The Influence of Exercise Load With and Without Different Levels of Blood Flow Restriction On Acute Changes in Muscle Thickness and Lactate
The Influence of Exercise Load With and Without Different Levels of Blood Flow Restriction On Acute Changes in Muscle Thickness and Lactate
The Influence of Exercise Load With and Without Different Levels of Blood Flow Restriction On Acute Changes in Muscle Thickness and Lactate
12367
Summary
Correspondence The aim of this study was to compare exercise with and without different degrees
Jeremy Paul Loenneke, Kevser Ermin Applied Phys-
of blood flow restriction (BFR) on acute changes in muscle thickness (MTH) and
iology Laboratory, Department of Health, Exercise
Science, and Recreation Management, The Univer-
whole blood lactate (WBL). Forty participants were assigned to Experiment 1, 2
sity of Mississippi, PO Box 1848, University, MS or 3. Each experiment completed protocols differing by pressure, load and/or
38677, USA volume. MTH and WBL were measured pre and postexercise. The acute changes
E-mail: jploenne@olemiss.edu in MTH appear be maximized at 30% one repetition maximum (1RM) with BFR,
Accepted for publication although the difference between 20% 1RM and 30% 1RM at the lateral site was
Received 14 October 2015; small (01 versus 02 cm, P = 009). Increasing the exercise load from 20% to
accepted 10 March 2016 30% 1RM with BFR produces clear changes in WBL (37 versus 55 mmol l 1,
P<0001). The acute changes in MTH and WBL for 30% 1RM in combination
Key words
KAATSU; muscle hypertrophy; muscle strength;
with BFR were similar to that observed with 70% 1RM and 20 and 30% to fail-
occlusion training; vascular resistance 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.
© 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 05 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
<45–509 cm 80 mmHg 100 mmHg 120 mmHg
would be used during the resistance exercise bouts with BFR.
51–559 cm 100 mmHg 130 mmHg 150 mmHg
Participants were then tested for their bilateral concentric one 56–599 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
Muscle thickness and lactate response, J. P. Loenneke et al. 3
Experiment 3 (n = 12): 20% = 20% 1RM to failure (non- thigh: the lateral and anterior surface of the thigh at a distance
BFR); 20%/60 BFR = 20% 1RM, 60% estimated arterial of 50% between the lateral condyle of the femur and the
occlusion pressure; and 30%/60 BFR = 30% 1RM, 60% esti- greater trochanter. Details on measuring MTH have been
mated arterial occlusion pressure. 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-
Resistance exercise protocols
ence (reliability) needed to be considered real was 4 mm for
Participants were randomly assigned to one of three experi- the anterior site and 2 mm for the lateral site.
ments. Once assigned, participants completed all of the proto-
cols in random order within that experiment. The protocols
Thigh circumference (33%)
were comparing exercise load, differing degrees of BFR and
exercise volume. The differing degrees of BFR were chosen to The circumference of the non-dominant thigh was measured
determine if differences could be observed across restrictive with a tape measure at the 33% site between the top of the
pressures. The maximum was set at 60% of estimated arterial patella (knee cap) and the inguinal crease. The 33% site was
occlusion as this has been previously shown to result in high measured on the initial visit in the supine position to deter-
levels of fatigue postexercise, with many of the participants mine the inflation pressure.
unable to complete the goal amount of repetitions (Loenneke
et al., 2013a). The HL protocol was completed with 1 min rest
One repetition maximum
between sets. All other protocols were separated by 30 s rest
periods between sets. A metronome was used to ensure that The maximum load that could be lifted through a full range
the participants held the cadence of 1-second for the concen- of motion with proper form was assessed and recorded as the
tric muscle action and 1-second for the eccentric muscle concentric 1RM. The bilateral knee extension 1RM was
action during the bilateral knee extension exercises. During assessed using standard 1RM procedures described previously
the control conditions, participants rested in the knee exten- (Loenneke et al., 2013a).
sion device but did not exercise. The protocols within each
experiment are found in Table 1. Prior to each condition
Blood flow restriction
MTH, whole blood lactate (WBL), haematocrit and torque
were measured in that order. In addition, immediately follow- With the participants in a seated position, the BFR cuffs
ing each exercise bout torque, WBL, haematocrit and MTH (5 cm, Hokanson Inc. Bellevue, WA, USA) were applied to
were measured again in that order. Torque, muscle activation the most proximal portion of each thigh. The cuffs were
and the perceptual responses were also measured and that data inflated to 50 mmHg for 30 s and then deflated for 10 s. The
have been published separately (Loenneke et al., 2015a,b) in cuff was then inflated to 100 mmHg for 30 s and then
response to previous reviewer comments and to allow for deflated for 10 s (unless 100 mmHg was the target pressure).
focused discussion. Both of the pre and postmeasurements The cycle of cuff inflation/deflation was repeated with the
were made in the absence of BFR. 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
Whole blood lactate
and then deflated and removed immediately following the
Fingertip blood samples were collected before and after final set of exercise. The final pressure was set to a percentage
(~3 min post) resistance exercise by the same investigator. of arterial occlusion estimated from thigh circumference
Details on measuring WBL have been described previously (Table 2). To determine estimated arterial occlusion, we used
(Loenneke et al., 2012c). a previous data set (Loenneke et al., 2012b), n = 116) and
plotted thigh circumference with arterial occlusion.
Haematocrit
Statistical analyses
Prior to and following the exercise bouts (~3 min post), a
drop of blood was also drawn up into a capillary tube follow- All data were analysed using the SPSS 18.0 statistical software
ing the finger sticks for whole blood lactate. Details on esti- package (SPSS Inc., Chicago, IL, USA) with variability repre-
mating plasma volume from haematocrit have been described sented as standard deviation (SD). The group characteristics
previously (Loenneke et al., 2012c). 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-
Muscle thickness
sured thigh circumference at the 33% site. The mean change
B-mode ultrasound measurements of MTH were made by the from baseline for MTH and WBL was used for analysis, to
same investigator at two anatomical sites on the non-dominant increase statistical power for comparing across experiments. A
© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
4 Muscle thickness and lactate response, J. P. Loenneke et al.
(a) (b)
(c) (d)
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≤005). Variability represented as standard deviations.
one-way Repeated Measures ANOVA with the between-subject With respect to WBL (Fig. 1C), there was no condition 9
factor of experiment (Experiment 1, 2 or 3) was completed experiment (P = 0975) or experiment effect (P = 0271), but
for all outcome variables. All posthoc comparisons were com- there was a condition main effect (P<0001). Follow-up tests
pleted using the least significant difference test. Statistical sig- revealed that the combined average of Condition 1 (HL, 30%
nificance was set at an alpha level of 005. Reliability (i.e. to failure and 20% to failure) and Condition 3 (30%/40 BFR,
minimal difference) for MTH and WBL was determined from 30%/50 BFR and 30%/60 BFR) was significantly greater than
the pre and postdata from the control visit within each experi- the combined average of Condition 2 (20%/40 BFR, 20%/50
ment (Weir, 2005). This calculation allowed us to know what BFR or 20%/60 BFR) (P<0001).
effect the exercise condition was having over that which could For changes in plasma volume (Fig. 1D), there was no con-
be expected from repeated testing (pre/post). The minimal dition 9 experiment (P = 0695) or experiment effect
difference needed to be considered real for MTH was 04 cm (P = 0163), but there was a condition main effect
for the anterior site and 02 cm for the lateral site and (P = 0038). Follow-up tests revealed that the combined aver-
05 mmol l 1 for WBL. 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
Results
combined average of Condition 3 (30%/40 BFR, 30%/50 BFR
There was no significant condition 9 experiment (P = 0998), and 30%/60 BFR) (P <0031).
condition (P = 0627), or experiment (P = 0139) effect for The exercise volume completed within each experiment has
the mean change in MTH at the anterior site suggesting that all been published previously. We extend the results in that manu-
exercise conditions changed similarly (Fig. 1A). In addition, script by calculating differences between experiments. There
there was no condition 9 experiment (P = 0574) or experi- was a significant condition 9 experiment (P = 0004) effect for
ment effect (P = 0352) for MTH at the lateral site (Fig. 1B), total exercise volume. Follow-up tests found significant between
but there was a condition main effect (P = 0018). Follow-up experiment differences for Condition 1 (P = 0022) but not for
tests revealed that the combined average of Condition 1 (HL, Condition 2 (P = 0788) or Condition 3 (P = 0931). Within
30% to failure, and 20% to failure) and Condition 3 (30%/40 Condition 1, the HL and 30% to failure condition completed
BFR, 30%/50 BFR, and 30%/60 BFR) was significantly greater significantly less work than the 20% to failure. The within-
than the combined average of Condition 2 (20%/40 BFR, 20%/ experiment differences in exercise volume have been published
50 BFR, or 20%/60 BFR) (P<002). previously (Loenneke et al., 2015a).
© 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
© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd
6 Muscle thickness and lactate response, J. P. Loenneke et al.
and non-BFR conditions despite significant differences in exer- BFR exercise, with 50 and 60% estimated arterial occlusion
cise volume (Loenneke et al., 2012d). providing no further augmentation in WBL or acute changes
In view of the results presented herein, the set of experi- in muscle thickness. These acute findings may have implica-
ments does possess some limitations. First, the amount of BFR tions for designing future studies as it suggest that exercise
was estimated for each participant from previous data col- load (30% versus 20% 1RM) may have a greater influence on
lected during supine rest but was not directly measured. This adaptation than the applied relative pressure (40 versus 50
was not done due to the complexities involved with measur- versus 60% estimated arterial occlusion pressure); when low-
ing changes in blood flow during exercise of the lower body. load exercise is not taken to volitional fatigue. This acute find-
Regardless, each participant did receive graded amounts of ing should be further tested through long-term training stud-
BFR which allowed for the central question of ‘does applied ies.
pressure matter?’ to be answered. Second, the WBL levels
were estimated from fingertip blood drops. Although changes
Acknowledgments
exceeded the error of the measurement (05 mmol l 1), this
measurement only allowed us to quantify systemic lactate The authors are not aware of any affiliations, memberships,
accumulation, it did not allow us to differentiate differences funding or financial holdings that might be perceived as
in lactate accumulation in or around the active muscle tissue. affecting the objectivity of this manuscript. This study was not
Third, although increases in MTH and decreases in plasma supported by any external funding. The authors thank Dr.
volume were observed which indicates a fluid shift did occur, Rosemary Knapp and Dr. Travis W. Beck for their helpful dis-
we are unable to definitively determine from this study cussion on study design.
whether or not the fluid was shifted into the actual muscle
cell. Lastly, it is noted that these acute load- and pressure-
Conflict of interest
dependent changes should be investigated further with long-
term training studies to determine if acute changes predict or The authors declare no conflict of interest.
correlate to chronic adaptation.
Author contribution
Conclusions
JPL, TA, RDL, DAB, and MGB: designed the study. JPL, DK,
In conclusion, this set of experiments suggests that manipulat- CAF, and RST: collected the data. JPL, DK, CAF, RST, TA,
ing the exercise load can produce changes in the acute WBL RDL, DA, and MGB: analysed and interpreted the data. JPL,
response to resistance exercise. Additionally, it appears that DK, CAF, RST, TA, RDL, DA, and MGB: wrote and edited the
moderate (40% estimated arterial occlusion) relative pressures manuscript.
may be all that is needed to maximize the acute response to
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