Effects of Blood Flow Restriction Exercise on Muscle Endurance and Aerobic Capacity in Different Populations: A Systematic Review and Meta-Analysis

doi:10.21203/rs.3.rs-2545926/v1

Download PDF

Research Article

Effects of Blood Flow Restriction Exercise on Muscle Endurance and Aerobic Capacity in Different Populations: A Systematic Review and Meta-Analysis

https://doi.org/10.21203/rs.3.rs-2545926/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

There is a lack of comprehensive understanding of the effect on aerobic capacity and muscle endurance by BFR’s application in different populations. SO the target was to elaborate the influence of BFR training on aerobic capacity and muscle endurance in different populations. A systematic review and meta-analysis were conducted. Literature was retrieved in PubMed, Web of Science, the Cochrane Library databases, Embase, CNKI (China National Knowledge Internet) and CBM (China Biology Medicine). 64 studies met the inclusion criteria, and 19 trials were included in the quantitative analysis. The main results showed that aerobic exercise combined with BFR (AE-BFR) and low-load resistance training with BFR (LBFR-RT) significantly improved athletes' aerobic capacity and muscle endurance, compared with aerobic exercise (AE) and low-load resistance training (LL-RT) (WMD = 2.47, p < 0.01; SMD = 1.15, p < 0.01). However, in the healthy, elderly and patients, no similar significant difference was found. In general, BFR training can significantly improve the muscle endurance and aerobic capacity of athletes. However, it remains to be seen whether the benefits of BFR are greater than non-BFR in the healthy and elderly, the impact of BFR on the patient needs to consider the pathophysiological characteristics of different diseases. The current evidence doesn’t support that anaerobic exercise (ANA-E) or high intensity interval training (HIIT) with BFR brings additional aerobic capacity gains. In addition, some new technological attempts deserve attention.

blood flow restriction

muscle endurance

aerobic capacity

different populations

Endurance is an important indicator of human health and athletic ability, which is the embodiment of physical fitness. Aerobic capacity and muscle endurance are common measures of endurance. There is no doubt that cardiopulmonary endurance is of great importance to health, to predict the occurrence and development of disease and the risk of death[1–3]. And insufficient muscle endurance can reduce performance in and adaptations to physiological challenges and increase risk of musculoskeletal pathology[4]. Endurance training can cause the body to adapt in many ways, such as the circulatory system, respiratory system, skeletal muscle and energy supply system. In the field of sports, endurance is an important index to measure the athletic level of athletes, and one of the key physical functions of athletes to improve in daily training[5]. Patients with sports injuries, in postoperative rehabilitation and elderly patients, due to long-term braking or disease restrictions, not only vulnerable to muscle atrophy and strength decline, but easily get lower endurance, which is obviously very harmful for patients' health and quality of life. Regular endurance training can make muscles, organs, heart and lung, blood, immune system and material metabolism regulation appear adaptive phenomenon to achieve endurance improvement. Therefore, it is undoubtedly necessary for all people to pay attention to and improve their endurance.

As we all know, moderate to high intensity resistance training and endurance training are the most common and also effective ways to enhance muscle and cardiopulmonary endurance. But many patients who are affected by poor physical conditions or diseases (severe cardiopulmonary dysfunction or early stage of fracture reconstruction, etc.) have difficulty in tolerating high intensity exercise (> 70% 1RM resistance exercise, > 85% VO2max endurance training, etc.). Therefore, blood flow restriction (BFR) training, which can improve body function with lower intensity exercise, is an option. BFR technology is used to compress the proximal limb by pneumatic or elastic cuff during traditional exercise to reduce the arteriovenous flow, which changes the physiological environment of limbs[6], so as to achieve greater strength and endurance growth. In recent years, BFR has received increasing attention in medical and athletic fields. Current studies held the view that BFR training has a significant advantage in promoting muscle mass and strength [7–11]. But researchers paid less attention to the effect of BFR on endurance, which is often their secondary research objective.

The acute physiological reaction of BFR and the long-term mechanism of muscle hypertrophy and strength enhancement have been extensively studied[6], but mechanism by which BFR improves endurance performance is not fully understood. BFR training has been shown to enhance muscle endurance by increasing muscle microvascular function and oxygenation, proliferation of type I fibers might also play a role[12–15]. One study showed that BFR training increases the percentage of maximal oxygen uptake (VO2max) sustained throughout exercise by increasing convective oxygen delivery to the legs and lowering thigh net lactate release[16]. Increased cell proliferation and capillarization contribute to improved endurance performance of local muscles[17, 18]. Further research has shown that the higher metabolic/cardiopulmonary adaptive response of endurance training-BFR seems to be associated with the activation of key genes that drive angiogenesis (vascular endothelial growth factor- VEGF and cytochrome oxidase subunit IV)[19, 20].

So far, some relevant studies have reviewed the effects of BFR on aerobic capacity[21–26], but there is still a lack of understanding of its application in different populations and the overall understanding of the effects of BFR on endurance. In particular, systematic evaluation on the growth of muscle endurance is rare. Therefore, by integrating a large number of research data, we tried our best to comprehensively explore the impact of BFR training on endurance in different populations, and based on the existing evidence, elaborated the objective influence of BFR training in these different populations. This could help us improve our understanding of this training model, or provide better evidence for further applications of BFR training in medicine and sports.

Our study was based on the Cochrane Handbook 5.3[27] and PRISMA checklist, and GRADEfprofile software was used to evaluate the quality of the research.

In this research field, VO2max and peak oxygen uptake (VO2peak) are commonly used to assess aerobic capacity. Therefore, a meta-analysis evaluated the aerobic capacity of BFR exercise. Considering its applicability to different groups, we defined ‘low intensity’ resistance training as ≤ 30% one-repetition maximum (1RM) and ‘high intensity’ as ≥ 70% 1RM.According to the American Heart Association(AHA),exercises below 70% VO2max are aerobic exercises, those above 85% VO2max are anaerobic exercises. Blood lactate concentration not exceeding 2mmol/L (considered the ‘first lactate threshold’) characterizes aerobic exercise; 4-6mmol/L (the ‘second lactate threshold’) indicates anaerobic exercise.

We classified the population according to its characteristics:

1.Healthy persons: adults who do not suffer from acute or chronic diseases that affect bodily function; 2. Athletes: an individual of young or adult age, amateur or professional, who is engaged in regular physical training and participates in official competitions[28]; 3. The elderly: those aged over 60 and in good health without serious diseases; 4. Patients: people suffering from various acute and chronic diseases that affect physical functions (such as heart failure, kidney failure, RA, ACL, etc.).

Search strategy and study selection

Current evidence was searched in the PubMed, Web of Science, the Cochrane Library, Embase, CNKI (China National Knowledge Infrastructure), and CBM (China Biology Medicine). All databases were searched from their establishment to 2022-12-04. The search hasn’t had restrictions on time, geography or language.

The search strategy combined the following keywords: "BFR", "blood flow-restricted", "vascular restriction", "blood flow strength training", "blood flow restriction", "ischaemia training", "KAATSU", "vascular occlusion training", "vascular occlusion", "BFR training", "occlusion training", "exercise", "training". Research information was exported from the database and stored in a citation manager. All duplicate studies were deleted before further process. Titles and abstracts of the retrieved articles were evaluated by two reviewers (Yulu Xiang, Lu Wang) to assess their eligibility for the meta-analysis. Differences are resolved by discussion and, if necessary, by third party adjudication, the third reviewer (Feng Xiong) will evaluate the article again. If the abstract lacks sufficient information to determine whether it meets the inclusion criteria, the reviewer will read the full text.

Inclusion and exclusion criteria

Study Design: only randomized controlled trials (RCT) were included.

Patients: there are no restrictions on the subjects.

Intervention: the study must have one type of exercise combined with BFR.

Controls: at least one control group was included. The blank control studies were acceptable.

Outcomes: must have included at least one objective indicator of muscle endurance or aerobic capacity.

Examples of objective indicators: number of repetitions, duration, volume of exercise, etc. (the ability to perform an exercise repeatedly); VO2max, VO2peak, six-minute walk test (6MWT), anaerobic threshold (AT) etc. (measures of aerobic capacity).

Exclusion criteria

Study Design: systematic reviews, narrative reviews, editorials, conference abstracts, letters, case reports were excluded. If the RCT design is uncertain and the author cannot be contacted, the study will be excluded.

Patients: nonhuman/cadaveric studies.

Intervention: only studying the acute response to BFR.

Controls: single-arm clinical trials were not included.

Outcomes: BFR treatment not relating to the endurance outcomes.

Data extraction

All articles were evaluated by two reviewers (JieFeng, Panyun Mu) independently, and then extracted data. Data to be extracted: (1) participant information (i.e., age, sex and weight), (2) Study information (i.e., experimental design scheme, training plan, exercise intensity, occlusal pressure, cuff type and intervention time), (3) outcome indicators: muscle endurance, aerobic capacity (i.e., VO2max, VO2peak, AT, ventilatory threshold (VT)). Finally, all articles were cross-checked to ensure accuracy. In case of disagreement, a third reviewer (Feng Xiong) cross-checked to ensure a consensus was reached.

Assessment of Risk Bias

The risk of bias was assessed with the Cochrane risk of bias tool[29]. We illustrated the potential biases of each study by making a table, graph and summary of the risk of bias.

The risk of bias for each study was independently assessed and cross checked by two researchers(Qiulin Deng, Lu Wang) using the methods recommended by the Cochrane Collaboration Handbook: (1) random sequence generation (2) allocation concealment (3) blind method (4) incomplete result data (5) selective result reporting (6) other biases. In these six areas, we made " low risk", "high risk" and "unclear risk" judgments to assess the risk of bias in each study.

Statistical analyses

Statistical analysis of the data was performed using RevMan (Review Manager Version 5.4, The Cochrane Collaboration, 2014) and study quality was assessed using GRADEfprofile software. Weighted mean difference (WMD) or standardized mean difference (SMD) was selected as the effect-size indices according to different characteristics of the data included in the study. When the measurement methods and metrics are unified among the studies, WMD was selected. Otherwise, SMD was selected. Simply put, SMD is the quotient of the difference between two means divided by the combined standard deviation, which eliminates the different effects of multiple research measurement units as well as the effects of multiple research absolute values. SMD were set at < 0.10: trivial effect, 0.10–0.34: small effect, 0.35–0.64: medium effect, 0.65–1.19: large effect, ≥ 1.20: very large effect[30]. Heterogeneity needs to be correctly and effectively detected before publications are merged, i.e., heterogeneity test (I²). When I² = 0, it indicates that there is no heterogeneity, and the higher the value of I², the greater the heterogeneity. The choice of model depends on the heterogeneity between studies. When there was no evidence of heterogeneity, the fixed-effect model was selected (I² < 50%, p > 0.05)[31].If not, a random-effect model was used. Alpha level was set to p < 0.05. The publication bias was judged by drawing a funnel plot and Eggers’ test. The funnel plot symmetric or p > 0.05 of Eggers’ test, no publication bias was found; otherwise, publication bias existed. To measure the stability of the results, we performed a sensitivity analysis. Thus, one study at a time was deleted and the effect of comparison between groups was examined.

Search Result

The database search yielded 5804 articles. After removing duplicates, 645 studies have been remained, which couldn’t be excluded according to title and abstract. Finally, 64 studies met our criteria previously set and were included in the final systematic review. 21 articles were excluded, caused not contain complete information or wasn’t RCT design. Finally, 19 studies with a total population of N = 429(muscle endurance:217,female 95;aerobic capacity: 212, female 9) were included in the quantitative analysis[32–50]. A detailed description of the selection process can be seen in Fig. 1.

It should be noted in particular that in quantitative analysis, WMD or SMD were selected as the effect-size indices according to different characteristics of the data. In studies involving muscle endurance, there are differences in the load and rate of the test for endurance, and also significant differences in the value of the results. Therefore, we chose SMD to eliminate the influence. Multiple comparisons in a study conducted quantitative analysis of muscle endurance of aerobic exercise with BFR(AE-BFR)[46], which did not have the above problems, so WMD was selected. We ensured the consistency of outcomes and metrics between studies involving aerobic capacity, so WMD was selected. However, the metrics of aerobic capacity of the high intensity interval training with BFR (HIIT-BFR) were inconsistent between studies, so SMD was selected as the effect-size indices.

Basic characteristics

There were 32 studies involving healthy people with 830 subjects, 227 females. In terms of training intensity, endurance training mainly focused on aerobic exercise, the intensity of resistance training ranged from 15%-90% 1RM, and the duration was mainly 6–8 weeks, only one study lasted for 2 weeks [51]. And the absolute values of pressure limiting blood flow was 80-360mmHg, and the AOP range was 40%-80%.

There were 13 articles involving athletes (n = 404, 114 females). The intensity of endurance training was mainly aerobic exercise, resistance training ranged from 20–80% 1RM, the duration span was large, from 1 week to 12 weeks. Absolute pressure values limiting blood flow were 120-230mmHg and the AOP ranged from 30–100%.

A total of 7 articles (150 people, 99 women) have studied the elderly. No study was about muscle endurance, and the exercise intensities of all researches were aerobic exercise. Some studies combined aerobic exercise with resistance training, the intensity of resistance training ranged from 20–80% 1RM. The duration was 6–16 weeks, absolute pressure values limiting blood flow were 50–200 mmHg and the AOP ranged from 50–80%.

12 articles focused on patients with different diseases (410 people, 142 females). The intensity of endurance training was mainly aerobic exercise, except for the HIIT for obese patients[52]. The intensity of resistance training was relatively low (25–50%1RM). Only the control group of one study underwent high-intensity training[53], but the specific intensity was not mentioned. The duration was mainly 3–12 weeks, but two studies were 6 months and 8 days respectively [54, 55]. Absolute pressure values limiting blood flow were 110-200mmHg, the AOP ranged from 30–60%.

Basic information of studies was detailed in Table 1,2. We counted adverse events in all the included literature, and only two researches recorded adverse events in two participants with BFR training (Supplementary Table 4). But no serious adverse event was recorded, and muscle soreness was the common discomfort. In addition to conventional techniques to restrict blood flow, Held et al. used elastic knee wraps (200*13cm) instead of pneumatic wraps[43]. Sundberg et al. used a large pressure chamber (21 m³), which reduced leg blood flow during exercise by about 20%[56].

Table 1

Basic characteristics of studies on muscle endurance
Study	Subjects	Group	N	Mal-e	Age(y)	Exercise program	Exercise intensity	Restriction pressure	Width of cuff	Duration	Outcome
Healthy people
Fahs et al. 2014	Middle-aged people	BFR	17(legs)	11	55 ± 7	knee extension(volitional fatigue)	30% 1RM	80% of AOP(no higher than 240 mmHg)	5 cm	6 weeks	no differences between the groups
Fahs et al. 2014	Middle-aged people	LL	17(legs)	11	55 ± 7	knee extension(volitional fatigue)	30% 1RM	80% of AOP(no higher than 240 mmHg)	5 cm	6 weeks	no differences between the groups
Neto et al. 2019	Active young people	CBFR	9	9	26.1 ± 5.0	bench press, front pull-down, triceps pulley and pulley biceps curl (Specify repetitions)	20% 1RM	80% of AOP	6 cm	6 weeks	there were no significant interactions between group x time
		IBFR	8	8	23.8 ± 5.6
		LL	8	8	22.2 ± 5.6
Jessee et al. 2018	healthy young participants	BFR low pressure	20 legs	20	21 ± 2(SE)	knee extensions(volitional fatigue)	15% 1RM	40% of AOP	10 cm	8 weeks	the increase in endurance was greater in the 15/80 condition compared to 15/0 and 70/0
		BFR high pressure	20 legs				15% 1RM	80% of AOP
		LL	20 legs				15% 1RM
		HL	20 legs				70% 1RM
Sousa et al. 2017	healthy young subjects	BFR	10	7	23.70 ± 4.90	unilateral knee extension (concentric failure)	20% 1RM	141.56 ± 12.19 and 129.83 ± 11.87 mm Hg (LL, HL + BFR)	18 cm	6 weeks	Improvements of all groups were Large
		LL	8	5	22.38 ± 2.61		20% 1RM
		HL	11	5	22.2 ± 5.6		80%1RM + 20% 1RM
		HL + BFR	8	5	24.75 ± 4.86		20% 1RM
Ramis et al. 2020	healthy and physically active males	BFR	15	15	23.53 ± 2.77	elbow flexors and knee extensors *(equal volume of training)	30% 1RM	Arm:20 mm Hg below SBP Thigh:40 mm Hg above the arm value	arm: 14 cm thigh: 16 cm	8 weeks	a rise when post-training in both groups. No differences between groups.
Ramis et al. 2020	healthy and physically active males	HL	13	13	24.46 ± 2.56		80% 1RM	Arm:20 mm Hg below SBP Thigh:40 mm Hg above the arm value	arm: 14 cm thigh: 16 cm	8 weeks
Zong-Yan et al. 2020	physically inactive adults	BFR	10	8	20.45 ± 0.21(SE)	intermittent static whole body vibration exercises	a static squat position at 100° knee flexion (26 Hz, 4 mm)	140-200mmHg	9 cm	8 weeks	the improvements were significantly higher in the BFR group p < 0.05
Zong-Yan et al. 2020	physically inactive adults	CON	10	8	21.09 ± 0.55	intermittent static whole body vibration exercises	a static squat position at 100° knee flexion (26 Hz, 4 mm)	140-200mmHg	9 cm	8 weeks
Pignanelli et al. 2020	healthy, young men	BFR	10 legs	10	24 (22, 27)	single-leg squats	30% 1-RM to task failure	60–70% of the lowest effective occlusive pressure	11 cm	6 weeks	An expected effect of time (p = 0.001) for the average power output of the groups
Pignanelli et al. 2020	healthy, young men	LL	10 legs	10	24 (22, 27)	single-leg squats	30% 1-RM to task failure	60–70% of the lowest effective occlusive pressure	11 cm	6 weeks
Buckner et al. 2020	Non-resistance trained men and women	BFR low pressure	20 arms	20	21.5 ± 2.4	unilateral elbow flexion exercise completed to volitional failure or 90 reps per set	15% 1RM	40% AOP	5 cm	8 weeks	a main effect of time [mean change = 7.9 (4.3, 11.6) repetitions, p < 0.001]
		BFR high pressure	20 arms				15% 1RM	80% AOP
		LL	20 arms				15% 1RM
		HL	20 arms				70% 1RM
Groennebaek et al. 2018	young, healthy, untrained men	BFR	12	12	23 (22; 24)	knee-extensions to a state of volitional fatigue	30% of 1RM	50% of AOP: 79 mmHg (74; 84 mmHg)	14 cm	6 weeks	no differences in strength-endurance capacity between BFR and HL
		HL	12	12	24 (23; 26)	4 sets of 12 knee-extension	70% of 1 RM: total volume of work 59.7% higher
		No-exercise	10	12	24 (21; 27)	No-exercise	70% of 1 RM: total volume of work 59.7% higher
Schwiete et al. 2021	Recreationally trained participants	BFR	10	10	22.8 ± 1.8	knee extension exercise (equal volume of training)	20% 1RM	80% of the individual arterial occlusion pressure	8cm	6 weeks	no any differences between-group be observed
Schwiete et al. 2021	Recreationally trained participants	resting -BFR	9	9	22.8 ± 1.8	knee extension exercise (equal volume of training)	20% 1RM	80% of the individual arterial occlusion pressure	8cm	6 weeks	no any differences between-group be observed
Zinner et al. 2017	not engaged regularly exercise individuals	VIBFR	12 legs	6	25 ± 2	squat exercises and lunges with each leg: VI (30 HZ, amplitude 1–2 mm)	70%– 80% of 1-RM (unequal volume of training)	the mean circumferential pressure: 35 ± 3 mmHg	strong compression tight	12 weeks	repetitions of muscular fatigue increased by 55% and 34%, respectively
Zinner et al. 2017	not engaged regularly exercise individuals	vibration (VI)	12 legs	6	25 ± 2		70%– 80% of 1-RM (unequal volume of training)	the mean circumferential pressure: 35 ± 3 mmHg	strong compression tight	12 weeks
Sieljacks et al. 2019	young, healthy, non-resistance‐trained men	BFR	14 legs	14	25 (23;27)	unilateral knee extensions	to volitional failure (25% of 1RM)	40% of seated AOP	14 cm	8 weeks	significant increases were observed within both legs with no differences between legs
Sieljacks et al. 2019	young, healthy, non-resistance‐trained men	75%BFR	14 legs	14	25 (23;27)	unilateral knee extensions	75% of the repetitions in F-BFRE	40% of seated AOP	14 cm	8 weeks
Lambert et al. 2021	healthy adults	BFR	16	13	27.6 ± 4.3	rotator cuff exercises	Initial resistance (20% isometric -max) (Unequal volume of exercise)	50% limb occlusion pressure	11.5cm	8weeks	the BFR group had significantly greater increases for cable internal rotation
Lambert et al. 2021	healthy adults	CON	16	10	25.8 ± 4.1	rotator cuff exercises		50% limb occlusion pressure	11.5cm	8weeks
Morley et al. 2021	adult participants	BFR low pressure	6	4	21.2 ± 1.6	single-leg knee extensions (unequal volume of exercise)	20%1RM	50% LOP	-	8 weeks	no significant differences between the groups
		BFR high pressure	7	4	23.7 ± 3.5		20%1RM	100% LOP
		HL	7	4	21.4 ± 1.5		70% 1RM	100% LOP
Davids et al. 2021	Recreation-ally active men and women	CBFR	16	9	23.8 ± 5.4	bilateral incline leg press, bilateral leg extension exercise	30% 1RM (equal volume of training)	50–60% AOP	10 cm	7 weeks	a time main effect (p, 0.001) existed for the total work
		IBFR	16	7	25.0 ± 58
		LL	10	4	24.0 ± 3.0
Torma et al. 2021	young men	BFR	11	11	24.1 ± 6.1	squats with ten repetitions + a warm-up session	70% of 1RM (equal volume of training)	220–230 mmHg	11cm	4 weeks	no significant differences were found between groups
Torma et al. 2021	young men	HL	11	11	23.9 ± 1.7	squats with ten repetitions + a warm-up session	70% of 1RM (equal volume of training)	220–230 mmHg	11cm	4 weeks	no significant differences were found between groups
Fekri-Kurabbaslou et al. 2022	young men	passive recovery (PRBFR)	10	10	22.38 ± 2.32	lat pulldown, chest press, shoulder press, hack squat, seated leg extension, and lying leg curl.	30% of 1RM (unequal volume of exercise)	60–80% of the calculated arterial blood occlusion	5 cm	6 weeks	The increase rate in ARBFR was more than PRBFR
Fekri-Kurabbaslou et al. 2022	young men	active recovery (ARBFR)	10	10	22.38 ± 1.92		30% of 1RM (unequal volume of exercise)	60–80% of the calculated arterial blood occlusion	5 cm	6 weeks	The increase rate in ARBFR was more than PRBFR
Early et al. 2020	healthy participants	BFR	11	3	24 ± 4	arm extension, arm curl, leg extension, leg curl, and heel raise	30% -50%1RM 60%-90% 1RM	250mmHg (upper body) or 350mmHg (lower body)	5.5 cm arms/ 7.0 cm legs	8 weeks	the greatest change in HL (91% change) and BFR (51% change).
		HL	10	5	23 ± 3
		No-exercise	10	3	23 ± 3	No exercise
1RM: one-repetition maximum LL: low-load resistance training HL: high-load resistance training; AOP: arterial occlusion pressure; LOP: limb occlusion pressure; CBFR: continuous-BFR IBFR: intermittent-BFR which releasing the pressure when rest
Athletes
Manimmanakorn et al. 2012	female netballers	BFR	10	0	20.2 ± 3.3	knee extensions; knee flexions	20% 1RM(volition-al fatigue)	160 to 230 mmHg	5 cm	5 weeks	BFR showed worthwhile gains in repetitions
		LL	10	0		knee extensions; knee flexions
		HT	10	0		Exercise + hypoxic air to generate an arterial blood oxygen saturation of 80%
Manimmanakorn et al. 2013	female netballers	BFR	10	0	20.2 ± 3.3	knee extensions; knee flexions	20% 1RM(volition-al fatigue)	160 to 230 mmHg	5 cm	5 weeks	CON showed a improvement, albeit considerably smaller than BFR
		LL	10	0		knee extensions; knee flexions
		HT	10	0		Exercise + hypoxic air to generate an arterial blood oxygen saturation of 80%
Bowman et al. 2019	recreational-level athletes	BFR	16 legs	10	27 ± 3.4	Lower limb training (Specify repetitions)	20% 1RM	80% of AOP	4 inchs	6 weeks	a greater increase of BFR in endurance
		No-BFR	16 legs
		LL	20 legs
Hosseini et al. 2022	Semiprofessional soccer players	BFR	10	19	15.9 ± 0.8	by approximately 45–65 minutes of soccer training	45% HRmax- Maximal effort	160 mmHg for the first week and increased by 10 mmHg each week	4 cm	6 weeks	the BFR group performed better than the CON group
Hosseini et al. 2022	Semiprofessional soccer players	CON	9	19	15.9 ± 0.8	by approximately 45–65 minutes of soccer training	45% HRmax- Maximal effort		4 cm	6 weeks	the BFR group performed better than the CON group
Bunevicius et al. 2019	middle-distance runners	BFR	12	-	22 ± 1	Foot flexor muscle force endurance training and calve strength training	20–80% of MVC	120 mmHg	4 cm	1 week	BFR: significant interaction between tests and muscle work capacity
Bunevicius et al. 2019	middle-distance runners	CON	12	-	23 ± 1		20–80% of MVC	120 mmHg	4 cm	1 week
Chen et al. 2022	endurance-trained male runners	BFR	10	10	21.6 ± 2.2	running on a treadmill	at 50% HRR (equal volume of training)	154 ± 6 mmHg(1.3times SBP)	14.2cm	8 weeks	BFR: knee extensor endurance was significantly higher
Chen et al. 2022	endurance-trained male runners	CON	10	10	21.6 ± 2.1	running on a treadmill	at 50% HRR (equal volume of training)	154 ± 6 mmHg(1.3times SBP)	14.2cm	8 weeks	BFR: knee extensor endurance was significantly higher
Patcharin et al. 2022	masters road cyclists	BFR	17	17	39.6 ± 3.8	trained on modified cycle ergometer	80% PPO + 60% PPO	30% AOP;at rest was set at 100% AOP	11 cm	12 weeks	No significant difference was observed among the three groups
		Low-CON	16	16	41.5 ± 4.5		65–70% PPO
		High-CON	17	17	41.7 ± 3.8		80% PPO
1RM: one-repetition maximum; MVC: maximal voluntary contraction LL: low-load resistance training; HL: high-load resistance training; AOP: arterial occlusion pressure; SBP: systolic blood pressure; PPO: peak power output; HRR: heart rate reserve
Patient
Zargi et al. 2018	undergoing arthroscopic ACL reconstruction	BFR	10	8	57 (54;61)	knee-extension exercise to volitional failure	the 40-repetition maximum	150 mmHg	14-cm	8 days	increase of BFR, decrease of CON
Zargi et al. 2018	undergoing arthroscopic ACL reconstruction	LL	10	8	44 (35;58)	knee-extension exercise to volitional failure	the 40-repetition maximum	20 mmHg	14-cm	8 days	increase of BFR, decrease of CON
Jønsson et al. 2020	women with rheumatoid arthritis	BFR	9	0	57 (54;61)	Low-intensity strength training in the LE, LP and LC machine(volitional fatigue)	LE and LC (30–40%), 1RM LP (50% 1RM)	50% of AOP	7 cm	4 weeks	no differences between the groups
Jønsson et al. 2020	women with rheumatoid arthritis	LL	8	0	44 (35;58)		LE and LC (30–40%), 1RM LP (50% 1RM)	50% of AOP	7 cm	4 weeks	no differences between the groups
Ampomah et al. 2019	adults with recurrent, nonspecific low back pain	BFR	14	5	28.4 ± 9.2	leg extension, plantar flexion, and elbow flexion exercises to task failure	25% of MVC	(142.9 ± 33.3 mmHg and 160.7 ± 34.2 mmHg for the arms and legs)	-	10weeks	no significant percent change in time to task failure of both groups
	adults with recurrent, nonspecific low back pain	LL	16	7	29.9 ± 9.9		25% of MVC		-	10weeks
Groennebaek et al. 2019	Patients with CHF (congestive heart failure)	BFR	12	10	66 ± 7	bilateral knee-extensions	30%1RM	50% of individually determined arterial occlusion pressures	14cm	6 weeks	BFR increased strength-endurance capacity compared with control and RIC
		RIC	12	12	62 ± 9	4 cycles of 5 min upper arm ischemia followed by 5 min of reperfusion
		No-exercise	12	12	63 ± 10
Ladlow et al. 2018	lower-limb injured men	BFR	14	14	33 ± 6	bilateral leg press, bilateral knee extensions	30% 1-RM	60% of this limb occlusion pressure	10cm	3 weeks	BFR: mean distance of 6-minute walk test significantly improved
Ladlow et al. 2018	lower-limb injured men	HL	14	14	33 ± 6	(deadlift, back squat, and lunges), per set were typically 6–8	high-load	60% of this limb occlusion pressure	10cm	3 weeks
Kacin et al. 2021	scheduled for ACL reconstruction	BFR	6	3	38 ± 6	knee extensions and flexions	40 RM to volitional failure	150 mmHg 20 mmHg	13.5 cm	3 weeks	significantly larger decrease in fatigue index knee extensors
		LL	6	3	38 ± 8
		No-exercise	6	3	38 ± 8
RM: repetition maximum LL: low-load resistance training HL: high-load resistance training; AOP: arterial occlusion pressure; ACL: anterior cruciate ligament RIC: remote ischemic conditioning

Table 2

Basic characteristics of studies on aerobic capacity
Study	Subjects	Group	N	male	Age(y)	Exercise program		Exercise intensity		Restriction pressure			Width of cuff		Duration	Outcome
Healthy people
Adalberto et al. 2019	healthy male volunteers	BFR	14	14	50.9 ± 3.7	Treadmill walking		6 km/h at a 5% grade		80 to 100 mmHg			18 cm		6 weeks	improvement in VO2max only for BFR
Adalberto et al. 2019	healthy male volunteers	CON	12	12	53.0 ± 3.1	Treadmill walking		6 km/h at a 5% grade		80 to 100 mmHg			18 cm		6 weeks	improvement in VO2max only for BFR
Paton et al. 2017	young, healthy, active participants	BFR	8	5	25 ± 7	Run on the treadmill		treadmill speed at 80% of each individual PRV (peak running velocity)		a perceived pressure of 7 out of 10			7.5 cm		4 weeks	reporting no significant differences between groups
Paton et al. 2017	young, healthy, active participants	CON	8	5		Run on the treadmill				a perceived pressure of 7 out of 10			7.5 cm		4 weeks	reporting no significant differences between groups
Keramidas et al. 2012	healthy, young untrained subjects	BFR	10	3	23.3 ± 3.9	trained on a Monark cycle ergometer		2 min work, 2min active recovery bouts at 90% of VO2maxPRESS (with cuff) and 50% of VO2max		90mmHg			-		6 weeks	VO2max, AT did not change after training in any of the two groups
Keramidas et al. 2012	healthy, young untrained subjects	CON	10	3	22.7 ± 4.7	trained on a Monark cycle ergometer				90mmHg			-		6 weeks
Da-wei et al. 2021	healthy young people	BFR	10	5	24.3 ± 3.8	limb linkage training		the loading of AT		250 mmHg			-		2 weeks	no significant differences between groups
	healthy young people	CON	10	3	24.1 ± 3.35	limb linkage training		the loading of AT		250 mmHg			-		2 weeks	no significant differences between groups
Beak et al. 2022	health male recreational runners	BFR	14	14	30.21 ± 4.93	running on a treadmill		40% VO2max		160–240 mmHg			-		8 weeks	The results indicated no significant time × group interaction effect on VO2max
Beak et al. 2022	health male recreational runners	CON	15	15	29.67 ± 3.06	running on a treadmill		40% VO2max		160–240 mmHg			-		8 weeks
Shalamzari et al. 2019	active collegiate women	IP-CE	8	0	22.3 ± 2.4	comprised of bouts of 2 min running on a treadmill with BFR interspersed by 1 min of recovery without BFR		60% V02max		160–240 mmHg			5 cm		4 weeks	there was no significant difference between groups
		CPP-IE	8	0	24.3 ± 4.0			60–85% V02max		160 mmHg
		CPC-IE	8	0	22.7 ± 2.6			60–85% V02max		240 mmHg
		IP-IE	8	0	21.8 ± 2.2			60–85% V02max		160–240 mmHg
Conceicao et al. 2019	healthy young men	BFR	10	10	21 ± 3		30 min continuous cycling	40% of VO2max		80% of the maximum tibial arterial pressure (95 ± 4.2 mmHg)			14cm		8 weeks	There was a significant group–time interaction for VO2max (p = 0.047) where CON and BFR groups, no changes were observed in the RT
		CON	10	10	24 ± 2		30 min of continuous cycling	70% of VO2max.
		RT	10	10	23 ± 3		maximum bilateral repetitions per set	70% of 1RM
Takashi Abe et al. 2010	young men	BFR	9	9	20–26		exercise on an electrically braked bicycle ergometer	40% of VO2max for 15 min		160mmHg, increased by 10 mmHg each week until 210 mmHg			-		8 weeks	VO2max increased in the BFR group (p < 0.05) but did not in the CON
Takashi Abe et al. 2010	young men	CON	10	10			exercise on an electrically braked bicycle ergometer	40% of VO2max for 45 min		160mmHg, increased by 10 mmHg each week until 210 mmHg
Chao et al. 2022	non-smoking, healthy and physically inactive students	BFR	13	4	19.85 ± 1.46		15-min training session	57–63% HRmax		200 mm Hg initially, then increased by 20 mm Hg for each week, until 340–360 mmHg			5-8cm		8 weeks	the VO2max significantly increased across all exercise groups and decreased in the No-exercise group
		HIIT	12	4	21.33 ± 2.54		4-min of running followed by 3-min of active resting	Run: 90–95%HRmax, resting at 64–76%HRmax
		CON	13	4	20.77 ± 1.96		45-min training	64–70% HRmax
		No-exercise	12	4	20.42 ± 1.93		-	-
Kim et al. 2016	healthy college-aged males	BFR	11	11	23.5 ± 3.4		20 minutes of cycling	30% HRR		160 mmHg and increased by 20 mmHg after the initial 3 weeks			5cm		6 weeks	VO2peak increased more in the CON group than other groups
		CON	10	10	21.6 ± 2.5			70% HRR
		No- exercise	10	10	22.1 ± 2.8			70% HRR
LU et al 2020	college students	L-BFR	9	9	22.44 ± 1.94		half squat	20% 1RM		120 mmHg			8 cm		12 weeks	significantly increased across BFR groups
		H-BFR	9	9	21.78 ± 2.05					180 mmHg
		CON	9	9	22.78 ± 2.22
Karabulut et al 2020	healthy recreationally active male	BFR	10	10	18–50		perform assigned specific exercise routine lasting 30 minutes on the treadmill	30–40% of their VO2 reserve		120–210 mmHg			5cm		6 weeks	a significance difference between BFR group and No-exercise group with BFR having a higher post-training VO2max
		L-CON	8	8				30–40% of their VO2 reserve
		H-CON	11	11				60–70% of their VO2 reserve (VO2R)
		No exercise	10	10
Sundberg et al. 1993	healthy males	BFR	10legs	10	28 range (23–33)		cycle at a constant pedalling rate of 60rpm	applying the highest tolerable work load that could be sustained at any given moment		50 mmHg above atmospheric pressure		a large pressure chamber (21 m³)			4 weeks	VO2peak was higher (P < 0.05) in the BFR leg than in the CON leg after training
Sundberg et al. 1993	healthy males	CON	10legs	10	28 range (23–33)		cycle at a constant pedalling rate of 60rpm			50 mmHg above atmospheric pressure		a large pressure chamber (21 m³)			4 weeks
Hori et al. 2022	healthy participants	BFR	9		22 ± 2 (SE)		cycle training program	45%VO2R-60% VO2R		160–230 mmHg		6 cm			8 weeks	VO2peak at Mid and Post between groups.
Hori et al. 2022	healthy participants	CON	9	8	21 ± 1		cycle training program	45%VO2R-60% VO2R		160–230 mmHg		6 cm			8 weeks	VO2peak at Mid and Post between groups.
VO2max: maximum oxygen uptake; VO2peak: peak oxygen uptake; AT: anaerobic threshold; 1RM: one-repetition maximum; RT: resistance training; HIIT: high intensity interval training; HRmax: maximum heart rate
Athletes
Park et al. 2010	college male basketball athletes	BFR	7	7	20.1 ± 1.2	Treadmill walking		4 km/h at 5% grade		160-220mmHg			11 cm		2 weeks	BFR: significantly increased VO2max, CON not
Park et al. 2010	college male basketball athletes	CON	5	5	20.8 ± 1.3	Treadmill walking		4 km/h at 5% grade		160-220mmHg			11 cm		2 weeks	BFR: significantly increased VO2max, CON not
Held et al. 2020	elite rowers	BFR	16	12	21.9 ± 3.2	Rowing cross and strength training		only boat- and indoor-rowing training + BFR		75% of elastic knee wraps maximum length			13 cm		5 weeks	VO2max increases of BFR were significant, CON did not
Held et al. 2020	elite rowers	CON	15	11	21.7 ± 3.7	Rowing cross and strength training		only boat- and indoor-rowing training + BFR		75% of elastic knee wraps maximum length			13 cm		5 weeks	VO2max increases of BFR were significant, CON did not
Amani-Shalamzari et al. 2020	male futsal players	BFR	6	6	23 ± 2	Futsal training		similar to high intensity aerobic exercises		110% SBP; increased by 10% each two sessions			13 cm		over three weeks	the overall between-group differences were deemed small and not significant
Amani-Shalamzari et al. 2020	male futsal players	CON	6	6	23 ± 2	Futsal training		similar to high intensity aerobic exercises		110% SBP; increased by 10% each two sessions			13 cm		over three weeks
Patcharin et al. 2022	masters road cyclists	BFR	17	17	39.6 ± 3.8	trained on modified cycle ergometer		80% PPO + 60% PPO		30% AOP;at rest was set at 100% AOP			11 cm		12 weeks	BFR group achieved a higher VO2max than the Low-CON group
		Low-CON	16	16	41.5 ± 4.5			65–70% PPO
		High-CON	17	17	41.7 ± 3.8			80% PPO
Yun-Tsung Chen et al. 2022	endurance-trained men	BFR	10	10	19–25	running training on a treadmill		50% HRR		153.8 ± 5.7 mm Hg (1.3 times SBP)			14.2cm		8 weeks	significant increases (p < 0.05) in VO2max for BFR group
Yun-Tsung Chen et al. 2022	endurance-trained men	CON	10	10		running training on a treadmill		50% HRR		153.8 ± 5.7 mm Hg (1.3 times SBP)			14.2cm		8 weeks	significant increases (p < 0.05) in VO2max for BFR group
Giovanna et al. 2022	endurance-trained athletes	BFR	10	10	23.9 ± 3.8	5 ×10-s maximal sprint followed by an active recovery		Anaerobic exercise		45% of femoral artery occlusion pressure			11 cm		2 weeks	increases of VO2peak in BFR group
		Interval-BFR	10	10	23.5 ± 3.6					during the rest-BFR
		CON	9	9	30.2 ± 9.9					during the rest-BFR
Manimmanakorn et al. 2012	female netballers	BFR	10	0	20.2 ± 3.3		knee extensions; knee flexions	20% 1RM		160 to 230 mmHg			5cm		5 weeks	Relative to control training, VO2max performance were substantially increased in the BFR group.
		LL	10	0			knee extensions; knee flexions
		HT	10	0			Exercise + hypoxic air to generate an arterial blood oxygen saturation of 80%
Mueller et al. 2014	endurance-trained males	BFR	11	11	26.7 ± 3.5		resistance exercise with WBV and vascular occlusion	70% 1RM		inflated to 200 mmHg		9cm			8 weeks	VO2peak were not altered in response to the two training interventions.
Mueller et al. 2014	endurance-trained males	CON	10	10	28.4 ± 4.8		resistance exercise	70% 1RM		inflated to 200 mmHg		9cm			8 weeks
VO2max: maximum oxygen uptake; VO2peak: peak oxygen uptake; SBP: systolic blood pressure; AOP: arterial occlusion pressure; PPO: peak power output; HRR: heart rate reserve; WBV: whole-body vibration
Elderly people
Ozaki et al. 2010	sedentary women	BFR	10	0	64 ± 3.16	treadmill walking		4.5 km/h and 1.6 degrees		140–200 mmHg			5 cm		10 weeks	There were significant (p < .05) time effects in both absolute and relative VO2peak
Ozaki et al. 2010	sedentary women	CON	8	0	68 ± 2.83	treadmill walking		4.4 km/h and 1.5 degrees		140–200 mmHg			5 cm		10 weeks
Clarkson et al. 2017	Sedentary older men and women	BFR	10	6	69 ± 6		10 min walking	4 km/h		60% LOP			10.5cm		6 weeks	There was a main effect for time (p < 0.01), and a group x time interaction (p < 0.001): six-minute walk test
Clarkson et al. 2017	Sedentary older men and women	CON	9	5	70 ± 7		10 min walking	4 km/h		60% LOP			10.5cm		6 weeks
Libardi et al. 2015	older individuals	BFR	10	༟	64 ± 4		walked or ran + the leg press exercise	60 to 85% VO2peak + 20–30% 1RM		50% of the necessary pressure for complete blood flow restriction (67 ± 8.0mmHg)			17.5cm		12 weeks	The CON and BFR groups showed significantly increased VO2peak from pre- to post-test
		CON	8		65 ± 3.7			60 to 85% VO2peak + 70–80% 1RM
		No-exercise	7		65 ± 4			60 to 85% VO2peak + 70–80% 1RM
Takashi et al. 2010	Older men and women	BFR	11	2	60 to 78		walked on a motor-driven treadmill	67 m/min for 20 minutes		160 mmHg, increased by 10 mmHg each week until 200 mmHg			-		6 weeks	There was no change in the estimated VO2peak for either group
Takashi et al. 2010	Older men and women	No-exercise	8	2			walked on a motor-driven treadmill	67 m/min for 20 minutes		160 mmHg, increased by 10 mmHg each week until 200 mmHg			-		6 weeks
Frota de Souza et al. 2018	healthy older adults	BFR-RT	11	5	63.7 ± 3.8		walked or ran for 40 min + the 45 ° leg press exercise	60 to 85% VO2peak + 20 to 30% 1RM		50% of the vascular occlusion pressure			18cm		12 weeks	There was an increase in VO2peak (p ≤ 0.04) in CT and BFR-CT groups
Frota de Souza et al. 2018	healthy older adults	RT	11	6			walked or ran for 40 min + the 45 ° leg press exercise	60 to 85% VO2peak + 70 to 80% 1RM		50% of the vascular occlusion pressure			18cm		12 weeks
Letieri et al. 2019	elderly women	BFR	11	0	69.40 ± 5.73		leg squat/ press/extension/flexion and stand plantar flexion	20–30% of 1RM		80% of the blood flow interruption pressure			13cm		16 weeks	The participants in the BFR group improved the performance
Letieri et al. 2019	elderly women	No- exercise	12	0	69.00 ± 6.39			20–30% of 1RM		80% of the blood flow interruption pressure			13cm		16 weeks	The participants in the BFR group improved the performance
Kargaran et al. 2021	elderly healthy women	BFR	8	0	62.9 ± 3.1		20-minute walk on a treadmill	45% HRR		50–155 mmHg and increased to reach 200 mmHg			5cm		8 weeks	observed a significant increase on 6-min walking in BFR group
		CON	8	0
		No exercise	8	0
LOP: limb occlusion pressure; VO2peak: peak oxygen uptake; 1RM: one-repetition maximum; RT: resistance training; HRR: heart rate reserve
Patient
Tanaka et al. 2018	post-infarction heart failure	BFR	15	15	58.5 ± 11.2		cycle ergometer	40–70% of the peak VO2peak	208.7 ± 7.4 mmHg		9 cm			6 months			significant differences in changes of VO2peak between the groups
Tanaka et al. 2018	post-infarction heart failure	CON	15	15	62.9 ± 11.0		cycle ergometer	40–70% of the peak VO2peak	208.7 ± 7.4 mmHg		9 cm			6 months
Lamberti et al. 2020	patients with MS	BFR	11	4	54 ± 11		interval walking (overground walking therapy)	8 out of 10 for the Borg’s rating of perceived exertion was reached; then, rest	30% of the systolic blood pressure'		6 cm			6 weeks			In the BFR group, the 6-minute walking distance improved significantly
Lamberti et al. 2020	patients with MS	CON	11	3	56 ± 10		interval walking (overground walking therapy)		30% of the systolic blood pressure'		6 cm			6 weeks
Groennebaek et al. 2019	Patients with congestive heart failure	BFR	12	10	66 ± 7		bilateral knee-extensions to the point of volitional fatigue	30%1RM	50% of individually determined arterial occlusion pressures		14cm			6 weeks			The walking distance improved by 35.9 m (CI, 12.7–59.1; p = 0.004) within BFR, greater than other groups.
		RIC	12	12	62 ± 9		4 cycles of 5 min upper arm ischemia followed by 5 min of reperfusion
		No-exercise	12	12	63 ± 10
Cardoso et al. 2020	Adult patients with chronic kidney disease on hemodialysis	BFR	19	9	49.4 ± 15.9		aerobic training, using a cycle ergometer	60–76% of maximal heart rate -	50% reduction in arterial blood flow		6cm			12 weeks			blood flow restriction group alone had an increase in walking distance
		CON	20	11	59.8 ± 16.1
		No-exercise	20	9	48.2 ± 13.6
Jørgensen et al. 2022	biopsy validated sIBM patients	BFR	8	6	68.6 ± 6.7		leg press, knee extension, knee flexion, calf raise, and ankle dorsiflexion	equal to ~ 25RM	110 mmHg		10cm			12 weeks			No pre-to-post intervention changes were observed in 2-min walk test
	biopsy validated sIBM patients	No exercise	11	9	69.8 ± 4.8			equal to ~ 25RM	110 mmHg		10cm			12 weeks
Franz et al. 2022	patients suffering from end-stage gonarthrosis	BFR	10	6	61.5 ± 8.8		the cycling exercise	Phase1/2:62.5 ± 17.5W/81.8 ± 15.2W	40% of the individual LOP		11.5 cm			6 weeks			a significant time effect only in BFR-group
		CON	10	7	64.2 ± 7.7			Phase1:69.0 ± 17.5) Phase2:76.5 ± 15.2W	20 mmHg
		No-exercise	10	7	66.3 ± 7.1			Phase1:69.0 ± 17.5) Phase2:76.5 ± 15.2W
Li et al. 2022	obese adults	BFR	17		22.1 ± 2.0		cycle on the ergometer, 3min rest, 3 min exerciser, four times	85% VO2max intensity	40% LOP		7 cm			12 weeks			No difference between BFR groups or BFR with HIIT
		I-BFR	16		21.6 ± 1.9
		HIIT	18		21.8 ± 1.8
		No-exercise	16		21.5 ± 1.5
VO2peak: peak oxygen uptake; MS: multiple sclerosis; 1RM: one-repetition maximum; sIBM: sporadic inclusion body myositis; LOP: limb occlusion pressure; HIIT: high intensity interval training

Risk of bias and research quality

The main finding of the bias risk assessment was that many studies did not clearly explain the implementation of randomization, allocation concealment, and blinding (Fig. 2、3). Although randomized controlled trials could be determined based on the full text information, the lack of detailed information about random methods might lead to the neglect of possible selection bias. BFR training was difficult to blind due to significant implementation differences, which could affect the quality of our evaluation. In blinding of participants and personnel assessment, due to the obvious difference between BFR training and traditional training, we believed that failure to implement blinding might impact the real effect of BFR training. Therefore, we rated studies with unclear blinding as ‘high risk. Only eleven studies were rated ‘low risk’, defined as those which explained a blinding method or utilized a non-inflatable cuff for the control groups. The quality of the research by GRADEfprofile software showed all quantitative analysis was “low quality” (Supplementary table 2). According to the scoring rules, all groups were "-1" in risk of bias and “-1” in imprecision. It was caused by the lack of detailed explanation of blind method, random method and allocation hiding in the included literature, and small sample size.

Quantitative Analysis

Healthy people

Muscle endurance

Low-load resistance training with BFR (LBFR-RT) VS Low-load resistance training (LL-RT) or High-load resistance training (HL-RT)

17 comparisons of 5 studies[32–34, 38, 40], which measured muscular endurance of healthy people following LBFR-RT, were included in this meta-analysis (Fig. 4). Quantitative analysis showed that heterogeneity was both low(LL-RT or HL-RT : I² = 20.8%/3.9%), therefore the fixed-effect model was adopted. The LBFR-RT improved muscle endurance, which was not statistically significant compared with LL-RT༈p > 0.05, SMD = 0.19, 95%CI -0.05—0.43), and the similar as LBFRT VS HL-RT༈p > 0.05, SMD = 0.19, 95%CI -0.12-0.51). No publication bias was found in funnel plot or Eggers’ test(Supplementary Fig. 2,3), sensitivity analysis showed that none of the articles had a significant impact on the results.

Aerobic capacity

Aerobic exercise with BFR (AE-BFR) VS aerobic exercise (AE)

4 studies with 6 comparisons investigated the effects of AE-BFR on aerobic capacity of healthy people (Fig. 5)[41, 45, 47, 50]. The results showed there was low heterogeneity (I² = 0.2%). AE-BFR was better than AE for healthy people on aerobic capacity, but was not statistically significant(p > 0.05, WMD = 1.02, 95%CI -0.73-2.77༉. No publication bias was found in funnel plot or Eggers’ test. Sensitivity analysis showed that Ferreira et al. [41], in which VO2max increased more in the AE-BFR, led to significant effect value changes(Supplementary Fig. 1). After removing the study, a bad effect with BFR was happened (WMD=-0.64, 95%CI -3.15-1.86). Heterogeneity analysis and comparison between groups were conducted in the study, accounting for gender, age, health, exercise intensity, pressure applied, and training.

Athletes

Muscle endurance

LBFR-RT VS LL-RT or AE-BFR VS AE

8 comparisons of 4 studies were incorporated in this meta-analysis of athletes on muscle endurance (Fig. 6,7)[35–37, 39]. The heterogeneity was both low for LBFR-RT and AE-BFR(I² = 34%/0%), the fixed-effect model was adopted. The LBFR-RT showed a large effect༈SMD = 1.15, p < 0.01, 95%CI 0.73–1.57༉, but the AE-BFR was the same with AE༈p > 0.05, WMD = 2.64, 95%CI -1.78-7.05༉. No publication bias was found in funnel plot or Eggers’ test, sensitivity analysis showed that muscle endurance results were not affected by any single study.

Aerobic capacity

AE-BFR VS AE or High intensity interval training with BFR(HIIT-BFR) VS High intensity interval training (HIIT)

6 studies including 11 comparisons measured the aerobic capacity of athletes after training with AE-BFR and HIIT-BFR (Fig. 8,9)[42–44, 46, 48, 49]. The heterogeneity results were 14.2%/0% (AE-BFR/HIIT-BFR). Quantitative analysis showed that AE-BFR had a significant effect for aerobic endurance(p < 0.01, WMD = 2.47, 95%CI 0.74–4.20). But HIIT-BFR didn’t show additional advantages༈p > 0.05, SMD = 0.12, 95%CI -0.26-0.50༉. Eggers’ test showed that there was a risk of publication bias in the HIIT-BFR part (p = 0.025) (Supplementary Fig. 2). Sensitivity analysis revealed that the aerobic capacity results were not affected by any study.

Qualitative analysis

Healthy people

Muscle endurance

•The effect of BFR on muscle endurance in healthy people have been inconsistent. Some studies have shown the improvement of muscle endurance after LBFR-RT[57, 58]. Pignanelli et al. had a greater sustained power output on endurance test, although the training volume of the BFR group was less than the control group[57]. In Davids’s study, only the value of endurance growth supported the BFR group (p > 0.05, intermittent BFR, 11.3 ± 15.6%; continuous BFR, 9.5 ± 12.2%; LL-RT, 3.6 ± 9.8%)[58]. Buckner and Sousa et al. showed no statistical difference in endurance growth between the BFR group and the non-BFR group[59, 60]. In the three comparisons of muscle endurance studied by Lambert et al.[61], only the cable internal rotation of rotator cuff exercises was significantly better than LL-RT (p < 0.01, ES = 0.89).

• Three studies have shown that the improvement of muscle endurance after LBFR-RT was similar to the HL-RT [59, 60, 62]. Only Morley et al. found that LBFR-RT improved muscle endurance much more (high pressure: 126%, 36.86 pre-to 83.57 post; low pressure: 87%, 46.33 pre-to 86.67 post) than HL-RT (14%, 41.0 pre to 46.86 post), although statistical results of the study showed no difference between groups[63].

• Some researchers studied some new application of BFR. Sieljacks et al. studied the effect of BFR training with different exercise volume on muscle endurance, and there was no difference on endurance growth after reducing the amount of exercise by 25% (p > 0.05)[64]. Cai and Zinner et al. found that the BFR could enhance the promoting effect of whole-body vibration (WBV) on endurance[65, 66]. Torma et al. applied BFR during the rest between exercise sets, but did not find that the intervention brought additional muscle endurance gains compared with HL-RT[67]. However, Schwiete et al. compared the intervention with conventional BFR, and found that had similar ability to improve muscle endurance[68]. Fekri-Kurabbaslou et al. tested whether there was a difference between active recovery and passive recovery during BFR training, and the result showed that active recovery had a positive effect on muscle endurance[69].

Aerobic capacity

The use of BFR has led to varying degrees of improvement in aerobic capacity in healthy people, but it is not clear whether this is differentiated from the benefits of non-BFR training. Conceicao, Karabulut and Lan et al. found that AE-BFR significantly improved aerobic endurance, but there was no significant difference with AE[19, 70, 71]. However, Sundberg, Takashi Abe et al showed that the effect of AE-BFR on improving aerobic capacity was much higher than AE[56, 72]. Amani-Shalamzari et al. tested the aerobic capacity after training with different exercise intensities (60%-85% VO2max) and restriction pressure (160–240 mmHg), and the VO2max of each group was improved to varying degrees[73]. Compared with anaerobic exercise (ANA-E), anaerobic exercise with BFR (ANA-BFR) did not bring significant changes in aerobic capacity[51, 74], and one study found that there was no change in VO2max after HIIT-BFR [75]. In LU 's study, participants' aerobic capacity was significantly improved after LBFR-RT for 12 weeks[76].

Athletes

Muscle endurance

Overall, BFR training has a significant effect on muscle endurance growth of athletes, except the combination of HIIT and BFR did not significantly improve the muscle endurance after training [48]. Manimmanakorn’s two articles showed that LBFR-RT significantly improved the performance of muscle endurance compared with LL-RT[35, 36]. Bunevicius et al. performed a short-term resistance training (20–80% maximum voluntary contraction-MVC), and muscle endurance improved slightly in the BFR group, but decreased in the control group[77]. Hosseini et al. introduced BFR into the routine training of football players, and the muscle endurance performance with BFR intervention was significantly better than the control group(p < 0.05)[78].

Aerobic capacity

Manimmanakorn et al. measured VO2max after LBFR-RT for 5 weeks, and the result showed that the improvement brought by LBFR-RT was significantly higher than by LL-RT[36]. Mueller et al. tried to incorporate BFR into a new training program (VBW + HL-RT), but did not result in improvement of aerobic capacity[79].

Old people

Aerobic capacity

Most researches have indicated that that the use of BFR safely improves aerobic capacity in older adults, but didn’t show a definite advantage. Libardi and Frota et al. instructed participants to perform AE + RT, LL-RT in the BFR training group, and HL-RT in the control group[80, 81]. After 12 weeks of intervention, the VO2peak of each group increased by about 10%. Hayao Ozaki showed that walk training with BFR improved the VO2peak level of the elderly, although there was no difference between groups[82]. Some studies used 6MWT to estimate the aerobic capacity roughly, and after several weeks of walk training with BFR, the 6MWT distance increased significantly [83, 84]. Letieri et al. performed the LBFR-RT, and the 6MWT distance also improved than before (p < 0.01)[85]. However, Abe et al. showed that walk training with BFR had no beneficial effect on VO2peak in the elderly (change, -2.8%, -2.2%)[86].

Patients

Muscle endurance

Although different diseases were involved, the overall result showed that BFR training safely improved patients' muscle endurance, and no serious adverse events associated with BFR happened in any studies. Patients with anterior cruciate ligament tears who received short-term LBFR-RT significantly improved muscle endurance compared with LL-RT (p < 0.05)[55, 87]. After 4 weeks of LBFR-RT, patients with rheumatoid arthritis achieved significant improvements in muscle endurance similarly to LL-RT [88]. Patients with congestive heart failure (CHF) have safely and effectively improved muscle endurance through LBFR-RT (increased by 4.6 repetitions, 95%CI, 0.3–9.0, p = 0.04)[89]. Ladlow et al. showed that muscle endurance was significantly improved after LBFR-RT in lower-limb injured adults[53]. But for patients with recurrent, nonspecific low back pain, the improvement of muscle endurance after LBFR-RT was not obvious, and not long-lasting [90].

Aerobic capacity

Most studies have demonstrated the benefit of BFR for the population with disease impairment, especially the significant effect of AE-BFR on increasing aerobic capacity. There were patients with post-infarction heart failure, chronic kidney disease on hemodialysis, or end-stage gonarthrosis participated underwent either AE or AE-BFR, and the results showed that AE-BFR achieved greater aerobic capacity improvement than AE[54, 91, 92]. Patients with multiple sclerosis (MS) and severe gait disabilities showed improvement in aerobic capacity after AE-BFR, but no difference with AE[93]. Patients with congestive heart failure (CHF) improved aerobic capacity by LBFR-RT (p < 0.05)[89]. However, patients with sporadic inclusion body myositis (sIBM) performed LBFR-RT, the distance of 2-minute walk test did not increase [94]. Li et al. found that in obese people, HIIT + BFR and HIIT showed the similar trend of improving aerobic capacity, the aerobic capacity of both groups was significantly improved after training[52].

This is the first study to evaluate changes in muscle endurance and aerobic capacity after BFR training in different populations. Overall, the safety of exercise with BFR is high. The use of BFR has shown significant benefits in both aerobic capacity and muscular endurance of athletes. However, it is unclear whether the benefit of BFR over non-BFR training on muscle endurance and aerobic capacity is greater in the healthy, elderly, and patients.

In the statistical analysis, for the athletes in the improvement of muscle endurance and aerobic capacity, resistance training and aerobic exercise with BFR all showed the existence of the significant advantage. But the significant advantage was not found in the healthy or patients. We tried to find the reasons for the differences between the populations, and limited the studies to AE-BFR VS AE for aerobic capacity and LBFR-RT VS LL-RT for muscle endurance, so as to reduce unnecessary interference. Finally, we conducted a comparison within the above two types of training to find out whether there were significant differences between populations in terms of exercise intensity, volume of exercise, restriction pressure and duration, etc. After statistics (Supplementary table 5,6), we found that in the aerobic capacity, the athletes performed short-duration and multi-frequency training mode, which was not common in other populations. However, no other notable differences were found, of course, the complexity and diversity of information from studies may also prevent us from finding a regular pattern.

In studies related to the elderly, all have focused on the improvement of aerobic endurance, perhaps because it was closely related to health level and risk of death[1–3], the results of most studies showed that BFR was beneficial to the elderly. In the patients, there were a variety of diseases involved, from cardiopulmonary diseases to skeletal muscle diseases, and even autoimmune diseases. The intensity of training and the pressure to restrict blood flow were mostly lower than other populations. Although many studies for patients supported that BFR can promote endurance, but we think when using or recommending it, it is very necessary to refer to the corresponding disease research, consider disease physiology, pathological differences and exercise risks. Such as sIBM and MS, the damage of those disease to muscle, nerve makes its exercise physiological reaction is different from the general population, may be different response to BFR[95, 96]. In the included studies, none of the elderly and patients had serious adverse events, and the use of BFR didn’t worsen the disease, which is consistent with the consensus of the current study[7, 97–100]. Although the use of BFR will aggravate the reaction of muscles and blood vessels[101–103], the BFR is a safe and reliable training technique under the premise of scientific and reasonable use.

In the statistical analysis, the effect of BFR on muscle endurance was confused, and the results between studies were contradictory. We tried to analyze the reasons for this situation. We found that some studies did not consider the greater discomfort associated with BFR training, and BFR-RT was more quickly to reach volitional fatigue under the same load [32, 34, 104–106]. This resulted in a lower number of exercise or repetitions in the BFR group than in the non-BFR group, ultimately might have an impact on evaluating the true effect of BFR on endurance.

Therefore, we compared studies using LBFR-RT to enhance muscle endurance. There were 13 studies and 30 comparisons, of which 5 studies and 10 comparisons varied significantly about repetitions or volume of exercise between the BFR training group and the control group, accounting for 38% and 33% of the total (Supplementary table 6). This showed the presence of such additional distractions in a considerable proportion of the studies, making it difficult to accurately evaluate the effect of BFR on muscle endurance. However, Sieljacks et al. found that the difference in the volume of exercise and repetitions in BFR training (100% repetitions and volume VS 75% repetitions and volume) did not cause the difference in muscle endurance[64], and Sieljacks and Bjornsen et al. found the similar result in muscle strength[64, 107]. Sieljacks et al. speculated that there might be a threshold of fatigue in BFR training, beyond which using a more fatigued protocol would not yield additional muscle adaptation. This may suggest the existence of BFR bottlenecks and a mechanism of action different from conventional training. At the same time, this study also provided a possibility of BFR application: less RPE, non-exhaustion BFR program with less delayed onset muscle soreness (DOMS) to improve exercise tolerance while maintaining endurance improvement. However, what should be clarified first is whether the BFR training with different repetitions and volume of exercise, the exhaustion and non-exhaustion BFR training with equal volume of exercise can bring about differences in endurance changes.

Among these included studies, we had some interesting findings. In some studies, the exercise intensity used in AE-BFR was significantly lower than that in AE, Kim and Migue et al. founded that improvements of VO2peak by AE-BFR were lower than AE without difference between groups, and the exercise intensity was 30%/70%HRR and 40%/70% VO2max[19, 47]. Low-intensity AE-BFR made a greater absolute increase in aerobic capacity than the high-intensity AE group in the studies by Lan and Karabulut[70, 71], no difference was found between groups. Overall, the current study showed that low-intensity AE-BFR can improve aerobic capacity, similarly with the high-intensity AE.

Athletes and sports enthusiasts often improve their aerobic capacity through short-time and high-intensity anaerobic exercise. And XU and Paton et al. didn’t find the difference between ANA-BFR and ANA-E on aerobic capacity[51, 74]. HIIT as a training mode that combines aerobic exercise with anaerobic exercise, can induce rapid muscular and cardiovascular adaptation[108, 109]. Some researchers applied BFR to HIIT. Li et al. found the aerobic capacity of HIIT-BFR was significantly improved[52], but not different with HIIT, which was consistent with the result of our quantitative analysis (p = 0.56). One study found that after HIIT, the VO2max of both the BFR group and CON group did not change[75]. Li and Giovanna et al. also compared BFR during exercise (E-BFR) with BFR during active recovery (R-BFR), and they had no difference in the increase of aerobic endurance[49, 52]. Thus, the current study has not found that the BFR brings additional aerobic capacity improvement to HIIT.

Several researches have studied the effects of resistance training on aerobic capacity and the effects of aerobic exercise on muscle endurance. A portion of these studies confirmed that LBFR-RT significantly elevated the aerobic endurance[76, 85]. Some studies measured muscle endurance and aerobic capacity together, and showed that both aerobic capacity and muscle endurance of LBFR-RT significantly increased[36, 89]. In the quantitative analysis of only one study, AE-BFR improved muscle endurance similarly as AE (WMD = 2.64,95%Cl, -1.78-7.05), the AE-BFR group only showed a significant advantage in the isokinetic knee extensor endurance. Recent studies showed that BFR-RT could promote the proliferation of type I fibers[12], and resistance training promote the expansion of the microvascular network in skeletal muscle[110]. Local hypoxia condition induced by AE-BFR induced an angiogenic reaction through the activation of VEGF, which is the core process of muscle endurance and VO2max increase induced by exercise[17, 19]. These studies demonstrated the possibility that an exercise mode (RT / AE) combined with BFR can effectively promote both aerobic capacity and muscle endurance, which could simplify the training mode and increase exercise gains. But no studies have been conducted to confirm that the improvement of aerobic capacity or muscle endurance by LBFR-RT is similar with AE-BFR.

BFR can reduce the exercise tolerance of participants because of higher perceptions of pain and effort. Some attempts of current studies made it possible to reduce this adverse effect of BFR. Some studies hoped to reduce the discomfort through releasing the cuff pressure when the rest between exercises. Neto and Davids et al. compared the intermittent LBFR-RT with continuous LBFR-RT, with no difference in enhancing muscle endurance[33, 58]. Neto et al. thought that BFR + RT could promote muscle endurance in some populations regardless of the restriction form (continuous or intermittent). And releasing the cuff pressure during rest also did not seem to hinder the acute physiological reaction of BFR-RT[111]. But the effect of the intermittent-BFR reducing discomfort of exercise didn’t seem to be significant, Davids et al. didn’t find a higher pain score during exercise with continuous-BFR than intermittent-BFR. And a meta-analysis showed that intermittent-BFR improved exercise tolerance (SMD = -0.42), but the statistical analysis showed no difference (95% CI-0.87 to 0.03, p = 0.07, I² = 0%)[112]. Torma and Schwiete et al studied the use of BFR during the rest of exercise (rest-BFR), and found that it could significantly increase muscle endurance[67, 68]. Schwiete et al. found that rest-BFR had similar effects to routine BFR on muscle endurance, and also found that the rest-BFR group caused significantly less perceptions of pain and effort than the routine BFR group by the same volume of exercise (p < 0.05). In another study by Torma[113], HL-RT combined with rest-BFR increased the mRNA of proteins that regulate angiogenesis, mitochondrial biogenesis, and muscle hypertrophy and repair. A study investigating the acute physiological reaction of rest-BFR also confirmed that rest-BFR with less ischemic persistent period and discomfort could achieve effective metabolic stress for muscle adaptation in moderate load RT (40% 1 RM)[114]. Thus, it seems that rest-BFR can reduce the adverse effects of BFR meanwhile maintaining improvement on muscle endurance.

Limitations

The main problem with this systematic evaluation was the diversity of data in the literature. Among the included studies, training modality, training duration, selected cuff width, occlusion pressure, measures of outcome indicators and measurement site differ to varying degrees. There is no general consensus on the current BFR training mode, which is objectively existing and unavoidable. In the comparative analysis, only studies with similar outcome indicators were compared. However, the difference of objective data may affect the quality of our system evaluation. Secondly, some of the included literatures failed to double blind or did not mention relevant information, which was mainly due to the significant difference between BFR training and non-BFR training, making it difficult to double blind researchers and experimental subjects in practical work. However, this can be avoided to some extent. For example, participants in different experimental groups are separated for training and measurement, different professionals are selected to guide the training and measure the outcome indicators, and the specified training program is strictly implemented. Non-BFR participants can tie cuff without inflating, or be given extremely low pressure. In addition, some of the included researches didn’t give detailed descriptions of random sequence generation and allocation concealment. We attempted to find registration information and contact the authors for more detailed information, but only a few authors responded to our request [37, 38, 43, 44, 52]. The total sample size of the quantitative analysis we included was 429 with 19 articles, but it was scattered in various groups and the sample size was not sufficient. Considering those limitations, our results should be used more carefully in recommendation.

Based on current data, the results need to be interpreted cautiously. BFR training has great safety under the premise of selecting personalized BFR schemes for different populations. BFR training can significantly improve the muscle endurance and aerobic capacity of athletes. However, it remains to be seen whether the benefits of BFR on muscle endurance and aerobic capacity are greater than non-BFR in the healthy and elderly, and the conclusions between studies are difficult to be consistent. And, the impact of BFR on the patient needs to consider the pathophysiological characteristics of different diseases. In addition, we have some interesting findings. The current evidence doesn’t support that ANA-E or HIIT with BFR brings additional aerobic capacity gains. We believe that some new applications of BFR technology warrant further investigation to reduce the adverse effects and risks of BFR (discomfort, acute muscle/vascular reactions) and improve exercise tolerance: one exercise pattern (RT/AE) combined with BFR which has the potential to effectively promote both aerobic and muscular endurance; intermittent BFR; non-exhaustive BFR; rest-BFR.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

Feng Xiong. and Lu Wang. Yulu Xiang. wrote the main manuscript text and JieFeng, Panyun Mu extracted data.Feng Xiong, Qiulin Deng prepared figures and tables，Yimei Hu reviewed the design and writing process of the article. All authors read and approved the final manuscript.

Acknowledgements

Thanks to the authors of the cited literature for providing detailed information. Medical writers, proofreaders and editors are also greatly appreciated for their help.

Kramer A. An Overview of the Beneficial Effects of Exercise on Health and Performance. Advances in experimental medicine and biology. 2020;1228:3–22.https://doi.org/10.1007/978-981-15-1792-1_1
Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002 Mar;14(11):793–801. https://doi.org/10.1056/NEJMoa011858.
Lee DC, Artero EG, Sui X, Blair SN. Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol (Oxford England). 2010 Nov;24(4 Suppl):27–35. https://doi.org/10.1177/1359786810382057.
Bemben MG. Age-related alterations in muscular endurance. Sports Med. 1998 Apr;25(4):259–69. https://doi.org/10.2165/00007256-199825040-00004.
Joyner MJ, Coyle EF. Endurance exercise performance: the physiology of champions. The Journal of physiology. 2008 Jan 1;586(1):35–44.https://doi.org/10.1113/jphysiol.2007.143834
Yu W, Song G, Liu Y. Benefit and physiological mechanism of low-intensity resistance training with blood flow restriction intervention on muscle fitness. Chin J Tissue Eng Res. 2022;26(17):2768–74. .https://doi.org/10.12307/2022.549.
Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51(13):1003–11. .https://doi.org/10.1136/bjsports-2016-097071.
Centner C, Wiegel P, Gollhofer A, Koenig D. Effects of Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older Individuals: A Systematic Review and Meta-Analysis. Sports Med. 2019 Jan;49(1):95–108. https://doi.org/10.1007/s40279-018-0994-1.
Dankel SJ, Jessee MB, Abe T, Loenneke JP. The Effects of Blood Flow Restriction on Upper-Body Musculature Located Distal and Proximal to Applied Pressure. Sports medicine (Auckland, NZ). 2016;46(1):23–33.https://doi.org/10.1007/s40279-015-0407-7
Gronfeldt BM, Lindberg Nielsen J, Mieritz RM, Lund H, Aagaard P. Effect of blood-flow restricted vs heavy-load strength training on muscle strength: Systematic review and meta-analysis. Scandinavian J Med Sci sports. 2020 May;30(5):837–48. https://doi.org/10.1111/sms.13632.
Lixandrao ME, Ugrinowitsch C, Berton R, Vechin FC, Conceicao MS, Damas F, et al. Magnitude of Muscle Strength and Mass Adaptations Between High-Load Resistance Training Versus Low-Load Resistance Training Associated with Blood-Flow Restriction: A Systematic Review and Meta-Analysis. Sports Med. 2018 Feb;48(2):361–78. https://doi.org/10.1007/s40279-017-0795-y.
Bjornsen T, Wernbom M, Kirketeig A, Paulsen G, Samnoy L, Baekken L et al. Type 1 Muscle Fiber Hypertrophy after Blood Flow-restricted Training in Powerlifters. Medicine and science in sports and exercise. 2019 Feb;51(2):288 – 98.https://doi.org/10.1249/mss.0000000000001775
Ferguson RA, Hunt JEA, Lewis MP, Martin NRW, Player DJ, Stangier C et al. The acute angiogenic signalling response to low-load resistance exercise with blood flow restriction.European journal of sport science. 2018Apr;18(3):397–406.https://doi.org/10.1080/17461391.2017.1422281
Kacin A, Strazar K. Frequent low-load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scandinavian J Med Sci sports. 2011 Dec;21(6):e231. 41.https://doi.org/10.1111/j.1600-0838.2010.01260.x.
Nielsen JL, Frandsen U, Jensen KY, Prokhorova TA, Dalgaard LB, Bech RD, et al. Skeletal Muscle Microvascular Changes in Response to Short-Term Blood Flow Restricted Training-Exercise-Induced Adaptations and Signs of Perivascular Stress. Front Physiol. 2020;11:556. https://doi.org/10.3389/fphys.2020.00556.
Christiansen D, Eibye K, Hostrup M, Bangsbo J. Training with blood flow restriction increases femoral artery diameter and thigh oxygen delivery during knee-extensor exercise in recreationally trained men. J Physiol. 2020 Jun;598(12):2337–53. .https://doi.org/10.1113/jp279554.
Jensen L, Bangsbo J, Hellsten Y. Effect of high intensity training on capillarization and presence of angiogenic factors in human skeletal muscle. The Journal of physiology. 2004 Jun 1;557(Pt 2):571 – 82.https://doi.org/10.1113/jphysiol.2003.057711
Pope ZK, Willardson JM, Schoenfeld BJ. Exercise and blood flow restriction. J strength conditioning Res. 2013;27(10):2914–26. https://doi.org/10.1519/JSC.0b013e3182874721.
Conceicao MS, Junior EMM, Telles GD, Libardi CA, Castro A, Andrade ALL et al. Augmented Anabolic Responses after 8-wk Cycling with Blood Flow Restriction. Medicine and science in sports and exercise. 2019 Jan;51(1):84–93.https://doi.org/10.1249/mss.0000000000001755
Larkin KA, Macneil RG, Dirain M, Sandesara B, Manini TM, Buford TW. Blood flow restriction enhances post-resistance exercise angiogenic gene expression. Medicine and science in sports and exercise. 2012 Nov;44(11):2077–83.https://doi.org/10.1249/MSS.0b013e3182625928
Formiga M, Ceballos A, Fay R, Hutchinson SS, Lesh A, Buscheck J, et al. Effect of exercise training with and without blood flow restriction on maximal oxygen consumption in healthy adults: A meta-analysis. Cardiopulm Phys Therapy J. 2019;30(1):e4. https://doi.org/10.1097/CPT.0000000000000104.
Perera E, Zhu XM, Horner NS, Bedi A, Ayeni OR, Khan M. Effects of Blood Flow Restriction Therapy for Muscular Strength, Hypertrophy, and Endurance in Healthy and Special Populations: A Systematic Review and Meta-Analysis. Clin J Sport Med. 2022;32(5):531–45. https://doi.org/10.1097/JSM.0000000000000991.
Castilla-López C, Molina-Mula J, Romero-Franco N. Blood flow restriction during training for improving the aerobic capacity and sport performance of trained athletes: A systematic review and meta-analysis. J Exerc Sci Fit. 2022 Apr;20(2):190–7. .https://doi.org/10.1016/j.jesf.2022.03.004.
Smith NDW, Scott BR, Girard O, Peiffer JJ. Aerobic Training With Blood Flow Restriction for Endurance Athletes: Potential Benefits and Considerations of Implementation. J strength conditioning Res. 2021 Jun. 28.https://doi.org/10.1519/jsc.0000000000004079.
Ferguson RA, Mitchell EA, Taylor CW, Bishop DJ, Christiansen D. Blood-flow-restricted exercise: Strategies for enhancing muscle adaptation and performance in the endurance-trained athlete. Exp Physiol. 2021;106(4):837–60. https://doi.org/10.1113/EP089280.
Chua MT, Sim A, Burns SF. Acute and Chronic Effects of Blood Flow Restricted High-Intensity Interval Training: A Systematic Review. Sports medicine - open.2022 2022Sep;8(1):122-.https://doi.org/10.1186/s40798-022-00506-y
Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane database of systematic reviews. 2019 Oct 3;10:Ed000142.https://doi.org/10.1002/14651858.Ed000142
Pelliccia A, Fagard R, Bjørnstad HH, Anastassakis A, Arbustini E, Assanelli D et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European heart journal. 2005 Jul;26(14):1422–45.https://doi.org/10.1093/eurheartj/ehi325
Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011 Oct 18;343:d5928.https://doi.org/10.1136/bmj.d5928
Schober P, Mascha EJ, Vetter TR. Statistics From A (Agreement) to Z (z Score): A Guide to Interpreting Common Measures of Association, Agreement, Diagnostic Accuracy, Effect Size, Heterogeneity, and Reliability in Medical Research. Anesthesia and analgesia. 2021 Dec 1;133(6):1633-41.https://doi.org/10.1213/ane.0000000000005773
Li HM, Zhang RJ, Shen CL. Accuracy of Pedicle Screw Placement and Clinical Outcomes of Robot-assisted Technique Versus Conventional Freehand Technique in Spine Surgery From Nine Randomized Controlled Trials: A Meta-analysis.Spine. 2020 Jan15;45(2):E111-e9.https://doi.org/10.1097/brs.0000000000003193
Fahs CA, Loenneke JP, Thiebaud RS, Rossow LM, Kim D, Abe T et al. Muscular adaptations to fatiguing exercise with and without blood flow restriction. Clinical physiology and functional imaging. 2015 May;35(3):167 – 76.https://doi.org/10.1111/cpf.12141
Neto GR, da Silva JCG, Freitas L, da Silva HG, Caldas D, Novaes JS, et al. Effects of strength training with continuous or intermittent blood flow restriction on the hypertrophy, muscular strength and endurance of men. Acta Scientiarum - Health Sciences. 2019;41(1). https://doi.org/10.4025/actascihealthsci.v41i1.42273.
Jessee MB, Buckner SL, Grant Mouser J, Mattocks KT, Dankel SJ, Abe T, et al. Muscle adaptations to high-load training and very low-load training with and without blood flow restriction. Front Physiol. 2018;9. https://doi.org/10.3389/fphys.2018.01448. OCT).
Manimmanakorn A, Manimmanakorn N, Taylor R, Draper N, Billaut F, Shearman JP et al. Effects of resistance training combined with vascular occlusion or hypoxia on neuromuscular function in athletes.European journal of applied physiology. 2013Jul;113(7):1767–74.https://doi.org/10.1007/s00421-013-2605-z
Manimmanakorn A, Hamlin MJ, Ross JJ, Taylor R, Manimmanakorn N. Effects of low-load resistance training combined with blood flow restriction or hypoxia on muscle function and performance in netball athletes. J Sci Med sport. 2013 Jul;16(4):337–42. https://doi.org/10.1016/j.jsams.2012.08.009.
Bowman EN, Elshaar R, Milligan H, Jue G, Mohr K, Brown P et al. Proximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial. Sports health. 2019 Mar/Apr;11(2):149 – 56.https://doi.org/10.1177/1941738118821929
Ramis TR, Muller CHdL, Boeno FP, Teixeira BC, Rech A, Pompermayer MG et al. Effects of Traditional and Vascular Restricted Strength Training Program With Equalized Volume on Isometric and Dynamic Strength, Muscle Thickness, Electromyographic Activity, and Endothelial Function Adaptations in Young Adults. Journal of strength and conditioning research. 2020 Mar;34(3):689 – 98.https://doi.org/10.1519/jsc.0000000000002717
Chen YT, Hsieh YY, Ho JY, Ho CC, Lin TY, Lin JC. Running interval training combined with blood flow restriction increases maximal running performance and muscular fitness in male runners.Scientific reports. 2022 Jun15;12(1):9922.https://doi.org/10.1038/s41598-022-14253-3
Early KS, Rockhill M, Bryan A, Tyo B, Buuck D, McGinty J, EFFECT, OF BLOOD FLOW RESTRICTION TRAINING ON MUSCULAR PERFORMANCE, PAIN AND VASCULAR FUNCTION.International journal of sports physical therapy. 2020 Dec;15(6):892–900.https://doi.org/10.26603/ijspt20200892
Ferreira A Jr, de Araujo AC, Chimin P, Okuno NM. Effect of walk training with blood flow restriction on oxygen uptake kinetics, maximum oxygen uptake and muscle strength in middle-aged adults.Medicina Dello Sport. 2019 Dec;72(4):616 – 27.https://doi.org/10.23736/s0025-7826.19.03402-1
Park S, Kim JK, Choi HM, Kim HG, Beekley MD, Nho H. Increase in maximal oxygen uptake following 2-week walk training with blood flow occlusion in athletes.European journal of applied physiology. 2010 Jul;109(4):591–600.https://doi.org/10.1007/s00421-010-1377-y
Held S, Behringer M, Donath L. Low intensity rowing with blood flow restriction over 5 weeks increases V̇O(2)max in elite rowers: A randomized controlled trial.Journal of science and medicine in sport. 2020Mar;23(3):304–8.https://doi.org/10.1016/j.jsams.2019.10.002
Amani-Shalamzari S, Sarikhani A, Paton C, Rajabi H, Bayati M, Nikolaidis PT, et al. Occlusion Training During Specific Futsal Training Improves Aspects of Physiological and Physical Performance. J sports Sci Med. 2020 Jun;19(2):374–82.
Beak HJ, Park W, Yang JH, Kim J. Effect of Low-Intensity Aerobic Training Combined with Blood Flow Restriction on Body Composition, Physical Fitness, and Vascular Responses in Recreational Runners. Healthcare (Basel, Switzerland). 2022 Sep 16;10(9).https://doi.org/10.3390/healthcare10091789
Chen YT, Hsieh YY, Ho JY, Lin TY, Lin JC. Running Training Combined With Blood Flow Restriction Increases Cardiopulmonary Function and Muscle Strength in Endurance Athletes. Journal of strength and conditioning research. 2022 May 1;36(5):1228-37.https://doi.org/10.1519/jsc.0000000000003938
Kim D, Singh H, Loenneke JP, Thiebaud RS, Fahs CA, Rossow LM, et al. Comparative Effects of Vigorous-Intensity and Low-Intensity Blood Flow Restricted Cycle Training and Detraining on Muscle Mass, Strength, and Aerobic Capacity. J strength conditioning Res. 2016 May;30(5):1453–61. .https://doi.org/10.1519/jsc.0000000000001218.
Tangchaisuriya P, Chuensiri N, Tanaka H, Suksom D. Physiological Adaptations to High-Intensity Interval Training Combined with Blood Flow Restriction in Masters Road Cyclists. Medicine and science in sports and exercise. 2022 May 1;54(5):830 – 40.https://doi.org/10.1249/mss.0000000000002857
Giovanna M, Solsona R, Sanchez AMJ, Borrani F. Effects of short-term repeated sprint training in hypoxia or with blood flow restriction on response to exercise. Journal of physiological anthropology. 2022 Sep 3;41(1):32.https://doi.org/10.1186/s40101-022-00304-1
Hori A, Saito R, Suijo K, Kushnick MR, Hasegawa D, Ishida K et al. Blood flow restriction accelerates aerobic training-induced adaptation of [Formula: see text] kinetics at the onset of moderate-intensity exercise. Scientific reports. 2022 Oct 28;12(1):18160.https://doi.org/10.1038/s41598-022-22852-3
Xu D, Wu J, Gui P, Xie Y. Effects of Short-term Lower Extremity Blood Flow Restriction Based on Limb Linkage Training on Endurance of Cardiopulmonary Endurance,Lower Extremity Muscle Endurance and Balance Function of Healthy Young People. Chinese Journal of Rehabilitation Theory and Practice. 2021 2021;27(12):1470-5
Li S, Guo R, Yu T, Li S, Han T, Yu W. Effect of High-Intensity Interval Training Combined with Blood Flow Restriction at Different Phases on Abdominal Visceral Fat among Obese Adults: A Randomized Controlled Trial. Int J Environ Res Public Health. 2022;19. 19).https://doi.org/10.3390/ijerph191911936.
Ladlow P, Coppack RJ, Dharm-Datta S, Conway D, Sellon E, Patterson SD, et al. Low-Load Resistance Training With Blood Flow Restriction Improves Clinical Outcomes in Musculoskeletal Rehabilitation: A Single-Blind Randomized Controlled Trial. Front Physiol. 2018;9:1269. https://doi.org/10.3389/fphys.2018.01269.
Tanaka Y, Takarada Y. The impact of aerobic exercise training with vascular occlusion in patients with chronic heart failure. ESC heart failure. 2018 Aug;5(4):586 – 91.https://doi.org/10.1002/ehf2.12285
Zargi T, Drobnic M, Strazar K, Kacin A. Short-Term Preconditioning With Blood Flow Restricted Exercise Preserves Quadriceps Muscle Endurance in Patients After Anterior Cruciate Ligament Reconstruction. Frontiers in physiology. 2018 Aug 24;9.https://doi.org/10.3389/fphys.2018.01150
Sundberg CJ, Eiken O, Nygren A, Kaijser L. Effects of ischaemic training on local aerobic muscle performance in man. Acta Physiol Scand. 1993 May;148(1):13–9. https://doi.org/10.1111/j.1748-1716.1993.tb09526.x.
Pignanelli C, Petrick HL, Keyvani F, Heigenhauser GJF, Quadrilatero J, Holloway GP et al. Low-load resistance training to task failure with and without blood flow restriction: muscular functional and structural adaptations. American journal of physiology Regulatory, integrative and comparative physiology. 2020 Feb 1;318(2):R284-r95.https://doi.org/10.1152/ajpregu.00243.2019
Davids CJ, Raastad T, James LP, Gajanand T, Smith E, Connick M et al. Similar Morphological and Functional Training Adaptations Occur Between Continuous and Intermittent Blood Flow Restriction. Journal of strength and conditioning research. 2021 Jul 1;35(7):1784-93.https://doi.org/10.1519/jsc.0000000000004034
Buckner SL, Jessee MB, Dankel SJ, Mattocks KT, Mouser JG, Bell ZW, et al. Blood flow restriction does not augment low force contractions taken to or near task failure. Eur J sport Sci. 2020 Jun;20(5):650–9. .https://doi.org/10.1080/17461391.2019.1664640.
Sousa J, Neto GR, Santos HH, Araújo JP, Silva HG, Cirilo-Sousa MS. Effects of strength training with blood flow restriction on torque, muscle activation and local muscular endurance in healthy subjects. Biology of sport. 2017 Mar;34(1):83–90. https://doi.org/10.5114/biolsport.2017.63738.
Lambert B, Hedt C, Daum J, Taft C, Chaliki K, Epner E et al. Blood Flow Restriction Training for the Shoulder: A Case for Proximal Benefit. The American journal of sports medicine. 2021 Aug;49(10):2716–28.https://doi.org/10.1177/03635465211017524
Groennebaek T, Jespersen NR, Jakobsgaard JE, Sieljacks P, Wang J, Rindom E et al. Skeletal Muscle Mitochondrial Protein Synthesis and Respiration Increase With Low-Load Blood Flow Restricted as Well as High-Load Resistance Training. Frontiers in physiology. 2018 Dec 17;9.https://doi.org/10.3389/fphys.2018.01796
Morley WN, Ferth S, Debenham MIB, Boston M, Power GA, Burr JF. Training response to 8 weeks of blood flow restricted training is not improved by preferentially altering tissue hypoxia or lactate accumulation when training to repetition failure. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme. 2021 Oct;46(10):1257-64.https://doi.org/10.1139/apnm-2020-1056
Sieljacks P, Degn R, Hollaender K, Wernbom M, Vissing K. Non-failure blood flow restricted exercise induces similar muscle adaptations and less discomfort than failure protocols.Scandinavian journal of medicine & science in sports. 2019Mar;29(3):336 – 47.https://doi.org/10.1111/sms.13346
Cai ZY, Wang WY, Lin JD, Wu CM. Effects of whole body vibration training combined with blood flow restriction on muscle adaptation. Eur J sport Sci. 2021 Feb;21(2):204–12. https://doi.org/10.1080/17461391.2020.1728389.
Zinner C, Baessler B, Weiss K, Ruf J, Michels G, Holmberg HC, et al. Effect of resistance training with vibration and compression on the formation of muscle and bone. Muscle Nerve. 2017 Dec;56(6):1137–42. .https://doi.org/10.1002/mus.25560.
Torma F, Bakonyi P, Regdon Z, Gombos Z, Jokai M, Babszki G et al. Blood flow restriction during the resting periods of high-intensity resistance training does not alter performance but decreases MIR-1 and MIR-133A levels in human skeletal muscle. Sports medicine and health science. 2021 2021-Mar;3(1):40 – 5.https://doi.org/10.1016/j.smhs.2021.02.002
Schwiete C, Franz A, Roth C, Behringer M. Effects of Resting vs. Continuous Blood-Flow Restriction-Training on Strength, Fatigue Resistance, Muscle Thickness, and Perceived Discomfort. Front Physiol. 2021;12:663665. https://doi.org/10.3389/fphys.2021.663665.
Fekri-Kurabbaslou V, Shams S, Amani-Shalamzari S. Effect of different recovery modes during resistance training with blood flow restriction on hormonal levels and performance in young men: a randomized controlled trial. BMC sports science, medicine & rehabilitation.2022 Mar25;14(1):47.https://doi.org/10.1186/s13102-022-00442-0
Lan C, Liu Y, Wang Y. Effects of different exercise programs on cardiorespiratory fitness and body composition in college students. J Exerc Sci Fit. 2022 Jan;20(1):62–9. https://doi.org/10.1016/j.jesf.2021.12.004.
Karabulut M, Esparza B, Dowllah IM, Karabulut U. The impact of low-intensity blood flow restriction endurance training on aerobic capacity, hemodynamics, and arterial stiffness. J Sports Med Phys Fit. 2021 Jul;61(7):877–84. https://doi.org/10.23736/s0022-4707.20.11526-3.
Abe T, Fujita S, Nakajima T, Sakamaki M, Ozaki H, Ogasawara R, et al. Effects of Low-Intensity Cycle Training with Restricted Leg Blood Flow on Thigh Muscle Volume and VO2MAX in Young Men. J sports Sci Med. 2010;9(3):452–8.
Amani-Shalamzari S, Rajabi S, Rajabi H, Gahreman DE, Paton C, Bayati M, et al. Effects of Blood Flow Restriction and Exercise Intensity on Aerobic, Anaerobic, and Muscle Strength Adaptations in Physically Active Collegiate Women. Front Physiol. 2019;10:810. https://doi.org/10.3389/fphys.2019.00810.
Paton CD, Addis SM, Taylor L-A. The effects of muscle blood flow restriction during running training on measures of aerobic capacity and run time to exhaustion. Eur J Appl Physiol. 2017 Dec;117(12):2579–85. .https://doi.org/10.1007/s00421-017-3745-3.
Keramidas ME, Kounalakis SN, Geladas ND. The effect of interval training combined with thigh cuffs pressure on maximal and submaximal exercise performance. Clinical physiology and functional imaging. 2012 May;32(3):205 – 13.https://doi.org/10.1111/j.1475-097X.2011.01078.x
Lu JM, Liu SY, Sun P, Li WL, Lian ZQ. [Effects of low intensity resistance training of blood flow restriction with different occlusion pressure on lower limb muscle and cardiopulmonary function of college students]. Zhongguo ying yong sheng li xue za zhi = Zhongguo yingyong shenglixue zazhi = Chinese journal of applied physiology. 2020 Nov;36(6):595–9.https://doi.org/10.12047/j.cjap.6032.2020.125
Bunevicius K, Grunovas A, Trinkunas E, Poderiene K, Silinskas V, Buliuolis A, et al. Low- and high-intensity one-week occlusion training improves muscle oxygen consumption and reduces muscle fatigue. J Sports Med Phys Fitness. 2019 Jun;59(6):941–6. .https://doi.org/10.23736/s0022-4707.18.08672-3.
Hosseini Kakhak SA, Kianigul M, Haghighi AH, Nooghabi MJ, Scott BR. Performing Soccer-Specific Training With Blood Flow Restriction Enhances Physical Capacities in Youth Soccer Players. Journal of strength and conditioning research. 2022 Jul 1;36(7):1972-7.https://doi.org/10.1519/jsc.0000000000003737
Mueller SM, Aguayo D, Lunardi F, Ruoss S, Boutellier U, Frese S et al. High-load resistance exercise with superimposed vibration and vascular occlusion increases critical power, capillaries and lean mass in endurance-trained men.European journal of applied physiology. 2014Jan;114(1):123 – 33.https://doi.org/10.1007/s00421-013-2752-2
Libardi CA, Chacon-Mikahil MP, Cavaglieri CR, Tricoli V, Roschel H, Vechin FC, et al. Effect of concurrent training with blood flow restriction in the elderly. Int J Sports Med. 2015;36(5):395–9. .https://doi.org/10.1055/s-0034-1390496.
de Souza TMF, Libardi CA, Cavaglieri CR, Gáspari AF, Brunelli DT, de Souza GV, et al. Concurrent Training with Blood Flow Restriction does not Decrease Inflammatory Markers. Int J sports Med. 2018 Jan;39(1):29–36. https://doi.org/10.1055/s-0043-119222.
Ozaki H, Sakamaki M, Yasuda T, Fujita S, Ogasawara R, Sugaya M et al. Increases in thigh muscle volume and strength by walk training with leg blood flow reduction in older participants. The journals of gerontology Series A, Biological sciences and medical sciences. 2011 Mar;66(3):257 – 63.https://doi.org/10.1093/gerona/glq182
Kargaran A, Abedinpour A, Saadatmehr Z, Yaali R, Amani-Shalamzari S, Gahreman D. Effects of dual-task training with blood flow restriction on cognitive functions, muscle quality, and circulatory biomarkers in elderly women. Physiology & behavior. 2021 Oct 1;239:113500.https://doi.org/10.1016/j.physbeh.2021.113500
Clarkson MJ, Conway L, Warmington SA. Blood flow restriction walking and physical function in older adults: A randomized control trial. J Sci Med sport. 2017 Dec;20(12):1041–6. .https://doi.org/10.1016/j.jsams.2017.04.012.
Letieri RV, Furtado GE, Nogueira Barros PM, Abrantes de Farias MJ, Antunez BF, Gomes BB, et al. Effect of 16-Week Blood Flow Restriction Exercise on Functional Fitness in Sarcopenic Women: A Randomized Controlled. Int J Morphology 2019. 2019;37(1):59–64. https://doi.org/10.4067/s0717-95022019000100059.
Abe T, Sakamaki M, Fujita S, Ozaki H, Sugaya M, Sato Y et al. Effects of low-intensity walk training with restricted leg blood flow on muscle strength and aerobic capacity in older adults. Journal of geriatric physical therapy (2001). 2010 Jan-Mar;33(1):34–40
Kacin A, Drobnic M, Mars T, Mis K, Petric M, Weber D, et al. Functional and molecular adaptations of quadriceps and hamstring muscles to blood flow restricted training in patients with ACL rupture. Scandinavian J Med Sci sports. 2021 Aug;31(8):1636–46. .https://doi.org/10.1111/sms.13968.
Jonsson AB, Johansen CV, Rolving N, Pfeiffer-Jensen M. Feasibility and estimated efficacy of blood flow restricted training in female patients with rheumatoid arthritis: a randomized controlled pilot study. Scandinavian journal of rheumatology. 2021 May 4;50(3):169 – 77.https://doi.org/10.1080/03009742.2020.1829701
Groennebaek T, Sieljacks P, Nielsen R, Pryds K, Jespersen NR, Wang J, et al. Effect of Blood Flow Restricted Resistance Exercise and Remote Ischemic Conditioning on Functional Capacity and Myocellular Adaptations in Patients With Heart Failure. Circulation Heart failure. 2019;12(12):e006427. https://doi.org/10.1161/CIRCHEARTFAILURE.119.006427.
Ampomah K, Amano S, Wages N, Volz L, Clift R, Ludin A, et al. Blood Flow–restricted Exercise Does Not Induce a Cross-Transfer of Effect: a Randomized Controlled Trial. Med Sci Sports Exerc. 2019;51(9):1817–27. .https://doi.org/10.1249/MSS.0000000000001984.
Cardoso RK, Araujo AM, Del Vechio FB, Bohlke M, Barcellos FC, Oses JP, et al. Intradialytic exercise with blood flow restriction is more effective than conventional exercise in improving walking endurance in hemodialysis patients: a randomized controlled trial. Clin Rehabil. 2020 Jan;34(1):91–8. https://doi.org/10.1177/0269215519880235.
Franz A, Ji S, Bittersohl B, Zilkens C, Behringer M. Impact of a Six-Week Prehabilitation With Blood-Flow Restriction Training on Pre- and Postoperative Skeletal Muscle Mass and Strength in Patients Receiving Primary Total Knee Arthroplasty. Front Physiol. 2022;13:881484. https://doi.org/10.3389/fphys.2022.881484.
Lamberti N, Straudi S, Donadi M, Tanaka H, Basaglia N, Manfredini F. Effectiveness of blood flow-restricted slow walking on mobility in severe multiple sclerosis: A pilot randomized trial. Scandinavian J Med Sci sports. 2020 Oct;30(10):1999–2009. https://doi.org/10.1111/sms.13764.
Jorgensen AN, Jensen KY, Nielsen JL, Frandsen U, Hvid LG, Bjornshauge M, et al. Effects of blood-flow restricted resistance training on mechanical muscle function and thigh lean mass in sIBM patients. Scand J Med Sci Sports. 2021. https://doi.org/10.1111/sms.14079.
Jensen KY, Nielsen JL, Schroder HD, Jacobsen M, Boyle E, Jorgensen AN et al. Lack of muscle stem cell proliferation and myocellular hypertrophy in sIBM patients following blood-flow restricted resistance training.Neuromuscular Disorders. 2022 Jun;32(6):493–502.https://doi.org/10.1016/j.nmd.2022.04.006
Nishii M, Nakano S, Nakamura S, Wate R, Shinde A, Kaneko S, et al. Myonuclear breakdown in sporadic inclusion body myositis is accompanied by DNA double strand breaks. Neuromuscul disorders: NMD. 2011 May;21(5):345–52. https://doi.org/10.1016/j.nmd.2011.02.004.
Manini TM, Clark BC. Blood flow restricted exercise and skeletal muscle health. Exercise and sport sciences reviews. 2009 Apr;37(2):78–85.https://doi.org/10.1097/JES.0b013e31819c2e5c
Tanaka Y. Efficacy of aerobic exercise training with vascular occlusion in patients with chronic heart failure. Eur Heart J. 2016;37:134. https://doi.org/10.1093/eurheartj/ehw431.
Loenneke JP, Thiebaud RS, Abe T. Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence. Scand J Med Sci Sports. 2014;24(6):e415–e22. https://doi.org/10.1111/sms.12210.
Bond CW, Hackney KJ, Brown SL, Noonan BC. Blood Flow Restriction Resistance Exercise as a Rehabilitation Modality Following Orthopaedic Surgery: A Review of Venous Thromboembolism Risk.The Journal of orthopaedic and sports physical therapy. 2019 Jan;49(1):17–27.https://doi.org/10.2519/jospt.2019.8375
Wernbom M, Paulsen G, Bjornsen T, Cumming K, Raastad T. Risk of Muscle Damage With Blood Flow-Restricted Exercise Should Not Be Overlooked. Clin J Sport Med. 2021 May 1;31(3):223-4.https://doi.org/10.1097/JSM.0000000000000755
Cristina-Oliveira M, Meireles K, Spranger MD, O’Leary DS, Roschel H, Peçanha T. Clinical safety of blood flow-restricted training?: A comprehensive review of altered muscle metaboreflex in cardiovascular disease during ischemic exercise. Am J Physiol - Heart Circ Physiol. 2020;318(1):H90. H109.https://doi.org/10.1152/ajpheart.00468.2019.
Domingos E, Polito MD. Blood pressure response between resistance exercise with and without blood flow restriction: A systematic review and meta-analysis. Life Sci. 2018;209:122–31. https://doi.org/10.1016/j.lfs.2018.08.006.
Spitz RW, Wong V, Bell ZW, Viana RB, Chatakondi RN, Abe T, et al. Blood Flow Restricted Exercise and Discomfort: A Review. J strength conditioning Res. 2022;36(3):871–9. .https://doi.org/10.1519/JSC.0000000000003525.
Bell ZW, Buckner SL, Jessee MB, Mouser JG, Mattocks KT, Dankel SJ et al. Moderately heavy exercise produces lower cardiovascular, RPE, and discomfort compared to lower load exercise with and without blood flow restriction.European journal of applied physiology. 2018Jul;118(7):1473–80.https://doi.org/10.1007/s00421-018-3877-0
Silva JCG, Domingos-Gomes JR, Freitas EDS, Neto GR, Aniceto RR, Bemben MG et al. Physiological and Perceptual Responses to Aerobic Exercise With and Without Blood Flow Restriction. Journal of strength and conditioning research. 2021 Sep 1;35(9):2479-85.https://doi.org/10.1519/jsc.0000000000003178
Bjornsen T, Wernbom M, Paulsen G, Berntsen S, Brankovic R, Stalesen H, et al. Frequent blood flow restricted training not to failure and to failure induces similar gains in myonuclei and muscle mass. Scandinavian J Med Sci sports. 2021 Jul;31(7):1420–39. .https://doi.org/10.1111/sms.13952.
Sultana RN, Sabag A, Keating SE, Johnson NA. The Effect of Low-Volume High-Intensity Interval Training on Body Composition and Cardiorespiratory Fitness: A Systematic Review and Meta-Analysis. Sports medicine (Auckland, NZ). 2019 Nov;49(11):1687 – 721.https://doi.org/10.1007/s40279-019-01167-w
Seiler S. What is best practice for training intensity and duration distribution in endurance athletes? International journal of sports physiology and performance. 2010 Sep;5(3):276 – 91.https://doi.org/10.1123/ijspp.5.3.276
Holloway TM, Snijders T, LJC JVANK, Verdijk VANL. LB. Temporal Response of Angiogenesis and Hypertrophy to Resistance Training in Young Men. Medicine and science in sports and exercise. 2018 Jan;50(1):36–45.https://doi.org/10.1249/mss.0000000000001409
Freitas EDS, Miller RM, Heishman AD, Ferreira-Junior JB, Araujo JP, Bemben MG. Acute Physiological Responses to Resistance Exercise With Continuous Versus Intermittent Blood Flow Restriction: A Randomized Controlled Trial. Frontiers in physiology. 2020 Mar17;11.https://doi.org/10.3389/fphys.2020.00132
Sinclair P, Kadhum M, Paton B. Tolerance to Intermittent vs. Continuous Blood Flow Restriction Training: A meta-Analysis. Int J Sports Med. 2022;43(1):3–10. https://doi.org/10.1055/a-1537-9886.
Torma F, Gombos Z, Fridvalszki M, Langmar G, Tarcza Z, Merkely B et al. Blood flow restriction in human skeletal muscle during rest periods after high-load resistance training down-regulates miR-206 and induces Pax7.Journal of sport and health science. 2021Jul;10(4):470–7.https://doi.org/10.1016/j.jshs.2019.08.004
Okita K, Takada S, Morita N, Takahashi M, Hirabayashi K, Yokota T et al. Resistance training with interval blood flow restriction effectively enhances intramuscular metabolic stress with less ischemic duration and discomfort. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme. 2019 Jul;44(7):759 – 64.https://doi.org/10.1139/apnm-2018-0321

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Effects of Blood Flow Restriction Exercise on Muscle Endurance and Aerobic Capacity in Different Populations: A Systematic Review and Meta-Analysis

Status:

Version 1

Abstract

Figures

Introduction

Methods

Search strategy and study selection

Exclusion criteria

Data extraction

Assessment of Risk Bias

Statistical analyses

Search Result

Basic characteristics

Risk of bias and research quality

Quantitative Analysis

Healthy people

Muscle endurance

Aerobic capacity

Athletes

Muscle endurance

Aerobic capacity

Qualitative analysis

Healthy people

Muscle endurance

Aerobic capacity

Athletes

Muscle endurance

Aerobic capacity

Old people

Aerobic capacity

Patients

Muscle endurance

Aerobic capacity

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1