Clin Physiol Funct Imaging (2012) doi: 10.1111/j.1475-097X.2012.01121.

Time under tension decreased with blood flow–restricted

exercise
Jeremy P. Loenneke1, Jacob M. Wilson2, Abhishek Balapur3, Austin D. Thrower4, Jeremy T. Barnes3
and Thomas J. Pujol3
1
Department of Health and Exercise Science, University of Oklahoma, Norman, OK, 2Department of Health Sciences and Human Performance, University of Tampa,
Tampa, FL, 3Department of Health, Human Performance, and Recreation, Southeast Missouri State University, Cape Girardeau, MO, and 4Edward Via College of
Osteopathic Medicine, Spartanburg, SC, USA

Summary

Correspondence Objectives: Exercise to failure results in similar muscle protein synthesis responses,
Jeremy Paul Loenneke, Department of Health and independent of intensity. However, low-intensity exercise likely requires more time
Exercise Science, University of Oklahoma, 1401
under tension and those with injuries may be incapable of sustaining the mechanical
Asp Avenue, Room 104, Norman, OK 73019-
0615, USA
stress to reach failure. Design: The purpose was to determine whether elastic knee
E-mail: jploenneke@ou.edu wraps (KW) provide a stimulus to decrease time under tension and overall volume
of work while maintaining a similar level of metabolic stress. Methods: Thirteen
Data collected from the Human Performance Lab at healthy subjects participated in a randomized crossover study consisting of three
Southeast Missouri State University. These data were trials. The first determined 1 repetition maximum (1RM) on the bilateral leg
presented at the 2011 ACSM Annual conference
extension. Subjects were then assigned to a blood flow restriction (BFR) or control
titled Time under tension decreased with blood flow
restricted exercise. (CON) group. After trial 2, subjects crossed over to the opposite trial. KW were
placed around the thigh of each leg during BFR. Leg extensions were completed at
Accepted for publication
30% 1RM until failure. Whole blood lactate (WBL) was taken pre-, post-, and 3 and
Received 25 June 2011;
accepted 22 December 2011 5 min postexercise. Heart rate (HR) was measured before, following the first and
second sets, and 3 and 5 min postexercise. Results: This study found KW provide a
Key words BFR stimulus allowing failure to occur sooner with similar metabolic stress
hypertrophy; KAATSU; lactate; muscle; protein postreperfusion. There were no differences in HR at any time point. Conclusions:
synthesis These results may benefit populations that cannot sustain the mechanical stress of
high-intensity exercise or low-intensity exercise that requires a longer sustained time
under tension.

(10–30% of maximal work capacity) (Abe et al., 2006). Muscle

Introduction
The American College of Sports Medicine (ACSM) recommends
lifting a weight of at least 70% of ones 1 repetition maximum
(1RM) to achieve muscular hypertrophy under normal condi-
tions, and it is believed that anything below this intensity rarely
produces substantial muscle hypertrophy or strength gains
(ACSM 2009). 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, professionals have sought
lower-intensity alternatives for such individuals.
One such alternative is blood flow restriction (BFR) training,
also known as KAATSU training. BFR training, as the name
implies, involves decreasing blood flow to a working muscle, by
application of a wrapping device, such as a blood pressure cuff.
Evidence indicates that this unique style of training can be
beneficial in clinical settings, as it produces positive training
adaptations equivalent to the physical activities of daily life
 2012 The Authors
Clinical Physiology and Functional Imaging  2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine
hypertrophy has been shown to occur during exercise as low as
20% 1RM with moderate BFR (160 mmHg) (Yasuda et al.,
2005), which can be beneficial to athletes (Takarada et al.,
2000a), patients in postoperation rehabilitation (specifically
ACL injuries), cardiac rehabilitation patients and the elderly
(Takarada et al., 2000b; Takano et al., 2005; Loenneke & Pujol,
2011). Some research indicates that BFR training might also be
beneficial for astronauts while in a zero-gravity environment
(Takano et al., 2005; Loenneke & Pujol, 2010).
Previous literature has discussed the efficacy and proposed
mechanisms of blood flow–restricted training in depth
(Loenneke & Pujol, 2009; Manini & Clark, 2009; Loenneke
et al., 2010b). The stimulation of muscle protein synthesis is one
of the prominent mechanisms involved in skeletal muscle
hypertrophy, and research demonstrates that low-intensity BFR
training stimulates protein synthesis, whereas a work-matched
low-intensity control did not (Fujita et al., 2007; Fry et al.,
2010). Interestingly, muscle protein synthesis, when exercising
1
2 Practical blood flow–restricted exercise, J. P. Loenneke et al.
at 30% 1RM with normal blood flow to muscular failure (not
work matched), has been shown to occur at rates equal to heavy
resistance training to failure (Burd et al., 2010b). Additionally,
Burd et al. (2010a) have demonstrated that three sets of
resistance exercise performed to muscular failure produces a
greater amplitude and duration in muscle protein synthesis than
one set of the same exercise to failure, highlighting an
importance of resistance exercise volume; however, one set to
muscular failure did significantly elevate muscle protein
synthesis. While the acute responses in these studies were
hypothesized to be predictive of chronic adaptations, they were
not definitive, as incongruence may exist between acute and
chronic changes following resistance training. In addition,
protein degradation was not measured in either of the
aforementioned studies, as the investigators completed their
research under the assumption that synthesis and not degrada-
tion is the more responsive variable to resistance exercise in
healthy humans (Rennie et al., 2004).
The hypothesis behind this protein synthetic response is that
low-intensity exercise to muscular failure forces a recruitment of
the fast twitch (FT) fibres (Loenneke et al., 2011c) through a
combination of volume and metabolic build-up. However, a
low-load protocol likely requires more repetitions to stimulate
muscle protein synthesis, and individuals with lower-limb
injuries or the elderly may be incapable of sustaining the
mechanical stress necessary to reach muscular failure.
Researchers have shown that BFR using a curved pneumatic
tourniquet cuff allows fewer repetitions to be completed until
muscular failure is reached when compared to low-intensity
exercise using the same load (30% 1RM). These findings suggest
that BFR training using a pneumatic tourniquet cuff allows
muscular failure to occur at an overall lower volume of work
(repetitions · load) because low-intensity exercise required
more repetitions to be completed. Furthermore, BFR training
research has indicated using integrated electromyography
(iEMG) (Takarada et al., 2000a,c; Moore et al., 2004) and
inorganic phosphate splitting (Suga et al., 2010) that recruit-
ment of the higher-threshold motor units (containing FT fibres)
does occur with lower-intensity exercise despite this reduced
volume, likely from the reduction in oxygen and subsequent
metabolic accumulation (e.g. lactate) (Loenneke et al., 2010b).
Whole blood lactate (WBL) (Takano et al., 2005), plasma lactate
(Takarada et al., 2000a; Takano et al., 2005; Reeves et al., 2006;
Fujita et al., 2007) and muscle cell lactate (Kawada & Ishii, 2005,
2008) have all been shown to increase in response to BFR.
Although this mode of training has demonstrated to result in
positive training adaptations, the safety of this training has been
questioned. Following an extensive review of the literature (e.g.
blood coagulation, cardiovascular damage and muscle damage),
Loenneke et al. (2011d) concluded that the current research on
BFR training, when used in a controlled environment by trained
and experienced personnel, provides a safe training alternative
for most individuals, regardless of age and training status.
Despite observed benefits, the BFR stimulus is typically
produced by a KAATSU Master Apparatus or modified blood
Clinical Physiology and Functional Imaging  2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine
pressure cuffs, which makes this mode of training available to
few because these devices are expensive and require specialized
skill to operate. These specialized apparatuses tend to be
expensive; thus, a need exists for the development of a practical
mode of applying an occlusive stimulus in hopes that more of
the population can receive the positive adaptations associated
with such training. Loenneke & Pujol (2009) proposed elastic
knee wraps (KW) as an affordable mode of BFR. Previous
research has investigated KW with intermittent BFR (Loenneke
et al., 2010a); however, time under tension, WBL and heart rate
(HR) responses have yet to be investigated using continuous
BFR from KW following two sets of exercise to muscular failure.
The purpose of this investigation was to examine time under
tension as well as the WBL and HR responses to two sets of
bilateral low-intensity (30% 1RM) knee extensor exercise to
muscular failure with and without practical BFR from KW.
Methods
In order to examine the effects of continuous BFR with elastic
KW on the knee extensors, the primary objective was to
compare the time under tension (repetitions), total work
(repetitions · load) and WBL responses to two sets to failure
of low-intensity bilateral knee extension exercise (30% 1RM)
with and without a BFR stimulus. HR was also investigated.
Elastic KW were used because they were easy to obtain,
affordable and practical.
Thirteen [age, 21Æ76 (2Æ27) year; height, 172Æ26 (9Æ62) cm;
body mass, 79Æ31 (23Æ17) kg] recreationally active, healthy men
(n = 8) and women (n = 5) participated in this study. The
subjects self-reported activity levels, and 11 of 13 reported
participating in aerobic-type exercise (walking, jogging,
cycling; 2–3 times per week for at least 30 min). Eight of the
13 reported participating in resistance-type exercise 2–3 times
per week for at least 60 min. Subjects were classified as
recreationally active because none indicated participation in a
consistent, structured, progressive training programme. Addi-
tionally, subjects indicated in a prestudy screening interview
that they had no known symptoms of impaired endothelial
function or known risk factors for cardiovascular or metabolic
diseases. Their strength levels were considered 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 caffeine was restricted for 12 h
before each test. Additionally, subjects were asked to maintain
their normal diet and were encouraged to arrive for testing
hydrated; however, dietary intake, caloric balance or hydration
status was not measured. Subjects were informed about the
procedures and potential risks of the tests before their informed
consent was obtained. The institutional review boards of the
universities approved this protocol, which was written in
accordance with the standards set by the Declaration of Helsinki.
Subjects bilateral knee extensor strength was tested using a
selectorized leg extension machine (CG5512; California Gym,
Pomona, CA, USA). Prior to testing, subjects performed
 2012 The Authors

low-intensity aerobic exercise on a treadmill, walking at
2Æ5 mph for 10 min to warm up their leg musculature. After
treadmill walking, subjects were instructed to perform 8–10
repetitions of the bilateral leg extension exercise. Following a
rest period of 90 s, the weight was increased, and subjects were
instructed to perform 4–6 repetitions. Following a rest of 90 s,
the weight was increased again and subjects were instructed to
perform one repetition. Weight was progressively increased
until 1RM was determined. For all subjects, the 1RM was
determined within five 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
approximately a 1-s concentric and a 1-s eccentric contraction,
a cadence previously used with BFR training (Takarada et al.,
2000a; Wernbom et al., 2006).
Testing trials were separated by at least 7 days and no more than
8 days. Trials were randomized with subjects completing two sets
of bilateral leg extensions with 30% 1RM to muscular failure
under normal conditions (CON) and the other trial completing
the same protocol with BFR. For the BFR trial, KW (Harbinger Red-
Line, Fairfield, CA, USA; 76 mm wide) were applied to the upper
thigh of both legs by the same investigator, as described and
depicted by Loenneke & Pujol (2009), immediately before the
exercise bout and were removed immediately following the
postexercise WBL measurement. KW were applied with the subject
standing in a straddled position. Subjects were instructed to tell the
investigator their perceptual response to the stimulus. If the subject
was in pain with the initial application of KW, the KW were
removed and reapplied. Subjects were instructed that any pain or
extreme discomfort from this mode of exercise should be from the
possible metabolic build-up, and not from the BFR stimulus itself.
Time under tension was determined by the number of
repetitions completed through a full ROM. Subjects were not
allowed to rest between repetitions, and if the subjects were
unable to complete the repetition through a full ROM, the set
was ended. Total volume of work completed was calculated by
multiplying repetitions completed by the weight used.
Whole blood lactate was indirectly measured using a
handheld analyser (Lactate Plus; Nova Biomedical Corporation,
Waltham, MA, USA). Fingertip WBL samples of approximately
0Æ7 ll by volume were collected prior to the start of the exercise
bout, immediately after the second set to failure, as well as 3 and
5 min into recovery using the manufacturer guidelines for
testing. The subjects fingers were cleaned with alcohol solution
prior to testing. Fingertips were punctured with a lancet, and the
first drop of blood was wiped off to decrease the chance of
contamination. The finger was lightly squeezed to form a second
drop of blood, and when the drop appeared, the end of the test
strip was touched with the blood drop until the test strip was
filled. WBL was measured prior to the start of exercise,
immediately postexercise, and 3 and 5 min into recovery.
Heart rate was monitored and transmitted to an attachment
worn on the wrist (FS1; Polar Electro, Lake Success, NY, USA).
 2012 The Authors
Clinical Physiology and Functional Imaging  2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine
Practical blood flow–restricted exercise, J. P. Loenneke et al. 3
HR was measured prior to the start of the exercise bout,
immediately after each set, and 3 and 5 min into recovery.
Data were analysed using PASW Statistics 18 (SPSS; Chicago,
IL, USA) with all variability represented using notation that is in
accordance with the Scientific Style and Format for standard deviation
(SD). Reliability was determined from the baseline measure-
ments from both days, which were used to determine the
intraclass correlations (ICC) of WBL and HR, which was used in
the calculation of the standard error of the measurement (SEM)
(SEM = SD1)ICC). The minimal differences (MD) needed to
be considered a real change for WBL and HR were calculated
from the SEM (MD = SEM · 1Æ96 2). Thus, anything exceed-
ing this MD could be considered a real change that exceeds the
error of the measurement (Weir, 2005).
Differences between trials were determined by analysing time
under tension (repetitions) and total work (repetitions · load)
using paired-sample t-tests with an alpha level set at 0Æ05. WBL
and HR were analysed using a repeated-measures analysis of
variance (ANOVA) with an alpha level of 0Æ05. When
significance was found, paired-sample t-tests were used to
determine pairwise differences using a Bonferroni-corrected
alpha level of 0Æ016 to control the family-wise error rate. To
increase power only post-, 3 min post- and 5 min postexercise
were included in the analysis of WBL. HR data for both sets of
exercise, and 3 and 5 min postexercise were included in the
analysis. The effect size for each pairwise comparison was
calculated using Cohens d (d = [(BFRmean-CONmean) ⁄ SD]).
Results
The mean load used for exercise in both trials was 25Æ13 (9Æ03)
kg. The time under tension was significantly lower with
practical BFR compared to CON for both the first (P = 0Æ001)
[BFR 20Æ92 (4Æ44) versus CON 28Æ23 (4Æ98) reps] and second
(P = 0Æ001) [BFR 4Æ46 (1Æ71) versus CON 11Æ23 (1Æ92) reps]
set of exercise. Total work was also significantly lower with
practical BFR compared to CON for both the first [BFR 520Æ89
(212Æ76) versus CON 689Æ13 (213Æ06) kg] and second
(P = 0Æ001) [BFR 115Æ56 (73Æ81) versus CON 281Æ03
(114Æ50) kg] set of exercise.
Whole blood lactate responses were significantly different
between BFR and CON (P = 0Æ005), with mean WBL levels of
4Æ5 (1Æ4) mmol l)1 for BFR and 5Æ9 (1Æ4) mmol l)1 for CON.
The MD to be considered real was exceeded (1Æ4 mmol l)1)
immediately post- and 3 min postexercise; however, signifi-
cance was only observed immediately postexercise (Table 1).
HR responses were not significantly different from each other at
any time point with a mean of 107 (18) bpm for BFR and 110
(16) bpm for CON (Table 2). The MD to be considered real was
not exceeded at any time point (22 bpm).
Discussion
In this study, practical BFR with KW provided a stimulus for
decreasing the time under tension for bilateral leg extension
4 Practical blood flow–restricted exercise, J. P. Loenneke et al.

Table 1 Mean values of whole blood lactate (WBL) following low- WBL, which was not determined in either of the aforementioned
intensity bilateral leg extensions to failure with blood flow restriction studies (Wernbom et al., 2006; Wernbom et al., 2009).
(BFR) and without (CON). WBL was measured before exercise (pre),
Research using integrated electromyography (Takarada et al.,
postexercise (post), 3 min postreperfusion (3 min), and 5 min
postreperfusion (5 min). 2000a; Takarada et al., 2000c; Moore et al., 2004) and inorganic
phosphate splitting (Suga et al., 2010) indicates that recruitment
WBL (mmol l)1) of the higher-threshold motor units (containing FT fibres) does
occur with low-load BFR training, likely from the reduction in
BFR CON Mean Dif. P value Cohens d
oxygen and subsequent metabolic accumulation (Loenneke
Pre 1Æ1 (0Æ5) 1Æ4 (0Æ4) )0Æ3 – – et al., 2010b). The accumulation of lactate has been shown to
Post 2Æ7 (1Æ4) 4Æ8 (1Æ4) )2Æ1b 0Æ001a )1Æ2 increase significantly in response to exercise with BFR (Takarada
3 min 5Æ0 (2Æ2) 6Æ8 (1Æ5) )1Æ8b 0Æ023 )0Æ7 et al., 2000a; Kawada & Ishii, 2005, 2008; Takano et al., 2005;
5 min 5Æ7 (1Æ7) 6Æ2 (1Æ7) )0Æ5 0Æ373 )0Æ2
Reeves et al., 2006; Fujita et al., 2007) when compared to a
a work-matched control. The current investigation found that
Indicates a significant difference between BFR and CON (P£0Æ016).
b
indicates exceeding the minimal differences to be considered real. All WBL was significantly higher in CON immediately following
values are expressed as means ±SD. exercise, but reperfusion resulted in a greater efflux of lactate
following BFR, resulting in no significant difference 3 min
Table 2 Mean values of heart rate (HR) following low-intensity postexercise. Previous BFR research, which showed significant
bilateral leg extensions to failure with blood flow restriction (BFR) and differences between groups with lactate, was matched for work.
without (CON). HR was measured before exercise (pre), following the This study found that despite CON performing more work, the
first set of exercise (post1), following the second set of exercise (post2), accumulation of lactate was similar. Lactate accumulation is
3 min postreperfusion (3 min) and 5 min postreperfusion (5 min).
significant as it may lead to increased fibre recruitment as well as
increases in circulating growth hormone (Loenneke et al.,
HR (bpm)
2010b). Both reduced oxygen and metabolic accumulation
BFR CON Mean Difference can increase fibre recruitment, mechanistically speaking,
through the stimulation of group III and IV afferents, which
Pre 75 (11) 78 (7) )3
Post1 129 (23) 134 (21) )5 may cause inhibition of the alpha motor neuron, resulting in an
Post2 125 (22) 129 (20) )4 increased fibre recruitment to maintain force and protect against
3 min 90 (15) 91 (13) )1 conduction failure (Yasuda et al., 2010). Fibre type recruitment
5 min 83 (17) 87 (12) )4 is important, because it is thought that muscle hypertrophy
occurs independently of exercise intensity, as long as FT fibres
All values are expressed as means ±SD.
are activated (Phillips, 2009; Loenneke et al., 2011c).
Although West et al. (2009) provide evidence that WBL plays
exercise, compared to low-intensity exercise under normal no direct role in muscle protein synthesis, it is still indicative
conditions. Decreasing the time under tension is significant as that both exercise conditions produced similar muscular
muscle protein synthesis is stimulated to a similar level, metabolic changes, despite the lower overall volume of work
independent of exercise intensity, as long as exercise is taken with BFR. In addition, the intramuscular environment (i.e.
to muscular failure (Burd et al., 2010b). KW provide a mode to metabolic stress) may play a large role in the training adaptation.
increase the intensity of low-load exercise, resulting in muscular Goto et al. (2005) showed that two different exercise regimens
failure occurring at an overall lower volume of work (repeti- at the same external intensity (3–5 sets of 10 at 75% 1RM)
tions · load) because low-intensity exercise under normal resulted in different muscle adaptations. The only difference
conditions required greater time under tension to be completed. between groups is that one group rested for 30 s midway
This is of importance because subjects exercising to failure through each exercise set. The group that did not rest midway
without BFR could potentially stop exercise premature of true through each set had greater increases in metabolic stress, which
muscular failure because of outside factors such as boredom. resulted in greater gains in strength, endurance and muscle mass
With the addition of BFR, the time to muscular failure is compared to the group that rested during each set. A separate
significantly reduced. study from our laboratory demonstrated that one set to
Although Wernbom et al. (2006, 2009) have previously muscular failure resulted in near-identical levels of WBL
shown that the restriction of blood flow reduces time to muscular 3 min postreperfusion despite significantly more work being
failure, they applied the restriction stimulus over a greater completed in the CON group (Loenneke et al., 2011a). The
amount of tissue area than the current investigation (135 mm current study exceeded the MD for both postexercise and 3 min
versus 76 mm). In addition, Wernbom et al. (2006) used an postreperfusion for the CON group, suggesting that adding an
intermittent protocol, whereas we used a continuous BFR additional set to muscular failure might delay the diffusion of
stimulus in an effort to increase the metabolic build-up within lactate out of the muscle. It might also be that adding an
the working muscle. The novelty of this study was the practical additional set of exercise to failure exceeds a volume threshold,
application of the restriction stimulus and the measurement of allowing differences to be seen between groups, which would
 2012 The Authors
Clinical Physiology and Functional Imaging  2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine
 Practical blood flow–restricted exercise, J. P. Loenneke et al. 5

not be observed with only one set of exercise. While it is known
that training to muscular failure results in a maximal stimulation
of muscle protein synthesis, overall volume of work is essential.
Although the WBL levels indicate that the overall intensity of
exercise was similar despite differences in time under tension
and work, it is currently unknown whether the decreases in
either of these variables observed with BFR negatively affects
muscle protein synthesis.
Previous research indicates that HR increases with BFR, which
can be attributed to the decreased venous return (Sumide et al.,
2009). This study found no differences between groups;
however, differences in HR were not expected because both
groups were working to volitional fatigue.
Although increases in muscle hypertrophy, strength and
endurance have been observed with BFR training, the applica-
tion 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 restrict blood flow (e.g.
elastic KW). Our research group is currently conducting a
training study to investigate the long-term safety and efficacy of
KW, investigating both the acute and chronic adaptation to this
practical mode of BFR. 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 BFR. Burd et al. (2010b) 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 synthesis rates were not measured, so
investigations should compare the rates of practical BFR with
both traditional training and a KAATSU Master Apparatus.
Perceptual responses to blood flow–restricted exercise with KW
were not investigated in the present investigation, but have been
previously. Unpublished observations from our laboratory as
well as published reports (Loenneke et al., 2010a, 2011b)
repeatedly observe KW to increase both ratings of perceived
exertion and pain when compared to regular low-intensity
exercise. However, although ratings are higher, perceptual
responses are similar to or slightly lower than those observed
previously with higher-intensity exercise for both perceived
exertion (Suminski et al., 1997; Hollander et al., 2003) and pain
(Suminski et al., 1997; Hollander et al., 2003; Hollander et al.,
2010). It is thought that this may possibly limit its application to
the highly motivated; however, more research is needed to
determine what potential limitations this may actually present.
A common and fair criticism of using KW for the restriction
of blood flow is the obvious inability to determine the degree of
restriction. However, previous research demonstrates that
applying a restriction stimulus to a narrow area requires greater
restriction to actually cause greater arterial occlusion (Crenshaw
et al., 1988). Thus, applying restriction to an area approximately
76 mm wide would be unlikely to completely restrict arterial
blood flow when using our method of application. In addition,
if the metabolite ⁄ volume threshold theory is correct (Loenneke
et al., 2011c), then the KW would only need to be applied with
the goal of light to moderate restriction, as this would be
sufficient to reduce the overall volume of work needed to reach
muscular failure.
In conclusion, knee extensor exercise with practical BFR from
KW provides a stimulus for decreasing the time under tension, as
determined by repetitions completed, for two sets of bilateral leg
extension exercise, compared to low-intensity exercise under
normal conditions. The metabolic stress while not statistically
different 3 min postreperfusion exceeded the MD to be consid-
ered a real increase in the CON condition; however, no differences
were observed 5 min postexercise. Although the MD was
exceeded, the overall WBL levels for BFR were similar to CON,
suggesting that each received a similar transient increase in
metabolic acidosis, despite the significant differences in workload.
Previous studies have found that the use of blood flow
occlusion will stimulate protein synthesis and lead to increased
skeletal muscle hypertrophy. Interestingly, low-intensity resis-
tance training without BFR maximally stimulates muscle protein
synthesis, provided that exercise is taken to muscular failure.
Despite this, exercising with low intensities could cause an
individual to prematurely cease exercise before actual muscular
failure is reached because of extrinsic factors such as boredom.
Exercising with continuous BFR from KW lowers the time under
tension needed to reach muscular failure and 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). This may also provide a mode of training for an
athlete to utilize during a period of deloading to maintain
and ⁄ or produce beneficial adaptations during a time of recovery
from high load resistance training.
Acknowledgments
This study was not supported by any outside funding source.

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