Journal of Science in Sport and Exercise (2020) 2:25–37

https://doi.org/10.1007/s42978-019-00034-4

REVIEW ARTICLE

Blood Flow‑Restricted Training in Older Adults: A Narrative Review

Abel Plaza‑Florido1   · Jairo H. Migueles1 · Antonio Piepoli2 · Pablo Molina‑Garcia1,3 · Maria Rodriguez‑Ayllon1 ·
Cristina Cadenas‑Sanchez1 · Jose Mora‑Gonzalez1 · Irene Esteban‑Cornejo1,4 · Francisco B. Ortega1

Received: 17 April 2019 / Accepted: 4 September 2019 / Published online: 10 October 2019
© Beijing Sport University 2019

Abstract
Background  Low-intensity resistance training (LI-RT) combined with blood flow restriction (BFR) is an alternative to
traditional moderate–high-intensity resistance training to increase strength and muscle mass. However, the evidence about
the efficacy of this novel training method to increase strength and muscle mass in healthy and older adults with patholo-
gies is limited. Furthermore, the possible risk and adverse effects with BFR training methodology in older adults should
be considered.
Objectives  (1) To summarize the current evidence on training with BFR strategies in older adults aiming to improve strength
and to increase muscle mass; and (2) to provide recommendations for resistance and aerobic training with BFR in older
adults based on the studies reviewed.
Methods  Studies that investigated the chronic responses to resistance training or aerobic training with BFR related to strength
and muscle mass changes in older adults were identified. Two independent researchers conducted the search in PubMed,
Web of Science, and Google Scholar databases from their inception up to November 1, 2018.
Results  Seventeen out of 35 studies, which performed resistance or aerobic training with BFR in older adults focused
on strength and muscle mass outcomes, were included in this review. Studies performing resistance and aerobic train-
ing with BFR found better improvements in strength and higher increase in muscle mass compared to non-BFR groups
that performed the same training protocol. High-intensity resistance training (HI-RT) without BFR provided greater
improvements in strength and a similar increase in muscle mass compared to light-intensity resistance training (LI-
RT) with BFR.
Conclusions  Current evidence suggests that LI-RT and/or aerobic training with BFR improves strength and increases
muscle mass in older people. Light-intensity training without BFR would normally not obtain such benefits. Therefore,
LI-RT and aerobic training with BFR is an alternative to traditional methods to improve strength and by way of an
increase in muscle mass, which are important in the elderly who have progressive muscle atrophy and are at higher risk
of falls.

Keywords  Hypertrophy · Strength · Vascular occlusion · Resistance training · Elderly adults

Jairo H. Migueles and Antonio Piepoli contributed equally.

* Abel Plaza‑Florido
abeladrian@ugr.es
1
PROFITH “PROmoting FITness and Health Through
Physical Activity” Research Group, Sport and Health
University Research Institute (iMUDS), Department
of Physical and Sports Education, Faculty of Sport
Sciences, University of Granada, Carretera de Alfacar, s/n,
CP 18071 Granada, Spain
2
Department of Health Sciences, Faculty of Health Sciences,
University of Jaén, Research Group CTS-026: Study Group
on Physical Activity, Physiotherapy and Health, Jaén, Spain
3
Department of Rehabilitation Sciences, KU
Leuven-University of Leuven, Leuven, Belgium
4
Department of Psychology, Center for Cognitive and Brain
Health, Northeastern University, Boston, MA, USA

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26
Introduction
The aging process is often characterized by a substantial
decrease in muscle mass, strength and physical function
[8, 9, 29]. This condition is considered a geriatric syn-
drome called sarcopenia [43]. The presence of sarcopenia
has been associated with several adverse consequences,
such as disability, high risk of falling and bone fractures,
poor quality of life, and a higher risk of mortality [21,
34, 35]. According to the European Group on Sarcopenia
in older people (EWGSP), the prevalence of sarcopenia
ranges from 17 to 33% among institutionalized older peo-
ple [2, 20]. Thus, an increase in strength and muscle mass
has clinical and public health consequences in this popula-
tion, and resistance training currently represents an effec-
tive treatment to control and even reverts sarcopenia [10].
To generate desirable training adaptations, the Ameri-
can College of Sports Medicine recommendations for
older adults suggests that resistance training should be
performed at high intensity. The intensity should increase
gradually from 60% to over 80% of the individual one rep-
etition maximum (1RM) [4, 33]. Supporting these recom-
mendations, several studies demonstrated that high-inten-
sity resistance training (HI-RT), i.e., ≥ 70% of 1RM, are
associated with improvements in strength and muscle mass
in older adults [39, 42]. However, the training progression
is usually compromised in advanced years of life due to
injuries, orthopedic limitations, and other pathologies that
negatively affect the musculoskeletal function [23].
A novel training alternative could be light-intensity resist-
ance training (LI-RT) with partial blood flow restriction
(BFR), i.e., 20–30% of 1RM. This type of training has been
demonstrated to be an effective method to improve strength
and to increase muscle mass compared to the classical HI-RT
in athletes and young adults [47, 48]. High metabolic stress
(i.e., accumulation of metabolites during exercise) could
play a key role in the increase in strength and muscle mass
observed with low-intensity BFR training, which acts via
several unique mechanisms (e.g., increased fast-twitch fiber
recruitment, muscle damage and systemic and localized hor-
mone production) irrespective of lower training intensities
[32]. Also, LI-RT with BFR has shown to be safe in young
healthy adults [5]. However, little is known about the clinical
application of resistance and aerobic training with BFR that
leads to improve strength and muscle mass in healthy and
older adults with pathologies. Likewise, potential risks and
adverse effects of training with BFR in older adults should
be discussed. This issue should be considered by profession-
als when applying this methodology of training with older
adults in clinical settings and fitness centers.
Therefore, the aims of the present narrative review were
(1) to provide an overview of the effects of resistance and
13
Journal of Science in Sport and Exercise (2020) 2:25–37
aerobic training with BFR on strength and muscle mass and
(2) to provide exercise recommendations of training with
BFR in older adults based on the studies reviewed (i.e., type
of exercise, duration, frequency, sets × repetitions, resting
time, intensity, exercises).
Methods
Two independent researchers (AP-F and AP) conducted the
search in PubMed, Web of Science, and Google Scholar
databases from inception up to November 1, 2018. The key-
words included blood flow restriction, occlusion, Kaatsu,
vascular occlusion, ischemia, hypertrophy, resistance train-
ing, strength training, aerobic exercise, walking training,
older people, and elderly people. We defined the inclusion
criteria as follows: (1) participants ≥ 55 years old, (2) inter-
vention studies using resistance training and/or aerobic train-
ing (walking/cycling) with BFR (specific duration was not
selected for interventions) and (3) report any measurement
of strength and/or muscle mass (i.e., isokinetic strength,
increase in 1RM and the cross-sectional area, etc.).
Results
Seventeen out of the 35 identified studies were included
in the review. Studies were not selected if they performed
resistance and aerobic training with BFR in older adults but
focused on outcomes that were not strength or muscle mass
(i.e., hemodynamic parameters, blood markers of inflamma-
tion, hormones, etc.). Detailed information about the inter-
ventions performed in the selected studies can be found in
Table 1.
Changes in Strength‑Associated Resistance
and Aerobic Training with BFR
Sixteen out of the seventeen articles listed in Table  1
reported changes in strength measurements. In general, the
groups that performed LI-RT in BFR conditions showed sig-
nificant improvements in different strength measurements
compared with LI-RT in non-BFR conditions (see Table 1).
Among the sixteen studies, thirteen performed resistance
training [7, 15, 18, 22, 30, 37, 40, 50–55] and three aerobic
training [1, 26, 27] with BFR (Fig. 1).
Concerning isometric knee strength, Yokokawa et al.
reported around 20.4% of improvements in BFR condition
[55]. In regard to isokinetic strength, Patterson et al. showed
around 20% of improvement in plantar isokinetic strength at
0.52 rad/s in BFR condition [30]. Likewise, improvements
in leg press exercise RM (1 repetition maximum) ranged
 Table 1  Summary of studies examining the effects of combined BFR training on musculoskeletal health in older adults (n = 17)
References Participants (age and Type of exercise Intensity of exercise (set × rep) Training frequency and Cuff pressure (width) Assessment technique (A)
sex) duration and results in the BFR
group

Abe et al. [1] 19 (60–78 years old and Walk training 45% of HR maximum reserve 5 × week 160–200 mmHg (training A: IKS, MIKS, CSA
11 females) (average HR 104 beats/min). 6 weeks pressure was increased  Isokinetic knee extension
20 min by 10 mmHg each week) and flexion torques: ↑ 7%
(cuff width not reported) and ↑ 16%
 Maximal isometric knee:
↑ 11%
 Muscle-bone CSA: ↑ 5.8%
and ↑ 5.1% thigh and
lower leg, respectively
 Ultrasound skeletal muscle
mass: ↑ 6.0% and ↑
10.7% for total and thigh,
Journal of Science in Sport and Exercise (2020) 2:25–37

respectively
Cook et al. [7] 36 (73.4–78.5 years old Resistance training: leg BFR LI-RT: 1–3 sets 30–50% 2 × week 1.5 times brachial systolic A: RM, CSA
and 21 females) extension, leg curl, and RM; volitional failure 12 weeks blood pressure and  1 RM leg extension and leg
horizontal leg press 60-s rest between sets and 3 min average pressure of press: ↑ 24% and 12%
machine exercises between exercises 184 ± 25 mmHg CSA: ↑ 4.3%
Non-BFR HI-RT: 70% RM
Gualano et al. 1 (case report; sporadic Resistance training: leg 3 × 15 RM; 30-s rest cuff pres- 2 × week 50% of total occlusion A: RM, CSA
[15] inclusion body press, knee extension, sure maintained 12 weeks pressure (65 mmHg)  Leg press: ↑ 15.9%
myositis) and squat exercises  Thigh CSA: ↑ 4.7%
(65 years old; male)
Jørgensen et al. 1 (case report; sporadic Resistance training: 30–35% RM 2 × week 100 mmHg (150 mm A: MMF, MHGS
[18] inclusion body unilateral leg press, 3–4 sets, reps until exhaustion. 12 weeks width)  Mechanical muscle func-
myositis; 74 years old; isolated knee exten- tion (maximal isometric
1 male) sion, seated calf raise strength, rate of force
development, and muscle
power): ↑ 38–92%
 Maximal horizontal gait
speed: ↑ 19%
Libardi et al. 25 (60.6–68.8 years old Endurance training and BFR LI-RT: endurance training: Endurance T: 2 days/ 50% RAOP: A: RM, CSA
[22] and not reported sex) resistance training (leg 50–80% ­VO2peak week, resistance T: 67 ± 8.0 mmHg (175 mm  1 RM 45° leg press: no
press) (30–40 min), resistance training: 2 days/week width, 920 mm length) significant difference
20–30% 1–RM (1 × 30 and 3 12 weeks between-group
× 15)  CSA: no significant differ-
60 s rest ence between-group
Non-BFR HI-RT: endurance
training: 50–80% V­ O2peak
(30–40 min), resistance train-
ing: 70–80% 1–RM (4 × 10)
60 s rest

13
27

28

Table 1  (continued)
References Participants (age and Type of exercise Intensity of exercise (set × rep) Training frequency and Cuff pressure (width) Assessment technique (A)
sex) duration and results in the BFR

13
group

Ozaki et al. [26] 23 (56–76 years old and Walk training 45% HRR 4 × week 200 mmHg (5 cm) A: IKS, CSA
18 females) (20 min) 10 weeks  Isokinetic knee extension:
↑ 8.7% (N/m)
 Isokinetic knee flexion: ↑
15% (N/m)
 CSA ↑ 3.2% ­cm2
Ozaki et al. [27] 18 (57–73 years old and Walk training 45% of HRR; mean tread- 4 × week 140–200 mmHg; elastic A: IKS, MIS, CSA, MV
females) mill speed and grade were 10 weeks cuff (5 cm wide) (magnetic resonance
4.5 ± 0.0 km/h and 1.6 ± 0.4 imaging)
20 min  Isokinetic knee extension:
↑ 8% (N/m)
 Isokinetic knee flexion:
↑ 22%
 Maximal isometric
strength: ↑ 5.9%
CSA thigh: 3.1%
MV thigh: 3.7%
Ozaki et al. [28] 26 (69 ± 1 years old and 3 groups-walking train- 70–85% of the age-predicted 2–4 × week (without Based on the circumfer- A: MT
11 females) ing + stair-climbing: maximum heart rate BFR) ence of the right thigh  No significant differences
(WS), (WS-BFR1), 20–30 min per session Additionally, 1–2× week (< 50 cm, 100 mmHg; and between groups
(WS-BFR2) (BFR groups) 50–55 cm, 120 mmHg.
11 weeks Cuff width 105 mm)
Patterson et al. 10 (62–73 years old and Resistance training: uni- 25% 1 RM; (3× failure); 1 min 3 × week 110 mmHg A: RM; MVC; MIT
[30] 2 females) lateral plantar flexion rest 4 weeks  Plantar flexion: RM ↑
14% kg
 Plantar flexion: MVC
↑18%
 MIT at 0.52 rad/s ↑ 20%
MIT at 1.05 rad/s ↑ 17%
Shimizu et al. 40 (67–75 years old and Resistance training: leg 20% RM (3 × 20) 3 × week Femoral SBP, brachial SBP A: RM
[37] 7 females) extension, leg press, 30 s rest 4 weeks (leg cuff width: 10 cm;  Leg extension (before:
rowing, chest press arm cuff width: 7 cm) 46.8 ± 11.1, after:
55.7 ± 16.7)
 Leg press (before:
138.7 ± 35.7, after:
154.4 ± 36.8)
 Rowing and chest press
increased but not signifi-
cantly
Journal of Science in Sport and Exercise (2020) 2:25–37
 Table 1  (continued)
References Participants (age and Type of exercise Intensity of exercise (set × rep) Training frequency and Cuff pressure (width) Assessment technique (A)
sex) duration and results in the BFR
group

Silva et al. [40] 15 (62.2 ± 4.53 years Resistance training: uni- BFR LI-RT: 30% RM, 4× fail- 2 × week 104.20 ± 7.88 mmHg A: RM
old, female osteopo- lateral knee extensions ure, 30-s rest 12 weeks (18 cm width)  Leg extension machine
rosis) Non-BFR HI-RT: 80% RM, 4×   BFR LI-RT
failure, 2-min rest (PRE = 35.85 ± 6.72,
POST = 40.10 ± 7.39)
  Non-BFR HI-RT
(PRE = 27.78 ± 3,45,
POST = 37.37 ± 4.58). No
significant differences
Thiebaud et al. 14 (61 ± 5 years old and Upper body: seated chest Non-BFR MHI: 70% to 90% 1 3 × week 80–120 mmHg (width A: RM, MT
[50] female) press, seated row and RM; 3 × 10, 1–2-min rest 8 weeks 3.3 cm). Only upper body  RM in Chest press, seated
seated shoulder press. BFR LI-RT 10–30% 1 RM, row, and shoulder press
Journal of Science in Sport and Exercise (2020) 2:25–37

Lower body: knee exten- 3×30–15–15, 30-s rest increased but there were
sion, knee flexion, hip Elastics bands were used no differences between
flexion, hip extension. groups
 Muscle thickness the pec-
toralis major: ↑ 17%
Vechin et al. [51] 23 (60.23–67.85 years Resistance training: leg 20–30% 1 RM (1 × 30 and 3 2 × week 50% tibial SBP (18 cm) A: RM, CSA
old and 9 females) press × 15) 12 weeks  Leg press RM: ↑17%
1-min rest  Quadriceps CSA: ↑ 6.6%
Yasuda et al. [52] 19 (61–84 years old and Resistance training: knee 20–30% RM 2 × week 120–270 mmHg (50 mm) A: RM, CSA
14 females) extension and leg press (1 × 30, 1 × 20, 1 × 15, 1 × 10) 12 weeks  Leg press RM: ↑ 33.4%
30 s rest  Leg extension RM: ↑
26.1%
 Quadriceps CSA: ↑ 8%
 Adductors CSA: ↑ 6.5%
 Gluteus maximus CSA: ↑
4.4%
Yasuda et al. [53] 17 (61–85 years old and Resistance training: “Heavy (green)” band for men 2 × week 120–270 mmHg (30 mm) A: MVIC, CSA
14 females) arm curl and triceps and “Thin (yellow)” band for 12 weeks  MVIC: ↑ 7.8%
pushdown women (elbow flexion)
(1 × 30 and 3 × 15)  MVIC: ↑ 16.1%
30 s rest between sets, 90 s (elbow extension)
between exercises  CSA elbow flexors ↑ 17.6%
 CSA elbow extensor ↑
17.4%

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29

30

Table 1  (continued)
References Participants (age and Type of exercise Intensity of exercise (set × rep) Training frequency and Cuff pressure (width) Assessment technique (A)
sex) duration and results in the BFR

13
group

Yasuda et al. [54] 30 (61–86 years old and Resistance training: 5–9 OMNI (extremely easy 0 to 2 × week 120–200 mmHg (50 mm) A: MVIC, RM, CSA
females) squat and knee exten- extremely hard 10) elastic band 12 weeks  Knee extension MVIC: ↑
sion (1 × 30 and 3 × 15) 13.7%
30 s rest between sets, 90 s  Knee extension RM: ↑
between exercises 7.6%
 Leg press RM: ↑ 16.4%
 Quadriceps CSA: ↑ 6.9%
Yokokawa et al. 51 (65 years old and 34 BFR: half squats, BFR: 3–5 sets, 10–15 reps, 20 s 2 × week 70–150 mmHg (45 mm) A: MVIC
[55] females) forward lunges, calf to 5 min rest 8 weeks  Left knee extension MVIC:
raises, knee lifts, ↑20.4%
crunches, knee flexion  Right knee extension
and extension while MVIC: ↑ 6.9%
seated
DBE: symmetrical and
asymmetrical move-
ments, forward and
lateral reach, forward
and backward steps,
standing and walk-
ing on a reduced base
of support, increas-
ing the complexity
of ambulatory tasks,
and functional ankle
strengthening

Higher/increase of the variable studied (↑)

BFR blood flow restriction, BFR-RT blood flow restriction resistance training, CON control, CSA muscle cross-sectional area, DBE dynamic balance exercise, ET endurance training, F female,
HI high intensity, HI-RT high-intensity resistance training, HRR heart rate reserve, IKS isokinetic knee strength, LI-BFR light-intensity blood flow restriction, M male, ME muscle endurance,
MHGS maximal horizontal gait speed, MIKS maximal isometric knee strength, MIS maximal isometric strength, MIT maximum isokinetic torque, MMF mechanical muscle function, MP mean
power, MT muscle thickness, MVC maximal voluntary contraction, MVIC maximal voluntary isometric contraction, NE no specification, OMNI-RES OMNI resistance exercise scale, RAOP rest-
ing arterial occlusion pressure, RM repetition maximum, RT resistance training, SBP systolic blood pressure, WS normal walking and stair-climbing, WS-BFR1 WS and BFR-walk once a week,
WS-BFR2 WS and BFR-walk twice a week
Journal of Science in Sport and Exercise (2020) 2:25–37
Journal of Science in Sport and Exercise (2020) 2:25–37 31
Fig. 1  Graphical illustra-
tion of the current evidence
around training with BFR in
older adults aiming to improve
strength and increase in muscle
mass. The symbols (+) or (=)
indicate that these training
approaches indicated by the
arrow gained more (+) or equal
(=) strength and/or muscle mass
from 12 to 33.4% [7, 15, 22, 37, 51, 52, 54], in leg exten-
sion RM from 7.6 to 26.1% [7, 37, 40, 52, 54] and increases
of + 15.7 and + 8.9 kg in leg press RM and leg extension in
BFR condition [37]. However, one study did not report sig-
nificant differences in rowing and chest press between BFR
and non-BFR conditions [50]. Plantar flexion RM showed
increases of 14% [30]. Light-intensity resistance training in
non-BFR conditions did not show significant increases in
strength measurements. However, similar improvements in
strength between LI-RT in BFR condition and HI-RT non-
BFR groups were also reported [40, 50, 51].
Related to the aerobic training programs with BFR, some
studies [1, 26, 27] reported increases in the knee extension
isometric strength ranging from 5.9 to 11.8%, the knee
extension isokinetic strength (N/m) ranging from 7 to 8.7%,
as well as in the knee flexion isokinetic strength (N/m) rang-
ing from 16 to 22% [1, 26, 27].
Changes in Muscle Mass Associated with Resistance
and Aerobic Training with BFR
Twelve articles out of the seventeen listed in Table  1
reported changes in muscle mass. Among the twelve stud-
ies, eight performed resistance training [7, 15, 22, 50–54]
and four performed aerobic training [1, 26–28] with BFR.
In general, the groups that performed LI-RT in BFR condi-
tions showed a significant increase in muscle mass compared
with LI-RT in non-BFR conditions. Some studies that per-
formed LI-RT with BFR reported cross-sectional area (CSA)
in the quadriceps from 6.9 to 8.0% of improvements [52, 54],
with adductors 6.5% and gluteus maximus 4.4% [52]. Also,
it has been reported CSA increase of 17.6% in the elbow
flexors and 17.4% in the extensors [53]. However, other stud-
ies reported similar increases in quadriceps CSA between
LI-RT with BFR and the HI-RT non-BFR groups [7, 22,
51]. Changes ranged from 3.6 to 7.9%. Likewise, Thiebaud
et al. [50] reported a significant but similar increase in pec-
toral muscle thickness (17%) in LI-RT with BFR and HI-RT
non-BFR groups.
Walking with BFR has a positive effect on muscle mass.
Abe et al. [1] reported an increase in the thigh muscle–bone
CSA of + 5.8% and +5.1% in the lower leg muscle–bone
CSA. Also, Ozaki et al. [26, 27] observed that the walking
BFR group increased their thigh muscle CSA (+ 3.2%) [27]
and their muscle CSA ­(cm2) in the thigh and quadriceps
(+ 3.1% and + 3.0%, respectively) [26]. However, another
study [28] reported no additional improvements in muscle
thickness after the inclusion of 1–2 sessions per week of
walking with BFR.
Discussion
Light-intensity resistance training or walking with BFR
seems to be more effective to increase strength and muscle
mass than the same training methods without BFR. In addi-
tion, HI-RT non-BFR seems to provide higher improvements
in strength compared to LI-RT with BFR. Furthermore,
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32
although the number of studies found was limited, similar
increases in muscle mass occurred with HI-RT without BFR
and LI-RT with BFR. Therefore, training with BFR may be a
viable alternative to HI-RT to improve strength and increase
muscle mass in older adults in scenarios where heavy loads
may not be safe or suitable.
Effects of Changes in Strength Associated
with Resistance and Aerobic Training with BFR
In general terms, participants in LI-RT in BFR condition
improved their strength more than LI-RT non-BFR. How-
ever, Shimizu et al. [37] reported no differences between
groups in 1 RM rowing and chest press exercises. A possible
explanation for the lack of improvement in rowing and chest
press is that the main muscles implicated in these exercises
(latissimus dorsi and pectoralis, respectively) do not work
under direct BFR, although increments in strength and gains
in muscle mass related to muscles proximal to the applied
pressure have been previously reported (chest, shoulder,
back) [11].
Importantly, similar improvements in resistance train-
ing with BFR compared to the traditional HI-RT non-BFR
groups have also been reported [40, 50, 51]. In the study of
Silva et al. [40], conducted on women with osteoporosis,
the HI-RT non-BFR group showed higher improvements in
1RM leg extension compared to the LI-RT group with BFR
(HI-RT non-BFR group: mean increase post-intervention
9.59 kg; and LI-RT with BFR group: mean increase post-
intervention 4.25 kg). Vechin et al. [51] also found that the
HI-RT non-BFR group increased the RM leg press more
than the LI-RT group with BFR (+ 54% and + 17%, respec-
tively). These higher strength improvements in the HI-RT
non-BFR groups can be due to predominant neural adapta-
tions to higher intensities. In addition, the strength differ-
ences can also be influenced by the different resting time
intervals between sets in the LI-RT with BFR groups (usu-
ally 30 s) and the HI-RT non-BFR groups (1–2 min). Hence,
this aspect should also be taken into consideration [12].
Nevertheless, Thiebaud et al. [50] found no significant
differences between healthy participants completing a LI-RT
with BFR and a moderate-to-high resistance training non-
BFR (70–90% RM, ranging from 7 to 9 on the OMNI Resist-
ance Exercise Scale). It is also possible that, in this study,
a different control of intensity (OMNI Resistance Exercise
Scale) with elastic bands and modification of elongation
might have produced similar improvements between groups
and contradictory findings reported in other studies [40, 51].
Furthermore, some studies have investigated adapta-
tions in older adults performing concurrent training with
BFR [22]. For instance, Libardi et al. [22] found no differ-
ences in lower body strength between the BFR and non-
BFR groups. The endurance training was the same for both
13
Journal of Science in Sport and Exercise (2020) 2:25–37
training groups, but strength training was different (BFR
group: 1 × 30 sets and 3 × 15 sets at 30% RM, non-BFR
group: 4 × 10 at 70% RM). The lack of differences between
groups can be due to the fact that LI-RT with BFR has pre-
viously shown to increase the recruitment of type II muscle
fibers [44, 45]. In addition, another study has shown similar
recruitment of type II muscle fibers between LI-RT with
BFR and HI-RT non-BFR [45]. The physiological mecha-
nism is not well understood, but it is suggested that partial
BFR causes low oxygen supply to active muscles and an
increase in metabolites and intramuscular pH [49]. In fact,
these results in altered recruitment patterns of the fibers
[44] lead to neuromuscular adaptation. The combination of
LI-RT with BFR and endurance training in the same micro-
cycle can be an interesting approach to improve strength in
older people with reduction of mechanical stress.
Changes in Muscle Mass Associated with Resistance
and Aerobic Training with BFR
Some studies have found higher increments in the CSA
of different muscles (e.g., quadriceps, adductors, gluteus
maximus, elbow flexors and extensors) in the LI-RT with
BFR groups with respect to LI-RT non-BFR groups [52,
54]. Similarly, Gualano et al. [15] found an increase in the
thigh CSA (4.7%) in a case report with a participant aged 65
affected by inclusion body myositis. Nonetheless, Thiebaud
et al. [50] did not show significant changes in biceps, triceps
and deltoid muscle thickness, using a protocol of training
with elastic bands.
Other studies reported similar increases in quadriceps
CSA between LI-RT with BFR and the HI-RT non-BFR
groups [7, 51]. Metabolic stress might be similar in LI-RT
with BFR and HI-RT non-BFR, which can explain the
similar increase in muscle mass [17]. However, neural
adaptations can determine differences in strength gains
between the abovementioned groups [17]. Likewise, some
studies reported that walking with BFR has a positive
effect on muscle mass while non-BFR conditions do not
[1, 26, 27]. However, another study of Ozaki et al. [28] did
not report additional improvements in muscle thickness
after the inclusion of 1–2 sessions per week. Possibly, the
frequency of walking with BFR conducted in this inter-
vention might have not been sufficient compared to higher
frequency used in other studies (frequency of 4–5 days per
week) [1, 27].
Potential Mechanisms
Light-intensity resistance training and walking with BFR
seem to be more effective to increase strength and mus-
cle mass than the same protocol without BFR. Fry et al.
[13] suggested some physiological mechanisms that could
Journal of Science in Sport and Exercise (2020) 2:25–37 33

explain this increment in older people. They found that a
single session of LI-RT with BFR increased muscle protein
synthesis by 56% 3 h after the end of the session, while
muscle protein synthesis did not increase performing the
same intervention without BFR. Likewise, they observed
increases in the phosphorylation of the ribosomal protein
S6 kinase beta-1 (S6K1) in the BFR condition, suggesting
enhanced mammalian target of rapamycin (mTORC1) sign-
aling following exercise. This could explain the increase in
protein synthesis after exercise observed in the BFR group.
Also, Gualano et al. [15] found a 3.97-fold increment in the
mechano growth factor and a 40% reduction in atrogin-1
gene expression. This suggests an increase in muscle protein
synthesis. Likewise, Santos et al. [36] found a 25% reduc-
tion of the myostatin mRNA level, which could explain the
physiological mechanisms by which LI-RT with BFR pro-
duces an increase in muscle mass.
In conclusion, LI-RT or walking with BFR seems to be
more effective to improve strength and increase muscle
mass than the same training protocols in non-BFR condi-
tions. Therefore, resistance training with BFR may be an
alternative to HI-RT to increase strength and muscle mass
in older adults compared to the same training protocol with-
out BFR. However, to interpret these findings, it should be
taken into account the differences in the methods used in the
studies in cuff pressure, different strength measures, differ-
ences in training modalities (i.e., failure and non-failure),
and different characteristics of the samples (not all the old
participants included in the studies were healthy, or suffered
from osteoporosis or from sporadic inclusion body myositis)
between studies.
Notwithstanding, a systematic review has been published
recently on this topic in healthy older adults [3]. In brief,
although many of the articles reviewed were similar in both
reviews, we did not exclude studies with older adults pre-
senting any pathology (e.g., body myositis, osteoporosis)
as Centner et al. did. Furthermore, Center et al. mention
that taking a thorough cardiovascular disease history from
each individual is important to avoid adverse events [3].
In this regard, we reviewed and discussed potential risks
and adverse effects of occlusive training in older adults
(“Risks, side effects, and contraindications of BFR in older
adults”). This issue should be considered by professionals
when applying this methodology of training to older adults
in clinical settings and fitness centers.
Exercise Recommendations Using Resistance
and Aerobic Training with BFR in Older
Adults
The recommended characteristics of the resistance and aero-
bic training with BFR for improving strength and increase
muscle mass are shown in Table 2. Although more inter-
vention studies comparing different protocols are needed,
based on the effectiveness of all the protocols included in
this review, we suggest a minimum of 4 weeks to improve
strength and muscle mass in older people, with 2–3 sessions/
week, at 20% of 1RM when LI-RT is combined with BFR
and 20 min at 45% of heart rate reserve when aerobic train-
ing (walking) is combined with BFR. Training with BFR
may be effective even with very low intensities (i.e., 20% of
1RM for LI-RT and 45% HRR for walking). The leg press,
knee extension, and squat exercises have shown beneficial
effects on the lower limbs and chest press, rowing, arm curl,
and triceps pushdown exercises in the upper limbs, but more
studies using different exercises are still needed.
We found it is important to highlight the methodologi-
cal differences between studies regarding the cuff pressure.
While some studies applied cuff pressure arbitrarily [12,
28], others controlled its application as a percentage of sys-
tolic blood pressure or as a percentage of resting arterial
occlusion pressure [22]. It is especially important to bear
in mind the considerations of Loenneke et al. [24], who
reported that wide cuffs restrict the arterial blood flow at
lower pressures than narrow cuffs (wide cuffs 13.5 cm and
narrow cuffs 5 cm). Also, limbs with a larger circumference
require higher occlusive pressures to reach the same level of

Table 2  Characteristics of combined BFR training in older adults based on the studies reviewed
Characteristics Recommendation

Type of exercise Resistance training/walking

Duration of program 4–12 weeks
Frequency 2–3 sessions/week in resistance training programs and 4–5 sessions/week in walking programs
Sets × repetitions, durations of walking session 3–4 sets of 15–30 repetitions; 20 min walking sessions
Rest interval between sets 20–60 s
Intensity 20–30% of 1 RM for LI-RT and 45% HRR for walking
Exercises Leg press, knee extension, squat for the lower body and chest press, rowing, arm curl, and
triceps pushdown exercises in the upper limbs

BFR blood flow restriction, HRR heart rate reserve, LI-RT light-intensity resistance training, RM repetition maximum

13

34
arterial occlusion [24]. Regarding pressure control, studies
should take into consideration the type of cuff used (wide
or narrow), trying to adjust the cuff to the limb circumfer-
ence. All aspects related to cuff width and pressure have
been explained in detail in a recent position stand, which
focused on the methodology for BFR training [31]. Detailed
information about methodological differences in cuff pres-
sure can be found in Table 1.
We encourage exercise professionals and physical thera-
pists to implement LI-RT with BFR to improve strength and
muscle mass (mainly in lower limbs) in older adults. The
performance of movements involving major muscle groups,
e.g., leg press, leg extension, and squat, has shown the most
significant improvements in strength and muscle mass.
Furthermore, beneficial muscular adaptations have been
reported with BFR training using absolute pressure values
ranging from 60 to 270 mmHg based on the studies included
in our review. Higher BFR pressures can induce discomfort
and augment cardiovascular response [25] and, therefore,
they are not recommended in this population. Using wide
cuffs may limit movement during the exercise [25]. Thus,
we recommend using low pressures and not extremely wide
cuffs to increase the adherence to exercise and avoid possible
risk with the implementation of training with BFR in older
adults. The cuff material (nylon vs. elastic) used is not a rel-
evant issue as it could not have a relevant effect on muscular
adaptations [25]. The pressure should be relative to the indi-
vidual based on the cuff used during the exercise (40–80%
of the arterial occlusion pressure). We should inflate the cuff
(i.e., the same cuff used during exercise), stopping before
blood flow ceases (100% of arterial occlusion pressure) and
using a 40–80% of that pressure during exercise [25].
Risks, Side Effects, and Contraindications
of BFR in Older Adults
The studies included in the present review did not report
adverse consequences of training with BFR in older adults.
In this context, Nakajima et al. [25] gave questionnaires to
instructors or leaders of 105 facilities to learn the side effects
while of training with BFR in all generations of people
(healthy and with pathology). They reported a reduced num-
ber of side effects. The main negative effects reported were
venous thrombus (0.055%), pulmonary embolism (0.008%),
and rhabdomyolysis (0.008%). In addition, Clark et al. [5]
reported safety (markers of coagulation and inflammation)
in LI-RT with BFR in young healthy adults. Nonetheless,
exercise pressor reflex can markedly increase the sympa-
thetic neural activity in several cardiovascular diseases [41],
and training with BFR does not have this possible response
in older adults.
13
Journal of Science in Sport and Exercise (2020) 2:25–37
Kacin et  al. [19] points to contraindications when
training with BFR: (1) having a family history of clotting
disorders (hemophilia, high platelets); (2) suffering from
hypertension I (SBP ≥ 140 mmHg); (3) having a past his-
tory of pulmonary embolus; (4) having suffered from a
hemorrhagic or thrombotic stroke. These contraindications
should be taken into consideration when using resistance
and aerobic training with BFR in older adults. In summary,
training with BFR is relatively safe, but caution should
be used by personal trainers and health care professionals
when implementing this novel training approach in older
adults. Several studies have shown that training with BFR
can lead to high creatine kinase values [16, 38], indicating
that potential risk for rhabdomyolysis could exist even in
healthy young people.
Practical Implications
The loss of strength and muscle mass with aging may result
in poor quality of life and impaired performance of daily liv-
ing activities [14, 46]. Training with BFR uses less mechani-
cal stress and may be an alternative to high-intensity train-
ing to improve strength and increase muscle mass in older
adults. Furthermore, not only improvements in strength and
muscle mass have been reported in older adults with BFR
training, but also the physical function has shown significant
improvement with BFR training in older adults [6]. This
review contains useful information about the characteris-
tics of training with BFR in older adults (studies including
adults over 55 years of age) that lead to improvements in
strength and increases in muscle mass, based on available
evidence. Furthermore, we propose exercise recommenda-
tions for health professional and personal trainers who use
resistance and aerobic training with BFR in older adults. The
goal is to provide guidance to those training with BFR and
recommendations for the correct implementation of resist-
ance training or walking with BFR in older adults. Moreo-
ver, this review sheds light on the characteristics that train-
ing with BFR should have to achieve considerable changes
in strength and muscle mass, which are precisely negatively
affected with age.
Importantly, the recommendations provided in our review
should be considered with caution due to the lack of rand-
omized controlled trials in older adults training with BFR
and the heterogeneity of the interventions. Furthermore, the
optimal level of pressure and cuff width cannot be addressed
in the present narrative review due to wide ranges provided
(i.e., 60–270 mmHg and 3–18 cm, respectively). In this
regard, a recent position stand explains in detail meth-
odological aspects (cuff width and pressure among other
Journal of Science in Sport and Exercise (2020) 2:25–37 35
aspects) of BFR training [31]. More interventions employing
training with BFR in older adults followed by systematic
reviews and meta-analysis will provide further insights into
this topic. Likewise, we think that this narrative review is
practical and useful to provide a general overview of the
current literature in this topic for clinical professionals and
personal trainers while more randomized controlled trials
are to be carried out.
Limitations and Strengths
The major limitation of the present review is the reduced
number of studies in older adults. Also, a narrative review
was performed instead of a systematic review. Unlike the
narrative review, systematic reviews are based on the find-
ings of comprehensive and systematic literature searches
with minimization of bias. Likewise, the quality assessment
of the studies was not performed.
Our narrative review provides practical recommenda-
tions for resistance training or aerobic training with BFR
in healthy and older adults with pathologies based on the
studies reviewed, although it should be taken into account
cautiously due to the heterogeneity related to the methodo-
logical issues about BFR pressures and cuff width reported
in the different studies.
Conclusions
Evidence suggests the effectiveness of resistance and aerobic
training with BFR interventions in older adults to increase
strength and muscle mass using low intensities as an alter-
native to the HI-RT. Improvements in strength and muscle
mass have important consequences in this population, who
is characterized by a progressive muscle atrophy and high
risk of falls. The information provided in this review could
be useful for clinical professionals and personal trainers for
the correct and successful implementation of resistance and
aerobic training with BFR in older adults.
Acknowledgements  CC-S is supported by a grant from the Spanish
Ministry of Economy, Industry and Competitiveness (BES-2014-
068829). A P-F, JHM, and J M-G are supported by the Spanish Min-
istry of Education, Culture and Sport (FPU 16/02760, FPU15/02645,
and FPU14/06837, respectively). FBO is supported by a grant from
the Spanish Ministry of Science, Innovation and Universities (RYC-
2011-09011). I E-C is supported by a grant from the Alicia Kop-
lowitz Foundation. M R-A is supported by the National Operational
Programme on Youth Employment. Additional support was obtained
from the Scientific Excellence Unit on Exercise and Health (UCEES)
and EXERNET Research Network on Exercise and Health in Spe-
cial Populations (DEP2005-00046/ACTI). This study has been par-
tially funded by the University of Granada, Research and Knowledge
Transfer Fund 2016, Excellence actions: Scientific Units of Excel-
lence; Unit of Excellence on Exercise and Health (UCEES), and by
the Andalusian Regional Government, Consejería de Conocimiento,
Investigación y Universidades and European Regional Development
Fund (ERDF), ref.SOMM17/6107/UGR. We are grateful to Ms. Car-
men Sainz-Quinn and Ms. Ana Yara Postigo-Fuentes for assistance
with the English language.
Compliance with Ethical Standards 
Conflict of interest  The authors do not have any conflict of interest to
disclose.
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