Acta Physiologica Hungarica, Volume 99 (4), pp.

400–410 (2012)
DOI: 10.1556/APhysiol.99.2012.4.4

The acute muscle swelling effects of blood flow

restriction
JP Loenneke, CA Fahs, RS Thiebaud, LM Rossow, T Abe, Xin Ye,
D Kim, MG Bemben
Department of Health and Exercise Science, Neuromuscular Research Laboratory, University of Oklahoma,
Norman, OK, USA

Received: May 4, 2012

Accepted after revision: July 17, 2012

The purpose of this study was to investigate the potential mechanisms behind the blood flow restriction (BFR)
stimulus in the absence of exercise. Nine participants completed a 10 minute time control and then a BFR protocol.
The protocol was five, 5-minute bouts of inflation with 3-minutes of deflation between each bout. The pressure was
set relative to each individual’s thigh circumference. Significant increases in muscle thickness were observed for
both the vastus lateralis (VL) [6%, p = 0.027] and rectus femoris (RF) [22%, p = 0.001] along with a significant
decrease in plasma volume [15%, p = 0.001]. Ratings of discomfort during the BFR protocol peaked at 2.7 (light
discomfort). There were no significant changes with whole blood lactate, electromyography (EMG), or heart rate
(HR), however, there was a trend for a significant increase in HR during the 5th inflation (p = 0.057). In conclusion,
this is the first study to demonstrate that the attenuation of both muscle atrophy and declines in strength previously
observed with brief applications of BFR may have been mediated through an acute fluid shift induced increase in
muscle size. This is supported by our finding that the changes in muscle thickness are maintained even after the cuffs
have been removed.
Keywords: electromyography, hypertrophy, KAATSU, lactate, occlusion training

Skeletal muscle is a highly plastic tissue that responds to the demands placed upon it. With
progressive overload, skeletal muscle synthesizes more contractile protein resulting in
skeletal muscle hypertrophy (for a review please see reference [2]), whereas immobilization
and muscular inactivity decreases muscle protein synthesis (29) and possibly the exercise
induced gene response (27), which may ultimately interfere with the ability of the muscle to
adapt to exercise when muscle activity is resumed.
Exercise in combination with blood flow restriction (BFR) has been demonstrated to
increase skeletal muscle size and strength, similar to that observed with high load resistance
training (21). Similarly, BFR without exercise has been shown to attenuate muscle atrophy
(13, 33). BFR is achieved by applying external pressure, usually with a wrap or pneumatic
cuff, to the proximal end of a limb which causes venous pooling in the limb and disruption of
arterial inflow to the muscle. The mechanisms behind the effect of low intensity exercise with
BFR are not completely known but have been hypothesized to occur from an accumulation
of metabolites leading to increased muscle fiber recruitment (34), increased muscle protein
synthesis (5, 6), blunting of muscle protein breakdown (17, 22), and possibly through an
exercise induced increase of endogenous hormones (32). Furthermore, recent evidence

Corresponding author: Jeremy Paul Loenneke

1401 Asp Avenue, Room 104, Norman, Oklahoma 73019-0615, USA
Phone: +1 (405) 325-5211; Fax: +1 (405) 325-0594; E-mail: jploenneke@ou.edu
0231–424X/$ 20.00 © 2012 Akadémiai Kiadó, Budapest
 Blood flow restriction 401

indicates that the elevation in muscle protein synthesis following low load resistance exercise
with BFR might also be induced through muscle cell swelling (5), as acute changes in muscle
size have been previously observed following this type of exercise (38).
Interestingly, BFR in the absence of exercise has been shown to result in an attenuation
of both muscle atrophy (measured by MRI and girth) and declines in strength following
anterior cruciate ligament reconstruction (33) and cast immobilization (12, 13). The
mechanisms behind the response have not been investigated outside of the Kubota et al. (13)
investigation which found no increase in systemic growth hormone with BFR only. In
contrast to BFR exercise, it is unlikely that any appreciable increase in metabolites or muscle
activity would occur in response to BFR alone. Therefore, a possible explanation for this
benefit may be an acute muscle cell swelling effect caused by the restriction of blood flow
(18). Thus, the purpose of this study was to investigate the potential mechanisms behind the
BFR stimulus in the absence of exercise. We hypothesized that BFR would result in a decrease
in plasma volume and an increase in muscle thickness, without measurable changes in whole
blood lactate or muscle activation

Methods
Participants
A total of ten (5 females and 5 males) participants with no known cardiovascular or metabolic
diseases visited the laboratory for two sessions of testing. All participants were tested at least
two hours post-prandial and were instructed to be hydrated and to avoid caffeine, medications,
and exercise on the days of their visits. Participants were excluded if they were pregnant,
hypertensive (brachial pressure > 140/90 mmHg), or had an ankle brachial index (ABI)
of less than 0.9. Further exclusion criteria included having more than one of the following
risk factors for thromboembolism: 1) obesity (BMI ≥ 30 kg/m2), 2) diagnosed Crohn or
inflammatory bowel disease, 3) a past fracture of a hip, pelvis or femur, 4) major surgery
within the last 6 months, 5) varicose veins or, 6) a family history of deep vein thrombosis or
pulmonary embolism (24). One female participant felt nauseous from the BFR and did not
finish the protocol; therefore her data was excluded from all analysis leaving a final sample
size of 9. The study received approval from the university’s institutional review board, and
each participant gave written informed consent before participation.

Study protocol
On the first visit to the laboratory participants’ height and body mass were measured using a
standard stadiometer and an electronic scale. Following this, they were asked to lie quietly in
a temperature controlled (22.5 °C) room for 10 minutes. After resting, measurements of
brachial blood pressure, ABI, and thigh circumference were taken. Thigh circumference was
taken to determine the restrictive cuff pressure used during the BFR protocol. Participants
were also familiarized with the Borg discomfort scale.
For the second visit, participants quietly rested for 10 minutes in the same room as the
first visit (22.5 °C). Participants sat upright on a table with their upper body inclined at about
45°, their knees fully extended, and legs supported on the table. Pillows were placed behind
the participants for back support. Participants’ legs were held in position using a padded
Velcro wrap to ensure that their legs did not move throughout testing. To ensure minimal

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402 Loenneke JP et al.

movement, the BFR cuffs were placed into position but were not fastened or inflated prior to
baseline (or Pre BFR) measurements. Electromyography (EMG), heart rate (HR), muscle
thickness (MTH), ratings of discomfort, lactate and hematocrit were measured after 10
minutes of rest and again after a 10-minute time control. The BFR cuffs were then attached
and inflated for five, 5-minute bouts with 3 minutes of deflation between each bout. This
protocol was chosen based on previous research showing an attenuation of muscle atrophy
(13, 33). EMG, HR, MTH, and ratings of discomfort were taken approximately 4 minutes
following each inflation and again approximately 2 minutes following each deflation. In
addition, lactate and hematocrit were taken 4 minutes into the 5th inflation and again 3 minutes
post BFR along with EMG, HR, MTH, and ratings of discomfort. Figure 1 is a schematic
representing the time table for measurements during visit 2.

Fig. 1. Study design.

Measurements were taken before (Pre CON) and after (Pre BFR) a 10-minute time control. The blood flow
restriction (BFR) cuffs were then inflated for 5 minutes and deflated for 3 minutes a total of 5 separate times.
Following inflation, measurements were taken 1 minute prior to deflation and again 1 minute prior to inflation.
At the 37-minute mark, the cuffs were taken off and measurements were taken again three (3 Min Post) minutes
after cuff removal. Arrows indicate the time point at which each measurement was taken

Systolic and diastolic blood pressure

Brachial systolic (bSBP) and diastolic (bDBP) blood pressure was measured using an
appropriate sized automatic blood pressure cuff (Omron, Model HEM-773). Blood pressure
was taken in duplicate and if either the bSBP or bDBP values were not within 5 mmHg a third
measurement was taken. The closest two values were averaged for analysis. All subjects had
blood pressures < 140/90 mmHg.

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Ankle brachial index (ABI)

The ABI is a ratio of the blood pressure in the lower legs to the blood pressure in the arms
and was used to detect peripheral vascular disease. With the participant supine, the bSBP
was  obtained in each arm using a hand-held bidirectional Doppler (MD4, Hokanson,
Bellevue, WA) probe placed on the artery at an angle of 45–60 degrees. A MV10 segmental
cuff attached to a manual handheld cuff inflator (Hokanson, Bellevue, WA) was placed
proximal to the Doppler probe and inflated on the limb to a supra-systolic pressure and then
slowly deflated until a pulse (arterial flow) was detected. Ankle blood pressure (ABP) was
measured at the posterior tibial artery using the same procedure. The ABI was calculated by
dividing ABP by the higher of the two brachial pressures. Peripheral vascular disease is
indicated by an ABI of < 0.9. All subjects had an ABI > 0.9.

Thigh circumference
The distance from the inguinal crease to the top of the patella was measured using a tape
measure and a mark was made on the leg 33% distal to the inguinal crease. Thigh circumference
was measured at this mark to capture an accurate representation of the site at which the cuffs
would be applied.

Muscle thickness (MTH)

B-mode ultrasound measurements of muscle thickness (MTH) were made at the thigh
midway between the lateral condyle of the femur (knee) and the greater trochanter (hip) on
the left leg. Distances between bony landmarks were measured with a tape measure and
marked with a pen. All ultrasound measurements were made using an Aloka SSD-500 (Tokyo,
Japan) ultrasound unit and a 5 MHz linear probe. The probe was coated with transmission gel
and placed perpendicular to the tissue interface at the marked sites without depressing the
skin. Vastus lateralis (VL) and rectus femoris (RF) MTH was determined as the distance from
the adipose tissue-muscle interface to the inter-muscular interface. Multiple images were
captured by the same experienced investigator (VL ICC = 0.99, RF ICC = 0.98) each time
and printed for analysis. Each image for the VL and RF was manually measured and averaged
at each time point.

Heart rate
Heart rate was measured continuously throughout using the NONIN pulse oximeter (NONIN
Model 8500, Plymouth, MN USA). The device was attached to the index finger of the
participant’s left hand and was removed following 3 minutes post BFR cuff removal.

Surface electromyography (EMG)

Surface EMG was used to record muscle activation (amplitude) along the right side of the
vastus lateralis muscle on the right leg. Electrodes were placed 2 cm apart according to
SENIAM guidelines along the vastus lateralis muscle and the reference electrode was placed
on C7. Vastus lateralis was determined as 2/3 the distance between the anterior spina iliaca
superior and the lateral side of the patella.

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404 Loenneke JP et al.

Whole blood lactate (WBL)

WBL was indirectly measured using a handheld analyzer (Lactate Plus, Nova Biomedical
Corporation, Waltham, MA, USA). Fingertip WBL samples of approximately 0.7 µL by
volume were collected by the same investigator using the manufacturer guidelines for testing.
The participant’ fingers were cleaned with alcohol prior to testing. Fingertips were punctured
with a lancet, and the first drop of blood was wiped off to decrease the chance of contamination.
The finger was lightly squeezed to form a second drop of blood, and when the drop appeared,
the end of the test strip was touched to the blood drop until the test strip was filled.

Hematocrit
A drop of blood was drawn up into a capillary tube following the finger stick for whole blood
lactate. These samples were taken in duplicate and centrifuged with CritSpin Microhematocrit
Centrifuge (StatSpin, Norwood, MA, USA), and read on a CritSpin Digital Reader (StatSpin,
Norwood, MA, USA). Percent changes in plasma volume (%∆PV) were determined from
hematocrit (Hct) with the following equations %∆PV = (100/(100 − Hct Pre CON) × 100
((Hct Pre CON − Hct Pre BFR)/Hct Pre BFR) for the change during the time control; %∆PV
= (100/(100 − Hct Pre BFR) × 100 ((Hct Pre BFR − Hct 5th Inflation)/Hct 5th Inflation) for the
change between the time control and four minutes into the 5th inflation; and %∆PV = (100/
(100 − Hct Pre BFR) × 100 ((Hct Pre BFR − Hct 3 Min Post)/Hct 3 Min Post) for the change
between the time control and 3 Min Post BFR (30, 35).

Rating of discomfort
A rating of discomfort was taken using Borg’s Discomfort Scale (CR-10+). Participants
received verbal instruction on rating discomfort prior to each visit, similar to those used by
Hollander et al. (10), but discomfort was only measured during the second visit to the
laboratory. This was done to ensure the participants were aware of how to rate the perceptual
response with the CR-10+ discomfort scale. Participants were asked, “What are your worst
experiences of discomfort? ‘Maximum discomfort (rating of 10)’ is your main point of
reference; it is anchored by your previously experienced worst discomfort. The worst
discomfort that you have ever experienced, the ‘Maximum discomfort’ may not be the highest
possible level of discomfort. There may be a level of discomfort that is still stronger than
your 10; if this is the case, you will say 11 or 12. If the discomfort is much stronger, for
example, 1.5 times ‘Maximum Discomfort’ you will say 15; any questions?” Participants
fully understood how to rate prior to actual testing.

Blood flow restriction (BFR)

Participants’ wore specially designed pressure cuffs (5 cm wide, Kaatsu-Master, Tokyo,
Japan) around the most proximal portion of both legs. The pressure cuffs are designed to
restrict venous return from the limbs while reducing arterial blood flow into the limbs. The
cuff pressure is maintained by an electronic air pressure system throughout the inflation. The
initial cuff pressure (baseline pressure of cuff when deflated) was set at 50 mmHg for all
participants. Inflated cuff pressure was relative to the participants’ thigh circumference.
Using previous data which suggests thigh circumference as the biggest predictor of arterial
occlusion pressure ([19], n = 116), we plotted thigh circumference with arterial occlusion to
determine an estimated arterial occlusion pressure for each participant. For the BFR protocol,
we used an inflation pressure of 70% of the participants’ predicted arterial occlusion pressure
to ensure that the inflated cuff pressure would not cause arterial occlusion (Table I).

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Table I. Blood flow restriction pressures

Thigh circ. (cm) Estimated arterial occ. pressure (mmHg) Pressure used (70%) (mmHg)
< 45–50 200 140
51–55 250 180
56–59 300 210
> 60 350 250
The pressures used for this study were based on thigh circumference (Thigh circ.) data from a previous
investigation (Adapted from (19))

Statistical analyses
Using the SPSS 18.0 statistical software package (SPSS Inc., Chicago, IL), one way repeated
measures analysis of variance (1 × 4 ANOVA) was utilized to determine significant changes
in dependent variables (i.e. MTH, WBL, Hematocrit, EMG, HR and ratings of discomfort)
from Pre time control, Pre BFR, 4 minutes into the 5th inflation, and 3 minutes post BFR cuff
removal. If significance was found (p < 0.05), a paired sample t-test was used to determine
where the difference was. These specific time points were chosen in order to correlate the
fluid shift with changes in muscle thickness as well as to maintain adequate statistical power.
A one-way repeated measures ANOVA (1 × 3) was utilized to determine significant percent
changes in MTH and plasma volume. Percent change values were determined by calculating
percent difference between Pre Con and Pre BFR (10-minute time control), Pre BFR and four
minutes into the 5th inflation, and Pre BFR and three minutes post cuff removal (3 Min Post).
Paired sample t-tests determined significant differences from the 10-minute time control.
Reliability for MTH was determined from the baseline (Pre time control) measurements
which were used to determine the intra-class correlations (ICC) of VL MTH and RF MTH,
which was used in the calculation of the standard error of the measurement (SEM) (SEM =
SD√1-ICC). The minimal differences (MD) needed to be considered a real change for
VL MTH and RF MTH was calculated from the SEM (MD = SEM × 1.96 √2). Thus, anything
exceeding this MD could be considered a real change that exceeds the error of the
measurement (36).

Results
The mean age, height, body mass and thigh circumference for the participants were 25 (3)
yrs, 1.75 (0.10) m, 76.3 (12.5) kg and 58.2 (4.7) cm, respectively. The one-way repeated
measures ANOVA found significant differences between Pre CON, Pre BFR, 4 minutes into
the 5th inflation, and 3 minutes post BFR cuff removal for VL MTH (p = 0.006, range: 27.9–
29.7 mm), RF MTH (p = 0.001, range: 22.5–27.5 mm), HR (p = 0.039, range: 57–69 bpm),
hematocrit (p = 0.001, range: 39–43.5%) and ratings of discomfort (p = 0.012, range: 0.0–
2.7) (Table II). The minimal difference needed to be considered real was surpassed at every
time point during and after the BFR protocol for both the VL (MD = 0.8 mm) and RF (MD =
0.9 mm). Although there were significant differences with HR, t-tests revealed that the
significant change was from Pre CON and the 5th Inflation (p = 0.029) and there was only a
trend between Pre BFR and the 5th inflation (p = 0.057). There were no significant changes in
WBL (p = 0.198, range: 0.7–0.9 mmol/L) (Table II). Significant percent changes were found
with VL MTH (p = 0.027), RF MTH (p = 0.001), and plasma volume (p = 0.001) between
control, four minutes into the 5th inflation and 3 Min Post (Fig. 2). There was no muscle
activity at any time point in the study; therefore, this was not statistically analyzed.
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406 Loenneke JP et al.

Table II. Acute changes with blood flow restriction (BFR)

Vastus Rectus Lactate Hematocrit Heart rate Discomfort

lateralis femoris
Pre CON 28.3 (5.2) 22.5 (3.0) 0.9 (0.4) 39.5 (3.0) 58 (9) 0.0 (0.0)
Pre BFR 27.9 (5.1) 22.5 (3.3) 0.8 (0.3) 39.0 (3.0) 58 (10) 0.1 (0.1)
1st inflation 29.2 (5.4)† 25.6 (3.7)† – – 71 (11) 1.4 (1.4)
1st deflation 29.0 (5.3)† 25.3 (3.4)† – – 62 (11) 0.8 (0.8)
2nd inflation 29.6 (5.3)† 26.0 (3.9)† – – 70 (11) 1.5 (1.5)
2nd deflation 29.2 (5.3)† 25.8 (3.6)† – – 63 (11) 0.9 (0.9)
3rd inflation 29.7 (5.2)† 26.6 (3.8)† – – 72 (11) 1.7 (1.6)
3 deflation
rd
29.2 (5.1)† 26.4 (3.7)† – – 64 (12) 1.1 (1.1)
4th inflation 29.7 (5.5)† 27.1 (3.8)† – – 70 (12) 2.2 (1.9)
4th deflation 29.6 (5.1)† 26.8 (3.8)† – – 63 (13) 1.2 (1.3)
5th inflation 29.7 (5.5)*† 27.4 (3.08)*† 0.7 (0.1) 43.5 (2.5)* 69 (18)£ 2.7 (2.7)*
3 Min Post 29.5 (5.4)*† 24.8 (4.0)*† 0.8 (0.1) 43.0 (2.5)* 57 (15) 0.9 (1.5)

Mean values (SD) of muscle thickness (mm), lactate (mmol/L), hematocrit (%), heart rate (bpm), and ratings
of discomfort throughout the study. Statistical analysis was completed at 4 different time points; before (Pre CON)
and after (Pre BFR) the time control, four minutes into the 5th inflation, and 3 minutes post cuff removal
(3 Min Post). * indicates a significant difference from Pre BFR (p < 0.05). † indicates exceeding the minimal
difference to be considered a real change with muscle thickness. £ indicates a trend for significance at 0.057

Fig. 2. Percent changes.

Data show the percent changes in muscle thickness (vastus laterals, rectus femoris) and plasma volume. The first
(white) box represents the percent change between the pre (Pre CON) and post time control (Pre BFR). The second
box (gray) represents the percent change from pre blood flow restriction (Pre BFR) and 4 minutes into the
5th inflation. The third box (dark gray) represents the percent change from pre blood flow restriction (Pre BFR) and
three minutes post cuff removal (3 Min Post). * represents a significant difference from the 10 minute time control
(Pre CON–Pre BFR), p < 0.05 (mean SD)

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Discussion
The primary finding of this study is that many of the proposed mechanisms for the benefits
observed for low load BFR resistance training are not observed in the absence of exercise.
The potential mechanism of acute muscle cell swelling from a plasma fluid shift may provide
a possible explanation for at least part of BFR’s role in muscle adaptation.
We observed significant increases in VL and RF muscle thickness following BFR
compressions. MTH measurements from ultrasound have previously been shown to provide
valid measurements of skeletal muscle when compared to a gold standard such as magnetic
resonance imaging (MRI) or computed tomography (CT) (26). This increase in VL and RF
muscle thickness suggests an increase in muscle cell swelling with BFR, due to a fluid shift
from the plasma into the muscles under BFR. It is probable that the initial increase in MTH
was mostly due to venous pooling and not necessarily a fluid shift into the muscle cells.
However, at some point during the protocol it is probable that a fluid shift into the muscle
cells did occur. This idea is supported by our observation of significant decreases in plasma
volume with a concomitant increase in skeletal muscle size that remained for at least
3 minutes post (cuffs were completely removed) BFR (Fig. 2). If this acute change in MTH
was due solely to venous pooling, these would have been back to baseline following the
removal of the cuff. High load resistance exercise has been shown to cause a similar type of
fluid shift with a decrease in plasma volume and an increase in muscle size (measured by
MRI) (25). The absolute and relative acute increases in muscle size were smaller for the VL
than the RF (Table I, Fig. 2). The reason for this is unknown but body position of the
participant may have played a role. Another possibility might be the anatomical feature of the
VL compared to the RF (monoarticular vs. polyarticular muscle).
As hypothesized, the BFR stimulus alone was not able to elicit measurable changes in
whole blood lactate or muscle activation as has been previously observed with low load BFR
exercise (20, 34). Therefore, these variables are unlikely to be playing a significant role with
the attenuation of muscle atrophy and strength losses previously observed with BFR in the
absence of exercise (12, 13, 33). It is, however, possible that a reduction in oxygen from
moderate BFR was able to produce at least small increases of intracellular lactate which we
were unable to detect with a measurement of whole blood lactate. Ratings of perceived
discomfort during the BFR stimulus did increase throughout the inflations and deflations,
with a peak mean of only 2.7 (light discomfort).
Although we measured acute changes in muscle size and plasma volume, we did not
measure signaling pathways; therefore, we are left to speculate about the potential cellular
effects of BFR. Several possibilities exist for how BFR may induce cellular swelling. BFR
may increase the hydrostatic pressure gradient thereby increasing the intracellular water flux.
In addition, some research indicates that BFR results in an increase in venous carbon dioxide
(37). This may occur as a consequence of a slight decrease in intracellular pH which would
lead to the production of hydrogen ions. Interestingly, pH-regulating transporters working in
parallel with each other have previously been shown to mediate cell volume changes (9).
To illustrate, the sodium/hydrogen exchanger exports hydrogen out of the cell where it would
combine with bicarbonate which would be exported out of the cell by the chloride/bicarbonate
exchanger. Outside of the cell CO2 would be produced and removed and the intracellular
sodium chloride would pull water into the cell (1, 31). In addition, evidence indicates that
these exchangers may work in concert with the Na+-K+-2Cl– cotransporter whose gradient
is  largely determined by sodium/potassium pump (7, 16). Together, these exchangers/
cotransporters may mediate the muscle cell to swell with BFR. Another possibility is an
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increase in serum- and glucocorticoid-inducible kinase-1 (SGK1) which is upregulated by

ischemic conditions and may play an important role in the regulation of muscle cell volume
(14, 15). Although BFR does not exactly mimic the stress of ischemia, it is probable that there
is a reduced rate of oxygen delivery.
Based on Haussinger’s hypothetical model for hepatocyte cell swelling (8), the muscle
adaptations observed with BFR alone may occur from a muscle cell swelling induced
activation of the mammalian target of rapamycin (mTOR) and mitogen-activated protein-
kinase (MAPK) pathways. Three distinct MAPK signaling modules, extracellular signal-
regulated kinases (ERK 1/2), p38 MAPK, and c-JUN NH2-terminal kinase (JNK), have been
associated with the adaptation of skeletal muscle, particularly from exercise (11). Interestingly,
c-JUN mRNA, a downstream target of the JNK pathway, has been observed to increase 30
minutes after the onset of hepatic cell swelling (4, 28). Also, expression of ERK 1/2, which
are proteins associated with osmosensing (3, 23), are increased following BFR exercise (5).
In addition to activating MAPK, low load BFR exercise results in activation of the mTOR
signaling pathway (5, 6). Future cellular studies are needed to confirm that 1) the fluid shift
resulted in an actual increase in muscle cell size and not just an increase in interstitial fluid
and 2) to determine the possible signaling mechanisms involved in the benefits observed
from this stimulus.
Our study had some limitations that need to be considered when interpreting the results.
First, although increases in muscle thickness and decreases in plasma volume were observed
which indicates that a fluid shift did occur, we are unable to definitively determine from this
study whether or not the fluid was shifted into the actual muscle cell. Also, the muscle
thickness measurements were only measured out until 3 minutes post exercise; therefore the
duration of change is unknown beyond 3 minutes. In addition, from the current study we are
unable to determine potential signaling pathways for the proposed muscle tissue changes
observed previously with this stimulus.
In conclusion, this is the first study to demonstrate that the attenuation of both muscle
atrophy and declines in strength previously observed with brief applications of BFR (in the
absence of exercise) may have been mediated through an acute fluid shift induced increase in
muscle size. This is supported by our finding that the changes in muscle thickness are
maintained even after the cuffs have been removed. In addition, metabolic accumulation (e.g.
lactate) one of the primary mechanisms thought to drive the increased muscle fiber activation,
does not occur in the absence of exercise.

Acknowledgement
The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived
as affecting the objectivity of this manuscript. None of the authors report a conflict of interest. This study was not
supported by any funding.

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