THE ACUTE RESPONSE OF PRACTICAL OCCLUSION IN
THE KNEE EXTENSORS
JEREMY P. LOENNEKE,1 MONICA L. KEARNEY,2 AUSTIN D. THROWER,3 SEAN COLLINS,1
1
AND THOMAS J. PUJOL
1
Department of Health, Human Performance, and Recreation, Southeast Missouri State University, Cape Girardeau, Missouri;
2
Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, Missouri; and 3Department of Biology,
Southeast Missouri State University, Cape Girardeau, Missouri
ABSTRACT
Loenneke, JP, Kearney, ML, Thrower, AD, Collins, S, and Pujol, TJ.
The acute response of practical occlusion in the knee
extensors. J Strength Cond Res 24(10): 2831–2834, 2010—Train-
ing at low intensities with moderate vascular occlusion results in
increased muscle hypertrophy, strength, and endurance. Elastic
knee wraps, applied to the proximal portion of the target muscle,
might elicit a stimulus similar to the KAATSU Master Apparatus.
The purpose of this study was to test the hypothesis that
intermittently occluding the leg extensors with elastic knee
wraps would increase whole-blood lactate (WBL) over control
(CON). Twelve healthy men and women participated in this
study (age 21.2 6 0.35 years, height 168.9 6 2.60 cm,
and body mass 71.2 6 4.16 kg). One repetition maximum
(1RM) testing for the leg extensors was performed on a leg
extension machine for the first trial, followed by occlusion
(OCC) and CON trials. Four sets of leg extension exercise (30–
15–15–15) were completed with 150-second rest between
sets at 30% 1RM. Whole-blood lactate, heart rate (HR), and
ratings of perceived exertion (RPEs) were measured after every
set of exercise and 3 minutes postexercise. Data were analyzed
using repeated-measures analysis of variance with statistical
significance set at p # 0.05. Whole-blood lactate increased in
response to exercise (p = 0.01) but was not different between
groups (OCC 6.28 6 0.66 vs. CON 5.35 6 0.36 mmol
L21, p =
0.051). Heart rate (OCC 128.86 6 4.37 vs. CON 119.72 6
4.10 b
min21) was higher with OCC from sets 2–4 (p # 0.03),
with no difference 3 minutes postexercise (p = 0.29). Rating of
perceived exertion was higher with OCC after every set (OCC
15.10 6 0.31 vs. CON 12.16 6 0.50, p = 0.01). In conclusion,
no differences exist for WBL between groups, although there
was a trend for higher levels with OCC. The current protocol for
practical occlusion did not significantly increase metabolic
Address correspondence to Jeremy P. Loenneke, jploenneke1s@semo.edu.
24(10)/2831–2834
Journal of Strength and Conditioning Research
Ó 2010 National Strength and Conditioning Association
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
stress more than normal low-intensity exercise. This study does not
support the use of knee wraps as a mode of blood-flow restriction.
KEY WORDS whole-blood lactate, hypertrophy, muscle,
occlusion training
INTRODUCTION
T
he American College of Sports Medicine recom-
mends training at intensities of at least 70% of one’s 1
repetition maximum (1RM) to receive increases in
skeletal muscle hypertrophy (3). Recently, training
at low intensities (20% 1RM) with moderate vascular occlusion
has resulted in muscle hypertrophy (25). Such results make
moderate vascular occlusion a promising technique to a variety
of populations, particularly those who cannot withstand high
mechanical stress on the joints. Moderate vascular occlusion
has resulted in increases in muscle cross-sectional area
(1,2,14,19–21,25), muscular strength (1,2,5,14,15,19–21), and
muscular endurance (9,20) without significant elevations of any
known markers for muscle damage (myoglobin, lipid peroxide,
creatine kinase) (1,20).
Blood-flow occlusion training is postulated to exert
beneficial adaptation through a variety of mechanisms (13).
One mechanism is through an accumulation of metabolites
such as lactate. Whole-blood lactate (WBL) (7,17), plasma
lactate (6,13,15), and muscle cell lactate (10,11) have all been
shown to significantly increase over control in response
to exercise with blood-flow restriction. Lactate accumulation
is significant, because growth hormone (GH) has been shown
to be stimulated by an acidic intramuscular environment (18).
Victor and Seals (22) indicated that a low pH stimulated
sympathetic nerve activity through a chemoreceptive reflex
mediated by intramuscular metaboreceptors and group III
and IV afferent fibers (22). Consequently, this same pathway
has been shown to play an important role in the regulation of
hypophyseal secretion of GH (8,22).
The occlusive stimulus is typically produced by a KAATSU
Master Apparatus or modified blood pressure cuffs, which
makes this mode of training available to few because these
devices are expensive and require a high level of skill
to operate (12). These specialized apparatuses tend to be
VOLUME 24 | NUMBER 10 | OCTOBER 2010 | 2831
 Practical Occlusion
expensive; thus, a need exists for the development of a
practical mode of applying an occlusive stimulus in the hope
that more of the population can receive the positive
adaptations associated with such training.
It has been postulated previously that elastic knee wraps,
when applied to the proximal portion of the target muscle,
might elicit a stimulus similar to that seen with the KAATSU
Master Apparatus (12). Elastic knee wraps are inexpensive
and easy to apply; thus, a pilot study was conducted with the
aim of investigating whether or not intermittently applying
knee wraps provide an adequate occlusive stimulus
to significantly increase WBL accumulation over a control
condition. Because of the novelty of using elastic knee wraps
as a mode to restrict blood flow, the study erred on the side
of caution, with knee wraps intermittently applied and rest
intervals set at 150 seconds between sets.
METHODS
Experimental Approach to the Problem
To examine the effects of intermittent vascular occlusion with
elastic knee wraps on the knee extensors, the primary
objective was to compare the WBL responses to 4 sets of low-
intensity bilateral leg extension exercise (30% 1RM) with and
without an occlusive stimulus. Heart rate and RPE were also
investigated. Elastic knee wraps were used because they were
easy to obtain, affordable, and practical.
Subjects
Twelve, recreationally active, healthy persons with no known
symptoms of impaired endothelial function or known risk
factors for cardiovascular or metabolic diseases took part
in this study. Subjects were recruited by word of mouth across
campus. Their strength levels were considered relatively
steady state, and no dramatic changes in their strength could
be expected during the time course of the study (3 weeks).
Subjects were permitted to train their quadriceps as usual up
to 48 hours before each testing trial. Alcohol was restricted
24 hours before each test, and caffeine was restricted 12 hours
before each test. Subjects were informed about the procedures
and potential risks of the tests before their informed consent
was obtained. The institutional review board at Southeast
Missouri State University approved the study.
Procedures
The subjects were tested for their bilateral knee extensor
strength using a selectorized leg extension machine (FL-100,
Flex Fitness Incorporated, Murrieta, CA, USA). Before testing,
subjects performed low-intensity aerobic exercise on a tread-
mill, walking at 2.5 mph for 10 minutes to warm up their leg
musculature. After treadmill walking, subjects were instructed
to perform 8–10 repetitions. After a rest period of 90 seconds,
weight was increased, and subjects were instructed to perform
4–6 repetitions. After a rest of 90 seconds, weight was
increased, and subjects were instructed to perform 1 repetition.
Weight was progressively increased until 1RM was de-
termined. All 1RMs were achieved within 5 attempts. One
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2832 Journal of Strength and Conditioning Research
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
repetition maximum was defined as the maximum weight that
could be lifted through a controlled, full range of motion
(ROM) with approximately a 1 second concentric and 1
second eccentric phase. Full ROM was visually defined as
completing a repetition from the starting angle of 90° to a full
lockout of 180°.
Occlusion and Control Testing Procedures
Testing trials were separated by at least 6 days and no more
than 8 days. The exercise protocol required subjects
to perform bilateral leg extensions at ;30% of their 1RM
for 4 sets, with a goal set at 30 repetitions for the first set
followed by 3 sets of 15 repetitions with 150 seconds of rest
between all sets. A repetition was counted if the movement
was completed through a controlled, full range of motion with
approximately a 1 second concentric and 1 second eccentric
phase. The OCC trial was completed first, so subjects who
were unable to meet the repetitions for a particular set, were
matched for total repetitions completed for that particular set
in the CON trial. For the OCC trial, 76-mm-wide knee wraps
(Red-Line, Harbinger, Napa, CA, USA) were applied to the
upper thigh, as depicted in a review article by Loenneke and
Pujol (12). The same investigator applied the elastic knee
wraps in each trial to maximize intrarater reliability. Upon
completion of each set, knee wraps were removed imme-
diately and reapplied before the next set. Control trial
methodology was the same as in the OCC trial, except that
knee wraps were not applied.
Lactate, Heart Rate, and Ratings of Perceived Exertion
Whole-blood lactate was measured using a handheld ana-
lyzer (Lactate Plus, Nova Biomedical Corporation, Waltham,
MA, USA). Fingertip WBL samples (ca. 0.7 ml by volume)
were collected before the start of the exercise bout,
immediately after each set, and 3 minutes into recovery
using the manufacturer guidelines for testing. The subjects’
fingers were cleaned with alcohol solution before 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 obtain 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.
Heart rate was monitored and transmitted to an attachment
worn on the wrist (FS1, Polar Electro, Lake Success, NY,
USA). Heart rate was measured before the start of the exercise
bout, immediately after each set, and 3 minutes into recovery.
Ratings of perceived exertion were determined after each set
of exercise using the standard Borg scale (4).
Statistical Analyses
All values are expressed as mean 6 SE. Whole-blood lactate,
HR, and RPE data were analyzed using repeated-measures
analysis of variance to determine significant differences
between OCC and CON. When significance was found,
Fisher’s least significant difference post hoc test was used to
determine pairwise differences. Significance was set at p # 0.05.
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TABLE 1. The mean values of WBL, HR, and RPE throughout the exercise bout.*†

WBL (mmol
L21) HR (b
min21) RPE (6–20)

Set OCC CON OCC CON OCC CON

1 5.43 6 1.79 5.05 6 1.12 149.72 6 5.60 149.54 6 18.67 16.58 6 0.52‡ 14.00 6 0.66
2 7.64 6 1.43 5.10 6 0.43 146.18 6 6.01‡ 136.09 6 5.96 16.83 6 0.49‡ 13.83 6 0.53
3 6.27 6 0.56 6.60 6 0.93 150.36 6 6.59‡ 130.45 6 5.52 17.66 6 0.39‡ 13.50 6 0.68
4 7.23 6 0.93 6.84 6 0.69 150.36 6 5.88‡ 129.45 6 5.05 18.41 6 0.45‡ 13.50 6 0.99
3-min post 7.9 6 0.63 6.72 6 0.67 102.09 6 4.30 97.63 6 3.23 N/A N/A
*WBL = whole-blood lactate; HR = heart rate; RPE = ratings of perceived exertion; OCC = occlusion; CON = control; N/A = not
applicable.
†All values are expressed as mean 6 SE.
‡Significant difference between OCC and CON (p # 0.05).

RESULTS maintained throughout the exercise bout, whereas our

Subjects’ characteristics were age 21.2 6 0.35 years, height
168.9 6 2.60 cm, and body mass 71.2 6 4.16 kg. Table 1
presents mean WBL, HR, and RPE values for each set
of exercise. Whole-blood lactate, HR, and RPE significantly
increased with exercise regardless of the training condition
(p = 0.001). There were no significant WBL differences
between OCC and CON (n = 10), although there was a
nonsignificant trend for WBL to be higher with OCC (6.28 6
0.66 vs. 5.35 6 0.36 mmol
L21; p = 0.051). Whole-blood
lactate for 2 subjects were excluded from analysis because
of incomplete data at 2 time points. Heart rate levels were
significantly different between OCC and CON (n = 11) for sets
2–4 with no difference 3 minutes postexercise (p = 0.29). Mean
HR was 128.86 6 4.37 b
min21 for OCC and 119.72 6 4.10
b
min21 for CON (p = 0.02). Heart rate data for 1 subject were
incomplete; thus, that subject’s HR was excluded from final
analysis. Ratings of perceived exertion levels were significantly
higher with OCC compared to CON after every set of leg
extension (OCC 15.10 6 0.31 vs. CON 12.16 6 0.50, p = 0.001).
DISCUSSION
The current study was the first to investigate the effects
of knee wraps as a practical mode of producing blood-flow
occlusion. This pilot study demonstrated that knee wraps did
not produce differences in WBL between OCC and CON but
that there were significant increases in HR and RPE with
practical occlusion.
This study found no difference in WBL between OCC and
CON; although previous research has demonstrated that lactate
is increased with blood-flow restriction (7,16–18,20), providing
1 mechanism by which GH is increased (8,22). Reasons for the
disparity may include the small sample size, reperfusion in
between sets, and the length of rest periods. Prior research used
30- to 60-second rest intervals (12), whereas this study used 150
seconds. The occlusion stimulus in past studies was applied and
investigation used intermittent occlusion. Intermittent occlu-
sion with 150-second rest intervals likely allowed glycolytic
fibers to fully recover between sets, making a rapid recruitment
of fast twitch fibers unnecessary. Another possibility is
occluding blood flow may result in a slower diffusion of lactate
out of the muscle tissue resulting in a more pronounced
intramuscular acidic environment and therefore a greater local
stimulation of group IV afferents before its diffusion out of the
cell (13). To illustrate, Reeves et al. (16) showed that although
occlusion training resulted in a greater GH response than
a nonoccluded control, there were no significant differences in
blood-lactate concentrations between groups.
Heart rate and RPE were significantly increased over CON
with practical OCC. Elevated HR has been shown previously
to occur with occlusion training, attributable to decreased
venous return (17). The current data indicate the subject’s
perceived exertion was greater with OCC, which is in
disagreement with other findings that found no differences
between training conditions (23,24). The discrepancy is
attributable to differing protocols because Wernbom et al.
(23,24) did not control for volume of work between groups.
The goal of their study was to examine endurance capacity;
thus, both groups were performing all-out sets. Ratings
of perceived exertion indicate that subjects perceive exercise
with practical occlusion to be of greater intensity than CON,
despite the same external load and volume of work.
The repetition protocol was modeled off previous inves-
tigations using moderate blood-flow restriction, where 1 set of
30 repetitions was completed followed by 3 more sets of
15 repetitions (30-second rest between sets) (1). However,
because of the novelty of knee wraps as an occlusion
stimulus, the protocol for this study was tailored to err on the
side of caution; thus, knee wraps were intermittently applied
and rest intervals were set at 150 seconds between sets.
With this being the first investigation using knee wraps as a
means of practical occlusion, limitations exist. One limitation

VOLUME 24 | NUMBER 10 | OCTOBER 2010 | 2833

Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
 Practical Occlusion
was the small sample size; however, with this being
preliminary research, the sample was adequate to allow for
a greater understanding of the acute response to practical
occlusion, specifically with exercise prescription, because the
current study demonstrated that subjects could tolerate
blood-flow restriction from knee wraps. In addition, although
metabolic stress has been implicated to cause the release of
favorable hypertrophic hormones, the only blood measure-
ment taken in this study was WBL. Future investigations
should measure the GH response to practical occlusion.
In conclusion, this pilot study demonstrated that there are
no significant differences for WBL between OCC and CON,
although there was a trend for higher levels with OCC
(p = 0.051). However, this study did find significant increases
for HR and RPE from an acute practical occlusion stimulus
with knee wraps. The current study also found that subjects
were able to tolerate practical occlusion with knee wraps, and
future investigations should examine shortened rest periods,
and a continuous occlusive stimulus throughout the exercise
bout. The need for an affordable, effective means to receive
the benefits of occlusion training exists, thus the need for
further research in the field of practical occlusion.
PRACTICAL APPLICATIONS
Previous studies have found that the use of blood-flow occlusion
will stimulate muscle hypertrophy (1,2,14,19–21,25). One
mechanism for the stimulus of increased protein synthesis is
a decrease in pH as a result of lactic acid production. In this
study, low-intensity exercise with intermittent occlusion using
elastic knee wraps did not increase metabolic stress more than
CON. The reperfusion of the muscles between sets may
moderate the effects of the occlusive stimulus and therefore not
create adequate stimuli for protein synthesis.
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