise and fatigue is neuroendocrinology an important
factor? J Clin Endocrinol Metab 2000; 85: 21672169
4 Borg G. Borgs Perceived Exertion and Pain Scales. Champaign, IL:
Human Kinetics; 1998
5 Burd NA, West DW, Staples AW, Holwerda AM, Moore D, Tang J, Baker
SK, Phillips SM. Influence of muscle contraction intensity and fatigue
on muscle protein synthesis (MPS) following resistance exercise. Med
Sci Sports Exerc 2009; 41: 149
6 Burd NA, Holwerda AM, Selby KC, West DW, Staples AW, Cain NE, Casha-
back JG, Potvin JR, Baker SK, Phillips SM. Resistance exercise volume
aects myofibrillar protein synthesis and anabolic signalling molecule
phosphorylation in young men. J Physiol 2010, doi:10.1113/
jphysiol.2010.192856
7 Harriss DJ, Atkinson G. International Journal of Sports Medicine Eth-
ical Standards in Sport and Exercise Science Research. Int J Sports Med
2009; 30: 701702
8 Hollander DB, Durand RJ, Trynicki JL, Larock D, Castracane VD, Hebert
EP, Kraemer RR. RPE, pain, and physiological adjustment to concen-
tric and eccentric contractions. Med Sci Sports Exerc 2003; 35:
10171025
9 Hollander DB, Reeves GV, Clavier JD, Francois MR, Thomas C, Kraemer
RR. Partial occlusion during resistance exercise alters eort sense and
pain. J Strength Cond Res 2010; 24: 235243
10 Lagally KM, Robertson RJ, Gallagher KI, Goss FL, Jakicic JM, Lephart SM,
McCaw ST, Goodpaster B. Perceived exertion, electromyography, and
blood lactate during acute bouts of resistance exercise. Med Sci Sports
Exerc 2002; 34: 552559 discussion 560
Loenneke JP et al. The Perceptual Responses to Occluded Int J Sports Med 2011; 32: 181184
View publication stats
11 Loenneke JP, Pujol TJ. The use of occlusion training to produce muscle
hypertrophy. Strength Condit J 2009; 31: 7784
12 Loenneke JP, Pujol TJ. KAATSU: Rationale for application in astronauts.
Hippokratia 2010; 14: 224224
13 Loenneke JP, Wilson GJ, Wilson JM. A Mechanistic approach to blood
flow occlusion. Int J Sports Med 2010; 31: 14
14 Manini TM, Clark BC. Blood flow restricted exercise and skeletal mus-
cle health. Exerc Sport Sci Rev 2009; 37: 7885
15 Moore DR, Burgomaster KA, Schofield LM, Gibala MJ, Sale DG, Phillips
SM. Neuromuscular adaptations in human muscle following low
intensity resistance training with vascular occlusion. Eur J Appl Phys-
iol 2004; 92: 399406
16 Suga T, Okita K, Morita N, Yokota T, Hirabayashi K, Horiuchi M, Takada
S, Omokawa M, Kinugawa S, Tsutsui H. Dose eect on intramuscular
metabolic stress during low-intensity resistance exercise with blood
flow restriction. J Appl Physiol 2010; 108: 15631567
17 Suminski RR, Robertson RJ, Arslanian S, Kang J, Utter AC, DaSilva SG,
Goss FL, Metz KF. Perception of eort during resistance exercise.
J Strength Cond Res 1997; 11: 261265
18 Takano H, Morita T, Iida H, Asada K, Kato M, Uno K, Hirose K, Matsumoto
A, Takenaka K, Hirata Y, Eto F, Nagai R, Sato Y, Nakajima T. Hemody-
namic and hormonal responses to a short-term low-intensity resist-
ance exercise with the reduction of muscle blood flow. Eur J Appl
Physiol 2005; 95: 6573
19 Takarada Y, Nakamura Y, Aruga S, Onda T, Miyazaki S, Ishii N. Rapid
increase in plasma growth hormone after low-intensity resistance
exercise with vascular occlusion. J Appl Physiol 2000; 88: 6165
20 Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusion
diminish disuse atrophy of knee extensor muscles. Med Sci Sports
Exerc 2000; 32: 20352039
21 Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Eects
of resistance exercise combined with moderate vascular occlusion on
muscular function in humans. J Appl Physiol 2000; 88: 20972106
22 Wernbom M, Augustsson J, Thomee R. Eects of vascular occlusion on
muscular endurance in dynamic knee extension exercise at dierent
submaximal loads. J Strength Cond Res 2006; 20: 372377
23 Wernbom M, Jarrebring R, Andreasson MA, Augustsson J. Acute eects
of blood flow restriction on muscle activity and endurance during
fatiguing dynamic knee extensions at low load. J Strength Cond Res
2009; 23: 23892395
24 Yasuda T, Abe T, Sato Y, Midorikawa T, Kearns CF, Inoue K, Ishii N.
Muscle fiber cross-sectional area is increased after two weeks of twice
daily KAATSU-resistance training. International Journal of KAATSU
Training Research 2005; 1: 6570