Mechanisms Behind Blood Flow Restricted Training and Its Effect Towards Muscle Growth

Journal of Strength and Conditioning Research Publish Ahead of Print
DOI: 10.1519/JSC.0000000000002384
Mechanisms Behind Blood Flow Restricted Training and its Effect Towards Muscle Growth
Paul Hwang and Darryn S. Willoughby*
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Department of Health, Human Performance, and Recreation, Exercise and Biochemical Nutrition
Laboratory, Baylor University, Waco, TX 76798, USA
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*Corresponding author
Darryn Willoughby, Ph.D.
Baylor University
Department of Health, Human Performance, and Recreation
Waco, TX 76798
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Phone: (254) 710-3504
E-mail: darryn_willoughby@baylor.edu
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Copyright ª 2017 National Strength and Conditioning Association

Blood Flow Restricted Training and Muscle Growth 1
ABSTRACT
It is widely established throughout the literature that skeletal muscle can induce hypertrophic
adaptations following progressive overload of moderate to high-intensity resistance training.
However, there has recently been a growing body of research that shows that the combination of
blood flow restriction (BFR) with low intensity resistance exercise can induce similar gains in
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muscular strength and hypertrophic adaptations. The implementation of external pressure cuffs
over the most proximal position of the limb extremities with the occlusion of venous outflow of
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blood distal to the occlusion site defines the BFR methodological protocol. There are various
mechanisms through which BFR training may cause the stimulations for skeletal muscle
hypertrophy and increases in strength. These may include increases in hormonal concentrations,
increases within the components of the intracellular signaling pathways for muscle protein
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synthesis such as the mTOR pathway, increases within biomarkers denoting satellite cell activity
as well as apparent patterns in fiber type recruitment. There have also been scientific findings
demonstrating hypertrophic effects within both blood-flow restricted limbs and non-blood flow-
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restricted muscles during BFR training programs. The purpose behind this critical review will be
to provide a comprehensive discussion on relevant literature that can help elucidate the potential
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underlying mechanisms leading to hypertrophic adaptations following BFR training programs.
This review will also explicate the various findings within the literature that focalizes on both
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blood flow-restricted limb and non-blood flow-restricted muscle hypertrophy following bouts of
BFR training. Furthermore, this critical review will also address the various needs for future
research in the many components underlying the novel modality of BFR training.
Key Words: Kaatsu, Occlusion Training, Skeletal Muscle Hypertrophy, Muscle Protein
Synthesis, Satellite Cells, Practical Blood Flow Restricted Training, Performance

INTRODUCTION
It is widely established that the implementation of resistance training can induce muscle
hypertrophic effects. The integration of manipulated variables of interest ranging from order of
exercises, intensity, volume, and frequency can present a potent stimulus towards increases in
muscle protein synthesis. The evaluation of the intensity behind the exercise induced resistance
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training has been highly attributed to neuromuscular adaptations and strength gains [1, 2].
Similarly, the moderate to high-intensity resistance training (60-85% of one repetition maximum
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or 1RM) has been found to also induce hypertrophic adaptations due to satellite cell activity [1].
The American College of Sports Medicine (ACSM) provides a statement that also recommends
utilizing at least 70% of the 1RM to gain hypertrophic adaptations for muscle growth [3, 4, 5].
This means that the implementation of intensity levels below this recommendation may not
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optimally produce muscle growth [3, 4]. However, it is important to mention that there have been
recent studies suggesting that the incorporation of lower intensities of exercise of higher
repetitions (30-50% 1RM; 20-35 repetitions) to failure may incur hypertrophic adaptations
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indicative of muscle growth [6, 7]. For further discussion on low versus higher load resistance
training effects upon hypertrophic adaptations, refer to the recent systematic review by
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Schoenfeld et al [8]. Nevertheless, it is important to mention that the utilization of high
resistance exercise loads at the recommended intensity by the ACSM may be detrimental upon
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specific populations due to the excessive mechanical stress placed upon the joints during the
exercise session as well as the potential risk for injury [9, 10]. These populations may include
those recovering from an injury, individuals suffering from chronic metabolic health
complications, those with disabled limbs as well as the elderly who cannot endure the continual
high mechanical stress due to heavy resistance training [11].

In light of this issue, it has been revealed in recent literature that the utilization of low
intensity resistance exercise with blood flow restricted training (BFR) can induce hypertrophic
effects similar to traditional high intensity resistance training [11]. BFR training, which is also
known as Kaatsu training can be applied to strengthen muscle within athletes and also be applied
to various comorbid factors such as cerebrovascular diseases, orthopedic diseases, obesity,
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cardiac diseases, neuromuscular diseases, diabetes, hypertension, and respiratory diseases [12].
This novel exercise approach is carried out at low intensities (20-50% 1RM) with moderate
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vascular occlusion [1, 13, 14].
Several studies utilizing BFR training has demonstrated that specific lower intensities of
20-30% 1RM in a period as short as 1-3 weeks with twice daily training sessions can result in
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increases of muscle cross-sectional area (CSA), muscle fiber CSA as well as strength gains [15].
Therefore, BFR training has progressively become a popular methodology through which muscle
hypertrophy can be obtained in various populations that may not be able to train under heavy
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resistance loads. The unique aspect of BFR training is that the application of elastic belts on the
most proximal region of the upper and lower extremities at a specified pressure for vascular
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occlusion can induce the positive effects of muscle hypertrophy through lower intensity
resistance training [16]. In addition, BFR training has been known to not only show muscle
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hypertrophy and hormonal secretions, but also result in less muscle damage (creatine kinase,
myoglobin, interleukin-6 (IL-6)) compared to traditional higher intensity resistance exercise with
no blood flow restriction [16]. According to the literature, the primary mechanisms through
which BFR training stimulates skeletal muscle growth include: metabolic accumulations that can
stimulate anabolic growth factors, the analysis of increased muscle protein synthesis through

specific intracellular signaling pathways, muscle damage, mechanotransduction, fiber type
recruitment patterns, potential evidence for satellite cell activity, production of reactive oxygen
species, as well as the attenuation of disuse atrophic effects from immobilization or injury [17,
18, 19, 20]. Additionally, it is suggested that mechanical tension and metabolic stress may act
synergistically in order to induce an optimal condition for the greatest hypertrophic potential [20].
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The focus of this critical literature review will be to define occlusion training or blood flow
restricted training, provide a comprehensive examination of the various mechanisms responsible
for the overall positive effects of muscle protein synthesis through BFR training, explicate the
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significant findings of BFR training towards skeletal muscle hypertrophy in occluded limbs as
well as non-BFR areas, briefly mention recent scientific evidence of the low-load BFR versus
traditional high load resistance training, the practical occlusion blood-flow restricted training, the
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differential effects of low-load BFR versus traditional low-load training to volitional fatigue, and
finally discuss the necessity for pursuits of future research within the relevant physiological
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mechanisms which may further augment the significance of occlusion training within the general
population.
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DEFINING OCCLUSION TRAINING
The concept behind low-intensity vascular occlusion or BFR training has emerged in
Japan as early as the 1960’s [1, 9]. This form of training which implements exercise while
restricting blood flow to the active working muscles was historically known as Kaatsu training

[9]. Traditionally, Kaatsu training has been known to utilize a specific patented Kaatsu-specified
training band (Kaatsu-Master, Sato Sports Plaza Ltd., Tokyo, Japan), which is known as an
airbag-contained belt that is connected to an electric pressure control system that monitors the
restriction pressure employed [16]. However, this type of training has also utilized the
application of a tourniquet that is placed onto the extremity of interest at the most proximal
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position [17, 21, 22]. Methodologically, this cuff is then inflated to reach the specified pressure
point at which blood flow is restricted [9, 17]. In other words, occlusion training or BFR training
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involves decreasing the blood flow to an active muscle by the application of these wrapping
devices such as a blood pressure cuff, practical knee wraps or specially designed patented
restrictive straps [17]. Once the cuffs are inflated to the designated set pressure, the subject
would carry out low intensity repetitions throughout the exercise session. The pressure applied
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should be at a high enough level to occlude venous return from the muscle but maintain the
arterial blood inflow into the active muscle [17, 23, 24].
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The optimal pressure at which performance is augmented towards the effect of skeletal
hypertrophy is widely diversified within the literature [1, 4, 17, 24, 25]. There are many studies
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that utilized BFR training with vascular occlusion with the application of high occlusion
pressures that are greater than 180 mmHg [2, 4, 21, 26]. However, the majority of these studies
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have found that the utilization of such high pressures was associated with pain. A study by
Sumide et. al [4] examined the effects of BFR training through the utilization of different applied
pressures of vascular occlusion at the proximal position of the thigh. These pressures included 0
mmHg, 50 mmHg, 150 mmHg, as well as 250 mmHg. This study has revealed that all subjects
exercising under vascular occluded pressures gained increases in strength.

However, total muscle work was increased at significant levels within the 50 and 150
mmHg pressure groups, which revealed that these pressure levels may induce positive benefits
from BFR training in comparison to higher pressures [4].
Various other studies implemented a BFR study with the progressive increase of training
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pressure to reach a final pressure relative to the subject’s systemic blood pressure (SBP) [11, 26,
27]. However, the inter-subject variation in SBP as well as the differences in restriction pressures
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due to the cuff width and circumference of the active muscle group may necessitate further
research for a standardized approach that is high in external validity [17]. It is important to note
that investigations that neglect cuff size and inter-subject differences in circumferences of limbs
can potentially decrease the efficacy of the study while causing a safety issue as well [12, 17].
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One study utilized an arbitrary pressure of 200 mmHg for each individual subject through which
a wider cuff (11 cm) was used [28]. The similar absolute pressure can be a problem with these
wider cuffs since differences in arterial occlusion pressure at rest as well as compromising
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cardiovascular functionality [17, 29]. Another study used narrow cuffs (5 cm) on 83 participants
through which 19 of these participants were reported to be above their arterial occlusion pressure
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at this arbitrary 200 mmHg BFR pressure [29]. Therefore, one major factor to consider when
applying this modality would be to ascertain the optimal width of the cuff [30]. Wider cuffs (13.5
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cm) have been suggested to induce greater ratings of pain and perceived exertion in comparison
to narrow cuffs (5.0 cm) during low-intensity BFR knee extensions at the same restrictive
occluded pressure [30]. Furthermore, additional research is needed to standardize a protocol that
can generalize BFR training to optimal pressures relative to any individual subjects.

Nevertheless, many of the studies found in the literature followed a general restricted-
pressure range between 140-200 mmHg within the BFR training regime based off a review by
Takashi Abe [31].
There is also a wide disparity in standardizing the type of material that each cuff is made
from. Most of the narrow cuffs are known to be made from elastic materials in contrast to the
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wider cuffs, which are made from nylon [29]. Other studies have utilized elastic knee wraps [26],
elastic belts with a pneumatic bag inside [11] or nylon blood pressure cuffs [13]. Nevertheless, it
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can be hypothesized that these differences in material of the cuffs may carry relative differences
between the efficacy in restricting blood flow and thus alter the differences in applied pressures
[1, 29, 31]. Recent data also shows that the application of an initial pressure of 50 mmHg to
narrow elastic cuffs (5 cm) prior to the inflation towards a specified target pressure can restrict
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blood flow similarly between conditions of rest and during exercise [17]. Further research should
be carried out to investigate the standardizations of initial pressures relative to the type and size
of the pressure cuffs.

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BFR AND MECHANISMS OF MUSCLE PROTEIN SYNTHESIS

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Hypertrophic Adaptations: Hormone Responses
Occlusion training or BFR is known to induce metabolic accumulations, which may

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include biomarkers such as whole blood lactate, plasma lactate as well as muscle cell lactate [1,
31]. The accumulation of these metabolites is known to present an acidic intramuscular
environment through which the stimulation of sympathetic nerve activity is mediated by
intramuscular metaboreceptors and group III and IV afferent fibers [1, 18, 19, 32].

The metabolite accumulation due to high intensity resistance exercise can also
compromise oxygen delivery to the muscle due to the continual compression of the arterial and
venous blood flow over the course of the exercise session, which can result in acute hypoxia and
lower intramuscular pH conditions [19]. The hypertrophic effects due to occlusion training may
also be explicated by the relationship between the metabolite accumulations and the increase in
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secreted hormone concentrations, which can enhance the anabolic effect and assist in muscle
protein synthesis (MPS) [19]. Thus these levels of circulating hormones interacting with their
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respective receptors can carry significance in the anabolic effects attributed to post-exercise
muscle growth.
Growth Hormone: GH
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The low pH environment induced by the metabolic accumulations is known to stimulate
growth hormone (GH) secretion, which is known to possibly have an interactive effect towards
muscle protein synthesis. There is continual debate over the direct hypertrophic actions of GH
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towards overall muscle protein synthesis. Many scientists believe that GH primarily functions to
assist in the overall process of skeletal muscle hypertrophy through the potentiating release of
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insulin growth factor 1 (IGF-1) [19]. However, other researchers believe that muscle protein
synthesis may require the additive approach of both GH and IGF-1 concentrations [19, 33].
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Future studies should be carried forth to better elucidate a stronger stance on the significance of
GH in the process of MPS.
In light of GH, there may be additional intramuscular metabolites that when stimulated
may cause changes in GH secretion rates such as changes in lactate levels, K+, H+ or hypoxia
conditions, however, the discuss of these factors go beyond the scope of this review.

The implementation of BFR training in one study has been found to elevate GH levels to
~290 [1]. Another study has found that skeletal muscle ischemia coupled with low intensity
resistance exercise through knee extensions acutely increased GH levels while reducing the
maximal voluntary contraction (MVC) [33]. It is known that the implementation of Kaatsu
training increased the post-exercise GH levels 10 fold above the control group with no blood-
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flow restriction [19, 34]. Goto et. al. [35] reported significant correlations between acute
exercise-induced increases in GH as well as increases within the cross-sectional area of the
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quadriceps following a bout of resistance exercise [35].
In contrast, skeletal muscle ischemia alone without the implementation of resistance
exercise decreased force capacity, but has not caused alterations in GH levels [19]. Another
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study examined the exogenous administration of GH in combination with resistance exercise,
which has not shown significant effects towards muscle protein synthesis [33]. Several other
studies have implemented the exogenous administration of recombinant GH with the induction
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of resistance exercise, which has not shown greater levels of muscle protein growth [36].
However, the large “spikes” in levels of GH during the post-exercise period may still have a
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significant association with the anabolic window priming for muscle protein synthesis [19].
Another intriguing finding was a study that found that temporary hormonal increases had no
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effect towards post-workout MPS when compared to a similar protocol with a measurement of
low hormonal levels [37]. This study also found that p70S6K phosphorylation was similar
between both of these groups, which can lead to the speculation that anabolic signaling may have
no relationship with the spikes in hormonal levels following exercise [37].

However, it is possible the MPS following exercise sessions may not always carry a
significant relationship with direct upregulation of chronic myogenic signals such as increased
anabolic hormonal levels [19, 37, 38]. Therefore, even with these conflicting results, the
physiological significance of GH secretion and its possible association with BFR and skeletal
muscle hypertrophy definitively necessitates further research.
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Peptide Hormone IGF-1
In addition, research has also shown that the administration of GH is known to elevate the
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liver isoform of IGF-1 within muscle as well as the mechano-growth factor (MGF) [1]. IGF-1 is
known as a growth factor that can be produced locally within the peripheral muscle tissue as well
as systemically by the liver in response to GH [1, 19]. This peptide hormone is known to have
mitogenic and anabolic effects towards skeletal muscle [39]. Increases in protein levels of IGF-1
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have been shown to be proportional towards increases within muscular strength following
sessions of resistance exercise [40]. One study found that resistance training with vascular
occlusion showed increases within circulating levels of IGF-1 alongside the growth in muscle
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volume [33, 41]. IGF-1 is known to be expressed within skeletal muscle, thus the availability
levels of this muscle growth factor alongside MGF as well as the negative regulatory factor
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myostatin may have a role in regulating skeletal muscle growth [33, 41]. However, presently, it
is still unclear if IGF-1 activity is increased directly in response to occlusion training. The locally
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expressed isoform of IGF-1 termed MGF has been known help facilitate the localized repair of
damaged tissue following mechanical stress induced by resistance training [19, 42]. Another
study found increases within IGF-1 activity in response to low intensity occlusion training [43].
In stark contrast, a study by Kawada and Ishii found no significant increases in IGF-1 following
a bout of occlusion training, which may be due to factors such as the intensity levels or

frequency of the training program [44]. There are many conflicting findings behind whether the
low intensity exercised induced occlusion training protocols have an effect towards elevating
IGF-1 levels post-exercise [34, 41, 45], which may necessitate further studies with minimal
methodological differences in order to confirm the potential associations that IGF-1 hormonal
levels may have towards the induction of BFR related training.
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It has also been proposed that one role that IGF-1 isoforms may have towards
hypertrophic effects of skeletal muscle may be towards the stimulation, proliferation, and fusion
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of satellite cells with existing muscle fibers [46, 47]. This fusion of the muscle stem cells can
play a role in optimizing the myonuclear domain ratio or DNA-to-protein ratio within muscle
tissue [46, 47]. Satellite cell activity in relation to BFR training will be discussed in further detail
in the section focused on intracellular signaling pathways.

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Anabolic Hormone: Testosterone
Testosterone is known as a hormone that is primarily synthesized and secreted by the

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Leydig cells of the testes by the hypothalamic-pituitary-gonadal axis (HPA) [48]. It is widely
established in the literature that testosterone carries forth anabolic effects on muscle protein
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synthesis and the decreasing of muscle cell proteolysis [49, 50]. Testosterone is known to also
have indirect hypertrophic effects through the potentiation with the release of other important
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anabolic hormones such as IGF-1, MGF and GH [19]. In addition, testosterone is known to have
a role in the mediation of the satellite cell activation and proliferation as well [19]. It is shown in
literature that post-exercise testosterone levels are higher within strength athletes compared to
endurance athletes or untrained individuals, leading to the speculation that trained athletes may
have higher post-exercise testosterone levels [51].

In light of this potential association between acute testosterone production and skeletal
muscle hypertrophy, BFR related studies have been explored towards investigating relationships
with testosterone levels. Several Kaatsu related studies have found no significance in post-
exercise elevated levels of testosterone following BFR exercise sessions [34, 52]. Therefore,
additional investigation into testosterone levels with BFR related training need to be
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implemented for conclusive data.
Hypertrophic Adaptations: Intracellular Signaling Pathways and Satellite Cell Activity
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Skeletal muscle growth occurs with the integration between protein synthesis and
degradation shifting towards protein synthesis. There are two major intracellular signaling
pathways through which molecular adaptations incurs the signaling for muscle growth in
response to progressive resistance overload. Muscle protein synthesis is achieved through this
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activation of the insulin-like growth factor 1-phosphoinositide-3-kinase-Akt/protein kinase B-
mammalian target of rapamycin (IGF1-PI3K-Akt/PKB-mTOR) signaling pathway and the
downregulation of the myostatin-Smad 3 pathway, which is known as a negative regulator of

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skeletal muscle growth [18, 19, 53]. Once Akt stimulates protein synthesis through the activation
of mTOR and its downstream effectors, the kinase mTOR is known to interact with proteins that
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can form two major complexes [18, 53]. These include the mTOR complex 1 (mTORC1), which
contains raptor and the mTOR complex 2 (mTORC2) containing rictor [18, 53].
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Within the Akt/mTOR pathway, the two major effectors of the mTORC1 complex
leading to protein synthesis include the eukaryotic translation initiation factor 4E-binding protein
1 (4E-BP1) and S6 kinase 1 (S6K1) [18]. The phosphorylation of S6K1 is known to be a critical
regulator towards exercised induced muscle protein synthesis.

A study found that the implementation of occlusion training upregulated the
phosphorylation of S6K1 at Thr389 three-fold post exercise session and continued to be elevated
relative to the control three hours post exercise bout [1]. In addition, since MGF, the isoform of
IGF-1 may have a possible responsibility in compensatory hypertrophy through its function in
repairing localized damaged tissue post exercise, it is important to note that this isoform carries
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out its signaling through the PI3K-Akt-mTOR pathway as well as the MAPK-ERK ½ pathway
[19]. Thus, further research may need to be carried out to explore how BFR related training
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might have increased activation within the intracellular signaling pathway of MAPK-ERK ½
pathway.
According to the literature, it is also known that a single bout of low-intensity resistance
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exercise with BFR can result in both an upregulation of the anabolic cell signaling mTOR
pathway within 3 hours of post exercise as well as a downregulation of the proteolytic transcripts
for skeletal muscle at 8 hours post exercise [23, 28, 34]. Another study found that acute low-load
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resistance exercise with BFR (30% 1 RM unilateral knee extensions with 5 sets to failure on both
BFR and free-flow leg) resulted in the enhancement of phosphorylation of p70S6K at Thr389 at
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1-hour post as well as 24 hours post exercise [15].

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In addition, this study by Wernbom et. al. [15] found an elevation of p38MAPK and
increased numbers of satellite cells (SC) within the BFR leg compared to the free-flow leg 1 hour
post exercise [15]. Following an acute bout of low-load strength training under BFR, long-term
load-induced muscle hypertrophy is known to be associated with the myonuclear domain, which
is relative to the satellite cell activation [15].

Thus, increases in the cross-sectional area of the muscle fiber following resistance
exercise may have a relationship with the number of myonuclei per muscle fiber. It is known
within the literature that systemically produced IGF-1Ea (one of the three distinct isoforms for
IGF-1) is known to mediate the satellite cell fusion [47], while locally expressed IGF-1 isoform
MGF functions in activating SC and looking over the proliferation and differentiation process
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[54, 55]. Thus, the optimization of the myonuclear content, which is based on the DNA-to-
protein ratio in skeletal muscle, may carry forth significance in the long term hypertrophic
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adaptation in muscle mass gains [18, 19]. Further extended discussion on the concept behind
satellite cell activity within skeletal muscle goes beyond the scope of this literature review.
Another study by Drummond et al. [45] also found increases in SC activity markers and
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myogenic regulatory factors (MRFs) p21 and MyoD as well as decreased myostatin mRNA
expressions at 3 hours post BFR training whereas the mRNA expressions of myogenin, cyclin
D1 and IGF-1 isoform MGF had no significant changes [45]. In contrast to this finding, a study
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by Manini et. al [56] found no significant changes within the mRNA expression levels of MRF
factors MyoD, myogenin, myostatin, and IGF-1 8 hours post acute BFR training at 20% 1RM
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[53]. However, another study found significant increases in the Pax-7 positive SC activity and
numbers of myonuclei following an acute training period under BFR training [57]. Layne et al.
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[58] sought to investigate the effects of BFR exercise upon changes in both the transcription and
translation of muscle growth including hepatocyte growth factor (HGF), c-Met, MyoD as well as
myf5. HGF is known as a potent stimuli instigating muscle satellite cell activation [58, 59]. This
study found that the implementation of low-load BFR at 40% 1RM through unilateral knee
extensions potentiated elevations in the post-exercise skeletal muscle expression of myogenic

genes, but decreased HGF protein expression 24 hours post-exercise in untrained individuals.
This finding of decreased HGF expression seemed in contrast to other studies that observed
elevations in satellite cell activity [57]. It is plausible that the increases in MyoD and myf5
mRNA expression post-exercise in this study, which is contrast to Manini et al [56], may be due
to the higher load (40% 1RM) as well as other potential confounders such as timing of blood
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draws, circadian profiles, overall dietary intakes, as well as genetic variations amongst subjects.
Nevertheless, in light of these findings associated with the activity in satellite cell markers, HGF-
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related muscle signaling, myonuclei, and MRF levels following BFR activity, it is imperative to
carry out future studies to gather additional data on the responsiveness of the biomarkers for
myogenesis during chronic training periods with applied BFR.

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Myostatin is known as a negative regulator for skeletal muscle growth. Myostatin is
known as a member of the transforming growth factor beta superfamily [18]. A study found that
the expression of myostatin inhibited SC proliferation since Myostatin-null mice had phenotypes
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of significant muscle hypertrophy and postnatal muscle growth, which may be attributed to
increased SC activity [1]. Following periods of mechanical overload through resistance exercise
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as well as in BFR induced training; it is known that there is a downregulation of myostatin gene
expression [1, 44]. Therefore, it is hypothesized that occlusion training may induce muscle
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hypertrophy due to the repressed activity of myostatin due to either hypoxia conditions or
metabolite accumulation due to BFR induced training [1]. Further discussion of the intracellular
components interacting with myostatin such as activin A or the transcriptional targets of the
transcription factors Smad2 or Smad3 go beyond the scope of the review paper, but can be
explored in the literature review by Schiaffino et. al. [18] in detail.

The implementation of occlusion training with analyses of mRNA expression of
myostatin and constructs within the myostatin-Smad2/3 intracellular signaling pathway should
be explored in further detail in future studies for additional data.
Hypertrophic Adaptations: Fiber Type Recruitment
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In accordance with occlusion training, it is known that compared to slow twitch muscle
fibers (ST), the fast twitch fibers (FT) are recruited quickly even though the intensity is low [1].
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In other words, BFR training can recruit fast twitch fibers without regards to the widely accepted
size principle in which ST fibers are recruited first with FT fibers being recruited as intensity
progresses. The rationale presented throughout the literature may be due to the hypoxia
conditions created by the vascular occlusion through which the additional recruitment of more
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motor units may take place to compensate for the deficit in overall force development [1, 60]. In
addition, the metabolite accumulations throughout the BFR training session may also induce the
increased recruitment of FT or higher-threshold motor units [19]. Several studies show through
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the utilization of electromyography (EMG) that during Kaatsu training, there was an increase in
the recruitment of FT muscle fibers [19, 61]. Another study implemented low intensity vascular
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occlusion training showed early fatigue of type I fibers due to the lack of delivery in oxygen,
thus showing a greater increase in the cross-sectional area of type II fibers by 27.6% compared to
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type I muscle fibers increase of 5.9% during a 2 week training program at 20% of 1 RM [31].
However, there is still a necessitation of further research to confirm if increased FT fiber
recruitment during BFR training has a direct association with the metabolically induced skeletal
muscle growth. Future studies should explore variances in intensity and volumes of BFR training
with EMG analysis to extend support for the increased FT fiber type recruitment.

Blood Flow Restricted Limb Hypertrophy vs. Non-Restricted Muscle Hypertrophy
Various studies have been carried out exploring the potential hypertrophic effects of
venous occlusion through the use of pressure cuffs on the proximal portion of the limbs.
However, the literature also presents findings associated with data that suggests hypertrophic
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adaptations insinuated upon non-restricted muscle during the BFR training program. These novel
findings will be explicated alongside other BFR limb hypertrophic studies in this section of the
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literature review.
The utilization of blood flow restricted training (BFR) during low intensity resistance
training (20-50% 1RM) has been noted to incur hypertrophic adaptations similar to high
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resistance exercise protocols [1, 10, 62]. The implementation of blood flow restriction upon the
lower limbs during walking sessions has been known to cause significant improvements within
the thigh muscle cross-sectional area (CSA) as well as showing increases within the knee joint
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strength of subjects in both young and elderly groups [10, 30, 63]. BFR related training has also
shown increases within a group of semi-professional rugby union athletes through the utilization
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of a cross-over design study with lower-body limb BFR (at a pressure of 180 mmHg on the
proximal feature of the thighs) and resistance exercise sessions of 5 sets of 5 repetitions of bench
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press, leg squats and pull-ups at 70% 1 RM [11, 64]. The results showed greater improvements
within all lifts as well as the maximum sprint time within the BFR group compared with the
control, which demonstrates that occlusion training can potentially induce strength gains and
fatigue resistance within trained athletes as well [64]. Another study with BFR training on
division IA football players showed significant increases in bench press and squat strength, upper

and lower chest girth, and left upper arm girth within the BFR group compared to the non-
restricted group [16]. This study utilized an intensity scheme of 30-20-20-20 repetitions at 20%
1RM for the bench press and squat exercises. Moreover, the subjects were randomly assigned to
train in practical BFR or non-BFR settings at a frequency of 3 times a week alongside their
normal off-season strength training sessions for a period of 4 weeks. After this period, the
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subjects were maxed tested for their respective 1RM of the bench press and squat through which
the BFR presented a significantly greater increase in strength in both exercises versus the control
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group [16]. This study also observed significantly greater elevations in the chest girth within the
BFR versus the control group. In a similar fashion, another study carried out a similar training
protocol within the cohort of college American football players. Within this study, the
participants trained at a frequency of 4 days per week for 7 weeks in a periodized fashion for
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upper and lower body in 4 different groups [65]. These groups included (1) a traditional high-
intensity training program, (2) a high-intensity training program supplemented with low-intensity
training, (3) a high-intensity training program supplemented with low-load BFR training, and
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lastly (4) a modified training program with only low-load BFR training [65]. The 1RM for bench
press and squat were implemented to ascertain muscular strength changes. The authors found
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that the group performing high-intensity supplemented with low-load BFR training demonstrated
the largest increases in 1RM squat strength. Moreover, the authors also found that the inclusion
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of the occlusion condition made no difference in the significant increases in all groups for thigh
and arm size [65]. A study by Abe et. al [66] showed that BFR training at 20% 1RM for a
duration of 8 days within an athlete subject group showed improvements within their overall
sprint performance. Another study carried out an 8 week daily Kaatsu walk training program
within older adults, which showed increases of assessments including Timed Up and Go, Six

Minute Walk Test, Ten Meter Walk Test, and lower extremity strength measures from 18.2% to
46.8% from baseline testing to post-test [63]. Circuit training with body weight alone has also
shown muscular hypertrophy when combined with moderate venous occlusion (BFR) within the
proximal ends of the upper and lower limbs of both sides at 80-120 mmHg [67]. This study
found a dramatic increase in the muscle cross-sectional area of both right and left limbs (3%
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increase) after 8 weeks of the training period within the BFR group compared to the control
group [67]. Another study by Abe et. al [68] showed concurrent improvements in VO2 max and
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muscle hypertrophy (thigh and quadriceps muscle cross-sectional area and volume increases by
3.4-5.1%) and isometric knee extension strength by 7.7% following an 8 week cycle training
protocol under BFR conditions compared to a non-BFR control group.

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In comparison to the various studies focusing on the hypertrophic effects attributed to the
blood flow restricted limb, there has been a few studies observing skeletal muscle growth within
non-blood flow-restricted muscle during the BFR exercise session. A study investigating the
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effects of low intensity squat (20% 1 RM) and leg curl exercises both with and without BFR
(blood flow-restricted proximal position on thigh) found the quadriceps, biceps femoris and
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gluteus maximus muscle volumes significantly increased within the BFR training group [66].
The non-BFR training group had little to no significant effects in muscle volume hypertrophy
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compared to the BFR group [66]. Another study observed significant increases within the cross-
sectional area or muscle thickness of the triceps brachii (8%) and pectoralis major (16%) muscles
following a low intensity (30% 1RM) bench press training program within the BFR group
compared to the non-BFR control group [2]. Another study observed a 6-week BFR low
intensity (30% 1RM) bench press training session on the upper arm and chest cross-sectional

area and found that both the triceps brachii and pectoralis major muscle cross-sectional area had
significant increases of 4.9% and 8.3% respectfully [69].
Based on these studies above, it is intriguing to see that non-blood flow-restricted
muscles can also have hypertrophic effects following bouts of BFR resistance exercise. One
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study analyzed both the blood flow restricted limb and non-blood flow-restricted muscles
following a BFR walking training program [70]. This study observed that the muscle volumes of
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the thigh and lower leg had increases of 3.8% and 3.2% respectfully within the BFR group, but
did not find increases within the non-BFR gluteus muscle volumes and the lumbar L4-L5 muscle
cross-sectional areas [70]. Thus, the conflicting pronounced effects of hypertrophy within both
BFR limb and non-blood flow restricted muscles following various modes of BFR exercise
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sessions necessitates future studies to gather additional data. In addition, specific changes to the
volume-load, recovery periods, variance within the time-under-tension, intensity ranges within
BFR training protocols as well as various types of modalities such as cycling, elevated walking,
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swimming, multi-joint resistance exercises should also be explored in further detail.

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Blood Flow Restriction and High Load Resistance Training
Although the majority of BFR research has been conducted with lighter intensities, recent
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studies have also investigated whether a higher-load BFR training can garner similar results. One
study observed rugby union players’ responses after performing the squat, pull-up and bench
press exercises at an intensity of 5 sets of 5 repetitions at 70%1RM either with or without the
applied BFR condition towards the lower limbs [71]. This study observed that the BFR group
had a significantly greater elevation in the 1RM for the bench press and squat in comparison to

the control group. Another study has been carried out to observe for acute and chronic responses
within the muscle to differing levels of blood flow restriction pressure [71]. Another study
observed that 8 weeks of the elbow flexion exercise training presented similar changes in muscle
size, peak isotonic strength, peak isokinetic torque and muscular endurance between low (40%
arterial occlusion) pressure and high (90% arterial occlusion) pressure [72]. However, some
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limitations within this study may include the low sample size as well as the potential chance for
error in using a standing dumbbell curl exercise against the wall as the exercise choice. Kim et
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al., [73] investigated the acute and chronic response comparing high-load resistance training to
low-load resistance training at a low-moderate blood flow restriction (50% arterial occlusion)
within the upper body in untrained men. The subjects were randomized to a high-load or low-
load protocol with BFR in which unilateral elbow flexion training was implemented for 8 weeks
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of training. Specifically, one arm of each participant was randomized to this high or low-load
with BFR. At each training session, the high load protocol included 3 sets of 10 repetitions at
75% 1RM whereas the LL-BFR protocol included 1 set of 30 repetitions followed by 3 sets of 15
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repetitions at 30% 1RM. The acute results from this study observed that low-load BFR with a
relatively low-moderate pressure (at 50% venous occlusion) presented similar changes in torque,
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muscle swelling as well as blood lactate concentrations in comparison to high-load training.
Moreover, the chronic results also presented evidence of no significant differences between
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groups on changes for muscle size as measured by the ultrasound technique for muscle thickness
of the elbow flexor muscles. However, these findings merit caution as this study only
incorporated one specific exercise and had a relatively small sample size. Therefore, it is too
early to state that low-load BFR may garner similar hypertrophic adaptations to high-load
training without additional chronic research.

Dankel et al [74] explored whether the application of blood flow restriction within young
resistance trained individuals (mean age 26 ± 3 years) can further augment muscle activation
during a subsequent set of high-load resistance exercise. Within this study, participants
completed two sets of unilateral dumbbell elbow flexion exercises to volitional fatigue at 70% of
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their 1RM. Following the first set, the experimental arm had the application of BFR to 70% of
the predetermined arterial occlusion pressure (during the interset rest period), in which the
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second set to volitional failure was implemented with both the control (non-BFR) and
experimental arm at the same intensity. The authors observed that the application of BFR during
the second set of exercise did not augment EMG amplitude, suggesting that BFR may be only
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able to augment muscle activation when lower loads of intensity are utilized. However,
limitations of this study include the use of surface EMG, which is not truly indicative of a direct
measure of muscle activation as well as the possibility of additional mechanisms of action
impacting muscle growth due to BFR on high-load training. Additionally, this was also an acute
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investigation, which limits generalization to chronic training periods, which may carry
differential responses with respect to BFR and high-load training.

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Practical Blood-Flow Restricted Training

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Recently, there has been the formulation of scientific studies that foreshown the
implementation of practical occlusion wraps to instigate the environmental conditions of
occluded blood-flow training. Whereas the patented specialized BFR cuffs is widely utilized in
previous studies, the high cost and proper training mechanisms for effective application serves as
a potential issue amongst generalization.

Moreover, the implementation of occluded training within a larger group population,
such as within athletes necessitates a more simplistic practical means. To this respect, the
utilization of elastic wraps has been proposed by Loenneke and Pujol through which practical
BFR (pBFR) can be instigated as a safe, ecologically sound and cost-effective means to stimulate
occlusion training [26]. Wilson et al [75] carried out a study through which 12 trained male
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participants carried out a traditional 30, 15, 15, 15 repetition scheme at a low intensity of 30%
1RM of the leg press exercise in either a non-BFR or low-intensity pBFR condition. In this study,
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the authors utilized knee wraps proximally on the femur at a pressure that led to venous
occlusion with the determination of blood flow through ultrasonography [75]. It is noteworthy to
mention that within this study, the pressures were ascertained by the usage of perceived
pressures: control (0 out of 10), moderate (7 out of 10), and tight (10 out of 10). The authors
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reported that moderate pBFR conditions resulted in a greater environmental condition of
metabolic stress with muscle swelling and consequential muscle activation in comparison to a
work-matched control [75]. Furthermore, the authors observed no elevations in indices of muscle
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damage with moderate pBFR resulting in venous but not arterial occlusion within all the
participants. Although Loenneke and Pujol [26] suggested this method of practical BFR, their
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study did not quantify the tightness of the wraps and did not verify if there was specifically
venous or arterial BFR. However, this study also highlights a major limitation through which the
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moderate perceived pressure could be widely variable amongst the participants even if the
ultrasonography presented venous occlusion [26]. Furthermore, this practical BFR methodology
is unable to directly ascertain the minimal blood pressure variable necessary to induce venous
occlusion while controlling for inter-subject variations in blood pressure.

As such, a moderate perceived feeling of pressure might be significantly different
amongst participants, further complicating the validity and reliability of this practical
methodology.
There have been a few studies carried out that integrated practical low-intensity BFR
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training to observe for muscular changes. Lowery et al [76] also conducted a study with 20
trained college male participants who were randomized into a crossover protocol with either the
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condition of practical BFR for the elbow flexors during the first 4 weeks (BFR-HI) or the second
4 weeks (HI-BFR) of a traditional 8-week resistance training program [76]. The authors observed
that the condition of practical BFR was able to instigate muscular hypertrophy in a similar
fashion to traditional high-intensity resistance training. Furthermore, the utilization of a low-

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intensity practical BFR condition upon the arms with a perceived pressure of 6-7 out of 10
resulted in similar hypertrophic gains as high-intensity training regardless of the order at which
these methods were implemented [76]. However, some limitations of this study include the lack
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of assessing the subject’s 1RM for the bicep curl exercise prior to the start of the study as well as
basing the tightness of the wraps solely upon one’s perceived pressure. Nevertheless, it is
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important to mention that these aforementioned studies suggest that the strategic implementation
of a practical BFR program alongside a strength-training program may still potentially serve to
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be an effective and feasible training modality for athletes and the general population.
Direct Effects of Blood Flow Restricted Exercise to Volitional Fatigue
Recently, there has been studies suggesting the role that low-load (30% 1-RM) resistance
exercise to volitional failure may also incur elevation of muscle protein synthesis for a longer

period of time compared to a higher load of resistance [77, 78]. Moreover, Yasuda et al. [78]
sought to explore whether low-load resistance exercise to volitional fatigue can induce anabolic
benefits associative of muscle swelling with and without blood flow restriction. This study
observed recruited young recreationally trained males who performed 4 sets of arm curl
exercises without BFR and with BFR in a randomized fashion (subjects carried out both
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conditions with each visit separated by a week). The exercise intensity was set at 20% 1RM to
volitional fatigue as defined as failure to keep up with the metronome. The main findings of this
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study included elevations in muscle swelling and concomitant muscle activation post-exercise
that did not differ between both conditions. Moreover, the authors reported that the low-load
resistance exercise to volitional fatigue presented an elevation in muscle swelling that lasted up
to 15 minutes irrespective of the BFR condition. This finding was in contrast to another study
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that observed BFR training to present a greater elevation in muscle size in comparison to non-
BFR training [79]. However, it is important to mention that in contrast to Yasuda et al. [78], Fahs
et al. [79] recruited a population of older untrained individuals that utilized unilateral knee
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extensor resistance training for a longer period of 6 weeks with the hopes to elicit increases in
muscle function. Nevertheless, the authors also reported evidence that similar observations of
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muscle swelling following low-load training to volitional fatigue with or without the BFR
protocol [79]. Farup et al. [80] also investigated whether a unilateral BFR and contralateral low-
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load non-BFR elbow flexion curl at 40% 1RM to volitional fatigue within young untrained
individuals would incur similar modes of hypertrophy. This study prescribed a training paradigm
of 3 days per week for a total period of 6 weeks through which magnetic resonance imaging
(MRI) was utilized to examine elbow flexor muscle volume and muscle water content
accumulations due to training adaptations.

Moreover, muscle thickness was measured utilizing ultrasound to ascertain muscle
swelling post-exercise. The authors, in a similar fashion to [78, 79] observed similar elevations
in muscle thickness and volume between BFR and non-BFR following 6 weeks of training [80].
Moreover, the authors reported that BFR and low-load non-BFR training at 40% 1RM was
equally capable of instigating muscle hypertrophy within the population measured in the study.
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Based upon the results of these studies, it is plausible that both BFR training at a low intensity to
volitional failure may be utilized as a viable alternative approach to obtain a hypertrophic effect
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similar to that observed in non-BFR traditional low-intensity training. Additionally, it is
important to mention that the application of low-load BFR training to volitional fatigue may
reduce the workload necessary to reach the threshold for fatigue [81, 82]. This means that the
total number of repetitions through the implementation of low-load BFR necessary to observe
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muscle adaptations similar to low-load unrestricted training may be lessened [81, 83].
Nevertheless, further research is still necessary to directly explore the mechanisms underlying
BFR training in response to low-intensity volitional fatigue.

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CONCLUSION AND FUTURE STUDIES

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The implementation of low-intensity resistance exercise (20-50% 1RM) training under
the condition of blood flow restriction can be an effective means to elicit skeletal muscle
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hypertrophy without a high level of mechanical stress upon the joints. Current research has
suggested that the use of BFR with low-load exercise may be effective to induce accruing
changes in muscular strength and hypertrophic adaptations [84]. Therefore, this novel type of
training can be beneficial towards the elderly, rehabilitation sessions, athletes recovering from
injury, and to also change the training stimulus during a resistance training cycle [84].

Furthermore, the practitioner working with athletes can also integrate this modality in still
allowing for progression in strength while reducing loads upon any associated tissues such as
muscular, tendinous, and bony [84]. However, there are several variables of interest that need to
be explored in further detail in order to finalize a stance behind the positive benefits from
occlusion training. The relationship between the hypertrophic effects of low-intensity resistance
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exercise training combined with BFR within the blood flow-restricted limb and non-blood flow
restricted muscles requires further elucidation. A comparative analysis of the volume-load,
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exercise intensity levels as well as the type of resistance exercise may be imperative towards
differentiating potential confounding variables responsible for the variance in hypertrophic
effects. Yasuda et al. [85] has investigated the effects of a short-term detraining (cessation of
activity) period upon muscle CSA and 1-RM within untrained men who participated in 6 weeks
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of bench press training in the condition of low-intensity BFR (20% 1RM) or traditional high
intensity (75% 1RM) [85]. Although the magnitude of increase within muscle CSA (pectoralis
major and triceps brachii) and 1-RM strength after 6 weeks of low intensity BFR training was
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smaller compared to high intensity training, the retention rate after short-term detraining was
similar between the two groups. These results may suggest that there may be major differences
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within the adaptations responses between traditional high-intensity training and low-intensity
BFR training, which may be due to factors such as neural adaptations and muscle size [85]. As
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such, this study opens a new avenue for future research further delineating the neural adaptations
underlying these comparative responses between BFR training and traditional high-intensity
training.

The utilization of new modalities of exercise machines such as cycling, swimming or arm
cycling may also be a new instrument through which BFR training can be analyzed. The
mechanisms behind muscle activation within BFR training-induced muscle hypertrophy may
also require future studies in order to better comprehend the micro-effects responsible for
skeletal muscle growth. Furthermore, this review has explicated potential mechanisms behind
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hypertrophic adaptations associated with BFR training such as hormonal responses, intracellular
signaling pathways, satellite cell activity, and fiber type recruitment patterns. Future studies
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should specifically explore the mechanisms responsible for both acute and chronic hypertrophic
adaptations following BFR training. This may include specific steps within the various
intracellular signaling pathways (Akt-mTOR, MAPK, Myostatin-Smad2/3) as well as variants in
different hormonal concentrations following BFR training. The research behind chronic
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hypertrophic adaptations through markers of satellite cell activation, proliferation and
differentiation is still lacking and should thus be explored within both lower and upper body
BFR training programs in detail.

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In addition, future blood flow restricted training should also explore biomarkers of
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muscle damage (IL-4, IL-6, TNF-alpha), as well as potential markers for bone formation
adaptations [86-89]. Interestingly, there are only a few studies that explored potential beneficial
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effects of BFR towards bone formation and growth [86, 87]. Recently, it has been hypothesized
that the implementation of low-intensity resistance exercise with BFR towards hypertrophic
adaptations may be due to an association with fluid shifts from the vascular space into the active
muscles, thus increasing its cross-sectional area [14]. Furthermore, future research should be
directed towards exploring the mechanisms responsible for this muscle-swelling phenomenon

within BFR training. Additional future studies should also explore potential associations within
the utilization of BFR methodologies on attenuating disuse atrophy (immobilization, spaceflight,
bed-ridden), and focusing on case-specific populations such as paraplegics, sarcopenia patients
or osteoporotic individuals.
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The potential risks and danger associated with blood flow restricted training due to
vascular occlusion and pressure differences of the applied cuff may stir skepticism within this
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novel training modality. However, the results of a national study showed that the implementation
of a Kaatsu training program within 12,642 individuals (male 45.4%, female 54.6%) of various
age ranges (less than 20 to greater than 80 years old) displayed minor incidences of side effects
such as venous thrombus (0.055%), pulmonary embolism (0.008%), and rhabdomyolysis

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(0.008%) [12]. Nevertheless, the methodologies behind the use of BFR training such as the
standardization of cuff pressures, perceived rate of pain, changes in cuff widths and type of
material should be still explored in future studies to mitigate further skepticism behind this
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potentially beneficial training modality. Even though the issues of safety by implementing this
type of training modality is beyond the scope of this review, there are additional papers that can
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be accessed to further elucidate the safety considerations as well as the risks and benefits with
blood flow restriction training [30, 90, 91]. Nevertheless, the utilization of blood flow restriction
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training at low intensities (20-30% 1RM) when carried out properly in accordance to what is
reported in the literature may be an effective strategy to allow for probable increases in muscle
mass and strength [10, 90, 91].

In summary, the implementation of BFR training during various phases of an athlete’s
periodized training program may be efficacious to counter the continual stress that may be placed
upon the body by high-intensity training [30]. Furthermore, the integration of low intensity BFR
in conjunction with a high-intensity progressive resistance training program have been suggested
to optimize a greater capacity for recovery while still promoting sound muscular development
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over time. Since low-loads of BFR exercise presents a different neural stimulus in comparison to
high-intensity resistance training, any optimal gains in muscular strength or hypertrophic
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adaptations may require conjunctive combinations of low-load BFR and traditional high-
intensity training [81]. This may be carried out strategically within athletes by implementing
low-intensity BFR training as a form of supplemental exercise after high-intensity resistance
training [16, 30, 63]. Moreover, there is still a paucity of research to examine the comparative
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effects between low-load BFR and high-load training within the upper body [81]. Nevertheless,
the implementation of BFR training can be potentially carried out within athletes as well as
within the general population with the strategic integration of low-intensity BFR that can elicit
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conditions of metabolic stress and mechanical tension to elicit muscular developments over time.
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A

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Figure Legends
Figure 1 - Possible Mechanisms of Muscle Growth from Blood Flow Restricted Training.

Translation Initiation
eted Hormonal Metabolite Fiber Type
via Intracellular Satellite Cell
Responses Accumulations Recruitment Muscle Cellul
Signaling Responses Activity
sterone, IGF-1, (i.e. Lactate) Patterns Swelling
(mTORC1, p70S6k) [15, 45, 57, 58]
33, 34, 43, 52] [1, 19, 31] [19, 31, 61]
[15, 28, 34]
D
Possible Mechanisms
TE
of Muscle Growth
Inflation of cuff to specified
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Cuff is applied to extremity of
pressure to occlude venous return
interest at the most proximal
from muscle while maintaining Blood Flow Restricted Training position for blood flow restriction
arterial blood inflow to active
[17, 21, 22]
muscle [9, 17, 23, 24]
C Possible Factors
C
Impacting Blood Flow
Restricted Training
A
Practical Cuffs (elastic Range of Targeted Exercise Load

Type of Cuff Material
knee wraps, nylon Pressure for Blood Intensity with Blood
(Wide vs. Narrow Cuffs)
blood pressure cuffs) Flow Restriction Flow Restricted
[11, 13, 28, 29, 30]
[26, 75] [7, 11, 17, 26, 27] Training [10, 30, 84]

Mechanisms Behind Blood Flow Restricted Training and Its Effect Towards Muscle Growth

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Mechanisms Behind Blood Flow Restricted Training and Its Effect Towards Muscle Growth

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Journal of Strength and Conditioning Research Publish Ahead of Print

Paul Hwang and Darryn S. Willoughby*

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adaptations following progressive overload of moderate to high-intensity resistance training.

underlying mechanisms leading to hypertrophic adaptations following BFR training programs.

Synthesis, Satellite Cells, Practical Blood Flow Restricted Training, Performance

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Schoenfeld et al [8]. Nevertheless, it is important to mention that the utilization of high

high mechanical stress due to heavy resistance training [11].

Copyright ª 2017 National Strength and Conditioning Association

to various comorbid factors such as cerebrovascular diseases, orthopedic diseases, obesity,

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specific intracellular signaling pathways, muscle damage, mechanotransduction, fiber type

restricted training, provide a comprehensive examination of the various mechanisms responsible

DEFINING OCCLUSION TRAINING

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exercising under vascular occluded pressures gained increases in strength.

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from BFR training in comparison to higher pressures [4].

Copyright ª 2017 National Strength and Conditioning Association

Takashi Abe [31].

of the pressure cuffs.

BFR AND MECHANISMS OF MUSCLE PROTEIN SYNTHESIS

Hypertrophic Adaptations: Hormone Responses

Occlusion training or BFR is known to induce metabolic accumulations, which may

31]. The accumulation of these metabolites is known to present an acidic intramuscular

environment through which the stimulation of sympathetic nerve activity is mediated by

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GH in the process of MPS.

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exercise-induced increases in GH as well as increases within the cross-sectional area of the

In contrast, skeletal muscle ischemia alone without the implementation of resistance

no relationship with the spikes in hormonal levels following exercise [37].

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muscle hypertrophy definitively necessitates further research.

Copyright ª 2017 National Strength and Conditioning Association

levels may have towards the induction of BFR related training.

in the section focused on intracellular signaling pathways.

Testosterone is known as a hormone that is primarily synthesized and secreted by the

have higher post-exercise testosterone levels [51].

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Hypertrophic Adaptations: Intracellular Signaling Pathways and Satellite Cell Activity

mammalian target of rapamycin (IGF1-PI3K-Akt/PKB-mTOR) signaling pathway and the

downregulation of the myostatin-Smad 3 pathway, which is known as a negative regulator of

regulator towards exercised induced muscle protein synthesis.

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A study found that the implementation of occlusion training upregulated the

1-hour post as well as 24 hours post exercise [15].

is relative to the satellite cell activation [15].

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extensions potentiated elevations in the post-exercise skeletal muscle expression of myogenic

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myogenesis during chronic training periods with applied BFR.

explored in the literature review by Schiaffino et. al. [18] in detail.

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The implementation of occlusion training with analyses of mRNA expression of

be explored in further detail in future studies for additional data.

Hypertrophic Adaptations: Fiber Type Recruitment

However, there is still a necessitation of further research to confirm if increased FT fiber

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Blood Flow Restricted Limb Hypertrophy vs. Non-Restricted Muscle Hypertrophy

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Copyright ª 2017 National Strength and Conditioning Association

protocol under BFR conditions compared to a non-BFR control group.