The Effectiveness of Low-Load Blood Flow Restriction (BFR) Training

On Strength and Muscle Hypertrophy Gains

Brittin Boyer, Gabriela Torres, and Tom Watson

 Abstract

Background

Blood flow restriction low load resistance training may serve as an alternative to high

load resistance training and may be tolerated by individuals who have knee osteoarthritis or who

are at risk of developing knee osteoarthritis. Blood flow restriction can be achieved by applying

external pressure on the desired limb using a pneumatic cuff. The pressure that is applied

obstructs venous outflow but maintains arterial inflow. Restricting blood flow to the proximal

portion of the quadriceps may lead to increasing muscle strength and hypertrophy.

Methods

A randomized study was conducted with the intention of testing the hypothesis; the

hypothesis states blood flow restriction low load resistance training may serve as an alternative

to high load resistance training and produce better results. The participants were eight freshman

students from the Health and Wellness class. The participants that were selected were a mix of

male and female, ranging from ages 18-19. Participants were randomly placed in either the

control or BRF group, resulting in four participants in each group. Regarding testing procedures,

the workout will range from thirty to forty-five minutes long and will include three exercises that

each have three to five sets of three to twenty-four repetitions in each set. Quadriceps strength

and hypertrophy will be tested specifically. Subjects utilizing BFR will work at a load decreased

by 50% in comparison to traditional style working subjects.

Results

Six participants fully completed the study and the follow-up assessment; the other two

lacked one of the measurements taken, but both completed the workout portion. Both the control

and BFR groups showed a substantial increase in quadriceps strength and hypertrophy.
Participants of the control group increased in their 1 rep-max (mean average = 21%), thigh

circumference (mean average = L: 0.83% and R: 2.05%), and lower extremity muscle mass

(mean average = L: 0.79% and R: 2.56%). Participants of the BFR group had even better results

and also increased in 1 rep-max (mean average = 26.4%), thigh circumference (mean average =

L: 5.67% and R: 2.89%), and lower extremity muscle mass (mean average = L: 5.22% and R:

2.54%).

Discussion

The results of this study showed the hypothesis to be true. Blood flow restriction training

does lead to increases in muscle strength and hypertrophy. Though it would be preferred that the

study lasted six to eight weeks, the results obtained during the four-week period surpassed

expectations. For future studies, changes will need to be made on how the study will need to be

performed. The time frame of this study should last longer than four weeks, with an increase in

participants as well. The study should not only focus on university students, but different

populations ranging from different ages. These changes would allow the results to reflect more

diverse and profound findings.

Background

Blood flow restriction gives the impression of being beneficial for people of all different

abilities. Regarding implementing BFR into practice, researchers and practitioners do not have a

common consensus; they do know, however, that if BFR is not appropriately employed, risk of

injury to the patient is prevalent. More so, ‘it is imperative to understand variations in cuff

application, exercise type, load, volume, rest, and training frequency must be properly

considered to design an effective BFR training program’.1 Although proven to be effective for

many patients and athletes, BFR training still has a long way to go regarding research and

training programs.

‘What is known is BFR induces hypoxia, increases metabolic effects, encourages

anabolic processes, regularly increases growth hormone levels, and reduces proteolysis’.2

Although there are many different benefits, like every type of training, controversies do exist.

‘Benefits include positive effects on bone health, strength gain in non-occluded muscles, and

reduce atrophy in knee extensor muscle; controversy exists in aerobic capacity changes’.2

Though many studies have been conducted, no standard training guidelines for blood flow

restriction have been implemented. Numerous researchers hypothesized that blood flow

restriction training would result in similar benefits as compared with conventional high-intensity

resistance training while inducing less pain. Nonetheless, tradition suggests that quadriceps

strength and hypertrophy is best achieved through high-intensity resistance training. High

resistance exercises are performed for 6-12 repetitions at 70-80% of your 1RM.

When beginning to understand blood flow restriction, it is important to interpret that even

without heavy loads, metabolic stress is thought to trigger certain mechanisms which mediate

muscle growth. If muscle growth can be accomplished without the heavy loading, then physical
degeneration and ill-health may be prevented. Moreover, recent evidence suggests that

comparable gains can be attained through blood flow restriction training. Techniques can present

similar gains in muscle mass, along with additional structural and physiological benefits.3

Research suggests, ‘Osteoarthritis is the most common form of arthritis and is considered

a major cause of musculoskeletal pain, functional impairment, and reduced independence in

older adults worldwide’.4 This being said, the benefits of resistance training with blood flow

restriction and its relevance in knee osteoarthritis is intriguing. Quadriceps muscle weakness is

considered not only as an important risk factor for OA but ‘also as a main determinant of

physical functioning in women with knee OA’.4 Therefore, quadriceps strengthening and

hypertrophy is thought as a first-therapy, making resistance training a common practice within

OA management. Importantly, patients with OA are often unable to exercise at such high-

intensities, limiting the application of conventional HI-RT. This creates a pathway for a

substitute that yields less pain: low intensity resistance exercise (20-30% 1RM) combined with

blood flow restriction.

In individuals that have not been diagnosed with symptomatic knee OA, ‘increasing knee

extensor strength will reduce the risk of developing the disease’.6 Resistance training with a load

of 70%-85% with 1RM has been shown to increase muscle hypertrophy, while a load of 60%-

70% increases muscle strength. Though resistance training may be a great option for increasing

muscle hypertrophy, it requires the individual to lift high loads. Individuals who have a history

of knee pain or injury may have difficulty lifting high loads. High loads can lead to further

complications and injury in these individuals.

Blood flow restriction low load resistance training may serve as an alternative to high

load resistance training and may be tolerated by individuals who have knee OA or who are at
risk of developing knee OA. We can achieve blood flow restriction by applying external pressure

on the desired limb using a pneumatic cuff. ‘The pressure that is applied obstructs venous

outflow but maintains arterial inflow’.5 Restricting blood flow to the proximal portion of the

quadriceps may lead to increasing muscle strength and hypertrophy.

There have been multiple studies conducted that show that BFR training leads to a

significant increase in muscle strength and volume. Though there are risk associated with BFR

training when not used appropriately, it has shown to be an alternative to traditional resistance

training. There have been several positive results when using BFR in individuals who are at risk

of developing knee OA or who have already been diagnosed with the disease. BFR low-load

training does not further their injury and many saw an increase in quadriceps strength without

pain. There are multiple benefits when it comes to using BFR, but the question is if it compares

to the increase in muscle strength and volume when doing traditional resistance training. The

objective of this study is to evaluate the effectiveness of low-load blood flow restriction (BFR)

training compared to high-load traditional weight training regarding strength and muscle

hypertrophy gains.

Methods

For participants to be included in this study, they had to be a student attending Trevecca

Nazarene University, enrolled in the Health and Wellness class, and in the age range of eighteen

to nineteen years old. Due to the nature of blood flow restriction training and the symptoms that

have the possibility to occur, exclusion criteria had to be presented to potential participants

before they could start the study. Participants were excluded from this study if they had a history
of cardiovascular disease, history of thrombosis or thromboembolism, were using cigarettes, or

were using hormonal drugs such as contraceptives.

In this study, students were randomly assigned to the control group or intervention group.

The control group used traditional weight training and the intervention group used BFR training.

With a total of eight students in the study, the groups were evenly distributed, and each consisted

of four students. Four females made up the control group, while the intervention group had three

females and one male. Students were expected to workout twice a week for four weeks, typically

during the Health and Wellness class period and were never left unsupervised when exercising.

Each workout in the study’s four weeks lasted approximately thirty minutes and started with a

five-minute warm-up on the bike or treadmill. The workout for both groups consisted of three

exercises which included: leg press with a normal stance, leg press with a wide stance, and knee

extension. Each of these exercises consisted of three to five sets of three to twenty-four

repetitions. The amount of repetitions varied and depended mostly on which group the

participant was in. The BFR group exercised at a 50% load decrease while training with a blood

flow restrictive cuff and doubled the amount of repetitions for each exercise when compared to

the traditional group. The idea behind these parameters was that using blood flow restriction

would allow participants to work at a lower load and achieve the same or better results when

compared to those using traditional weight training.

This study was focused on measuring quadriceps strength and hypertrophy. To compare

strength and hypertrophy between the two groups, both baseline and final measurements were

taken. Strength was measured by performing a one-repetition maximum on leg press with a

normal stance, while hypertrophy was measured by taking quadriceps circumference and using

the SECA scan to evaluate muscle mass in the lower extremities. Taking baseline and final
measurements allowed for comparison not only between the two groups, but also revealed

individual gains.

Results

Although all eight participants finished four weeks of workouts, only six participants

completed all three baseline and final measurements. One participant did not complete the final

one-repetition maximum testing, due to muscular injury and the other participant failed to

complete an initial baseline testing for quadriceps circumference. The measurements they failed

to complete were not included in the average for the group. Even though these two participants

did not fully complete the study, the testing measures they did complete still proved to aid in the

study’s overall results.

For the control group, baseline and final averages were taken for average one-repetition

maximum on leg press, average lower extremity muscle mass in both left and right legs, and

average thigh circumference for both left and right legs. At baseline, the control group had an

average one-repetition maximum on leg press of 402.5 pounds. The baseline average for lower

extremity muscle mass on the left leg was 11.19 pounds, while the right leg was 11.36 pounds.

For average baseline thigh circumference measurements, the left leg was 21.33 inches and the

right leg was 21.27 inches. Due to minimum and maximum values among participants in the

control group being considerably close, these averages were easy to determine and were not

pulled one way or the other because of an outlying measurement. Only thirty pounds separated

minimum and maximum leg press one-repetition maximums. The lower extremity muscle mass

minimums and maximums on both legs were separated by a little more than three pounds, but

less than four pounds and the thigh circumference minimums and maximums were separated by
 ***Table for Control Group individual strength and hypertrophy gains

two inches on both legs. Final averages for the control group increased to 510 pounds for the

one-repetition maximum on leg press, 11.54 pounds on the left leg and 11.80 pounds on the right

leg for lower extremity muscle mass, and 21.50 inches on the left leg and 21.83 inches for thigh

circumference. Each average measurement, when comparing baseline to final, increased in the

traditional weight training group.

Regarding percent change of the control group’s measurements, each percent change was

positive because each measurement increased from baseline to final. For one-repetition

maximum on the leg press, the average percent change increase was 21.1%. The lower extremity

1RM Results LE Muscle Results Thigh Results

Leg Press Mass (lbs) Circumference

without (inches)

BFR (lbs)
Subject Initial Ending Percent Initial Ending Percent Initial Ending Percent

Number Change (%) Change (%) Change (%)

5 410 450 9.76% L: 9.53 L: 9.87 L: 3.58% N/A L: 19.2 N/A

R: 9.86 R: 10.17 R: 3.14% R: 19.5

6 380 540 42.11% L: 11.03 L: 12.09 L: 9.61% L: 22 L: 22 L: 0%

R: 11.28 R: 12.31 R: 9.13% R: 22 R: 22.5 R: 2.27%

7 410 540 31.71% L: 13.23 L: 12.80 L: -3.25% L: 22 L: 22 L: 0%

R: 12.93 R: 12.78 R: -1.16% R: 21.8 R: 22 R: 0.92%

8 410 Muscular N/A L: 10.98 L: 11.41 L: 3.92% L: 20 L: 20.5 L: 2.5%

Injury R: 11.38 R: 11.95 R: 5.01% R: 20 R: 21 R: 5%

muscle mass average percent change increase was 0.79% on the left leg and 2.56% on the right

leg. The thigh circumference average percent change increase was 0.83% on the left leg and

2.05% on the right leg. Even though the study only lasted four weeks, gains were obviously

made regarding strength and hypertrophy in the lower extremities.

 Similarly, the BFR group had their baseline and final measurements tested using an

average one-repetition maximum on the leg press, average lower extremity muscle mass for both

left and right legs, and average thigh circumference for both left and right legs. At baseline, the

BFR group had an average one-repetition maximum on leg press of 390 pounds. The baseline

average for lower extremity muscle mass on the left leg was 10.63 pounds, while the right leg

was 10.75 pounds. For average baseline thigh circumference measurements, the left leg was 20.5

inches and the right leg was 21.08 inches. Final averages for the BFR group increased to 530

pounds for the one-repetition maximum on leg press, 10.88 pounds on the left leg and 11 pounds

on the right leg for lower extremity muscle mass, and 21.63 inches on both the left and right legs

for thigh circumference. Each average measurement, when comparing baseline to final, increased

in the restricted blood flow weight training group.

Regarding percent change for the BFR group’s measurements, all but two percent

changes were positive because each measurement increased from the baseline to the final. For

one-repetition maximum on the leg press, the average percent change increase was 26.4%. The

lower extremity muscle mass average percent change increase was 5.22% on the left leg and

2.54% on the right leg. The thigh circumference average percent change increase was 5.57% on

the left leg and 2.89% on the right leg. To reiterate, even though the study only lasted four

weeks, gains were obviously made regarding strength and hypertrophy in the lower extremities.

This was the ideal situation concerning final results, proving the hypothesis and creating an

intriguing perspective of alternative methods for increasing muscular strength and hypertrophy,

without the implementation of heavy loading and high-impact exercise.

 1RM Results LE Muscle Results Thigh

Leg Press Mass (lbs) Circumference

with BFR (inches)

(lbs)
Subject Initial Ending Percent Initial Ending Percent Initial Ending

Number Change(%) Change(%)

1 320 450 40.63% L: 9.60 L: 9.99 L: 4.06% L: 17 L: 18.5

R: 9.71 R: 10.07 R: 3.71% R: 17.5 R: 18.5

2 360 500 38.89% L: 9.09 L: 8.97 L: -1.32% L: 21 L: 23

R: 9.12 R: 9.10 R: -0.22% R: 21 R: 23

3 540 720 33.33% L: 14.17 L: 14.53 L: 2.54% L: 23 L: 24

R: 14.37 R: 14.69 R: 2.23% R: 24 R: 24

4 340 450 32.35% L: 9.65 L: 10.04 L: 4.04% L: 21 L: 21

R: 9.79 R: 10.13 R: 3.47% R: 21.8 R: 21

***Table for BFR Group individual strength and hypertrophy gains

Discussion

The conclusions that can be drawn from results, although not explicitly proven, are that

blood flow restrictive (BFR) low-load training is equally as effective, if not exceedingly so, at

increasing muscular strength and hypertrophy in comparison to traditional methods. Under the

influence of an occluding device and restricting venous return, the study was more than capable

still to yield positive results.

Prior to testing, the topic was researched thoroughly and although hopeful to see the

results that occurred, there was a bit of uncertainty concerning the results due to such a short

study. Reviewed results seemed muddled and inconclusive, but some articles provided hope,

advocating the technique and the benefits were profound. Studies hypothesize that blood flow

restriction training induces skeletal muscle hypertrophy through a variety of mechanisms and has

a number of attached physiological and metabolic tendencies: the ability to increase fiber type
recruitment, metabolic accumulation, stimulation of muscle protein synthesis, and cell swelling,

each individual of one another, but more than likely working in correspondence. It is for these

reasons, supported by results, that initiating a positive return works as such.

Some strengths of the study included the reliability of subjects, and the consistency of

training and testing as researchers. Each individual involved, whether researcher or subject, was

more than willing to participate to generate the greatest results possible. Despite limitations such

as time constraints and a small sample size, the group as a whole was not defined by

circumstances; amazing results were fashioned in a short period of time. With such incredible

results in such a short span of time, this may be the one surprise of the study. There was a lot of

ambiguity in just how well the results would turn out. Although hope for this study was strong

amongst researchers, there was no assurance the results would be as astounding as they are.

If future research on this topic were to be considered, contemplating making some

changes would be necessary. The featured training program this time around was only four

weeks in length. When providing a larger time frame, it is convincing the results would be

further magnified and undoubtedly more credible. In addition to this, utilizing a larger sample

size, not restricted to a small number of university students, would allow the results to reflect

more diverse and profound findings. Even though making necessary changes is imperative to

more conclusive research in the future, studies revisiting the idea of blood flow restriction

training in place of traditional weight training should be more widely recognized.

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