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4 authors, including:
Chris Fahs
Jacob M Wilson
University of Oklahoma
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Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy
Department of Health and Exercise Science, The University of Oklahoma, Norman, OK, USA
Department of Exercise Science and Sport Studies, University of Tampa, Tampa, FL, USA
a r t i c l e
i n f o
Article history:
Received 11 April 2011
Accepted 15 July 2011
Available online xxxx
a b s t r a c t
Traditionally it has been thought that muscle hypertrophy occurs primarily from an overload stimulus
produced by progressively increasing an external load using at least 70% of ones concentric one repetition maximum (1RM). Blood ow restricted exercise has been demonstrated to result in numerous positive training adaptions, specically muscle hypertrophy and strength at intensities much lower than this
recommendation. The mechanisms behind these adaptions are currently unknown but a commonly cited
concept is that acute elevations of systemic hormones, specically growth hormone (GH), play a large
role with resistance training induced muscle hypertrophy, possibly through stimulating muscle protein
synthesis (MPS). We hypothesize that the alterations in the intramuscular environment which results
in the rapid recruitment of FT bers, is the large driving force behind the skeletal muscle hypertrophy
seen with blood ow restriction, whereas the external load and systemic endogenous hormone elevations
may not be as important as once thought. It is further hypothesized that although skeletal muscle hypertrophy can be achieved at low intensities without blood ow restriction when taken to muscular failure,
the overall volume of work required is much greater than that needed with blood ow restriction.
2011 Elsevier Ltd. All rights reserved.
Introduction
Traditionally it has been thought that muscle hypertrophy occurs primarily from an overload stimulus produced by progressively increasing a mechanical load using at least 70% of ones
concentric one repetition maximum (1RM) [1]. As a muscle is overloaded from increased mechanical work, the added stress increases
amino acid transport into cells, which in turn enhances the synthesis of contractile proteins, actin and myosin. Muscle hypertrophy
occurs from both an increase in the thickness and in the number
of myobrils. Although hypertrophy occurs in both slow twitch
(ST) and fast twitch (FT) bers, the latter has a greater potential
for growth [2].
The American College of Sports Medicine (ACSM) recommends
lifting a weight of at least 70% 1RM to achieve muscular hypertrophy as it is believed that anything below this intensity rarely produces substantial muscle growth [1]. However, numerous studies
using resistance exercise training combined with blood ow
restriction have shown muscle hypertrophy to occur with a training intensity as low as 20% 1RM [37]. Blood ow restricted resistance training may induce hypertrophy through a variety of
mechanisms [8], with the most commonly cited mechanism being
a robust elevation in growth hormone (GH) levels [9]. It is accepted
Exercise intensity
Exercise intensity, dened as a percentage of ones concentric
1RM, has long been used as a guide for muscle hypertrophy exercise prescription. Interestingly, if we accept that acute imbalances
between MPS and muscle protein breakdown (MPB) are the main
driving force of muscle hypertrophy, then exercise intensity may
actually be of less importance. Kumar et al. [12] found that the rate
0306-9877/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.mehy.2011.07.029
Please cite this article in press as: Loenneke JP et al. Blood ow restriction: The metabolite/volume threshold theory. Med Hypotheses (2011), doi:10.1016/
j.mehy.2011.07.029
Fiber recruitment
Literature demonstrates similar MPS responses independent of
exercise intensity as determined by concentric %1RM [13,15,16].
MPS signaling from resistance training occurs primarily from the
activation of signaling proteins, primarily S6K1, which is approximately 3- to 4-fold higher in FT bers compared to ST (40). Phosphorylation of this signaling protein has shown to be predictive
of skeletal muscle hypertrophy (41). This supports FT ber recruitment being an important variable to consider when assessing potential for the accretion of muscle mass. Blood ow restricted
resistance exercise research has demonstrated that recruitment
of the higher threshold motor units (containing FT bers) does occur with lower intensity exercise. Investigations have shown increased integrated electromyography (iEMG) [5,9,22] and
inorganic phosphate splitting [23], likely from the reduction in
oxygen and subsequent metabolic accumulation, during blood ow
resistance restricted exercise. Both reduced oxygen and metabolic
accumulation can increase ber recruitment, mechanistically
speaking, through the stimulation of group III and IV afferents
which may cause inhibition of the alpha motorneuron, resulting
in an increased ber recruitment to maintain force and protect
against conduction failure [24].
Thus, muscle hypertrophy occurs independently of exercise
intensity, as long as FT bers are activated [25]. This may seem
to question the application of blood ow restriction training, if
similar results can be seen without restricting blood ow. However, such a low load exercise protocol without blood ow restriction would require signicantly more repetitions to be completed
in order to stimulate an increase in myobril MPS [2628]. Those
with lower limb injuries or the elderly may be incapable of sustaining the mechanical stress necessary to reach muscular failure. Thus
we hypothesize, based on current literature, that blood ow
restriction induces muscle failure earlier (i.e. -at a lower volume
of work) compared to non-restricted resistance exercise at the
same intensity [2628]. Based on this hypothesis, it appears that
resistance exercise protocols for blood ow restriction might maximize training adaption using sets to failure rather than the commonly used four set protocol which is 30 repetitions for the rst
set, followed by 3 sets of 15.
Please cite this article in press as: Loenneke JP et al. Blood ow restriction: The metabolite/volume threshold theory. Med Hypotheses (2011), doi:10.1016/
j.mehy.2011.07.029
Fig. 1. The relationship between exercise volume, motor units recruited, and protein synthesis. As intensity increases from 3055% of ones repetition maximum the higher
threshold motor units are recruited. Once a certain amount of volume has been reached, as indicated by the threshold marker in the center of the gure, maximal protein
synthesis from exercise will occur. This occurs independent of exercise intensity provided the metabolic stress and/or volume is adequate to recruit the highest threshold
motor units.
Discussion
Current literature indicates muscle hypertrophy is largely
dependent upon elevated myobril MPS, which is independent of
external load as long as the volume and/or metabolic stress is sufcient to recruit FT bers (Fig. 1). Burd and co-workers have demonstrated that three sets of resistance exercise (70% 1RM)
performed to muscular failure produces a greater amplitude and
duration in MPS than one set of the same exercise to failure, highlighting the importance of resistance exercise volume [46].
Although we have long thought systemic increases of endogenous hormones play a role in myobril MPS and muscle hypertrophy, Wilkinson et al. [11] caution that those appear to only be
retrospective correlations. In addition, the role of muscle damage
in muscle hypertrophy may also be a spurious correlation, since
muscle hypertrophy occurs with blood ow restriction training
without elevations in known indices of muscle damage [9,47].
Muscle hypertrophy can occur through a variety of factors and
many of the mechanisms associated with growth are capable of
working independently of each other due to numerous redundancies built into the pathway (e.g. mTOR stimulation independent of
local growth factors) [48]. We hypothesize that the application of
blood ow restriction results in a rapid recruitment of FT ber
recruitment. Although, we do not believe that FT ber recruitment
is the single factor involved in the hypertrophic response to an
exercise stimulus, many of these other mechanisms (e.g. transcription factors, local growth factors, and satellite cells) likely occur in
concert with recruitment of higher threshold motor units observed
with blood ow restriction raining.
To illustrate, resistance exercise activates a signaling network
that regulates the expression of muscle growth factors such as
IGF-1, MGF, and myostatin. Local elevations in both IGF-1 and
MGF are positively associated with MPS [49] and both are impor-
Please cite this article in press as: Loenneke JP et al. Blood ow restriction: The metabolite/volume threshold theory. Med Hypotheses (2011), doi:10.1016/
j.mehy.2011.07.029
Please cite this article in press as: Loenneke JP et al. Blood ow restriction: The metabolite/volume threshold theory. Med Hypotheses (2011), doi:10.1016/
j.mehy.2011.07.029
[43] Spangenburg EE, Le Roith D, Ward CW, Bodine SC. A functional insulin-like
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Resistance exercise volume affects myobrillar protein synthesis and anabolic
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Please cite this article in press as: Loenneke JP et al. Blood ow restriction: The metabolite/volume threshold theory. Med Hypotheses (2011), doi:10.1016/
j.mehy.2011.07.029