International Journal of Sports Physiology and Performance, 2023, 18, 1461-1465

https://doi.org/10.1123/ijspp.2023-0135
© 2023 Human Kinetics, Inc. INVITED COMMENTARY

An Updated Panorama of Blood-Flow-Restriction Methods

Brendan R. Scott,1,2 Olivier Girard,3 Nicholas Rolnick,4 James R. McKee,1 and Paul S.R. Goods1,2
1
Murdoch Applied Sports Science Laboratory, Discipline of Exercise Science, Murdoch University, Perth, WA, Australia; 2Center for Healthy Aging,
Murdoch University, Perth, WA, Australia; 3School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, WA, Australia;
4
The Human Performance Mechanic, CUNY Lehman College, New York, NY, USA

Background: Exercise with blood-flow restriction (BFR) is being increasingly used by practitioners working with athletic and
clinical populations alike. Most early research combined BFR with low-load resistance training and consistently reported
increased muscle size and strength without requiring the heavier loads that are traditionally used for unrestricted resistance
training. However, this field has evolved with several different active and passive BFR methods emerging in recent research.
Purpose: This commentary aims to synthesize the evolving BFR methods for cohorts ranging from healthy athletes to clinical
or load-compromised populations. In addition, real-world considerations for practitioners are highlighted, along with areas
requiring further research. Conclusions: The BFR literature now incorporates several active and passive methods, reflecting a
growing implementation of BFR in sport and allied health fields. In addition to low-load resistance training, BFR is being
combined with high-load resistance exercise, aerobic and anaerobic energy systems training of varying intensities, and sport-
specific activities. BFR is also being applied passively in the absence of physical activity during periods of muscle disuse or
rehabilitation or prior to exercise as a preconditioning or performance-enhancement technique. These various methods have been
reported to improve muscular development; cardiorespiratory fitness; functional capacities; tendon, bone, and vascular
adaptations; and physical and sport-specific performance and to reduce pain sensations. However, in emerging BFR fields,
many unanswered questions remain to refine best practice.

Keywords: KAATSU, vascular occlusion, resistance training, aerobic exercise, muscle

Since the late 1990s, numerous studies have demonstrated that needed). Additionally, we will highlight practical applications for
substantial improvements in muscle strength and size are possible BFR methods and areas requiring further research.
using low-load resistance training if combined with wearing limb
tourniquets or inflatable cuffs during exercise.1 While the precise
mechanisms are not known, these adaptations are likely facilitated Active BFR Methods: Resistance Training
by acute augmentation of metabolic stress, muscle fiber recruitment, Low-Load Resistance Training
and intramuscular signaling processes that result from restricting
blood flow to and from the exercising musculature.2 The consensus The most heavily researched and established application of active
is that blood flow should be partially restricted rather than fully BFR is in combination with low-load resistance training to improve
occluded when implemented during exercise,3 and so this technique muscular development. While heterogeneity exists in the protocols
is primarily referred to as “blood flow restriction” (BFR), regardless implemented, researchers generally agree that training with low
of whether it is applied passively or during exercise. loads (20%–40% 1-repetition maximum), moderate volumes (eg, 4
Considering the benefits for low-load BFR resistance training sets of 30/15/15/15 repetitions or sets to failure), and brief rest
(BFRRT), practitioners and scientists have implemented BFR periods (30–60 s), combined with BFR at 40% to 80% of the
combined with other exercise stimuli (eg, energy systems training pressure required to occlude arterial blood flow at rest (ie, the
or sports-specific activities), or even passively, to take advantage of arterial occlusion pressure), results in substantial muscular adapta-
the heightened physiological responses to BFR. The purpose of this tion.3 Increases in muscle size4 and strength5 following low-load
commentary is to synthesize these evolving BFR methods across BFRRT have previously been reported as comparable to traditional
cohorts ranging from healthy athletes to clinical and load-com- high-load resistance training, though more recent analyses suggest
promised populations (Figure 1). These different BFR methods that high-load training elicits greater muscular adaptations.6 Ben-
have been distinguished as “active” (ie, BFR combined with efits for muscles proximal to the cuff have also been reported, with
exercise training) or “passive” (ie, implementing BFR separate BFR during bench press increasing pectoralis major muscle
from exercise), and further categorized into methods which can be thickness over a 2-week training intervention compared with
considered as “established” (ie, have substantial research to support unrestricted exercise.7 The benefits of low-load BFRRT on muscu-
their use) or “developing” (ie, potential benefits, but more evidence lar development have been demonstrated in cohorts ranging from
healthy trained powerlifters8 to older people.9
Aside from improvements in muscle size and force-generating
Girard https://orcid.org/0000-0002-4797-182X
Rolnick https://orcid.org/0000-0003-0430-5015
capacity, low-load BFRRT has been shown to induce similar tendon
McKee https://orcid.org/0000-0002-5365-4927 hypertrophy to high-load unrestricted training.10 There is emerging
Goods https://orcid.org/0000-0003-2585-6852 evidence indicating that low-load BFR exercise can increase
Scott (Brendan. [email protected]) is corresponding author, https:// markers of bone formation,11 while incorporating BFR during
orcid.org/0000-0002-2484-4019 postsurgery rehabilitation training can attenuate bone loss.12
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1462 Scott et al

Figure 1 — Schematic overview of the BFR methods that have been developed and assessed in scientific literature. BFR indicates blood-flow
restriction; IPC, ischemic preconditioning; Mod, moderate; RIPC, remote IPC.

Vascular adaptations have also been reported following BFRRT.13 training, a recent systematic review has reported some potential
Interestingly, the effects of BFR on mRNA expression of hypoxia benefits.17 Adding BFR to high-load resistance exercise can
inducible factor-1α and vascular endothelial growth factor seem acutely increase lifting velocity and post-BFR performance
more potent when combined with resistance than for aerobic (ie, postactivation performance enhancement).17 However, further
exercise.13 Finally, a developing application of low-load BFR research is required in this area, with Tian et al17 reporting on only 3
exercise is in reducing sensitivity to pain, with growing evidence studies, one of which observed BFR to negatively impact on
suggesting that BFR exercise can increase pressure pain thresh- performance.18
olds.14 The cuff pressure and whether or not exercise is performed
to failure also impact the exercise-induced hypoalgesia.14
Active BFR Methods: Energy Systems
High-Load Resistance Training
Training
Traditionally, high-load (≥70% 1-repetition maximum) resistance Low-Intensity Aerobic Training
training is prescribed to athletes and healthy populations to increase Combining BFR with low-intensity aerobic training (BFRAT) at
muscle size and strength.15 Researchers have been interested in intensities <50% aerobic capacity or heart rate reserve3 has
whether adding BFR to high-load resistance training might augment emerged as an innovative training modality that may combine the
these training outcomes, as has been shown for low-load resistance benefits of aerobic and resistance training. There is reasonable
training, for over 15 years.16 However, results for this approach have evidence demonstrating that BFRAT can yield cardiovascular and
been equivocal, with a recent well-designed investigation of 49 muscular benefits in populations ranging from healthy young
healthy men finding no differences between BFR or control groups athletes to older adults.19 Improvements in functional capabilities
in muscle size or strength outcomes following an 8-week training have also been reported in older people.9 Other benefits may
program, despite an increase in metabolic stress with BFR.15 include acute improvements in executive function,20 as well as
While there is little evidence that muscle size or strength are significant local and systemic hypoalgesia effects.21 These benefits
further improved by incorporating BFR during high-load resistance make BFRAT an attractive option for various compromised
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 A Panorama of BFR Methods 1463

populations, including those who may not tolerate high-intensity exercise prescription adjustments (eg, exercise-to-rest ratios) so
exercises, traditional resistance training, or even BFRRT. that training loads are carefully managed, and movement quality
Although BFRAT is generally considered less perceptually and or technique is not sacrificed if important for sport-specific
hemodynamically demanding than BFRRT,22 observed muscle adaptations.
hypertrophy and strength changes are superior to work-matched
low-intensity aerobic training but inferior to BFRRT.19 This is
particularly beneficial for older adults, load-compromised popula- Passive BFR Methods
tions, or individuals recovering from injury, as it can facilitate During Rest or Immobilization
improvements in muscular strength, endurance, and functional
capacity without imposing excessive stress on joints or the cardio- Prolonged inactivity as a result of illness, injury, surgery, or aging
vascular system. often results in reduced muscle size and strength.31 While exercise
Despite the growing body of evidence supporting the benefits can often be prescribed to minimize atrophy, scenarios such as
of BFRAT as an established training method, more work is needed immobilization following surgery can make exercise difficult or
to optimize the protocols used in research and practice. Existing impossible. The use of passive BFR (BFRP) has been found to
literature on BFRAT is characterized by considerable heterogeneity reduce atrophy in elderly coma patients32 and provide a superior
in terms of exercise modalities, cuff pressure, and training dura- treatment to isometric training in healthy adults undergoing cast
tions, making it challenging to determine the most effective immobilization.33 However, it should be noted that Iversen et al34
approach for different populations and goals.19 However, as re- were not able to replicate these findings in physically active
searchers continue to investigate BFRAT using the personalized individuals following anterior cruciate ligament reconstruction.
pressures which are currently recommended,3 a better understand- Furthermore, a recent systematic review31 noted that while BFRP
ing of protocols needed to attain the desired benefits from BFRAT is potentially useful to mitigate atrophy during limb disuse, studies
will be achieved. in this area are at high risk of bias. Further research is warranted to
confirm the efficacy of BFRP for attenuating atrophy.
Moderate- and High-Intensity Energy Systems
Training Neuromuscular Stimulation
Recently, BFR has been examined during moderate- or high- Adding BFR to neuromuscular electrical stimulation (BFRNMES)
intensity interval training (BFRIT) as a developing method to has been investigated as an approach to facilitate muscular devel-
exacerbate the physiological stimulus for adaptation. Moderate- opment without voluntary contractions. Developing evidence sug-
to high-intensity running or cycling BFRIT has been shown to gests that BFRNMES protocols performed with high training
improve leg muscle size and strength,23 rate of force develop- frequencies (twice daily, 5 d/wk for 2 wk) can result in greater
ment,24 maximal aerobic capacity23 or its physiological determi- improvements in muscle strength and hypertrophy compared with
nants,25 and anaerobic performance,24 compared with unrestricted neuromuscular electrical stimulation alone.35 This is attributed to
exercise. Applying BFR in the period immediately following each BFR’s ability to enhance metabolic stress induced by neuromus-
effort during sprint interval training (4–7 × 30-s sprints separated cular electrical stimulation, stimulating muscle protein synthesis.
by 4.5-min rest) increases aerobic capacity compared with a non- The combination of BFR and neuromuscular electrical stimulation
BFR group.26 While 2 weeks of repeated sprint training (10-s may create a synergistic effect that enables muscle hypertrophy as a
sprints with 20-s recovery) can improve aerobic and anaerobic passive intervention. Although positive effects are not always
performance, completing this training with BFR did not further reported,36 this technique holds promise for attenuating muscle
improve these responses.27 Practitioners should consider that atrophy. It can be recommended for individuals experiencing
higher intensity BFR training may exacerbate fatigue, which could disuse with significant muscle weakness and atrophy, notably to
negatively impact training quality or exercise tolerance if appro- enhance muscle strength, muscle size, and functional capacity in
priate exercise prescription adjustments are not made. athletes recovering from orthopedic injuries (eg, knee or hip
replacement surgery, anterior cruciate ligament reconstruction)
and immobilized populations (eg, prolonged bed rest).37
Active BFR Methods: Sport Training
Ischemic Preconditioning
Performing sport-specific drills (eg, lunges in badminton) and
activities (eg, small-sided games in team sports) with BFR has Local (IPC) and remote ischemic preconditioning (RIPC) involves
recently gained popularity, yet most of our knowledge comes from a protocol of repeated vascular occlusion and reperfusion. While
soccer and futsal.28–30 Combining BFR with small-sided games is the application of IPC and RIPC is similar to the use of BFR during
an intervention to boost aerobic and anaerobic fitness, while rest or immobilization (aimed to reduce atrophy), the intended
simultaneously improving technical and tactical skills.28 In semi- outcomes are quite different. The use of IPC is primarily targeted at
professional soccer players, for instance, sport-specific training improving subsequent exercise performance in occluded muscle
with BFR to the legs improved lower body muscular endurance, groups, while RIPC is usually implemented remotely to reduce
change-of-direction ability, and aerobic and soccer-specific fit- subsequent ischemic injury. A 2016 meta-analysis concluded that
ness.30 Adding BFR to sport-specific training likely enhances while findings have proven equivocal, IPC results in small im-
muscle activation and hormonal responses without increasing provements to aerobic exercise performance, with unclear effects
training time.29 Therefore, this approach may become useful during on power and sprint performance, potentially confounded by
intense training periods in both uninjured (eg, preseason or training inconsistent methodologies.38 Performance enhancement is
camps) and load-compromised (eg, rehabilitation settings) athletes. thought to be driven not only by vascular responses to IPC, but
Potential drawbacks to this developing method include using faster also a range of neurophysiological, and psychophysiological
fatigue development and “unnatural” movement patterns, requiring factors.39
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1464 Scott et al

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