Journal of Sports Sciences

ISSN: 0264-0414 (Print) 1466-447X (Online) Journal homepage: https://www.tandfonline.com/loi/rjsp20

The influence of biological sex and cuff width on

muscle swelling, echo intensity, and the fatigue
response to blood flow restricted exercise

Vickie Wong, Takashi Abe, Raksha N. Chatakondi, Zachary W. Bell, Robert W.

Spitz, Scott J. Dankel & Jeremy P. Loenneke

To cite this article: Vickie Wong, Takashi Abe, Raksha N. Chatakondi, Zachary W. Bell, Robert
W. Spitz, Scott J. Dankel & Jeremy P. Loenneke (2019): The influence of biological sex and cuff
width on muscle swelling, echo intensity, and the fatigue response to blood flow restricted exercise,
Journal of Sports Sciences

To link to this article: https://doi.org/10.1080/02640414.2019.1599316

Published online: 04 Apr 2019.

Submit your article to this journal

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=rjsp20
JOURNAL OF SPORTS SCIENCES
https://doi.org/10.1080/02640414.2019.1599316

PHYSIOLOGY AND NUTRITION

The influence of biological sex and cuff width on muscle swelling, echo intensity,
and the fatigue response to blood flow restricted exercise
Vickie Wong, Takashi Abe, Raksha N. Chatakondi, Zachary W. Bell, Robert W. Spitz, Scott J. Dankel
and Jeremy P. Loenneke
Department of Health, Exercise Science, and Recreation Management, Kevser Ermin Applied Physiology Laboratory, The University of Mississippi,
University, MS, USA

ABSTRACT ARTICLE HISTORY

The purpose was to determine if the muscle swelling, echo intensity, and fatigue responses to blood Accepted 26 February 2019
flow restriction differs based on cuff width (Experiment 1), applied pressure (Experiment 2), and sex.
KEYWORDS
Ultrasound of muscle was taken before and after exercise. In Experiment 1 (n = 96), men swelled more Occlusion training;
than women and more with a narrow cuff than a wide cuff (0.60 cm vs. 0.52 cm). Expressed as ultrasound; echo intensity;
a percentage change, there were no longer differences between cuffs (Narrow: 15% vs. Wide: 14%) or cuff pressure; fluid shifts
sex (Men: 14% vs. Women: 15%). Echo intensity remained unchanged. Women required more repeti-
tions to reach task failure in sets 2, 3, and 4. In Experiment 2 (n = 87), men swelled more than women
(Men: 0.46 cm vs. Women: 0.31 cm). Expressed as a percentage change, there were no differences. Echo
intensity decreased in both conditions and to a greater extent with a higher applied pressure. If the
acute muscle swelling response is important for initiating long term adaptation, then our results
indicate that neither cuff width, sex, nor applied pressure will differentially impact the adaptation
observed via this mechanism. Changes in echo intensity were inconsistent and the utility of this
measurement may need to be reconsidered.

Introduction Bemben, 2012; Yasuda, Loenneke, Thiebaud, & Abe, 2012).

The acute change in muscle thickness (i.e. acute swelling) is
Low load resistance exercise in combination with blood flow
hypothesized to be a shift of intracellular fluid, given that the
restriction has been shown to produce similar changes in
change in muscle thickness occurs with a concomitant
muscle growth as traditional high load resistance exercise
decrease in plasma volume (Kim, Loenneke, et al., 2017;
(Lixandrão et al., 2015; Jessee, Buckner, et al., 2018b).
Loenneke et al., 2017). In support of this hypothesis, Yasuda
Notably, blood flow is only partially restricted and still
et al. (2012) found that a condition which resulted in the
increases in response to exercise (Mouser, Laurentino, et al.,
greatest acute changes in ultrasound measured muscle swel-
2017b; Mouser et al., 2018). The beneficial effects observed
ling produced the largest change in muscle size measured by
with this form of training suggests that blood flow restriction
magnetic resonance imaging. Since swelling is a purported
training may be efficacious for those who are seeking to
mechanism for the muscular changes observed with blood
increase muscle size without the use of higher external
flow restriction training, it is important to better understand
loads. What is less known, is whether there are sex differences
if there are potential sex differences in the acute swelling
in these responses. A sizeable portion of the blood flow
response. For example, previous work suggests that women
restriction literature is completed only in men (Counts et al.,
have greater time to fatigue than men during blood flow
2018). The studies which do include women often pool their
restricted exercise (Labarbera, Murphy, Laroche, & Cook,
responses together with the men, making it difficult to deter-
2013). It was not known whether these sex differences are
mine if sex differences are present.
also found in the muscle swelling response to this form of
Changes in muscle size following blood flow restriction
exercise.
training may, in part, be due to an accumulation of metabo-
Throughout upper body blood flow restriction literature,
lites in the working muscle from the artificial reduction in
there are a variety of cuff widths used with studies imple-
blood flow. This trapping of metabolites around the fiber
menting both narrow (Jessee, Mattocks, et al., 2018c) and
may create an anabolic environment through fatigue induced
wider cuffs (Kim, Lang, Pilania, & Franke, 2017; Laurentino
increases in muscle activation (Dankel, Mattocks, et al., 2017a;
et al., 2016). Although wide cuffs require a lower absolute
Jessee, Mattocks, et al., 2018a). Another proposed mechanism
pressure to restrict the same amount of blood flow (Mouser,
is the acute cell swelling response, which has been hypothe-
Dankel, et al., 2017a), some studies suggest that the growth
sized to favorably impact net protein balance (Jessee,
response may be attenuated directly under the cuff (Ellefsen
Mattocks, et al., 2018a; Loenneke, Fahs, Rossow, Abe, &
et al., 2015; Kacin & Strazar, 2011). If muscle swelling is

CONTACT Jeremy P. Loenneke jploenne@olemiss.edu P.O. Box 1848. University, MS 38677

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this manuscript.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 V. WONG ET AL.
a mechanism for changes in muscle size, one hypothesis for
this attenuation might be a reduced swelling response
directly under the cuff. This might suggest that limb cover-
age may be something to consider when implementing
blood flow restricted exercise. In contrast to these studies,
one study suggests that when the pressure is made relative
to the individual and the cuff, there does not appear to be
an attenuation of muscle growth (Laurentino et al., 2016).
However, there is some suggestion that the measurement
site (i.e. 50% distance of upper arm) used in that study
would not place the measurement site directly under each
cuff. If there were attenuations under the cuff, this may
have removed the ability to detect these differences.
Given the suggested role of the acute cell swelling response
for changes in muscle size, an investigation into the impact
of cuff width on this proposed mechanism is of importance.
From a methodological perspective, it is also useful to
determine whether cuff width impacts the sex differences
in fatigability. A better understanding of sex differences (or
lack thereof) may help to improve not only the safety of
blood flow restriction but also the effectiveness.
Another methodological consideration is the pressure being
applied to each cuff width. For example, it is recommended that
the pressure be made relative to the size of the limb and the
width of the cuff (Mattocks et al., 2018). Both variables can be
accounted for by setting the pressure relative to the arterial
occlusion pressure with the specific cuff that will be used for
the exercise. Failure to account for the cuff width can result in
a higher than intended pressure being applied to the limb. This
was observed in a recent study (Kim, Lang, et al., 2017), whereby
a wide cuff was inflated to a pressure that was originally used
with a narrower cuff. The restriction of blood flow in that study
was likely much greater than originally intended, which poten-
tially explains the large dropout rate noted in their study. It was
not known whether this unintentionally high pressure negatively
impacts the acute swelling or fatigue response.
Therefore, the purpose of this study was to examine the acute
fluid shifts and repetitions to failure following low load blood flow
restricted exercise in response to cuffs of differing widths (5 cm
wide vs. 12 cm wide; Experiment 1) inflated to the same relative
pressure (40% of resting arterial occlusion pressure). The fluid
shifts were determined by ultrasound measured muscle thickness
and echo intensity. Though the exact utility of echo intensity has
been questioned (Jenkins, 2016), quantifying echo intensity may
provide insight for the balance between extracellular fluid and
intracellular fluid. We also determined if this change was impacted
by sex given the paucity of data examining women in the blood
flow restriction literature (Counts et al., 2018). A secondary pur-
pose was to determine if the acute fluid shifts and repetitions to
failure are impacted by applying a pressure obtained for a narrow
cuff to a wide cuff (Experiment 2).
Methods
Participants
One hundred-five men and women between the ages of
18–35 were recruited to participate in this study.
Participants reviewed and filled out the Physical Activity
Readiness Questionnaire (Par-Q) to get clearance to exercise.
All participants were tested at least 2 hours postprandial,
were instructed to avoid caffeine 8 hours prior to testing,
alcohol and elbow flexor exercise for 24 hours prior to
testing and avoid naive vigorous physical activity for
48 hours prior to testing. Participants were excluded if
they regularly used tobacco within the previous 6 months,
had any orthopedic injury preventing exercise, or met two
or more of the following risk factors for thromboembolism
(Motykie et al., 2000): body mass index ≥ 30; take birth
control pills; diagnosis of Crohn’s Disease; past fracture of
hip, pelvis, or femur; major surgery within last 6 months;
varicose veins; family or personal history of deep vein
thrombosis; or family or personal history of pulmonary
embolism. The study received approval from the university’s
institutional review board, and each participant gave written
informed consent before participation.
Experimental design
This study was a crossover design consisting of two separate
experiments. Day 1 consisted of the completion of paper-
work and for determination of who met the inclusion criteria.
If still eligible, measurements of height, body mass, and a test
of one repetition maximum (1RM) strength in each arm was
completed. Next, participants were familiarized with
a metronome (unloaded elbow flexion) to practice exercising
at the assigned pace for Experiment 1 (Day 2) and
Experiment 2 (Day 3). Metronome cadence was set for 60
beats per minute (one second concentric; one second
eccentric). Participants were then scheduled for
their second visit. Each experiment was separated by
a minimum of 3 days and no more than 10.
Experiment 1 protocol
Participants completed two different blood flow restriction
conditions in random order (one each arm). The cuff widths
were randomly assigned to each arm. Conditions involved
four sets of unilateral low load (30% 1RM) elbow flexion
exercise to volitional failure with 30 seconds of rest
between each set. Conditions involved exercise with
a pneumatic cuff placed at the most proximal region of
the participants’ upper arm and inflated to 40% of the
individual’s resting arterial occlusion pressure. The only dif-
ference being the width of the cuff applied (5 cm vs.
12 cm). Muscle thickness was measured before and after
each exercise bout in the supine position. Testing began
with 10 minutes of quiet seated rest to ensure that the
arterial occlusion pressure was at resting. Following this,
arterial occlusion pressure was measured in the standing
position within the randomly assigned arm to exercise
first. This was used to set the pressure for exercise.
Participants then completed four sets of unilateral elbow
flexion to failure with 30 seconds of rest in between sets.
The second condition was executed in a similar fashion
within the other arm, with the only difference being cuff
widths.

Experiment 2 protocol
On a separate day, 3–10 days later, participants returned to
the laboratory to complete two conditions in random order
(one each arm). The exercise protocol was similar to
Experiment 1. The only difference was that in this experi-
ment, both arms exercised with the same wide cuff (12 cm).
The important distinction was that one of the wide cuff
conditions had the relative arterial occlusion pressure set
for exercise based of the pressure obtained with a narrow
cuff (5 cm; known as the 12/5 condition). By design, this
would produce a higher absolute applied pressure, and thus
also a higher relative pressure (being that the same size cuff
was used). Similar to the first experiment, muscle thickness
was measured for each arm before and immediately after
exercise.
Muscle thickness and echo intensity
For both experiments, B-Mode ultrasound (Logiq-e GE,
Fairfield, CT, United States) was used to assess changes in
muscle thickness before and after exercise in the supine posi-
tion. Baseline measurements were taken at the same time, but
post exercise measurements were obtained immediately fol-
lowing after each specific condition. Muscle thickness was
taken at 70% of the distance between the acromion process
and the lateral epicondyle. The frequency was set at 10 MHz,
dynamic range of 75 decibels, and a gain of 49 decibels.
Images were taken perpendicular to the anterior upper arm
using a small electronic level with a digital readout (Metriks,
Ontario, Canada) that was attached to the ultrasound probe.
To also eliminate any inconsistencies, the same person took all
ultrasound measurements. The probe was generously coated
with transmission gel and held perpendicular over the anterior
upper arm (i.e. biceps brachii and brachialis) with care taken as
to not depress the dermal surface. System setting parameters
were maintained throughout the study. Two images were
taken for each condition at each time point (8 total images
for each experiment). Muscle thickness was determined as the
distance between the subcutaneous adipose tissue-muscle
interface and muscle-bone interface of the humerus. Images
were stored and analyzed following data collection using the
ultrasound software.
The same images used for muscle thickness were also
used for quantifying echo intensity. Echo intensity was
determined using an automated gray scale analysis. The
scale ranged from 0 (black) to 255 (white) using Image-J
software (National Institute of Health, Bethesda, MD, United
States). A rectangular region of interest was drawn as large
as possible, excluding aspects that demonstrated subcuta-
neous adipose tissue or the bone region. Echo-intensity
measurements were saved, stored, and analyzed using
Image-J software.
Arterial occlusion
For both experiments, arterial occlusion pressure was deter-
mined in the standing position immediately before the bout of
exercise. Dependent upon the condition, either a narrow
JOURNAL OF SPORTS SCIENCES 3
(5 cm) or wide (12 cm) nylon cuff (SC5 Hokanson, Bellevue,
WA) was placed on the most proximal portion of the partici-
pant’s upper arm. A hand-held Doppler probe (MD6,
Hokanson, Bellevue, WA) was placed at the wrist, over the
radial artery, to detect a pronounced auditory signal of
blood flow. The cuff was inflated using an E20 Rapid Cuff
Inflator (Hokanson, Bellevue, WA) until there was no audible
signal of blood flow from the Doppler probe. The lowest cuff
inflation pressure at which the blood flow distal to the cuff
was no longer detectable was defined as arterial occlusion
pressure. Once the arterial occlusion pressure was determined,
the cuff was deflated, and the cuff pressure was set to 40% of
resting arterial occlusion pressure.
One repetition maximum
One-repetition maximum was determined as the greatest
load a participant was able to lift properly through a full
range of motion. One-repetition maximum for unilateral
elbow flexion was assessed in both arms on visit one. The
starting arm was chosen randomly from a coin flip.
Participants began testing with a warm-up of unilateral
elbow flexion on both arms. Warm-up consisted of 5–10
repetitions using 2–5 kgs. Each attempt during testing
began with participants standing with their feet shoulder
width apart, their heels, back, and shoulders against a wall,
along with the arm fully extended and supinated by their
side. They were then handed a loaded dumbbell and
encouraged to complete a full range of motion for the
unilateral elbow flexion. Full range of motion was for the
concentric portion of the lift only, as the load was taken at
the top portion of the movement following a successful lift.
The load was progressively increased until the participant
was not able to lift a load greater than their previously
successful attempt. Each attempt was separated by 90 sec-
onds of rest.
Exercise protocol
The exercise protocol consisted of four sets of unilateral
elbow flexion to volitional or task failure. Repetitions were
completed to the beat of a metronome, with a set cadence
of 60 beats per minute (one second concentric; one second
eccentric). Loads were set at 30% of the individual’s 1RM
and cuff pressure was set to 40% of the individual’s arterial
occlusion pressure of the arm to exercise. 30 seconds of rest
was allotted between sets of exercise. Similar protocols have
been used before when studying blood flow restriction
resistance exercise (Jessee et al., 2017, 2018; Loenneke
et al., 2015).
Statistical analysis
The following tests were completed for both Experiment 1
and Experiment 2. A Bayesian repeated measures analysis of
variance (ANOVA), with a between subject factor of sex was
used to compare changes in muscle thickness, echo inten-
sity and repetitions with a default prior of 0.5 for the fixed
effects (r scale Cauchy prior width = 0.5). We analyzed both
4 V. WONG ET AL.
absolute and relative (% of baseline) changes in order to
account for the potential influence of sex differences at
baseline. For example, men might swell more on an abso-
lute level due to having a larger muscle size at baseline but
the relative change might be similar. Thus, we elected to
use both absolute and relative changes for muscle thickness
and echo intensity. Bayes factors (BF10) were used to pro-
vide evidence for (BF10 of ≤ 0.33) or against the null (BF10 of
≥ 3.0) hypothesis. A BF10 of “3” means that the observed
data are 3 times more likely under the alternative than the
null hypothesis. Likewise, a BF10 of 0.33 means that the
observed data are 3 times more likely under the null than
the alternative hypothesis. To detect evidence for or against
the condition x sex interaction, the interaction model (con-
dition + sex + condition * sex) was divided by the main
effects model (condition + sex). If there was evidence for an
interaction, follow up comparisons of conditions within each
sex were made using a Bayesian paired sample t-test with
a default Cauchy prior of 0.707 (centered on zero).
Comparisons of sex between conditions were made using
a Bayesian independent samples t-test with a default
Cauchy prior of 0.707 (centered on zero). Default priors
were made as recommended by Wagenmakers and collea-
gues (Wagenmakers et al., 2018). Data is presented as mean
(standard deviation) unless otherwise stated. Data was ana-
lyzed using JASP Version 0.9.0.1 (Netherlands) and using the
BayesFactor package in RStudio version 1.1.414 (https://
www.r-project.org/).
Results
Participants in experiment 1 and experiment 2
One-hundred five participants came into the laboratory for the
initial testing visit. Two participants could not be scheduled
Figure 1. Muscle thickness and echo intensity for Experiment 1 (n = 96) between narrow (5 cm) and wide cuffs (12 cm), separated between sex. (a) The absolute
change in muscle thickness. (b) The absolute change in echo intensity. (c) The change in muscle thickness when made relative (% change from baseline). (d) The %
change from baseline in echo intensity. Bayes factors (BF10) were used to provide evidence for (BF10 of ≤ 0.33) or against the null (BF10 of ≥ 3.0) hypothesis. The
median is the middle bar and represents the posterior density of the change under the alternative hypothesis and the upper and lower bars represent the 95%
credible interval of that posterior density.
within the three to ten-day period and were therefore
excluded, three decided against participation following the
initial visit, three did not arrive for their scheduled visit and
could not be contacted following their initial visit, and one
participant failed the Par-Q. Thus, 96 participants were
included in the final analysis for Experiment 1 [Men (n = 48):
22 (3) y; 177.0 (7.5) cm; 81.9 (14.9) kg, Women (n = 48): 21 (2) y;
163.0 (6.7) cm; 66.0 (14.2) kg]. The same sample was used for
Experiment 2. One participant could not be rescheduled for
the Experiment 2 visit, one participants data was excluded due
to tester error, three participants did not arrive for their prear-
ranged time and could not be rescheduled, three dropped out
voluntarily, and one participant got light headed during the
arterial occlusion pressure measurement. Thus, 87 participants
were included in the final analysis for Experiment 2 [Men
(n = 45): 22 (3) y; 177.0 (7.8) cm; 81.89 (15.3) kg, Women
(n = 42): 21 (2) y; 162.9 (6.3) cm; 66.6 (14.8) kg].
Experiment 1
Arterial occlusion pressure
The relative arterial occlusion pressure was the same by
design (i.e. 40% of resting arterial occlusion pressure) but
the absolute pressure applied differed by cuff size (BF10:
4.516e+21, error% 9.680e-28). The narrow cuff exercised
with a higher absolute pressure than the wide cuff
[60 mmHg vs. 49 mmHg; median δ (95% CI): 1.996 (1.666,
2.352)].
Acute muscle thickness
For acute changes in muscle thickness (Figure 1(a, c)), we
found evidence for the interaction model (BF10: 675,829.441,
error % 4.390 for interaction model compared to the main
effects model of BF10: 215,009.761, error % 1.934; 675,829.441/
215,009.761 = 3.143). Within men, there was evidence for the
 JOURNAL OF SPORTS SCIENCES 5

Table 1. Muscle thickness and echo intensity for Experiment 1 and 2 separated by sex.
Muscle thickness (cm) Echo intensity (AU)
Men Women Men Women
Experiment 1 (n = 96)
5 cm condition Pre 3.90 (0.45) 2.72 (0.25) 63.2 (7.4) 62.7 (8.8)
5 cm condition Post 4.50 (0.49) 3.15 (0.32) 64.8 (8.0) 64.9 (8.7)
Median δ (95% Credible Interval) 3.6 (2.8, 4.4) 2.73 (2.1, 3.3) 0.15 (−0.12, 0.42) 0.24 (−0.03, 0.52)
Bayes Factor (BF10) 1.210e +26 7.023e +20 0.293 0.710
12 cm condition Pre 3.87 (0.41) 2.75 (0.29) 61.4 (8.0) 63.0 (7.1)
12 cm condition Post 4.39 (0.44) 3.18 (0.32) 60.7 (7.0) 63.3 (8.1)
Median δ (95% Credible Interval) 3.98 (3.1, 4.8) 3.53 (2.78, 4.33) −0.08 (−0.36, 0.18) 0.04 (−0.23, 0.31)
Bayes Factor (BF10) 5.722e +27 3.126e +25 0.190 0.165
Experiment 2 (n = 87)
12/5 cm condition Pre 3.97 (0.46) 2.79(0.27) 67.5 (13.5) 74.8 (14.6)
12/5 cm condition Post 4.42 (0.49) 3.09 (0.32) 59.9 (11.5) 66.8 (10.3)
Median δ (95% Credible Interval) 3.0 (2.5, 3.5) 2.25 (1.78, 2.7) −0.87 (−1.22, −0.53) −0.80 (−1.1, −0.44)
Bayes Factor (BF10) 1.228 e + 21 1.104e+15 63,777.597 7545.553
12 cm condition Pre 3.90 (0.38) 2.77 (0.27) 67.6 (12.4) 71.5 (14.8)
12 cm condition Post 4.38 (0.43) 3.10 (0.33) 62.8 (9.3) 69.1 (9.9)
Median δ (95% Credible Interval) 4.19 (3.6, 4.8) 2.54 (2.05, 3.03) −0.52 (−0.83, −0.20) −0.25 (−0.55, 0.04)
Bayes Factor (BF10) 5.124 e + 26 7.081 e + 16 47.012 0.698
Experiment 1 compared a narrow cuff (5 cm) to a wide cuff (12 cm) with both inflated to 40% of each individual’s arterial occlusion pressure. Experiment 2 compared
a wide cuff (12 cm) inflated to 40% of the arterial occlusion pressure with a wide cuff inflated to 40% of the arterial occlusion pressure for a narrow cuff (12/5).
Bayes factors (BF10) were used to provide evidence for (BF10 of ≤ 0.33) or against the null (BF10 of ≥ 3.0) hypothesis. The median represents the posterior density of
the effect size under the alternative hypothesis and the 95% credible interval of that posterior density. Data is presented as mean (standard deviation) unless
otherwise stated.

alternative hypothesis with the narrow cuff resulting in greater of sex (BF10: 0.217, error % 4.721) and no evidence for or against
swelling than the wide cuff (BF10 = 61.71, error % = 3.535e −8). the null with the main effect of condition (BF10: 1.035, error %
In contrast, there was evidence to suggest that the changes 1.133).
for women were similar between conditions (BF10 = 0.158,
error % = 7.198e −6). When comparing changes within each
Repetitions
cuff, men swelled more than women with the narrow cuff
Comparisons between condition and sex were made within
(BF10 = 31,936, error % = 4.023e −8) and the wide cuff (BF10
each set (Table 2). Within the first set there was evidence
= 148.3, error % = 2.937e −6). Pre and post muscle thickness
against the interaction model (BF10: 6.703, error % 1.815 for
values are provided in Table 1 with all conditions showing
interaction model compared to the main effects model of BF10:
a change from baseline. When changes in muscle thickness
27.661, error % 3.987; 6.703/27.661 = 0.242). Although no evi-
were made relative (% change from baseline), there was no
dence for sex differences were present, there was an effect of
evidence of an interaction (BF10: 0.394, error % 2.968 for
condition with the narrow cuff resulting in more repetitions. For
interaction model compared to the main effects model of
set 2, there was no evidence of an interaction (BF10:
BF10: 0.467, error % 1.774; 0.394/0.467 = 0.845). There was
376,092.400, error % 2.876 for interaction model compared to
also no main effect of sex (BF10 = 0.426, error % = 0.850) or
condition (BF10 = 1.064, error % = 1.128) when using the
relative values. Table 2. Repetitions separated by sex and individual sets.
Repetitions
Echo intensity Set 1 Set 2 Set 3 Set 4
For absolute changes in echo intensity (Figure 1(b)), we found Experiment 1 (n = 96)
evidence against the interaction model (BF10: 0.048, error % 5 cm condition Men 33 (10) 11 (4) 9 (4) 8 (3)
5 cm condition Women 36 (10) 14 (5) 11 (6) 12 (7)
2.354 for interaction model compared to the main effects 12 cm condition Men 30 (10) 9 (3) 7 (2) 6 (2)
model of BF10: 0.219, error % 1.085; 0.048/0.219 = 0.217). 12 cm condition Women 32 (6) 11 (3) 9 (3) 9 (3)
Evidence was provided for the null with the main effect of Condition Effect (BF10) 62.131 24,780.143 335.951 11,382.773
Sex Effect (BF10) 0.437 12.492 9.827 93.3
sex, suggesting that echo intensity changed similarly between Experiment 2 (n = 87)
men and women (BF10: 0.236, error % 1.832). There was no 12/5 cm condition Men 29 (5) 9 (3) 7 (3) 6 (2)
evidence for or against the null with respect to condition (BF10: 12/5 cm condition Women 29 (7) 10 (3) 8 (3) 8 (4)
12 cm condition Men 30 (7) 9 (3) 7 (2) 7 (2)
0.951, error% 1.196). Pre and post echo intensity values are 12 cm condition Women 29 (9) 10 (4) 9 (5) 8 (5)
provided in Table 1 with no condition providing evidence for Condition Effect (BF10) 0.190 1.725 6.325 1.198
a change from baseline. When changes in echo intensity were Sex Effect (BF10) 0.355 0.756 0.784 2.903
made relative (% change from baseline; Figure 1(d)), there was Experiment 1 compared a narrow cuff (5 cm) to a wide cuff (12 cm) with both
inflated to 40% of each individual’s arterial occlusion pressure. Experiment 2
evidence provided against the interaction (BF10: 0.045, error % compared a wide cuff (12 cm) inflated to 40% of the arterial occlusion
2.597 for interaction model compared to the main effects pressure with a wide cuff inflated to 40% of the arterial occlusion pressure
model of BF10: 0.219, error % 2.030; 0.045/0.219 = 0.207). for a narrow cuff (12/5). Bayes factors (BF10) were used to provide evidence for
(BF10 of ≤ 0.33) or against the null (BF10 of ≥ 3.0) hypothesis. Data is
There was evidence for the null with respect to the main effect presented as mean (standard deviation) unless otherwise stated.
6 V. WONG ET AL.
the main effects model of BF10: 322,092.337, error % 1.454;
376,092.400/322,092.337 = 1.168) but there was a main effect
of sex and condition. Similar findings were observed for sets 3
(BF10: 680.137, error% 2.030 for the interaction model compared
to the main effects model of BF10: 3196.033, error% 1.780;
680.137/3196.033 = 0.212) and 4 (BF10: 346,302.518, error%
2.531 for the interaction model compared to the main effects
model of BF10: 1.084e +6, error% 3.014; 346,302.518/1.084e
+6 = 0.320) where no interaction was observed but there
were main effects of condition (5 cm > 12cm) and sex
(Women > Men).
Experiment 2
Arterial occlusion pressure
By design, the absolute pressures applied between conditions
were different (BF10: 1.989e +23, error% 4.320e −26) with the
pressure applied being higher in the 12/5 condition compared
to the 12 cm condition [60 mmHg vs. 49 mmHg; median δ
(95% CI): 2.306 (1.911, 2.697)].
Acute muscle thickness
For changes in acute muscle thickness (Figure 2(a, c)), there was
evidence against the interaction model (BF10: 608,146.823, error
% 4.997 for interaction model compared to the main effects
model of BF10: 2.429e +6, error % 1.929; 608,146.823/2.429e
+6 = 0.250). There was no evidence of a condition main effect
(BF10 = 0.763, error % = 1.536) but there was a main effect of
sex (BF10 = 2.993e +6, error % = 0.996) with men swelling more
than women. When changes in muscle thickness were made
relative (% change from baseline), there was evidence against
the interaction model (BF10: 0.073, error % 5.497 for interaction
model compared to the main effects model of BF10: 0.299, error
Figure 2. Muscle thickness and echo intensity for Experiment 2 (n = 87) between a wide cuff (12 cm) and a wide cuff inflated to a pressure meant for a narrow cuff
(12/5), separated between sex. (a) The absolute change in muscle thickness. (b) The absolute change in echo intensity. (c) The change in muscle thickness when
made relative (% change from baseline). (d) The % change from baseline in echo intensity. Bayes factors (BF10) were used to provide evidence for (BF10 of ≤ 0.33) or
against the null (BF10 of ≥ 3.0) hypothesis. The median is the middle bar and represents the posterior density of the change under the alternative hypothesis and the
upper and lower bars represent the 95% credible interval of that posterior density.
% 1.359; 0.073/0.299 = 0.246). There was no evidence for or
against the null with respect to the main effects of condition
(BF10 = 0.895, error % = 1.483) and sex (BF10 = 0.340, error
% = 1.075).
Echo intensity
For echo intensity (Figure 2(b, d)), there was no evidence for
the interaction model (BF10: 5.665, error % 4.222 for inter-
action model compared to the main effects model of BF10:
13.507, error % 2.708; 5.665/13.507 = 0.419). There was
a main effect of condition (BF10 = 52.556, error % = 2.235)
where the 12/5 cm condition resulted in a larger decrease in
echo intensity than the 12 cm condition. There was no main
effect of sex (BF10 = 0.238, error % = 1.175) Pre and post
echo intensity values are provided in Table 1. When echo
intensity was made relative (% change from baseline), there
was no evidence for the interaction model (BF10: 11.518,
error % 5.412 for interaction model compared to the main
effects model of BF10: 29.212, error % 2.860; 11.518/
29.212 = 0.394). There was a main effect of condition
(BF10 = 74.299, error % = 1.862) but not sex (BF10 = 0.375,
error % = 1.072).
Repetitions
Similar to Experiment 1, repetitions were analyzed sepa-
rately by sets (Table 2). There was no evidence for the
interaction model for set 1 [BF10 from interaction model
divided by BF10 of the main effects model], (= 0.356), 2
(= 0.229), 3 (= 0.347), or 4 (= 0.247) after removing the
influence of the main effects model for each of the sets.
There was a main effect of condition within set 3 with the
12 cm condition completing more repetitions (BF10: 6.325,
error % 2.465).

Discussion
The main findings from the current study are: (1) the absolute
change in muscle swelling was greater in men than women;
(2) the absolute change in swelling was greater for men with
a narrow cuff than a wide cuff; (3) there were no sex or cuff
differences when muscle swelling was expressed as
a percentage change; and (4) there were no changes in echo
intensity when comparing a narrow cuff to a wide cuff
(Experiment 1), but there was a decrease in echo intensity
with the wide cuff inflated to a higher pressure (Experiment 2).
The acute swelling response is one proposed mechanism to
explain the increase in muscle size when blood flow restriction
is combined with low load resistance exercise (Jessee,
Mattocks, et al., 2018a; Loenneke et al., 2012; Yasuda et al.,
2012). The idea being that blood flow restricted exercise can
induce large increases in intracellular metabolites leading to
a muscle cell swelling effect. This increase in muscle swelling
would be detected by an intrinsic volume sensor which would
result in the activation of anabolic pathways (Loenneke et al.,
2012; Low & Taylor, 1998). This hypothesis is commonly tested
by measuring acute changes in muscle size with (Kim,
Loenneke, et al., 2017) or without (Yasuda et al., 2012) an
estimate of plasma volume. Acute changes in muscle swelling
are consistently observed when exercising with a narrow cuff
(Farup et al., 2015; Kim, Loenneke, et al., 2017; Yasuda et al.,
2012), but it was unknown how the width of the cuff affected
this response. Our results indicate that muscle swelling occurs
following exercise with both cuff widths, but that men may
swell more at an absolute level using a narrow cuff than
a wide cuff. Together, this indicates that if there are attenua-
tions of muscle growth directly under the cuff as previously
suggested (Ellefsen et al., 2015; Kacin & Strazar, 2011), then the
cause is unlikely to be an inability of the muscle to acutely
swell. There was, however, a blunting of absolute swelling
within the men exercising with a wide cuff. This might suggest
that it is not an inability to swell but a blunting of that
swelling response which may impact adaptation. This requires
further study.
Recent recommendations for blood flow restriction suggest
that the pressure should be made relative to the cuff width
used and the size of the limb to which it is applied (Mattocks
et al., 2018). Both cuff width and limb size can be accounted
for by setting the pressure relative to the limbs resting arterial
occlusion pressure. Although multiple independent groups
now conduct research using relative pressures, there are still
studies implementing “pressures used previously” as rationale
for their chosen pressure (Christiansen, Murphy, Bangsbo,
Stathis, & Bishop, 2018; Gundermann et al., 2014; Kim, Lang,
et al., 2017). Within the last year, a study (Kim, Lang, et al.,
2017) applied a universal pressure to a 16 cm wide cuff and
cited Cook, Brown, Deruisseau, Kanaley, and Ploutz-Snyder
(2010) as justification for this pressure selection. The study
cited used a narrow cuff, which means the pressure applied
with the 16 cm cuff was likely much higher than intended.
Previous work has shown that as the relative pressure
increases, the amount of blood flow decreases (Mouser,
Laurentino, et al., 2017b), the cardiovascular response
increases (Jessee et al., 2017), and the exercise becomes
JOURNAL OF SPORTS SCIENCES 7
more discomforting (Jessee et al., 2017; Mattocks et al.,
2017). In contrast to these variables, our results suggest that
applying a higher than intended pressure did not affect the
muscle swelling response. This is consistent with previous data
in a narrow cuff that suggests that the swelling response is
similar, provided the exercise is taken to or near task failure
(Buckner et al., 2018; Dankel, Jessee, et al., 2017b; Loenneke
et al., 2017). Similar to Experiment 1, this suggests that the
swelling response from applying a pressure meant for
a narrow cuff to a wide cuff is unable to explain any of the
potential attenuations of muscle under the cuff when using
a wider cuff (Ellefsen et al., 2015; Kacin & Strazar, 2011).
Echo intensity is a measurement of pixel density quantified
from an ultrasound image. This measurement has been used
as an estimate of fatty infiltrate (Pillen et al., 2009), connective
tissue (Fukumoto et al., 2012), edema (Damas et al., 2016), and
glycogen (Nieman, Shanely, Zwetsloot, Meaney, & Farris,
2015). How echo intensity changes in response to an acute
bout of exercise has not been well studied (Medeiros,
Mantovani, & Lima, 2017; Nieman et al., 2015). We hypothe-
sized that echo intensity may be able to inform us as to the
location of the fluid shift following blood flow restricted exer-
cise. Notably, previous work suggests that muscle swelling is
accompanied with a decrease in plasma volume (Kim,
Loenneke, et al., 2017). This indicates that the fluid likely
shifted intracellularly, though it cannot be known for certain
that the fluid did not simply shift into the interstitium. Given
that echo intensity has been used as a surrogate of edema
before (Damas et al., 2016), we reasoned that it may offer
insight into the location of the fluid shift. Our results, however,
were inconsistent. When comparing a narrow cuff to a wide
cuff inflated to equal relative pressures, there were no differ-
ences or pre to post changes within men or women. When
comparing a wide cuff with a wide cuff inflated to a narrow
cuffs pressure, there was an indication of a pressure depen-
dent decrease (main effect of condition). However, in contrast
to Experiment 1, there were pre to post changes in echo
intensity within Experiment 2. Given that one of the conditions
was identical between the experiments, we are unable to
explain the discrepancy. Notably, these findings were
observed even when controlling for probe tilt which is
known to have a large influence on echo intensity (Dankel
et al., 2018). Based on these findings, we suggest great caution
in the interpretation of echo intensity.
The majority of recommendations for blood flow restric-
tion have been inferred primarily from research which
included only men (Counts et al., 2018). Women have been
underrepresented throughout the blood flow restriction lit-
erature and when they are included, the sample size is
insufficient to appropriately compare them to men (Counts
et al., 2018). This is an important point because there may
be physiologic differences between men and women, parti-
cularly when it comes to fatigue resistance. Previous data
suggests that women have better muscular endurance than
men with isometric trunk extension exercise (Clark, Manini,
Thé, Doldo, & Ploutz-Snyder, 2003). Another study found
that women required more repetitions to reach task failure
than men during low load blood flow restricted isotonic
knee extension exercise (Labarbera et al., 2013). Data from
8 V. WONG ET AL.
Experiment 1 extended those findings to upper body uni-
lateral elbow flexion with main effects being noted for cuff
width and sex. Exercising with a narrow cuff required more
repetitions to reach task failure. In addition, similar to other
studies, women required more repetitions to reach task fail-
ure than men (Labarbera et al., 2013). Although both cuffs
were inflated to the same relative pressure, the wide cuff
may have produced a more fatiguing environment within
the muscle. Whilst the blood flow reduction at rest is similar
between a narrow and a wide cuff (Mouser et al., 2017a), the
influence of exercise may alter this relationship. The effect of
cuff width, as opposed to absolute pressure, is supported by
the results of Experiment 2 (i.e. both conditions exercised
with same cuff width). In this study, repetitions were closer
together between conditions than when comparing
a narrow and a wide cuff. It should be mentioned that
while our analysis in Experiment 2 did not find evidence
for an effect of condition (outside of set 3) or sex, there was
also not evidence provided for the null. This is to be con-
sidered when examining the repetitions to task failure.
The influence of sex on muscle swelling and changes in
echo intensity was more consistent. The only evidence for an
interaction occurred with the absolute swelling response, with
men observing a greater change in swelling with the narrow
cuff compared to the wide cuff. Though there was evidence
that there was a difference in response, the difference
between cuffs was small and the meaningfulness of this dif-
ference is unknown. Of note, this difference disappeared when
looking at the relative changes (% change from baseline). No
sex differences were observed in echo intensity. Taken
together, this seems to suggest that the swelling response
occurs in both men and women and the relative fluid shift is
likely to be similar between sexes. Thus, if sex differences exist
in response to blood flow restriction training, it is unlikely due
to differences in the acute cell swelling response.
Limitations
The present study is not without limitation. Firstly, we are
inferring muscle cell swelling from ultrasound muscle thick-
ness measures. As such, we were not able to confirm if this
fluid is shifting into the muscle cells or just into the inter-
stitial space. We attempted to use a measurement of echo
intensity to help us better infer the location of this fluid
shift, but this measurement appeared to produce inconsis-
tent findings. Secondly, we did not control for the phase of
the menstrual cycle. This may be something to consider, but
each experiment was completed in a single visit and imple-
mented a within subject design. Any effect the menstrual
cycle had on one condition would have the same effect on
the condition completed on the other arm. The within sub-
ject design controls for the majority of differences, but it is
possible that the acute swelling response is different across
different phases of the menstrual cycle. If true, pooling the
responses of women within different phases could impact
the outcome. Although possible, we hypothesize that this is
unlikely.
Conclusions
Muscle swelling is a purported mechanism for the increase in
muscle size observed following long term participation in
blood flow restricted exercise. Our findings showed that mus-
cle swelling occurred following exercise for both narrow and
wide cuffs. Men swelled more using the narrow cuff compared
to the wide cuff, albeit, a small difference. As a relative change
from baseline, men and women swelled similarly. If the acute
swelling response is important for initiating long term adapta-
tion, then our results indicate that neither cuff width nor sex
will differentially impact the adaptation observed via this
mechanism. In addition, while applying a higher than
intended pressure may impact the cardiovascular response
and perceived discomfort, this is unlikely to alter the acute
swelling response. Changes in echo intensity were inconsis-
tent and the utility of this measurement may need to be
reconsidered.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
Buckner, S. L., Jessee, M. B., Dankel, S. J., Mattocks, K. T., Mouser, J. G.,
Bell, Z. W., . . . Loenneke, J. P. (2018). Acute skeletal muscle responses to
very low-load resistance exercise with and without the application of
blood flow restriction in the upper body. Clinical Physiology and
Functional Imaging. doi:10.1111/cpf.12557
Christiansen, D., Murphy, R. M., Bangsbo, J., Stathis, C. G., & Bishop, D. J.
(2018). Increased FXYD1 and PGC-1α mRNA after blood flow-restricted
running is related to fibre type-specific AMPK signalling and oxidative
stress in human muscle. Acta Physiologica (Oxford, England), 223(2),
e13045.
Clark, B. C., Manini, T. M., Thé, D. J., Doldo, N. A., & Ploutz-Snyder, L. L.
(2003). Gender differences in skeletal muscle fatigability are related to
contraction type and EMG spectral compression. Journal of Applied
Physiology, 94(6), 2263–2272.
Cook, S. B., Brown, K. A., Deruisseau, K., Kanaley, J. A., & Ploutz-Snyder, L. L.
(2010). Skeletal muscle adaptations following blood flow-restricted
training during 30 days of muscular unloading. Journal of Applied
Physiology (Bethesda, Md.: 1985), 109(2), 341–349.
Counts, B. R., Rossow, L. M., Mattocks, K. T., Mouser, J. G., Jessee, M. B.,
Buckner, S. L., . . . Loenneke, J. P. (2018). Let’s talk about sex: Where are
the young females in blood flow restriction research? Clinical Physiology
and Functional Imaging, 38(1), 1–3.
Damas, F., Phillips, S. M., Lixandrao, M. E., Vechin, F. C., Libardi, C. A., &
Roschel, H., ... Ugrinowitsch, C. (2016). Early resistance training-induced
increases in muscle cross-sectional area are concomitant with edema-
induced muscle swelling. European Journal of Applied Physiology, 116(1),
49–56.
Dankel, S. J., Abe, T., Bell, Z. W., Jessee, M. B., Buckner, S. L.,
Mattocks, K. T., . . . Loenneke, J. P. (2018). The impact of ultrasound
probe tilt on muscle thickness and echo-intensity: A cross-sectional
study. Journal of Clinical Densitometry. doi:10.1016/j.jocd.2018.10.003
Dankel, S. J., Jessee, M. B., Buckner, S. L., Mouser, J. G., Mattocks, K. T., &
Loenneke, J. P. (2017b). Are higher blood flow restriction pressures
more beneficial when lower loads are used?. Physiology International,
104(3), 247–257.
Dankel, S. J., Mattocks, K. T., Jessee, M. B., Buckner, S. L., Mouser, J. G., &
Loenneke, J. P. (2017a). Do metabolites that are produced during
resistance exercise enhance muscle hypertrophy?. European Journal of
Applied Physiology, 117(11), 2125–2135.

Ellefsen, S., Hammarström, D., Strand, T. A., Zacharoff, E., Whist, J. E.,
Rauk, I., . . . Rønnestad, B. R. (2015). Blood flow-restricted strength
training displays high functional and biological efficacy in women: A
within-subject comparison with high-load strength training. American
Journal of Physiology-Regulatory, Integrative and Comparative
Physiology, 309(7), R767–R779.
Farup, J., de Paoli, F., Bjerg, K., Riis, S., Ringgard, S., & Vissing, K. (2015).
Blood flow restricted and traditional resistance training performed to
fatigue produce equal muscle hypertrophy. Scandinavian Journal of
Medicine & Science in Sports, 25(6), 754–763.
Fukumoto, Y., Ikezoe, T., Yamada, Y., Tsukagoshi, R., Nakamura, M.,
Mori, N., . . . Ichihashi, N. (2012). Skeletal muscle quality assessed from
echo intensity is associated with muscle strength of middle-aged and
elderly persons. European Journal of Applied Physiology, 112(4),
1519–1525.
Gundermann, D. M., Walker, D. K., Reidy, P. T., Borack, M. S.,
Dickinson, J. M., Volpi, E., & Rasmussen, B. B. (2014). Activation of
mTORC1 signaling and protein synthesis in human muscle following
blood flow restriction exercise is inhibited by rapamycin. American
Journal of Physiology - Endocrinology and Metabolism, 306(10), E1198–
E1204.
Jenkins, N. D. M. (2016). Are resistance training-mediated decreases in
ultrasound echo intensity caused by changes in muscle composition,
or is there an alternative explanation? Ultrasound in Medicine & Biology,
42(12), 3050–3051.
Jessee, M. B., Buckner, S. L., Mouser, J. G., Mattocks, K. T., Dankel, S. J.,
Abe, T., . . . Loenneke, J. P. (2018b). Muscle adaptations to high-load
training and very low-load training with and without blood flow
restriction. Frontiers in Physiology, 9. doi:10.3389/fphys.2018.01448
Jessee, M. B., Dankel, S. J., Buckner, S. L., Mouser, J. G., Mattocks, K. T., &
Loenneke, J. P. (2017). The cardiovascular and perceptual response to
very low load blood flow restricted exercise. International Journal of
Sports Medicine, 38(08), 597–603.
Jessee, M. B., Mattocks, K. T., Buckner, S. L., Dankel, S. J., Mouser, J. G.,
Abe, T., & Loenneke, J. P. (2018a). Mechanisms of blood flow restriction:
The new testament. Techniques in Orthopaedics, 33(2), 72.
Jessee, M. B., Mattocks, K. T., Buckner, S. L., Mouser, J. G., Counts, B. R.,
Dankel, S. J., . . . Loenneke, J. P. (2018c). The acute muscular response to
blood flow-restricted exercise with very low relative pressure. Clinical
Physiology and Functional Imaging, 38(2), 304–311.
Kacin, A., & Strazar, K. (2011). Frequent low-load ischemic resistance
exercise to failure enhances muscle oxygen delivery and endurance
capacity. Scandinavian Journal of Medicine & Science in Sports, 21(6),
e231–e241.
Kim, D., Loenneke, J. P., Ye, X., Bemben, D. A., Beck, T. W., Larson, R. D., &
Bemben, M. G. (2017). Low-load resistance training with low relative
pressure produces muscular changes similar to high-load resistance
training. Muscle & Nerve, 56(6), E126–E133.
Kim, J., Lang, J. A., Pilania, N., & Franke, W. D. (2017). Effects of blood flow
restricted exercise training on muscular strength and blood flow in
older adults. Experimental Gerontology, 99, 127–132.
Labarbera, K. E., Murphy, B. G., Laroche, D. P., & Cook, S. B. (2013). Sex
differences in blood flow restricted isotonic knee extensions to fatigue.
The Journal of Sports Medicine and Physical Fitness, 53(4), 444–452.
Laurentino, G. C., Loenneke, J. P., Teixeira, E. L., Nakajima, E., Iared, W., &
Tricoli, V. (2016). The effect of cuff width on muscle adaptations after
blood flow restriction training. Medicine and Science in Sports and
Exercise, 48(5), 920–925.
Lixandrão, M. E., Ugrinowitsch, C., Laurentino, G., Libardi, C. A.,
Aihara, A. Y., Cardoso, F. N., . . . Roschel, H. (2015). Effects of exercise
intensity and occlusion pressure after 12 weeks of resistance training
JOURNAL OF SPORTS SCIENCES 9
with blood-flow restriction. European Journal of Applied Physiology;
Heidelberg, 115(12), 2471–2480.
Loenneke, J. P., Fahs, C. A., Rossow, L. M., Abe, T., & Bemben, M. G. (2012).
The anabolic benefits of venous blood flow restriction training may be
induced by muscle cell swelling. Medical Hypotheses, 78(1), 151–154.
Loenneke, J. P., Kim, D., Fahs, C. A., Thiebaud, R. S., Abe, T., Larson, R. D., . . .
Bemben, M. G. (2015). Effects of exercise with and without different
degrees of blood flow restriction on torque and muscle activation.
Muscle & Nerve, 51(5), 713–721.
Loenneke, J. P., Kim, D., Fahs, C. A., Thiebaud, R. S., Abe, T., Larson, R. D., . . .
Bemben, M. G. (2017). The influence of exercise load with and without
different levels of blood flow restriction on acute changes in muscle
thickness and lactate. Clinical Physiology and Functional Imaging, 37(6),
734–740.
Low, S. Y., & Taylor, P. M. (1998). Integrin and cytoskeletal involvement in
signalling cell volume changes to glutamine transport in rat skeletal
muscle. The Journal of Physiology, 512(Pt 2), 481–485.
Mattocks, K. T., Jessee, M. B., Counts, B. R., Buckner, S. L., Grant Mouser, J.,
Dankel, S. J., . . . Loenneke, J. P. (2017). The effects of upper body
exercise across different levels of blood flow restriction on arterial
occlusion pressure and perceptual responses. Physiology & Behavior,
171, 181–186.
Mattocks, K. T., Jessee, M. B., Mouser, J. G., Dankel, S. J., Buckner, S. L.,
Bell, Z. W., . . . Loenneke, J. P. (2018). The application of blood flow
restriction: Lessons from the laboratory. Current Sports Medicine Reports,
17(4), 129–134.
Medeiros, D. M., Mantovani, R. F., & Lima, C. S. (2017). Effects of
low-intensity pulsed ultrasound on muscle thickness and echo intensity
of the elbow flexors following exercise-induced muscle damage. Sport
Sciences for Health, 13(2), 365–371.
Motykie, G. D., Zebala, L. P., Caprini, J. A., Lee, C. E., Arcelus, J. I., Reyna, J. J.,
& Cohen, E. B. (2000). A guide to venous thromboembolism risk factor
assessment. Journal of Thrombosis and Thrombolysis, 9(3), 253–262.
Mouser, J. G., Dankel, S. J., Jessee, M. B., Mattocks, K. T., Buckner, S. L.,
Counts, B. R., & Loenneke, J. P. (2017a). A tale of three cuffs: The
hemodynamics of blood flow restriction. European Journal of Applied
Physiology, 117(7), 1493–1499.
Mouser, J. G., Laurentino, G. C., Dankel, S. J., Buckner, S. L., Jessee, M. B.,
Counts, B. R., . . . Loenneke, J. P. (2017b). Blood flow in humans follow-
ing low-load exercise with and without blood flow restriction. Applied
Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition
Et Metabolisme, 42(11), 1165–1171.
Mouser, J. G., Mattocks, K. T., Dankel, S. J., Buckner, S. L., Jessee, M. B.,
Bell, Z. W., . . . Loenneke, J. P. (2018). Very low load resistance exercise in
the upper body with and without blood flow restriction: Cardiovascular
outcomes. Applied Physiology, Nutrition, and Metabolism = Physiologie
Appliquee, Nutrition Et Metabolisme. doi:10.1139/apnm-2018-0325
Nieman, D. C., Shanely, R. A., Zwetsloot, K. A., Meaney, M. P., & Farris, G. E.
(2015). Ultrasonic assessment of exercise-induced change in skeletal
muscle glycogen content. BMC Sports Science, Medicine and
Rehabilitation, 7(1), 9.
Pillen, S., Tak, R. O., Zwarts, M. J., Lammens, M. M. Y., Verrijp, K. N.,
Arts, I. M. P., . . . Verrips, A. (2009). Skeletal muscle ultrasound:
Correlation between fibrous tissue and echo intensity. Ultrasound in
Medicine & Biology, 35(3), 443–446.
Wagenmakers, E.-J., Love, J., Marsman, M., Jamil, T., Ly, A., Verhagen, J., . . .
Morey, R. D. (2018). Bayesian inference for psychology. Part II: Example
applications with JASP. Psychonomic Bulletin & Review, 25(1), 58–76.
Yasuda, T., Loenneke, J. P., Thiebaud, R. S., & Abe, T. (2012). Effects of
blood flow restricted low-intensity concentric or eccentric training on
muscle size and strength. PloS one San Francisco, 7(12), e52843.