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DOI 10.1007/s40279-014-0288-1
REVIEW ARTICLE
Key Points
The blood flow restriction (BFR) stimulus should be
individualized for each participant. In particular,
consideration should be given to the restrictive
pressure applied and cuff width used.
BFR elicits the largest increases in muscular
development when combined with low-load
resistance exercise, though some benefits may be
seen using BFR alone during immobilization or
combined with low-workload cardiovascular
exercise.
For healthy individuals, training adaptations are
likely maximized by combining low-load BFR
resistance exercise with traditional high-load
resistance exercise.
1 Introduction
It is generally accepted that significant adaptation to
resistance exercise requires moderate- or high-load training, using loads equivalent to at least 70 % of 1-repetition
maximum (1RM) [1]. However, mounting evidence now
supports the use of blood flow restriction (BFR) combined
with low-load resistance exercise (*2040 % 1RM) to
enhance morphological and strength responses. This novel
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3 Cuff Application
3.1 Type of Cuff
The BFR technique generally involves application of a
tourniquet [34], inflatable cuff [35] or elastic knee wraps
[36] at the top of each arm or leg to restrict blood flow into
the muscle, and occlude blood flow out of the muscle.
While elastic automated cuff systems have been developed
and popularized in Japan, it may be more practical to
employ inflatable cuffs or simple elastic wraps, particularly
when large groups are performing BFR. The use of elastic
knee wraps in particular has been recently popularized in
research and real-world contexts as a practical method for
implementing BFR without the need for expensive specialized equipment [36]. Furthermore, it has been shown
that the narrow nylon cuffs commonly used in BFR
research provide a stimulus similar to 5 cm elastic cuffs
when inflated to the same target pressure (with an initial
pressure of 50 mmHg), both at rest [37] and during exercise [38]. This suggests that any differences between cuffs
are predominantly due to cuff width and not to cuff
material.
Therefore, one of the most important factors to consider
when applying BFR is the width of the cuff. Researchers
have used a range of cuff widths for both the legs
(4.518.5 cm) and the arms (312 cm) [39]. Wider cuffs
(13.5 cm) have been shown to cause greater ratings of pain
and perceived exertion and to limit exercise volume during
low-load BFR knee extension exercise when compared
with narrow cuffs (5.0 cm) inflated to the same restrictive
pressure [40]. Wider cuffs transmit pressure through soft
tissue differently to narrow cuffs, which has obvious
implications for subsequent training adaptations. To illustrate, Loenneke et al. [41] recently reported that wide cuffs
(13.5 cm) restrict arterial blood flow at lower pressures
than narrow cuffs (5.0 cm). Indeed, some individuals did
not reach complete arterial occlusion using narrow cuffs on
the legs, even at pressures of up to 300 mmHg [41]. These
results suggest that it may be easier to reach the desired
level of occlusive pressure using wider cuffs in the lower
body. However, wider cuffs may inhibit the normal range
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4 Exercise Stimulus
4.1 Type of Exercise
Interestingly, BFR alone during periods of muscular
unloading has been found to attenuate disuse atrophy [2,
49, 50]. For example, Takarada et al. [2] reported that BFR
alone (five sets of 5 min BFR with 3 min of free flow
between sets at a pressure of 180260 mmHg) can attenuate post-operative disuse atrophy in patients recovering
from surgical reconstruction of the anterior cruciate ligament. Additionally, research using a cast immobilization
model has demonstrated that BFR alone applied in an
intermittent fashion (five sets of 5 min with 3 min of free
flow between sets) may prevent disuse weakness induced
by chronic unloading, even when using restrictive pressures as low as 50 mmHg [49, 50]. The application of BFR
during periods of bed rest or immobilization is a novel
strategy that may be used to aid in recovery from injury or
surgery, even when unloaded movements cannot be tolerated. Nonetheless, BFR must be combined with an exercise
stimulus for enhanced muscular development. Even simply
walking with BFR has been shown to facilitate small
improvements in muscle strength and size [1922].
Ozaki et al. [21] have demonstrated that elderly adults
who trained 4 days per week for 10 weeks using lowworkload walk training (20 min at 45 % heart rate reserve)
displayed increases in maximum knee joint strength
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of metabolites will no doubt affect performance in subsequent sets, it is likely to be a predominant mechanism
underpinning adaptation to BFR exercise [81]. Furthermore, venous pooling between sets will increase cellular
swelling, which is also considered to have an important
role in the hypertrophic response [25, 82].
4.5 Training Frequency
Low-load resistance exercise with BFR can be completed
more frequently than more traditional resistance training
programmes. High-frequency low-load resistance training
(twice daily for 2 weeks with 20 % 1RM) has resulted in
greater increases in squat and leg curl 1RM, and CSA of
the thigh and hip muscles, when combined with BFR [54].
Similarly, just 6 days of twice-daily low-load BFR resistance training has produced substantial hypertrophic and
strength responses, comparable to studies employing
longer training durations and a higher load or volume of
exercise [53]. Importantly, even with high training frequencies, markers of muscle damage (creatine phosphokinase and myoglobin) and oxidative stress (lipid peroxide)
were not elevated during or after BFR training [54]. Collectively, research has observed BFR resistance exercise to
cause no prolonged decrements in muscle function, no
prolonged muscle swelling, muscle soreness ratings similar
to those with submaximal low-load controls, and no elevation in blood biomarkers of muscle damage [57].
Brief periods of high-frequency BFR resistance training
may therefore be beneficial during a period of planned
overload. However, extended periods of high-frequency
training using only BFR resistance exercise may result in
increased levels of training monotony in participants, particularly in athletic populations. As with any resistance
training programme, BFR training should be periodized
appropriately to ensure both optimal adaptive responses
and to limit boredom in participants. Table 1 presents a
summary of the recommendations presented in this review
regarding the implementation of BFR exercise for both
clinical and athletic cohorts.
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Table 1 Summary of recommendations for the application of blood flow restriction during resistance training for enhanced hypertrophic and
strength adaptations
Recommendation
Factors to consider
Cuff application
Trunk muscles can also benefit from BFR during multi-joint exercises
Cuff type
Occlusive pressure
Exercise loads
Training volume
Inter-set rest
3045 s
Training frequency
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Fig. 1 Simplified flowchart for the practical implementation of blood flow restriction strategies for clinical, healthy and athletic populations.
Contraindications for blood flow restriction have been described by Nakajima et al. [6]. BFR blood flow restriction, 1RM 1-repetition maximum
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7 Conclusions
The addition of BFR to low-load resistance exercise
enhances hypertrophic and strength responses. Although
the mechanisms that drive these adaptations are not yet
clear, this novel training strategy has important implications for individuals who cannot train using heavy loads.
BFR alone can attenuate muscle atrophy during periods of
disuse, and BFR combined with low-workload aerobic
exercise can result in hypertrophy and strength increases
(albeit small). Recent research has also demonstrated that
well-trained athletes can benefit from low-load BFR
training, either as an independent training method, or more
substantially in combination with traditional high-load
resistance training. When training with BFR, it is important
to ensure that the cuff width used is appropriate and the
restrictive pressure is specific to each individual limb. It
appears that muscles of the limbs and trunk can benefit
from BFR training, meaning that both single- and multijoint exercises can be prescribed for training programmes.
Low exercise loads should be employed (2040 % 1RM) in
conjunction with short inter-set rest periods (3060 s) and
relatively high training volumes (5080 repetitions per
exercise) to ensure a sufficient physiological stimulus is
achieved. Furthermore, as BFR training does not markedly
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