Clin Physiol Funct Imaging (2016) doi: 10.1111/cpf.

12367

The influence of exercise load with and without different

levels of blood flow restriction on acute changes in muscle
thickness and lactate
Jeremy P. Loenneke1, Daeyeol Kim2, Christopher A. Fahs3, Robert S. Thiebaud4, Takashi Abe5,
Rebecca D. Larson2, Debra A. Bemben2 and Michael G. Bemben2
1
Kevser Ermin Applied Physiology Laboratory, Department of Health, Exercise Science and Recreation Management, The University of Mississippi, University, MS,
2
Department of Health and Exercise Science, University of Oklahoma, Norman, OK, 3Division of Education and Counseling, Lindenwood University-Belleville, IL,
4
Department of Kinesiology, Texas Wesleyan University, Fort Worth, TX, USA and 5National institute of Fitness and Sports in Kanoya, Kanoya, Kagoshima,
Japan

Summary

Correspondence
Jeremy Paul Loenneke, Kevser Ermin Applied Phys-
iology Laboratory, Department of Health, Exercise
Science, and Recreation Management, The Univer-
sity of Mississippi, PO Box 1848, University, MS
38677, USA
E-mail: jploenne@olemiss.edu
Accepted for publication
Received 14 October 2015;
accepted 10 March 2016
Key words
KAATSU; muscle hypertrophy; muscle strength;
occlusion training; vascular resistance
The aim of this study was to compare exercise with and without different degrees
of blood flow restriction (BFR) on acute changes in muscle thickness (MTH) and
whole blood lactate (WBL). Forty participants were assigned to Experiment 1, 2
or 3. Each experiment completed protocols differing by pressure, load and/or
volume. MTH and WBL were measured pre and postexercise. The acute changes
in MTH appear be maximized at 30% one repetition maximum (1RM) with BFR,
although the difference between 20% 1RM and 30% 1RM at the lateral site was
small (0
1 versus 0
2 cm, P = 0
09). Increasing the exercise load from 20% to
30% 1RM with BFR produces clear changes in WBL (3
7 versus 5
5 mmol l 1,
P<0
001). The acute changes in MTH and WBL for 30% 1RM in combination
with BFR were similar to that observed with 70% 1RM and 20 and 30% to fail-
ure, albeit at a lower exercise volume. These findings may have implications for
designing future studies as it suggest that exercise load (to a point) may have a
greater influence on acute changes in MTH and metabolic accumulation than the
applied relative pressure.

anism is the accumulation of metabolites (e.g. lactate) around

Introduction
Blood flow restriction (BFR) in combination with resistance
exercise has been shown to result in muscular benefits across
a variety of populations, including the elderly (Takarada et al.,
2000), highly trained athletes (Takarada et al., 2002), those
recovering from injuries (e.g. ACL, osteochondral fracture)
(Lejkowski & Pajaczkowski, 2011; Loenneke et al., 2013b), as
well as a patient diagnosed with an idiopathic inflammatory
myopathy (Gualano et al., 2010). These muscular benefits have
been observed independent of a high load (~20–30% concen-
tric 1RM) and the stimulus appears to be relatively safe (Loen-
neke et al., 2014, 2011b). The reported mechanisms behind
these effects are likely incomplete but one mechanism may be
the acute increase in muscle thickness. This acute increase has
been observed following the application of BFR alone (Loen-
neke et al., 2012c) or in combination with resistance exercise
(Fahs et al., 2015; Martin-Hernandez et al., 2013; Yasuda et al.,
2012). To this point, Yasuda et al. (2012) provided data that
acute changes in MTH may be important for increases in mus-
cle mass following training with BFR. Another potential mech-
the working muscle (Sugaya et al., 2011). This accumulation
of metabolites may provide some explanation for why differ-
ences in muscle mass are observed even when the volume of
work is similar (Laurentino et al., 2012).
Given that both acute MTH and the accumulation of
metabolites have been hypothesized as mechanisms of muscle
growth, an investigation into which combination of exercise
load and pressure elicits the largest increase in those variables
may be important from a methodological perspective. In addi-
tion, comparing those responses observed with low-load resis-
tance exercise combined with BFR to those observed with
low-load resistance exercise to failure without BFR is impor-
tant as both protocols have been shown to result in favourable
skeletal muscle adaptations (Fahs et al., 2015; Loenneke et al.,
2012e; Mitchell et al., 2012). Understanding the differences in
the acute muscular response between protocols may help with
designing more optimal studies in the future. A review of the
literature found that these acute differences have never been
examined across protocols of different loads and pressures
(Ingram & Loenneke, 2015). Thus, the purpose of this study

© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 1
2 Muscle thickness and lactate response, J. P. Loenneke et al.

was to compare the effects of resistance exercise with and proper form was assessed and recorded as the concentric
without different degrees of BFR on acute changes in MTH 1RM. After recording a successful 1RM attempt, participants
and lactate accumulation, since both have been hypothesized were familiarized with the cadence of the exercise using a
as potential mechanisms behind the beneficial effects of low- metronome and completed two submaximal (30% 1RM, two
load resistance training. To investigate this across several dif- sets of 10) sets under BFR to familiarize them with the stimu-
ferent conditions, we ran three experiments with three sepa- lus. The methods for the conditions requiring BFR have been
rate groups of physically active men. described previously.(Loenneke et al., 2015a) Participants were
then scheduled for their first four visits (three exercise condi-
tions, one control, Table 1) with a minimum of five and a
Methods
maximum of 10 days between visits. The final pressure for
Forty-five physically active men aged 18–35 years were the BFR conditions was set to a percentage of arterial occlu-
recruited to participate (Experiment 1: n = 15, Experiment 2: sion estimated from thigh circumference (Table 2) (Loenneke
n = 15, Experiment 3: n = 15). Physically active was defined et al., 2012b). The individual conditions within each of the
as being active three or more days per week with a whole experiments will be abbreviated in the results and discussion
body resistance training component two or more days per as follows:
week for at least the last 3 months. Physically active partici- Experiment 1 (n = 14): High Load (HL) = 70% 1RM (non-
pants were used to better reflect the actual acute responses to BFR); 20%/40 BFR = 20% 1RM, 40% estimated arterial
different exercises. The use of this population decreases the occlusion pressure; and 30%/40 BFR = 30% 1RM, 40% esti-
chance of erroneously quantifying acute changes more reflec- mated arterial occlusion pressure.
tive of muscle damage/stress from an unaccustomed bout of Experiment 2 (n = 14): 30% = 30% 1RM to failure (non-
exercise (Murton et al., 2014). In addition, three separate BFR); 20%/50 BFR = 20% 1RM, 50% estimated arterial
experiments were used with three separate groups of partici- occlusion pressure; and 30%/50 BFR = 30% 1RM, 50% esti-
pants to lessen the chance of producing and quantifying a mated arterial occlusion pressure.
training effect. Participants who were hypertensive (>140/
90 mmHg), those who used tobacco regularly within the past
6 months, and those who had more than one risk factor for Table 1 Exercise protocols.
thromboembolisms (Motykie et al., 2000) were excluded from
participating. Of those initial 45, only 40 completed all of the Protocol % 1RM % Arterial occ. Rest (s)
testing sessions. Two participants were excluded following the Experiment 1
initial visit because they had resting supine blood pressures Condition 1 4 9 10 70 0 60
≥140/90 mmHg. One participant sustained a knee injury Condition 2 30-15-15-15 20 40 30
prior to Visits 2–5 and was excluded from further participa- Condition 3 30-15-15-15 30 40 30
Condition 4 0 0 0 –
tion. One participant sustained a hamstring injury following
Experiment 2
Visit 2 and withdrew from further participation. Both of these Condition 1 4 9 Failure 30 0 30
injuries occurred outside of the laboratory and were not Condition 2 30-15-15-15 20 50 30
related to this research study. One participant completed the Condition 3 30-15-15-15 30 50 30
first three visits but was unable to schedule the fourth within Condition 4 0 0 0 –
Experiment 3
the 5–10 day window required. Thus, he was excluded from
Condition 1 4 9 Failure 20 0 30
further all analyses. The study received approval from the Condition 2 30-15-15-15 20 60 30
University’s institutional review board, and each participant Condition 3 30-15-15-15 30 60 30
gave written informed consent before participation. Condition 4 0 0 0 –
During the initial screening visit, participants had their
height (to the nearest 0
5 cm) and body mass (to the nearest %1RM, percentage of one repetition maximum; %Arterial Occ., per-
centage of estimated arterial occlusion; Rest, rest between sets.
0. 1 kg) measured to calculate body mass index (BMI). Next,
blood pressure and ankle brachial index were measured in the
supine position to exclude those who may be hypertensive or
Table 2 Blood flow restriction pressures.
those who had indications of peripheral vascular disease. Fol-
lowing this, thigh circumference was measured with a tape Pressure used Pressure used Pressure used
measure at the 33% site between the top of the patella (knee Thigh circ. (40% AO) (50% AO) (60% AO)
cap) and the inguinal crease to determine the pressure that
<45–50
9 cm 80 mmHg 100 mmHg 120 mmHg
would be used during the resistance exercise bouts with BFR.
51–55
9 cm 100 mmHg 130 mmHg 150 mmHg
Participants were then tested for their bilateral concentric one 56–59
9 cm 120 mmHg 150 mmHg 180 mmHg
repetition maximum (1RM) on the knee extension machine ≥60 cm 140 mmHg 180 mmHg 210 mmHg
(NT 1220; Nautilus, Louisville, CO, USA). The maximum load
that could be lifted through a full range of motion with Circ, circumference; AO, estimated arterial occlusion.

© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd

Experiment 3 (n = 12): 20% = 20% 1RM to failure (non-
BFR); 20%/60 BFR = 20% 1RM, 60% estimated arterial
occlusion pressure; and 30%/60 BFR = 30% 1RM, 60% esti-
mated arterial occlusion pressure.
Resistance exercise protocols
Participants were randomly assigned to one of three experi-
ments. Once assigned, participants completed all of the proto-
cols in random order within that experiment. The protocols
were comparing exercise load, differing degrees of BFR and
exercise volume. The differing degrees of BFR were chosen to
determine if differences could be observed across restrictive
pressures. The maximum was set at 60% of estimated arterial
occlusion as this has been previously shown to result in high
levels of fatigue postexercise, with many of the participants
unable to complete the goal amount of repetitions (Loenneke
et al., 2013a). The HL protocol was completed with 1 min rest
between sets. All other protocols were separated by 30 s rest
periods between sets. A metronome was used to ensure that
the participants held the cadence of 1-second for the concen-
tric muscle action and 1-second for the eccentric muscle
action during the bilateral knee extension exercises. During
the control conditions, participants rested in the knee exten-
sion device but did not exercise. The protocols within each
experiment are found in Table 1. Prior to each condition
MTH, whole blood lactate (WBL), haematocrit and torque
were measured in that order. In addition, immediately follow-
ing each exercise bout torque, WBL, haematocrit and MTH
were measured again in that order. Torque, muscle activation
and the perceptual responses were also measured and that data
have been published separately (Loenneke et al., 2015a,b) in
response to previous reviewer comments and to allow for
focused discussion. Both of the pre and postmeasurements
were made in the absence of BFR.
Whole blood lactate
Fingertip blood samples were collected before and after
(~3 min post) resistance exercise by the same investigator.
Details on measuring WBL have been described previously
(Loenneke et al., 2012c).
Haematocrit
Prior to and following the exercise bouts (~3 min post), a
drop of blood was also drawn up into a capillary tube follow-
ing the finger sticks for whole blood lactate. Details on esti-
mating plasma volume from haematocrit have been described
previously (Loenneke et al., 2012c).
Muscle thickness
B-mode ultrasound measurements of MTH were made by the
same investigator at two anatomical sites on the non-dominant
© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Muscle thickness and lactate response, J. P. Loenneke et al. 3
thigh: the lateral and anterior surface of the thigh at a distance
of 50% between the lateral condyle of the femur and the
greater trochanter. Details on measuring MTH have been
described previously (Abe et al., 1994). In addition, the inves-
tigator was blinded to the condition and time point for the
analysis of each one of the MTH images. The minimal differ-
ence (reliability) needed to be considered real was 4 mm for
the anterior site and 2 mm for the lateral site.
Thigh circumference (33%)
The circumference of the non-dominant thigh was measured
with a tape measure at the 33% site between the top of the
patella (knee cap) and the inguinal crease. The 33% site was
measured on the initial visit in the supine position to deter-
mine the inflation pressure.
One repetition maximum
The maximum load that could be lifted through a full range
of motion with proper form was assessed and recorded as the
concentric 1RM. The bilateral knee extension 1RM was
assessed using standard 1RM procedures described previously
(Loenneke et al., 2013a).
Blood flow restriction
With the participants in a seated position, the BFR cuffs
(5 cm, Hokanson Inc. Bellevue, WA, USA) were applied to
the most proximal portion of each thigh. The cuffs were
inflated to 50 mmHg for 30 s and then deflated for 10 s. The
cuff was then inflated to 100 mmHg for 30 s and then
deflated for 10 s (unless 100 mmHg was the target pressure).
The cycle of cuff inflation/deflation was repeated with the
cuff pressure increasing in increments of 40 mmHg until the
target inflation pressure was reached. The cuff was inflated to
the target inflation pressure prior to the first set of exercise
and then deflated and removed immediately following the
final set of exercise. The final pressure was set to a percentage
of arterial occlusion estimated from thigh circumference
(Table 2). To determine estimated arterial occlusion, we used
a previous data set (Loenneke et al., 2012b), n = 116) and
plotted thigh circumference with arterial occlusion.
Statistical analyses
All data were analysed using the SPSS 18.0 statistical software
package (SPSS Inc., Chicago, IL, USA) with variability repre-
sented as standard deviation (SD). The group characteristics
for each have been published elsewhere,(Loenneke et al.,
2015a) however, there were no significant between group
differences in age, height, body mass, 1RM or supine mea-
sured thigh circumference at the 33% site. The mean change
from baseline for MTH and WBL was used for analysis, to
increase statistical power for comparing across experiments. A
4 Muscle thickness and lactate response, J. P. Loenneke et al.
(a)
(c)
Figure 1 Mean changes in for anterior thigh muscle thickness (MTH) (a), lateral thigh MTH (b), whole blood lactate (c) and plasma volume
(d). Conditions with different letters represent significant differences between conditions (P≤0
05). Variability represented as standard deviations.
one-way Repeated Measures ANOVA with the between-subject
factor of experiment (Experiment 1, 2 or 3) was completed
for all outcome variables. All posthoc comparisons were com-
pleted using the least significant difference test. Statistical sig-
nificance was set at an alpha level of 0
05. Reliability (i.e.
minimal difference) for MTH and WBL was determined from
the pre and postdata from the control visit within each experi-
ment (Weir, 2005). This calculation allowed us to know what
effect the exercise condition was having over that which could
be expected from repeated testing (pre/post). The minimal
difference needed to be considered real for MTH was 0
4 cm
for the anterior site and 0
2 cm for the lateral site and
0
5 mmol l 1 for WBL.
Results
There was no significant condition 9 experiment (P = 0
998),
condition (P = 0
627), or experiment (P = 0
139) effect for
the mean change in MTH at the anterior site suggesting that all
exercise conditions changed similarly (Fig. 1A). In addition,
there was no condition 9 experiment (P = 0
574) or experi-
ment effect (P = 0
352) for MTH at the lateral site (Fig. 1B),
but there was a condition main effect (P = 0
018). Follow-up
tests revealed that the combined average of Condition 1 (HL,
30% to failure, and 20% to failure) and Condition 3 (30%/40
BFR, 30%/50 BFR, and 30%/60 BFR) was significantly greater
than the combined average of Condition 2 (20%/40 BFR, 20%/
50 BFR, or 20%/60 BFR) (P<0
02).
© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
(b)
(d)
With respect to WBL (Fig. 1C), there was no condition 9
experiment (P = 0
975) or experiment effect (P = 0
271), but
there was a condition main effect (P<0
001). Follow-up tests
revealed that the combined average of Condition 1 (HL, 30%
to failure and 20% to failure) and Condition 3 (30%/40 BFR,
30%/50 BFR and 30%/60 BFR) was significantly greater than
the combined average of Condition 2 (20%/40 BFR, 20%/50
BFR or 20%/60 BFR) (P<0
001).
For changes in plasma volume (Fig. 1D), there was no con-
dition 9 experiment (P = 0
695) or experiment effect
(P = 0
163), but there was a condition main effect
(P = 0
038). Follow-up tests revealed that the combined aver-
age change in plasma volume of Condition 1 (HL, 30% to
failure and 20% to failure) and Condition 2 (20%/40 BFR,
20%/50 BFR or 20%/60 BFR) was significantly less than the
combined average of Condition 3 (30%/40 BFR, 30%/50 BFR
and 30%/60 BFR) (P <0
031).
The exercise volume completed within each experiment has
been published previously. We extend the results in that manu-
script by calculating differences between experiments. There
was a significant condition 9 experiment (P = 0
004) effect for
total exercise volume. Follow-up tests found significant between
experiment differences for Condition 1 (P = 0
022) but not for
Condition 2 (P = 0
788) or Condition 3 (P = 0
931). Within
Condition 1, the HL and 30% to failure condition completed
significantly less work than the 20% to failure. The within-
experiment differences in exercise volume have been published
previously (Loenneke et al., 2015a).

Discussion
To our knowledge, this is the first study investigating the
acute changes in MTH and WBL with different exercise proto-
cols with and without BFR. These two acute variables are
important as they have both been previously hypothesized to
play a role in chronic muscle adaptation to low-load resistance
training. The results of this series of experiments suggest that
increasing the exercise load from 20% to 30% 1RM with BFR
produces clear changes in WBL. Further, acute changes in
MTH (i.e. muscle swelling) appear be increased at 30% 1RM
with BFR, although the difference between 20% 1RM and
30% 1RM is small. The changes in MTH and WBL for 30%
1RM in combination with BFR were similar to that observed
with HL, 30% to failure, and 20% to failure, albeit at a lower
exercise volume. These data provide a better understanding of
the differences in the acute response which may be important
when designing future studies investigating the chronic adap-
tation to BFR.
Acute changes in MTH have previously been hypothesized
to play a role in the beneficial adaptations observed with BFR,
however, to date no study had compared the acute changes in
MTH in response to different pressures and exercise loads
(Loenneke et al., 2012a). The hypothesized relationship
between muscle growth and the acute change in MTH (cell
swelling) is based largely on Haussinger’s hypothetical model
for hepatocyte cell swelling (Haussinger, 1996), which sug-
gests that muscle cell swelling is detected by an intrinsic vol-
ume sensor. The activation of this volume sensor may lead to
an activation of the mechanistic target of rapamycin (mTOR)
pathway (Loenneke et al., 2012a). A recent animal study pro-
vides support for this as they found that repetitive cycles of
restriction, in the absence of exercise, increased both cell
swelling and signalling through the mTOR pathway (Nakajima
et al., 2016). An interesting finding is that the acute changes
in MTH appeared fairly similar across all exercise conditions
within each experimental group. This finding, in combination
with the similar drop in plasma volume across conditions,
suggests that a similar fluid shift into the muscle cells
occurred across conditions. It is acknowledged that there were
slight differences between conditions at the lateral site, how-
ever, these were small and unlikely to be meaningful. This is
similar to recent study completed in the upper body which
found that the acute change in MTH was similar between two
different conditions despite drastic differences in exercise vol-
ume (Yasuda et al., 2015). Although speculative, this may sug-
gest that acute changes in MTH are a requisite for skeletal
muscle growth, but in itself is not sufficient since it is not
augmented to a large degree by different exercise loads and
pressures. This is supported from a number of studies that
have observed acute increases in MTH following the applica-
tion of BFR in combination with low-load resistance exercise
(Fahs et al., 2015; Yasuda et al., 2015, 2012) and regular resis-
tance exercise in the absence of BFR (Martin-Hernandez et al.,
2013; Ploutz-Snyder et al., 1995; Yasuda et al., 2015). The
© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
Muscle thickness and lactate response, J. P. Loenneke et al. 5
similar changes across conditions in the present investigation
suggest that given an adequate stimulus, skeletal muscle can
only swell a finite amount before its maximal volume capacity
is reached.
The increase in WBL occurs due to fast glycolysis and the
accumulation of this lactate along with other metabolites has
been hypothesized to play an important role in skeletal muscle
adaptation through increased muscle fibre recruitment (Loen-
neke et al., 2011a; Ozaki et al., 2016). There is also some sug-
gestion that lactate, itself, may be anabolic for skeletal muscle.
For example, Oishi et al. (2015) found that lactate significantly
increased myogenin and follistatin protein levels and phospho-
rylation of P70S6K while decreasing the levels of myostatin
relative to a control. A number of studies have observed
increases in WBL following low-load resistance exercise in
combination with BFR (Loenneke et al., 2012d; Yasuda et al.,
2010, 2015). Of those studies investigating the acute increases
in lactate following BFR in combination with resistance exer-
cise, only one has investigated those changes across different
pressures (100 mmHg versus 160 mmHg) and it was com-
pleted in the upper body. To illustrate, Yasuda et al. (2010)
investigated unilateral elbow flexion muscle contractions com-
pleted at 20% 1RM (30 repetitions, followed by three sets of
15) and 70% 1RM (three sets to failure). The 160 mmHg
condition had a greater increase in lactate than the
100 mmHg condition, but the non-BFR 70% 1RM condition
had the greatest increase in lactate. This is in contrast to the
current set of experiments which found that increasing the
load from 20% to 30% 1RM produced significant increases in
WBL, however, increasing pressure did not augment this
response. This discrepancy between studies is unknown but
may be due to the method of applied pressure as the previous
study used the same pressure for everyone, independent of
limb size. This may be an important point as it has been
shown that a larger limb requires a greater pressure. The cur-
rent set of experiments does support the Yasuda et al. (2010)
finding that 70% 1RM leads to a greater change in lactate than
20% 1RM with BFR. The authors suggested that this difference
is unlikely due to differences in tissue oxygenation levels since
venous oxygen partial pressure and venous oxygen saturation
were similar between all exercise conditions. Instead, it seems
more likely that 70% 1RM requires a greater dependence on
anaerobic metabolism than muscle contractions performed at
20% 1RM, indicating a greater energetic demand with higher
loads. Interestingly, when the load was increased from 20% to
30% 1RM, the change in lactate was similar to that observed
with the HL condition, suggesting that this intensity/pressure
combination may produce an intramuscular stress similar to
HL exercise. The acute increase in lactate from the non-BFR
conditions also reflects an increased energetic demand. The
20% and 30% to failure conditions produced similar increases
in lactate as the HL condition. This is not surprising as these
low-load conditions should result in similar metabolic
responses if exercise is continued to true muscular failure. To
illustrate, postexercise lactate levels are similar between BFR
6 Muscle thickness and lactate response, J. P. Loenneke et al.

and non-BFR conditions despite significant differences in exer-
cise volume (Loenneke et al., 2012d).
In view of the results presented herein, the set of experi-
ments does possess some limitations. First, the amount of BFR
was estimated for each participant from previous data col-
lected during supine rest but was not directly measured. This
was not done due to the complexities involved with measur-
ing changes in blood flow during exercise of the lower body.
Regardless, each participant did receive graded amounts of
BFR which allowed for the central question of ‘does applied
pressure matter?’ to be answered. Second, the WBL levels
were estimated from fingertip blood drops. Although changes
exceeded the error of the measurement (0
5 mmol l 1), this
measurement only allowed us to quantify systemic lactate
accumulation, it did not allow us to differentiate differences
in lactate accumulation in or around the active muscle tissue.
Third, although increases in MTH and decreases in plasma
volume were observed which indicates a fluid shift did occur,
we are unable to definitively determine from this study
whether or not the fluid was shifted into the actual muscle
cell. Lastly, it is noted that these acute load- and pressure-
dependent changes should be investigated further with long-
term training studies to determine if acute changes predict or
correlate to chronic adaptation.
Conclusions
In conclusion, this set of experiments suggests that manipulat-
ing the exercise load can produce changes in the acute WBL
response to resistance exercise. Additionally, it appears that
moderate (40% estimated arterial occlusion) relative pressures
may be all that is needed to maximize the acute response to
BFR exercise, with 50 and 60% estimated arterial occlusion
providing no further augmentation in WBL or acute changes
in muscle thickness. These acute findings may have implica-
tions for designing future studies as it suggest that exercise
load (30% versus 20% 1RM) may have a greater influence on
adaptation than the applied relative pressure (40 versus 50
versus 60% estimated arterial occlusion pressure); when low-
load exercise is not taken to volitional fatigue. This acute find-
ing should be further tested through long-term training stud-
ies.
Acknowledgments
The authors are not aware of any affiliations, memberships,
funding or financial holdings that might be perceived as
affecting the objectivity of this manuscript. This study was not
supported by any external funding. The authors thank Dr.
Rosemary Knapp and Dr. Travis W. Beck for their helpful dis-
cussion on study design.
Conflict of interest
The authors declare no conflict of interest.
Author contribution
JPL, TA, RDL, DAB, and MGB: designed the study. JPL, DK,
CAF, and RST: collected the data. JPL, DK, CAF, RST, TA,
RDL, DA, and MGB: analysed and interpreted the data. JPL,
DK, CAF, RST, TA, RDL, DA, and MGB: wrote and edited the
manuscript.

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