European Journal of Applied Physiology

https://doi.org/10.1007/s00421-018-3877-0

ORIGINAL ARTICLE

Moderately heavy exercise produces lower cardiovascular,

RPE, and discomfort compared to lower load exercise
with and without blood flow restriction
Zachary W. Bell1 · Samuel L. Buckner1 · Matthew B. Jessee1 · J. Grant Mouser1 · Kevin T. Mattocks1 · Scott J. Dankel1 ·
Takashi Abe1 · Jeremy P. Loenneke1

Received: 29 December 2017 / Accepted: 26 April 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose  To determine the acute cardiovascular and perceptual responses of low-load exercise with or without blood flow
restriction and compare those responses to that of moderately heavy exercise.
Methods  Twenty-two participants completed unilateral elbow flexion exercise with a moderately heavy-load- [70% one-
repetition maximum (1RM); 70/0] and with three low-load conditions (15% 1RM) in combination with 0% (15/0), 40%,
(15/40) and 80% (15/80) arterial occlusion pressure. Participants exercised until failure (or until 90 repetitions per set). The
cardiovascular response (arterial occlusion) was measured pre and post exercise and the perceptual responses [ratings of
perceived exertion (RPE) and discomfort] were determined before and after each set of exercise.
Results  For arterial occlusion pressure, the lower-load conditions had greater change from pre to post compared to 70/00
(e.g., 15/80: 44 vs. 70/0: 34 mmHg). RPE was highest across the sets for the 15/80 condition with the other conditions hav-
ing similar RPE (e.g., set 4: median rating of 17.2 for 15/80 vs. ~ 15.5 for other conditions). Ratings of discomfort were also
greatest for the 15/80 condition (15/80 > 15/40 > 15/0 > 70/0). Exercise volume within the 15/0 and 15/40 conditions were
similar but were significantly greater than that observed with the 15/80 and 70/0 conditions.
Conclusion  Low-load exercise to volitional failure results in a greater cardiovascular response to that of moderately heavy-
load exercise. When high pressure is applied to low load exercise, there is a reduction in exercise volume but an elevated
perceptual response that may be an important consideration when applying this stimulus in practice.

Keywords  Perceptual response · Ischemia · Kaatsu · 15% 1RM · Volitional failure

Abbreviations 15/80 15% one-repetition maximum/80% arterial

1RM One-repetition maximum occlusion pressure
15/0 15% one-repetition maximum/0% arterial 70/0 70% one-repetition maximum/0% arterial
occlusion pressure occlusion pressure
15/40 15% one-repetition maximum/40% arterial ANOVA Analysis of variance
occlusion pressure RPE Ratings of perceived exertion

Communicated by William J. Kraemer.

Introduction
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s0042​1-018-3877-0) contains The use of blood flow restriction by itself (Kubota et al.
supplementary material, which is available to authorized users.
2011), in combination with low-intensity aerobic (Abe et al.
* Jeremy P. Loenneke 2006) or low-load resistance exercise (Takarada et al. 2002;
jploenne@olemiss.edu Ellefsen et al. 2015), has been shown to produce beneficial
1
adaptations to skeletal muscle. To induce blood flow restric-
Department of Health, Exercise Science, and Recreation tion, a cuff is applied to the top of a limb and inflated to a
Management, Kevser Ermin Applied Physiology Laboratory,
The University of Mississippi, P.O. Box 1848, University, pressure to partially reduce arterial inflow into a limb and
MS 38677, USA restrict blood flow out of the limb (Mouser et al. 2017).

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 European Journal of Applied Physiology

Although low-load resistance exercise with blood flow differences across conditions in the cardiovascular and per-
restriction has been shown to produce beneficial muscular ceptual responses using a similar measurement protocol
adaptations, concerns still remain over the cardiovascular (Jessee et al. 2017; Mattocks et al. 2017). Participants were
(Spranger et al. 2015) and perceptual responses to this type engaged in resistance-based training a minimum of twice per
of exercise (Loenneke et al. 2011). One method used to week for the previous 6 months and were familiar with the
quickly assess the cardiovascular response to this type of dumbbell elbow flexion (biceps curl) exercise. Participants
exercise is to measure the change in the arterial occlusion were excluded if they used tobacco (6-month previously),
pressure (Barnett et al. 2016; Mattocks et al. 2017; Jessee hypertension medication, if they had an orthopedic injury
et al. 2017). The arterial occlusion measurement is similar preventing exercise, below 18 or above 35 years of age, or if
to the more traditional measurement of systolic blood pres- they had a BMI ≥ 30 kg/m2. Participants were also excluded
sure but often measured with a narrower cuff (i.e., width). if they met two or more of the following risk factors for
Previous literature suggests that the cardiovascular thromboembolism: currently taking birth control, diag-
and perceptual responses appear to respond in a pressure- nosed with Crohn’s disease, past fracture of the hip, pelvis,
dependent manner with greater pressures eliciting greater or femur, major surgery within the last 6 months, varicose
responses (Mattocks et al. 2017; Jessee et al. 2017). This veins, family or personal history of deep vein thrombosis, or
is important given that blood flow restriction in combina- family or personal history of pulmonary embolism (Motykie
tion with loads less than 30% one repetition (1RM) seem to et al. 2000). All participants were informed of the experi-
require higher applied pressures to be efficacious (Lixandrão mental procedures as well as any potential risks that were
et al. 2015). Of note, the previous studies implemented pro- associated with the study before giving written informed
tocols with set goal repetitions and it is currently unknown consent. The study was approved by the University’s Insti-
how these findings may change if designed to induce failure tutional Review Board.
on every set. For example, when low-load resistance exer-
cise is taken to volitional failure, the muscle adaptations
observed are similar to that with low-load resistance exer- Experimental design
cise using blood flow restriction (Fahs et al. 2015) as well
as higher load resistance exercise (Ogasawara et al. 2012; This study was a randomized crossover design with all par-
Morton et al. 2016); albeit with higher exercise volumes. ticipants completing all conditions. Participants came to the
Although this may seem to question the utility of blood flow lab for three separate visits and were specifically instructed
restriction, there is likely a point where the load becomes to: (1) not exercise 24 h before each testing visit; (2) not
too low (≤ 15% 1RM) to maximally stimulate the muscle consume caffeine within 8 h of each testing visit; and (3)
(Holm et al. 2008) and the application of blood flow restric- not consume food within 2 h of each testing visit. The initial
tion may be necessary to produce beneficial adaptations. If visit was for completion of paperwork and for determina-
true, having an understanding of the acute blood pressure tion of exclusion criteria. If participants met the inclusion
and perceptual responses to this type of exercise may pro- criteria for the study, they were then measured for height
vide useful information for both the safety and long-term and body mass to the nearest 0.1 cm and 0.1 kg with the use
compliance of performing a high number of contractions of a stadiometer and a standard digital scale (Seca, Chino,
with and without blood flow restriction. The study of very USA). Standing arterial occlusion pressure was determined
low loads may have implications for rehabilitation where the in both arms to familiarize them with that measurement
implementation of a maximum strength test is not always and then participants completed a one-repetition maximum
possible or accurate (Yow et al. 2018). In those situations, (1RM) test on each arm for their elbow flexors (biceps curl).
the application of a very low load may be the best strategy Participants were then familiarized with blood flow restric-
initially. Thus, the purpose of this study was to investigate tion exercise. For visits 2 and 3, participants returned to
the cardiovascular and perceptual responses to very low- the lab to randomly complete two, out of a possible four
load resistance exercise with and without different levels of conditions, with the other two conditions being completed
blood flow restriction and compare the response to that of on the final visit. Conditions involved a moderately heavy
moderately heavy-load resistance exercise. load (70% 1RM), a very low load (15% 1RM), a very low
load with moderate blood-flow restriction (40% of rest-
ing arterial occlusion pressure) or a very low load with a
Participants greater level of blood flow restriction (80% of resting arterial
occlusion pressure); coded as 70/0, 15/0, 15/40, and 15/80,
Twenty-two participants (10 females and 12 males) volun- respectively. Testing a condition consisted of the partici-
teered to participate in the study. Sample size was based off pant resting quietly (10 min before condition 1 and 15 min
of previous studies from our laboratory that noted significant before condition 2) followed by a measurement of standing

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European Journal of Applied Physiology

arterial occlusion pressure on each arm using a hand-held an assumed maximum. Each attempt during testing began
Doppler probe. Participants then completed one of the four with participants standing with their feet shoulder width
conditions at the set percentage for the prescribed load and apart, their heels and back against a wall, and the arm fully
required cuff inflation pressure. Before set 1, and after the extended and supinated by their side. Once in proper posi-
completion of each set, participants were asked to give their tion they were handed a loaded dumbbell and encouraged to
rating of perceived exertion (RPE) and then were asked for complete a full range of elbow flexion while maintaining an
their level of discomfort at 20 s after the final repetition for upright position. Attempts began by completing one repeti-
that specific set. The only exception being after set 4, when tion at an estimated 60–75% of maximum, and the load was
the perceptual ratings were determined following the arterial progressively increased until the participant was unable to
occlusion pressure measurement. For the moderately heavy- lift a load greater than their previously successful attempt.
load exercise, participants were allotted 90 s of rest between After each attempt, participants were given a 90-s rest period
sets and 30 s for the very low-load exercise. Immediately before attempting the next load. An attempt was deemed
after the completion of set 4, participants were measured unsuccessful if the participant could not complete the full
again for standing arterial occlusion pressure in the exer- range of motion, or if they were unable to maintain strict
cised arm. The cuff was then deflated and removed and the form with their heels, shoulders, and back against a wall.
participants were asked to rate their perceptual response to One-repetition maximum was determined as the greatest
set 4. Participants then rested quietly for 15 min after which load a participant was able to lift properly through a full
all testing was repeated in the opposite arm, using a new range of motion.
combination of load and pressure. All restrictive pressures
applied were based upon the arterial occlusion pressure
measurement taken immediately prior to each exercising Exercise protocol
condition.
Exercise consisted of four sets to failure (or up to 90 repeti-
tions each set, whichever came first) that of unilateral bicep
Arterial occlusion pressure curls at 70% 1RM, 15% 1RM, or 15% 1RM with either
moderate (40% resting arterial occlusion pressure) or higher
Standing arterial occlusion pressure was measured before (80% resting arterial occlusion pressure) blood flow restric-
each bout of exercise, and immediately after exercise. A tion. However, sets were capped at 90 repetitions if failure
5-cm-wide nylon cuff (SC5 Hokanson, Bellevue, WA) was was not reached. 90 repetitions represents 3 min of continu-
placed on the most proximal portion of the participant’s ous exercise and we chose this based off previous acute data
upper arm. A hand-held Doppler probe (MD6, Hokan- showing that this time under tension is capable of inducing
son, Bellevue, WA) was placed at the wrist over the radial elevations in myofibrillar protein synthesis and beyond this
artery until an auditory signal of blood flow was found. The the cellular response may become more oxidative, stimu-
cuff was slowly inflated using an E20 Rapid Cuff Inflator lating only mitochondrial protein synthesis rather than the
(Hokanson, Bellevue, WA) until there was no longer an indi- myofibrillar subfraction (Burd et al. 2012). All sets were
cation of blood flow from the Doppler probe. The lowest cuff designed to try and reach failure (if possible with a very low
inflation pressure at which the blood flow distal to the cuff load) because it has been suggested that this provides a more
was no longer detectable was defined as arterial occlusion fair comparison across conditions as it takes into account
pressure. The post-exercise arterial occlusion measurement differences in strength endurance (Dankel et al. 2017). Each
was taken immediately after exercise by increasing the infla- participant completed four sets to a metronome (1 s concen-
tion pressure of the cuff, which was already inflated during tric: 1 s eccentric) with 30 s of rest between low-load sets
the bout of exercise. Once arterial occlusion was determined, and 90 s of rest between the moderately heavy-load sets.
the cuff was immediately deflated and removed from the
upper arm (Barnett et al. 2016; Mattocks et al. 2017; Jessee
et al. 2017). Blood flow restriction

Blood flow restriction was applied by placing a 5-cm-wide

One‑repetition maximum nylon cuff (SC5, Hokanson, Bellevue, WA) to the proximal
portion of the exercising limb and inflating it to either 40
One-repetition maximum for unilateral elbow flexion was or 80% of pre-exercise arterial occlusion. These particu-
assessed in both arms on visit 1 to determine the appropri- lar pressures were used as they are common in the blood
ate relative load for all conditions. Participants began the flow restriction literature and they have both been shown to
test following a warm up of 5–10 repetitions using 30% of elicit muscle adaptation (Counts et al. 2016; Loenneke et al.

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 European Journal of Applied Physiology

2016). For the 70/0 and 15/0 conditions, the cuff was kept on not normally distributed, a Friedman non-parametric test
during exercise but was inflated to a pressure of 0 mmHg. was used to determine differences between conditions and,
if significant, Wilcoxon non-parametric tests were used to
determine which conditions were different from each other.
Ratings of perceived exertion (RPE) Data are presented as mean (SD) and change scores are pre-
and discomfort sented as means and 95% confidence intervals. For percep-
tual responses data are represented as 25th, 50th, and 75th
Participants were informed in depth on how to rate their percentiles. Statistical significance was set a priori at an α
exertion (RPE) and discomfort to ensure they understood the level of 0.05.
scale being used. Similar scales have been employed previ-
ously by our laboratory and others which allowed for com-
parison across studies (Yasuda et al. 2010; Loenneke et al. Results
2016; Mattocks et al. 2017; Jessee et al. 2017). Individuals
were asked to rate their level of exertion using the standard Participant characteristics
Borg 6–20 scale. This was asked before any exercise was
performed, and then again immediately following each set of In total, 10 females and 12 males [age 22 (2.8) years; height
exercise. A rating of discomfort was obtained using Borg’s 174.7 (10.3) cm; body mass 76.3 (17.3) kg; 1-RM left arm
Discomfort Scale (CR10 +). It was explained to participants 19.7 (8.9) kg; 1-RM right arm 20.1 (8.9) kg] completed all
that the scale was rated from 0 to 10 with a score of ten rep- testing conditions but the arterial occlusion pressure meas-
resenting their previously worst felt discomfort. They were urement was unable to be determined at the post for two
then instructed that a rating of 10 was their reference point participants, leaving a sample size of 20 for that measure-
and they could exceed 10 if the discomfort they felt was ment (9 females, 11 males).
greater than what they have ever felt previously. Participants
were then asked if they had any questions. All participants Arterial occlusion pressure
fully understood the scale prior to exercise. Notably, our
discomfort scale did not have any words written on it outside For arterial occlusion pressure, there was a significant
of “no discomfort” and “maximal discomfort”. Ratings of interaction of condition × time (p = 0.049) and follow-up
discomfort were taken immediately before exercise, as well tests revealed that arterial occlusion pressure was increased
as 20 s after sets 1, 2, and 3, and immediately following the from pre to post (Fig. 1, p < 0.001) within all conditions.
arterial occlusion pressure measurement for set 4. Discom- There were no significant differences across conditions at
fort was taken 20 s after each set because participants in pre-
vious studies anecdotally noted greater discomfort later in
the rest periods and it was thought that this provided a more
accurate representation of the level of discomfort caused by
the exercise protocol (Counts et al. 2016).

Statistical analysis

All data were analyzed using SPSS 23.0 statistical software

package (IBM, Chicago, IL, USA). To detect any interac-
tion effect of condition and time for arterial occlusion, a 4
(condition) × 2 (time) repeated measures analysis of variance
(ANOVA) was used. If there was a significant interaction,
a one-way repeated measures ANOVA was used to reveal
differences across conditions within each time point, and
a paired samples t test was used to find differences across Fig. 1  Changes in arterial occlusion pressure. Conditions are labeled
as percentages of one-repetition maximum/percentage of arterial
time within each condition. For comparisons of perceptual
occlusion pressure. No error bars are provided because this would not
responses (RPE and discomfort), a Friedman non-paramet- provide any information on the variability in response to the interven-
ric test was used to reveal any differences between condi- tion. The variability of the intervention is noted under each condition
tions within each time point (pre, set 1, set 2, set 3, set 4). as the mean change (95% confidence interval of the change). Differ-
ent letters indicate significant differences across conditions at the post
If a significant difference was revealed, Wilcoxon-related
measurement (p ≤ 0.05). If at least one letter is the same, those con-
samples non-parametric tests were used to find where those ditions are not significantly different. Asterisk indicates a significant
differences occurred. Given that the exercise volume was pre to post change

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European Journal of Applied Physiology

pre (p = 0.103) but there were at post (p = 0.003) with 15/80 Exercise volume
having a significantly higher increase than 70/0. Although
this study was not designed to investigate sex differences, For exercise volume, there was a significant difference
we have provided the relative changes in arterial occlusion across conditions (Fig. 2, p = 0.001). Relative to traditional
pressure for each sex. When separated by condition the resistance exercise, the exercise volume was greater with
changes were as follows: [mean change (95% CI)] 15/0: 29 lower loads (15/0 and 15/40) but was attenuated with greater
(23, 36)% increase for men vs. 26 (19, 34)% increase for pressure (15/80).
women; 15/40: 35 (29, 41)% increase for men vs. 23 (16,
30)% increase for women; 15/80: 35 (26, 45)% increase for
men vs. 22 (12, 32)% increase for women; and 70/0: 28 (21, Discussion
34)% increase for men vs. 19 (12, 27)% increase for women.
The primary findings from this study are as follows: (1)
Ratings of perceived exertion the arterial occlusion pressure increased post exercise
in all conditions, but traditional higher load exercise had
There were no significant differences for ratings of perceived
exertion across conditions at pre (Table 1, p = 0.392). Sig-
nificant differences were revealed within each set of exercise
(sets 1–4, p < 0.001), with 15/80 noting the highest ratings
throughout. Ratings separated by sex can be found in Sup-
plementary Table 1.

Ratings of discomfort

There were no differences in discomfort across conditions at

pre (Table 1, p = 0.261). There were significant differences
across conditions within each set of exercise (p < 0.001) with
the greatest ratings being with blood flow restriction and the
lowest ratings being with moderately heavy-load exercise
(15/80 > 15/40 > 15/0 > 70/0). Ratings separated by sex can Fig. 2  Exercise volume. Conditions are labeled as percentages of
be found in Supplementary Table 2. one-repetition maximum/percentage of arterial occlusion pressure.
The bar represents the median volume for each condition and the 25th
and 75th percentiles for each condition are noted directly below each
condition. Different letters indicate significant differences across con-
ditions (p ≤ 0.05). If at least one letter is the same, those conditions
are not significantly different

Table 1  Ratings of perceived Perceptual responses to various load and pressure combinations

exertion (RPE) and discomfort
Load/pressure Pre Set 1 Set 2 Set 3 Set 4

Rating of perceived exertion

 15/0 6, 6, 6 8.7, 13, ­16a 11, 15, 17.2a 13, 15.5, 17.2a 13, 16, ­18a
 15/40 6, 6, 6 10, 13, ­16a 13, 15, 17.5a 14, 15.5, 17.2a 14, 15, ­19a
 15/80 6, 6, 6 12, 15, 17.2b 14, 16, 18.2b 15, 17, ­19b 15, 17.2, ­20b
 70/0 6, 6, 6 10.5, 12.5, ­15a 11.7, 14.5, ­16a 13, 15, 17.2a 13.75, 16, ­17a
Ratings of discomfort
 15/0 0, 0, 0 1, 3, 5.2a 2, 4.5, ­7a 2.7, 4.5, ­7a 2.7, 5.5, ­7a
 15/40 0, 0, 0 2, 4.5, ­6b 2, 5.5, ­7b 2.7, 6, ­8b 2.7, 6, 8.2b
 15/80 0, 0, 0 5, 6, 6.2c 6, 6, ­8c 5.7, 6.5, 8.2c 5.7, 6.5, 8.2c
 70/0 0, 0, 0 0, 1, ­3d 0, 2, ­4d 0, 2.5, 4.2d 0, 3, 4.2d

Conditions are labeled as percentages of one-repetition maximum/percentage of arterial occlusion pressure.

Different letters indicate significant differences across conditions within each set (p ≤ 0.05). If at least one
letter is the same, those conditions are not significantly different. Values are presented as 25th, 50th, and
75th percentiles

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 European Journal of Applied Physiology

the smallest change; (2) the RPE was greatest in the 15/80 arterial occlusion pressure. However, the greater perception
condition; (3) the discomfort was greatest in the low-load of effort cannot be driven by pressure alone or even exer-
conditions and was augmented by the applied pressure cise volume per se as there were no significant differences
(15/80 > 15/40 > 15/0 > 70/0); and (4) exercise volume between the other low-load conditions (i.e., 0 or 40% arterial
was highest for the 15/0 and 15/40 conditions but apply- occlusion at 15% 1RM). Mattocks et al. (2017) found similar
ing a higher relative pressure reduced volume down to that results with the highest pressure (90% arterial occlusion)
observed with traditional higher load exercise. resulting in the highest RPE values and found no difference
Exercising with or without blood flow restriction between the 0 and 50% arterial occlusion pressure conditions
increases arterial occlusion pressure immediately post exer- during the final sets of exercise. The addition of a traditional
cise; similar to previous work using similar protocols (Bar- higher load condition is novel to this line of research and
nett et al. 2016; Mattocks et al. 2017; Jessee et al. 2017). Of suggests that the perceived effort associated with higher
note, however, the current study did not observe a pressure- load resistance exercise is lower than the lower load condi-
dependent increase in the cardiovascular response. The exer- tions. These observations, coupled with the results of the
cise protocol and inflation pressures used, rather than the present study, suggest that the perception of effort is greatest
volume of exercise completed per se, likely explains at least in the low-load exercise conditions with the application of
part of the discrepancy in the results. To illustrate, the major- high blood flow restriction; particularly when the majority
ity of participants in the current study exercised to volitional of the participants are exercising to volitional failure. It is
failure by the fourth set of exercise (15/0: 72%; 15/40: 77%; noted that these results are in contrast to the investigation
15/80: 90%; 70/0: 100%), whereas participants in the Jessee by Loenneke et al. (2016) who found that RPE was simi-
et al. investigation completed a non-failure protocol (i.e., lar across different applied blood flow restriction pressures
at 15% 1RM). Although Mattocks et al. reported that the ranging from 40 to 90% arterial occlusion. The reason for
majority of participants did exercise to failure; they still this discrepancy is unknown but may be due to the small
observed an augmentation at the highest applied pressure incremental changes in applied pressure used in that study
(90% arterial occlusion) but similar increases at the lower as well as the potential contribution of an order effect. Future
applied pressures (0, 10, 30, 50% arterial occlusion pressure) studies may try account for the order different pressures are
when exercising at 30% 1RM. This is in partial agreement applied to see if this may affect how individuals perceive the
with our findings, in that we observed no augmentation from effort of exercise.
applying 40 and 80% arterial occlusion pressure to exercise Ratings of discomfort were highest for the low-load exer-
at 15% 1RM. Thus, despite differences in exercise volume cise conditions and within the low-load conditions, increased
(Fig. 2) between the low-load conditions, with and without with increasing pressure (80 > 40 > 0% arterial occlusion).
different levels of blood flow restriction, the cardiovascular This increased rating with increasing pressure is consist-
response immediately post exercise was similar. The mod- ent with previous studies using similar pressures (Counts
erately heavy resistance exercise condition did observe an et al. 2016; Mattocks et al. 2017; Jessee et al. 2017). As
increase in arterial occlusion, but this change was less than formerly mentioned, Loenneke et al. (2016) is the only study
that observed in the lower load conditions with or without to date that did not find a difference in ratings of discomfort
blood flow restriction. This is contrary to that observed by across varying levels of blood flow restriction (40–90% arte-
Brandner et al. (2015) who found that high-load exercise rial occlusion). Reasons for the discrepancy may include
(80% 1RM) produced a significantly greater blood pressure that mentioned earlier but may also be related, in part, to
response than the low-load condition (20% 1RM) exercising when the discomfort ratings were assessed. In that study,
under continuous blood flow restriction. Disparate methods discomfort was assessed immediately at the end of each set,
likely explain the lack of agreement between studies (voli- whereas the present study determined the participants’ level
tional failure vs. not). Taken together, the results seem to of discomfort 20 s after the final repetition for sets 1, 2, 3
suggest that when effort is matched by having participants and then immediately after set 4. Rating discomfort within
exercise to volitional failure, the cardiovascular response is the rest period, particularly with blood flow restriction, may
augmented over traditional higher load resistance exercise. elevate discomfort levels due to the pooling of blood and
Blood flow restriction training at low loads accompanied the inactivation of the skeletal muscle pump. Nevertheless,
with a high-relative pressure (80% arterial occlusion pres- the level of discomfort achieved with low-load exercise
sure) resulted in elevated responses for RPE that is consist- with or without blood flow restriction is greater than that of
ent with previous work using similar methods (Counts et al. traditional higher load resistance exercise. Such effects are
2016; Mattocks et al. 2017; Jessee et al. 2017). Recently, likely driven by volume and applied pressure. For exam-
Jessee et al. (2017) found that exercising at 15% 1RM with ple, low loads with moderate pressure (15/40) or low loads
80% arterial occlusion pressure augmented the perception alone (15/0) lead to ratings of discomfort greater than that
of effort over the 15% 1RM condition exercising with 40% observed with the moderately heavy-load condition. Both of

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European Journal of Applied Physiology

these low-load conditions also completed the greatest vol- similar to that of traditional higher load resistance exercise.
ume of exercise. Interestingly, the low-load condition with Despite these observations, little was known about the car-
high pressure (15/80) rated the highest levels of discomfort, diovascular and perceptual response to very low-load exer-
but the volume in that condition was similar to that observed cise to failure and how this might differ from traditional
with the moderately heavy-load condition. This suggests an resistance exercise. Our findings suggest that the cardiovas-
effect of the applied pressure and may be something to con- cular response, as measured by changes in arterial occlusion
sider when implementing blood flow restriction with very pressure, was greatest with the low-load conditions. In addi-
low loads to volitional failure. tion, when high-relative pressures of blood flow restriction
This study is not without limitations. The use of two con- were applied to low-load exercise, the perceptual response
ditions within the same visit may be something to consider was greater than that observed with moderately heavy-load
as the initial bout of exercise may have altered the subse- resistance exercise or lower-load exercise with and without
quent bout. However, to try and minimize this, a 15-min the application of moderate blood flow restriction.
period of quiet rest was observed prior to the second bout
of exercise to allow for a washout period. In addition, rest- Acknowledgements  The authors are not aware of any affiliations,
memberships, funding, or financial holdings that might be perceived
ing arterial occlusion pressures were taken in both limbs at as affecting the objectivity of this manuscript. This study was sup-
the onset of the visit and then taken prior to the start of the ported, in part, though funding from the Japanese Society of Wellness
second exercise bout to account for any residual elevations and Preventive Medicine.
from the first bout of exercise. Previous work suggests that
there are no significant changes [mean difference 95% CI of Author contributions  ZWB acquired and interpreted the data, per-
formed statistical analysis, and drafted the manuscript. SLB, MBJ,
2.7 (− 1.7, 7.4) mmHg] in the arterial occlusion pressure of JGM, KTM, SJD conceived of the study, acquired and interpreted the
the second arm assessed before any exercise and after the data, and critically reviewed the manuscript. TA and JPL conceived of
rest period following the first condition (Jessee et al. 2017). the study, interpreted the data, helped with statistical analysis, critically
Second, the present study used a narrow 5cm-wide nylon reviewed the manuscript, provided oversight of data collection, and
provided funding for the project.
cuff and it is possible that a cuff of differing size may elicit
a different response. The cardiovascular response was also
measured as a change from pre to immediately post exer-
cise. Whether this represents the cardiovascular response
during exercise remains unknown (i.e., is lower load also
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