Clin Physiol Funct Imaging (2018) doi: 10.1111/cpf.

12557

Acute skeletal muscle responses to very low-load

resistance exercise with and without the application of
blood flow restriction in the upper body
Samuel L. Buckner1, Matthew B. Jessee2, Scott J. Dankel3, Kevin T. Mattocks4, J. Grant Mouser5,
Zachary W. Bell3, Takashi Abe3 and Jeremy P. Loenneke3
1
USF Muscle Laboratory, Division of Exercise Science, University of South Florida, Tampa, FL, 2School of Kinesiology, University of Southern Mississippi,
Hattiesburg, 3Kevser Ermin Applied Physiology Laboratory, Department of Health, Exercise Science, and Recreation Management, The University of Mississippi,
University, MS, 4Department of Exercise Science, Lindenwood Belleville, Belleville, IL, and 5Department of Kinesiology and Health Promotion, Troy University,
Troy, AL, USA

Summary

Correspondence
Jeremy Paul Loenneke, Kevser Ermin Applied Phys-
iology Laboratory, Department of Health, Exercise
Science, and Recreation Management, The Univer-
sity of Mississippi, P.O. Box 1848, University,
MS, USA
E-mail: jploenne@olemiss.edu
The authors are not aware of any affiliations,
memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of
this manuscript.
Accepted for publication
Received 31 July 2018;
accepted 6 November 2018
Key words
blood flow restriction; ischaemia; Kaatsu; low-load;
volitional failure
The purpose was to examine the acute skeletal muscle response to high load exer-
cise and low-load exercise with and without different levels of applied pressure
(BFR). A total of 22 participants completed the following four conditions: elbow
flexion exercise to failure using a traditional high load [70% 1RM, (7000)], low
load [15% 1RM,(1500)], low load with moderate BFR [15%1RM+40%BFR
(1540)] or low load with greater BFR [15% 1RM+80%BFR(1580)]. Torque and
muscle thickness were measured prior to, immediately post, and 15 min
postexercise. Muscle electromyography (EMG) amplitude was measured through-
out. Immediately following exercise, the 7000 condition had lower muscle thick-
ness [4
2(1
0)cm] compared to the 1500 [4
4 (1
1)cm], 1540 [4
4(1
1)cm] and
1580 [4
5(1
0)cm] conditions. This continued 15 min post. Immediately follow-
ing exercise, torque was lower in the 1500 [31
8 (20) Nm], 1540 [28
3(16
9)
Nm, P<0
001] and 1580 [29
5 (17) Nm] conditions compared to the 7000 con-
dition [40 (19) Nm]. Fifteen minutes post, 1500 and 1540 conditions demon-
strated lower torque compared to the 7000 condition. For the last three
repetitions percentage EMG was greater in the 7000 compared to the 1580 condi-
tion. Very low-load exercise (with or without BFR) appears to result in greater
acute muscle swelling and greater muscular fatigue compared to high load
exercise.

to volitional failure (Fahs et al., 2015). This would suggest

Introduction
Low-load resistance exercise with the application of blood
flow restriction (BFR) has been shown to result in similar
increases in muscle size as traditional resistance exercise (Lau-
rentino et al., 2012; Ozaki et al., 2013; Fahs et al., 2015; Kim
et al., 2017). This allows individuals the option to increase
muscle size without the additional burden of a heavy external
load. The use of BFR could be advantageous for individuals
recovering from injury (Ohta et al., 2003), individuals of
advancing age (Vechin et al., 2015), or those simply intimi-
dated by or less likely to engage in high load resistance exer-
cise. Interestingly, low-load resistance training by itself
(without the application of blood flow restriction) appears to
result in similar muscle size and strength adaptations as low-
load resistance exercise with BFR when exercise is performed
that BFR does not necessarily enhance the response of low-
load resistance exercise, but simply decreases the number of
repetitions necessary to reach momentary failure.
Considering that BFR does not appear to augment muscle
adaptations above those observed with low loads taken to
volitional failure (Fahs et al., 2015; Farup et al., 2015), its effi-
cacy could seemingly be questioned. However, it seems plau-
sible there may be a point at which training loads become too
low to disturb blood flow and produce a metabolic environ-
ment capable of increasing motor unit recruitment. In such
situations where ‘very low loads’ [i.e. 15% of one-repetition
maximum (1-RM)] are used, BFR may be necessary, as
metabolically induced motor unit recruitment or cell swelling
mechanisms produced by BFR may increase the robustness of
the stimulus. Lixandrao et al. (2015) found that increasing

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 1
2 Very low-load exercise with blood flow restriction, S. L. Buckner et al.
relative occlusion pressure from 40% to 80% augmented mus-
cle growth when training with a 20% 1RM load, but had no
greater effect when a 40% load was used. Although this study
used a protocol that did not allow individuals to train to voli-
tional failure these results suggested that restrictive pressures
may be more important at lower loads (i.e. ≤20% 1RM).
When performed without BFR, Holm et al. (2008) found that
very low load (15
5% 1RM) unilateral knee extension exercise
performed for 12 weeks resulted in less muscle growth com-
pared to traditional resistance exercise.
In an attempt to better understand the stimulus of very low
loads, our laboratory observed the acute responses to a variety
of loads (10%–20% 1RM) with and without BFR. We found
that higher pressures during very low-load (10%–15% 1RM)
exercise increased fatigue (decrement in torque). In addition,
we found that individuals in the 10–15% 1RM conditions
completed all repetitions regardless of the pressure applied.
One limitation of this study was the use of a protocol that
stopped individuals before they reached volitional failure (30
repetitions followed by 3 sets of 15 repetitions). It seems rea-
sonable to assume that the differences observed between the
conditions and pressures may be eliminated by a protocol that
allowed individuals to train to failure on each set (Dankel
et al., 2017b). However, it is largely unknown if it is possible
to reach volitional failure with loads as low as 15% of 1RM.
Thus, the purpose of the present study is to examine the acute
skeletal muscle response (i.e. acute muscle swelling, acute tor-
que decrements and muscle activity) following a variety of
resistance training protocols (high loads and very low loads
with different levels of arterial occlusion pressure (AOP)) in
the upper body with all groups training to failure or complet-
ing 90 repetitions per set (whichever comes first).
Methods
Participants
Twenty-three resistance-trained (regularly performing upper
body resistance training for at least 6 months) males and
females volunteered for the present study. Sample size was
based on previous studies observing changes between condi-
tions of similar acute outcomes (Dankel et al., 2017a; Jessee
et al., 2017). One individual did not complete all the testing
sessions; therefore, their data were excluded from all further
analyses. Thus, 22 young adults (12 males, 10 females) were
included in the present analysis. All participants were
instructed to refrain from: (i) eating 2 h prior and (ii) con-
suming caffeine 8 h prior to AOP measurements during all
testing visits. In addition, participants were instructed to
refrain from exercise 24 h before all visits. If participants had
more than one risk factor for thromboembolism (Motykie
et al., 2000) then they were excluded from participation (e.g.
family history, obesity, recent major surgery). The study
received approval from the University’s Institutional Review
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Board and each participant gave written informed consent
prior to participation.
Study design
Participants reported to the laboratory on three separate occa-
sions. If the participant consented and did not meet any exclu-
sion criteria, their standing height and body mass were
measured. Following this, AOP pressure was determined in
both arms (used for familiarization). To illustrate, in random
order, participants had a 5 cm nylon cuff placed at the top of
each arm (one at a time). Pressure was increased by inflating
the cuff until there is a cessation of blood flow to the distal
portion of the limb as detected by a Doppler probe. The cuff
was then removed and participants rested for 5 min at which
point the cuff was put on the next arm to undergo the same
procedure. Following this, the participant performed a 1RM
test to measure elbow flexion strength in both arms. Next,
participants performed one set of familiarization with BFR
exercise in each arm, followed by familiarization to
dynamometer strength testing. During the next two visits
(visit 2 and visit 3 which were each separated by 10–
20 days), participants completed 4 testing conditions (2 per
visit). A total of 10–20 days were allotted between visits as
the lower body was also studied (in alternating fashion as part
of a larger study). Strength levels were considered relatively
steady state, and no dramatic changes in their strength could
be expected during the time course of the study.
For visits two and three, the participants completed two of
the four possible conditions per visit. Conditions consisted of
four sets of elbow flexion exercise to failure using a tradi-
tional high load [70% 1RM (7000)], very low load [15%
1RM, 1500)], very low load with moderate BFR [15% 1RM
40% AOP (1540)], or very low load with greater BFR [15%
1RM 80% AOP (1580)]. AOP pressure was measured prior to
each exercise bout. Torque and muscle thickness were mea-
sured prior to exercise as well as immediately post, and
15 min postexercise. Further, electromyography (EMG) ampli-
tude was measured throughout the four sets of exercise. Each
visit lasted approximately 90 min, with two randomized con-
ditions completed during each visit (i.e. all participants com-
pleted all conditions).
Arterial occlusion determination
Participants stood upright while a 5 cm wide, nylon cuff (SC5
Hokanson, Bellevue, WA) was placed on the most proximal
portion of the participant’s upper arm. A hand-held Doppler
probe (MD6, Hokanson, Bellevue, WA) was placed at the
wrist over the radial artery until an auditory signal of blood
flow was found. The cuff was slowly inflated using an E20
Rapid Cuff Inflator (Hokanson, Bellevue, WA) until there was
no longer an indication of blood flow from the Doppler
probe. The lowest cuff pressure at which the blood flow distal
 Very low-load exercise with blood flow restriction, S. L. Buckner et al. 3
to the cuff was no longer detectable was defined as arterial
occlusion pressure.
One repetition maximum
Unilateral elbow flexor strength was measured using a dumb-
bell in both arms while participants stood with their back
against the wall. One-repetition maximum (1-RM) was
defined as the heaviest load that could be lifted one time with
good form through the full range of motion). Participants
were supervised by trained personnel during all strength test-
ing. 1RM was typically obtained within 3–5 attempts.
Standardized exercise protocol
For visits two and three, participants exercised one limb with
either a traditional high load (70% 1RM), or a very low-load
combined with no, moderate (40% AOP), or high restriction
pressure (80% AOP). Participants completed a total of four
different conditions over visits 2–5. For the high load exer-
cise, the protocol consisted of four sets of elbow flexion exer-
cise performed to failure. For low-load training, exercise was
performed until volitional failure or until 90 repetitions were
completed, whichever occurred first. Ninety repetitions repre-
sent 3 min of continuous exercise, which we chose based off
previous acute data showing that extended contraction times
begin to stimulate the synthesis of mitochondrial (aerobic like
response) proteins (Burd et al., 2012). Since our ultimate goal
is to understand the hypertrophic potential of this stimulus,
we believe this was an appropriate cut-off. In the high load
condition sets were separated by 90 s rest and in the other
low-load conditions, sets were separated by 30 s rest periods.
Isometric torque
Isometric torque was measured on a dynamometer (Biodex
Quickset System 4). The chair was adjusted for each individ-
ual, with the settings recorded to ensure the same testing con-
ditions for each experimental visit. For testing, participants
were asked to flex their arm against an immovable object as
hard as possible to determine their maximal isometric
strength. All isometric testing was performed at 60° of elbow
flexion. Each isometric contraction lasted until a decline in
maximal torque was observed (approximately 5 s).
EMG amplitude
Surface electromyography (EMG) for the biceps brachii was
measured during all exercise visits. Biceps brachii electrodes
were placed on the line between the medial acromion (shoul-
der area) and the antecubital fossa (elbow joint) at a distance
of 1/3 from the antecubital fossa. A reference electrode was
placed on the 7th cervical vertebrae (bony part of back of
neck). The surface electrodes were connected to an amplifier
and digitized (iWorkx, Dover, NH, USA). The signal was
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
filtered (low-pass filter 500 Hz; high-pass filter 10 Hz), ampli-
fied (10009) and sampled at a rate of 1 kHz. The skin was pre-
pared for electrode placement by lightly shaving the electrode
placement area to remove excess body hair, using a roughing
pad to remove dead skin, and then cleaning area with a sterile
alcohol wipe. Electrodes were placed in accordance with the
Seniam guidelines for EMG (Hermens et al., 1999).
Muscle thickness
B-mode ultrasound (GE, Fairfield, CT, USA) was used to mea-
sure muscle thickness. Muscle thickness was measured as the
distance between the muscle-bone and muscle-adipose inter-
face. The ultrasound probe (8–10 MHz) was placed on the
skin surface while using conductive gel to avoid depressing
the skin. Measurements of muscle thickness were made on the
anterior aspect of the participant’s upper arm at 70% of the
distance from the acromion process to the olecranon process.
This measurement was made before exercise, immediately
after and 15 min after exercise.
Statistics
Using the SPSS 24.0 statistical software package (SPSS Inc.,
Chicago, IL), a 4 9 3 (condition 9 time) repeated measure
ANOVA was used to determine any differences in muscle
thickness and torque between conditions in the upper body.
To determine any differences in EMG amplitude for the first
three and last three repetitions for each of the exercise sets
across conditions, two separate 4 9 4 (condition 9 reps)
repeated measures ANOVA were used. If there were interac-
tions, we ran one-way ANOVAs across time within each
condition, as well as across conditions within each time
point. Statistical significance for all tests will be set at an
alpha level of 0
05. Due to the relatively small number of
comparisons made, we did not Bonferroni correct the
alpha.
Results
Demographics
A total of 22 resistance-trained males (n = 12) and females
(n = 10) [mean (SD); age 22 (2) years; height: 174
7 (10
4)
cm; body mass: 76 (17) kg; RA 1RM: 20
1 (8
9)kg; LA
1RM: 20
1 (8
9) kg] were recruited to participate in this
study.
Muscle thickness
For muscle thickness, there was a group 9 time interaction
(P<0
001). Immediately following exercise, the 7000 condition had
lower muscle thickness values compared to the 1500 [mean differ-
ence = 0
16 (0
2) cm, P = 0
001], 1540 [mean difference = 0
23
(0
2) cm, P = 0
001] and 1580 [mean difference = 0
26 (0
2) cm,
4 Very low-load exercise with blood flow restriction, S. L. Buckner et al.
P = 0
001] conditions. There were no significant differences
between any of the low-load conditions at this time point. This con-
tinued 15 min postexercise, with the high load condition having
lower muscle thickness values compared to 1500 [mean differ-
ence = 0
12 (0
2) cm], 1540 [mean difference = 0
17 (0
2) cm,
P = 0
003] and 1580 [mean difference = 0
21 (0
2) cm, P<0
001]
conditions. There were no significant differences between any of the
low-load conditions at this time point. For all conditions, muscle
thickness increased from pre to postexercise (P<0
001), remaining
elevated above baseline 15 min postexercise (P<0
001). Changes in
muscle thickness, relative to baseline, are displayed in Fig. 1.
Isometric torque
For Isometric torque, there was a condition 9 time interac-
tion (P<0
001). Immediately following exercise, the torque
values were significantly lower in the 1500 [mean differ-
ence = 8
1 (12) Nm, P = 0
004], 1540 [mean differ-
ence = 11
6 (8
4) Nm, P<0
001] and 1580 [mean
difference = 10
4 (13
1) Nm, P = 0
002] conditions com-
pared to the 7000 condition. There were no significant differ-
ences between any of the low-load conditions at this time
point. At 15 min postexercise, 1500 [mean differ-
ence = [ 7
6 (11
7) Nm, P = 0
007) and 1540 [mean differ-
ence = 8
9 (10
3) Nm, P = 0
001] conditions demonstrated
lower torque values compared to the 7000 [47 (23) Nm]
condition. There were no other significant differences between
conditions at this time point. For all conditions, torque
decreased immediately following exercise (P<0
001), increas-
ing towards baseline, but remaining depressed 15 min follow-
ing the exercise bout (P<0
001; Fig. 2).
Electromyography
Two individuals failed to complete repetitions on at least
one set of exercise and were excluded from analysis of EMG.
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Thus, 20 individuals were included in the final analysis. For
the first three repetitions, there was a condition 9 set inter-
action (P<0
001). Follow-up analysis showed that the high
load condition displayed greater relative EMG amplitude
compared to all low-load conditions across all sets (P<0
001,
Table 1). In addition, the 1580 condition displayed greater
relative EMG amplitude compared to the 1500 condition
during the first set. For the 1500 and 1540 conditions, there
was a general trend for increased relative EMG amplitude
across the first three sets, with EMG amplitude remaining
similar between sets 3 and 4. The 1580 condition displayed
increased relative EMG amplitude from sets 1 to sets 2, with
values remaining similar thereafter (P<0
001). Within the
7000 condition relative EMG amplitude was only signifi-
cantly different between sets 1 and sets 4 (P = 0
04,
Table 1).
There was no condition 9 set interaction (P = 0
35) for
the last three repetition; however, there were main effects
of condition (P = 0
03) and set (P = 0
001) Percentage
EMG amplitude was greater in the high load condition
compared to the 1580 condition [P = 0
007, mean differ-
ence of 18
6 (29) %]. There were no other significant dif-
ferences between conditions. Across sets, relative EMG
amplitude was greater in set 1 [66
7(21
8)%] compared to
set 4 [62
9(21
400%] (P = 0
032), in set 2 [69
1 (24
4)
%] compared to set 3 [64
2(20
2)%] (P = 0
003) and in
set 2 [69
1(24
4)%] compared to set 4 [62
9(21
400%]
(P<0
001).
Repetitions
The 7000 condition completed less repetitions than all low-
load conditions. In addition, high pressure (80% AOP)
reduced the number of repetitions completed compared to the
1500 and 1540 conditions. Repetitions across sets for all con-
ditions are presented in Table 2.
Figure 1 Displays muscle thickness values
across time for each condition. There was a
condition 9 time interaction (P<0
001). Dif-
ferent letters indicate conditions within a
given time point were significantly different
from one another. Across time within each
condition, all time points were significantly
different from one another (P<0
05). *Notes
a significant difference from the pre value
within each condition at a given time point.
Data represented as mean (SD).
 Very low-load exercise with blood flow restriction, S. L. Buckner et al. 5

Figure 2 Displays isometric torque values across time for each condition. There was a condition 9 time interaction (P<0
001). Different letters
indicate conditions within a given time point were significantly different from one another. Across time within each condition, all time points
were significantly different from one another (P<0
05). *Notes a significant difference from the pre value within each condition at a given time
point. Data represented as mean (SD).

pre to postexercise (low-loads producing greatest change),

Discussion
The primary findings of the present study were as follows: 1)
All groups displayed an acute muscle swelling response (low-
loads producing greatest change), with the swelling being
greatest immediately postexercise, decreasing towards baseline
15 min postexercise; 2) Torque decreased in all groups from
increasing towards baseline 15 min post; 3) EMG amplitude
(relative to maximal isometric torque) was greater in the high
load condition compared to the very low-load conditions; and
4) BFR decreased the number of repetitions performed in the
low-load conditions, with high pressure completing less repe-
titions compared to low pressure.

Fatigue and electromyography

Table 1 Surface electromyography.
In the present study, measures of isometric torque were used
Across sets
as a surrogate for fatigue. We observed greater torque decre-
First 3 Set 1 Set 2 Set 3 Set 4 (P<0.01) ments in all low-load conditions (regardless of pressure) com-
pared to the traditional high load condition. Further, the
1500 33 (16)a 45 (19)a 48 (18)a 48 (17)a 1v2, 1v3,
torque decrements observed were greater than what has been
1v4, 2v3
1540 28 (11)a,b 41 (14)a 45 (15)a 46 (13)a 1v2, 1v3, 1v4, previously reported, with decreases of 40, 46 and 48%
2v3, 2v4 observed for the 1500, 1540 and 1580 conditions, respec-
1580 24 (11)b 41 (12)a 42 (13)a 46 (18)a 1v2, 1v3, 1v4 tively. This is nearly twice the 26% decrease that was observed
7000 71 (34)c 67 (26)b 66 (27)b 65 (27)b in the traditional high load condition. The decrements in the
Last 3 Set 1a,c Set 2a Set 3c,e Set 4d,e present study were also greater than those observed by Dankel
et al. (2017a), who found decreases of 15% and 20% for
1500 65 (30) 66 (28) 62 (24) 61 (22) 1540 and 1580 conditions respectively when exercise was not
1540 62 (23) 67 (27) 64 (20) 62 (24)
performed to volitional failure (performed 1 set of 30 repeti-
1580 58 (27) 63 (39) 56 (33) 54 (32)
7000* 81 (31) 77 (30) 73 (25) 73 (27) tions followed by 3 sets of 15). Considering that changes in
isometric torque are considered a surrogate for fatigue, it is
Surface electromyography amplitude expressed a as a percentage of not surprising that the torque decrements were so large in the
maximal isometric torque. For the first three repetitions, there was a low-load conditions. For example, the amount of fatigue nec-
condition 9 set interaction (P<0.001). Conditions with the same let-
essary to render an individual incapable of overcoming a load
ter indicate conditions within a given set were not significantly differ-
ent from one another (P>0.05). The ‘Time’ column displays of 15% 1RM is much greater than the level of fatigue needed
comparisons across time that were significantly different from one to render them incapable of overcoming a load of 70% of
another (P<0.05). For the last three repetitions, there was a main 1RM. If an individual fatigues at 70% 1RM then the load
effect for condition (P = 0.03) and time (P = 0.001). An asterisks could be lowered (e.g. 50% 1RM) and they would still be
indicates a condition was significantly different (P<0.05) compared to
capable of doing another repetition because they still have a
the 1580 condition. For the last three repetitions, sets with the same
letter indicates that the EMG amplitude for that set was not signifi- large portion of their force capacity remaining. However, if
cantly different (P>0.05). an individual can no longer lift 15% of their 1RM, the

© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
6 Very low-load exercise with blood flow restriction, S. L. Buckner et al.
Set 1 %Failure Set 2 %Failure Set 3 %Failure
1500 87 (7) 13 54 (30) 68 45 (31)
1540 82 (14) 27 54 (31) 63 39 (29)
1580 72 (21) 54 30 (26) 90 22 (25)
7000 8 (2) 100 5 (2) 100 5 (3)
Repetitions for each condition across sets. Means (SD) are displayed across sets for all condi-
tions. In addition, the percentage of individuals who reached failure for all conditions across sets
are provided.
amount of force capacity they have remaining is limited.
Taken into consideration with the EMG data, it seems likely
that the protocol was able to increase motor unit recruitment
despite the low load used, with no differences noted with or
without the application of restrictive pressure. This is similar
to the findings of Kacin & Strazar (2011) and who observed
similar EMG activity between legs exercising to volitional fail-
ure at 15% 1RM with or without the application of ischaemic
pressure. Although it is unclear how close to failure the con-
trol group was in this study (matched the volume of the BFR
group which trained to failure), authors suggest that ‘differ-
ences in muscle activation between ischaemic and control
exercise disappear when exercises are performed at maximal
efforts’(Kacin & Strazar, 2011). Thus, performing exercise to
or near volitional failure may be particularly important when
employing loads as low as 15% 1RM. In support, the present
study also observed higher relative EMG amplitudes (~54–
67% isometric torque during the last three repetitions of each
set) compared to those observed by Dankel et al. (2017a)
whilst employing loads of 15% 1RM not to volitional failure
(~36–43% of maximal isometric torque during the last three
repetitions of each set). It appears that higher level of EMG
amplitude can be accomplished with lower loads if individuals
train to or near failure/fatigue; however, these values are still
lower than those observed with high load resistance training.
Acute changes in muscle thickness
Haussinger et al. (1993) suggested that cellular hydration may
act as an anabolic proliferative signal, resulting in a shift
towards anabolism. Although much of the understanding of
cell swelling is derived from research in hepatocyte cells
(Haussinger et al., 1993; Loenneke et al., 2012a), it is still pos-
tulated as a mechanism to explain why BFR may attenuate
skeletal muscle loss during periods of disuse and may ulti-
mately play a role during all resistance type activities (Loen-
neke et al., 2012b,c). Although it is unclear if cell swelling is
a ‘mechanism’ for muscle growth, a similar swelling response
has been documented following a number of resistance train-
ing protocols. If not anabolic on its own, the presence of a
swelling response may be indicative that a sufficient stimulus
was achieved with the resistance training protocol. Our labo-
ratory has observed a remarkably similar acute swelling
© 2018 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Table 2 Repetitions across sets for each
Set 4 %Failure condition.
72 42 (32) 72
77 38 (31) 77
90 22 (28) 86
100 4 (1) 100
response across a number of different resistance exercise pro-
tocols in the upper (Counts et al., 2015, 2016; Buckner et al.,
2017) and lower body (Loenneke et al., 2017). Dankel et al.
(2017a) noted subtle differences in the acute swelling
response, with acute swelling tending to be greater with
increasing pressure and intensity when comparing the
responses to 10, 15 and 20% 1RM with moderate (40% AOP)
and high (80% AOP) restrictive pressures. The acute swelling
response in the present study was greater than values previ-
ously observed in the literature for the low-load training
groups. Specifically, we observed acute changes of 0
55
(0
22) cm, 0
51 (0
19)cm and 0
56 (0
20)cm immediately
following exercise for the 1500, 1540 and 1580 training
groups, respectively. Following traditional high load resistance
training, we observed a more typical acute swelling response
of 0
27 (0
14) cm. It is unclear is this exaggerated swelling
response is indicative of a fluid shift into the muscle cell or
the interstitial space. However, increases in muscle thickness
with concomitant decreases in plasma volume have been
observed following lower body exercise with BFR (Loenneke
et al., 2017) and during lying rest with a series of inflations
and deflations of restrictive pressure (Loenneke et al., 2012c).
Given this decrease in plasma volume and increase in muscle
size, it seems probable that acute swelling following BFR rep-
resents a fluid shift into the cell. Future research could seek to
better determine the location of the fluid shift and the impact
the lymphatic system may have on the redistribution of fluid
following BFR.
Repetitions to or near failure
Blood flow restriction decreases the number of repetitions to
volitional failure compared to regular low-load training, pre-
sumably through a reduction in oxygen, and an accumilation
of metabolites (Loenneke et al., 2012a). For example, Jessee
et al. (2017) found that higher pressures typically resulted in
fewer repetition completed compared to lower pressures when
employing a standardized exercise protocol (30 repetitions on
set 1, followed by 3 sets of 15) with 30% of 1RM. Nonethe-
less, across a wide range of restrictive pressures (0%, 10%,
20%, 30%, 50%, or 90% AOP) all groups appeared to reach
volitional failure as demonstrated by individuals’ inability to
perform all of the goal repetitions. When implementing this
 Very low-load exercise with blood flow restriction, S. L. Buckner et al. 7

same protocol with lower loads (10, 15 or 20% of 1RM)
together with moderate (40% AOP) or high (80% AOP) restric-
tive pressure, our research group found that individuals in the
15% 1RM condition completed all repetitions regardless of the
pressure applied. These results suggest that a standardized exer-
cise protocol may not be as effective when using very low
loads, since exercising to or near volitional failure appears
important for achieving a similar stimulus across individuals
(Dankel et al., 2017b). For example, It has been demonstrated
that females are more resistant to fatigue than males (Clark
et al., 2005), and that endurance athletes are more fatigue-resis-
tant than weight-trained individuals (Richens & Cleather,
2014). Thus when performing an arbitrary number of repeti-
tions, an individual’s ability to reach failure may be dependent
on their local muscular endurance. The present results also
brought into question the ability to reach volitional failure
when using such light loads. The present study found that the
majority of individuals, regardless of pressure, reached voli-
tional failure by the first or second set of exercise with 15% of
their 1RM. There were only 6, 5 and 3 individuals to complete
all repetitions during the final set for the 1500, 1540 and 1580
conditions, respectively. Although BFR does not appear to aug-
ment the acute muscular response to very low loads, it does
decrease the repetitions necessary to reach volitional failure.
Limitations
The present study is not without limitation. Firstly, we are
inferring muscle cell swelling from ultrasound muscle thick-
ness measures. As such, we were not able to confirm if this
fluid shift is occurring into the muscle cells or just into the
interstitial space. In addition, surface EMG amplitude, as
opposed to more sophisticated techniques (such as decompo-
sition), was used to measure muscle activation. Thus, we can
get an idea of muscle activation; however, we cannot deter-
mine actual motor unit recruitment. Finally, our results repre-
sent acute changes and provide limited information on the
chronic adaptations observed with each cuff type; thus, future
research is necessary to confirm that these adaptations reflect
the acute response. Despite these limitations, our findings pro-
vide an important addition to the BFR literature, using a
within subject model to further develop our understanding of
the efficacy of BFR when very low loads are utilized.
Conclusion
Results of the present study shed important light regarding
the efficacy of blood flow restriction when very low exercise
loads are used. Such low loads may have implications for clin-
ical populations, which may include: individuals recovering
from injury (Ohta et al., 2003), individuals coming off bed
rest (Cook et al., 2010) or those limited by other muscu-
loskeletal disorders, in whom the ability to perform traditional
resistance exercise may be limited (Ohta et al., 2003). Our
findings demonstrate that very load loads (15%1RM) produce
similar decreases in torque, and similar increases in muscle
thickness when performed to or near volitional failure with or
without the addition of restrictive pressure. In addition, high
pressures decreased the number of repetitions performed to
volitional fatigue. Results of the present study also showed
that acute changes in muscle thickness, and isometric torque
are much greater than those observed in the high load train-
ing group, or previous investigations examining low loads.
Although the long term implications of these responses are
presently unknown, our results would suggest that if low
loads are implemented the addition of restrictive pressure does
not appear necessary if all sets are taken to/near volitional fail-
ure.
Acknowledgments
None.
Conflict of Interest
The authors declare no conflict of interest.

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