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Journal of Science and Medicine in Sport 14 (2011) 95–99

Original paper

Blood flow restriction by low compressive force prevents disuse

muscular weakness
Atsushi Kubota a,∗ , Keishoku Sakuraba a,b , Sadao Koh c , Yuji Ogura d , Yoshifumi Tamura e
a Sportology Center, Juntendo University, Tokyo, Japan
bDepartment of Sports Medicine, School of Health and Sports Science, Juntendo University, Chiba, Japan
c Koh Orthopaedic Clinic, Saitama, Japan
d Department of Physiology, St. Marianna University School of Medicine, Kanagawa, Japan
e Department of Medicine, Metabolism and Endocrinology, School of Medicine, Juntendo University, Tokyo, Japan
Received 8 December 2009; received in revised form 9 August 2010; accepted 19 August 2010

Abstract
Repetitive blood flow restriction prevents muscular atrophy and weakness induced by chronic unloading. However, it was unclear which
external compressive force for blood flow restriction was optimal to prevent muscular dysfunction. The present study was intended to investigate
the effects of repeated muscle blood flow restriction at low pressure on muscular weakness induced by immobilization without weight bearing.
Using casts, the left ankles of 11 healthy males were immobilized for 2 weeks. Subjects were instructed to walk using crutches with no weight
bearing during the period. Subjects were divided randomly into two groups: a restriction of blood flow (RBF) group (application of external
compressive force of 50 mm Hg) and a control (CON) group (no intervention). We measured changes in the muscle strength of the knee
extensor–flexor and ankle plantar flexor. The percent changes in knee extensor torque at 60◦ /s under eccentric contraction in the RBF group
were significantly smaller than in the CON group (−12.5 ± 10.7% and −30.1 ± 10.9%, p < 0.05). The percent changes in knee flexor torque
when performing an eccentric contraction at 60◦ /s, an isometric contraction, or a concentric contraction at both 60 and 300◦ /s in the RBF
group were significantly smaller than those in the CON group (p < 0.05). In conclusion, our results show that repetitive restriction of blood
flow with 50 mm Hg cuff pressure to the lower extremity reduces muscular weakness induced by chronic unloading.
© 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Keywords: Skeletal unloading; Muscular atrophy; Muscle strength; Immobilization; Weightlessness

1. Introduction ventive effect against muscle atrophy and weakness induced

Chronic unloading resulting from space flight,1–4 bed
rest,5–9 and immobilization10–13 induces muscular atrophy
and reduces muscle strength. It has been demonstrated that
resistance training prevents disuse muscle atrophy.14–16 We
showed in an earlier study that repetitive blood flow restric-
tion during a 2-week immobilization and non-weight bearing
period prevents muscle weakness and atrophy.16 The pre-
ventive effects were more pronounced than those achieved
through isometric training and the results of that study suggest
that blood flow restriction, like resistance training, has a pre-
∗ Corresponding author at: Department of Sports Medicine, School of
Health and Sports Science, Juntendo University, Chiba, Japan.
E-mail address: akubota@juntendo.ac.jp (A. Kubota).
by disuse.
It remains unclear how blood flow restriction prevents
muscle dysfunction induced by chronic unloading. The effect
of resistance training was ameliorated when it was combined
with blood flow restriction.17–20 Therefore, it is hypothesized
that the intramuscular accumulation of phosphate metabolites
and hydrogen ions influence the hypertrophic effects of con-
tinuous muscle contraction.21 Data obtained from our earlier
study16 suggest that blood flow restriction with 200 mm Hg
cuff pressure prevents disuse muscle atrophy. Based on
those results, it is hypothesized that intramuscular metabolic
changes induced by ischemia prevent muscle atrophy induced
by chronic unloading.16 Furthermore, the previous study22
showed that the effects of resistance exercise with blood
flow restriction, even the application of lower cuff pressure

1440-2440/$ – see front matter © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2010.08.007
96 A. Kubota et al. / Journal of Science and Medicine in Sport 14 (2011) 95–99
(50 mm Hg), significantly increased muscle strength. There-
fore, it is assumed that repetitive blood flow restriction per se
(without any exercise) with 50 mm Hg cuff pressure prevents
disuse atrophy. The present study was designed to investi-
gate the effects of repeated muscle blood flow restriction at
low pressure (50 mm Hg) on muscular weakness induced by
immobilization and non-weight bearing.
2. Methods
Subjects were 11 healthy untrained males without a his-
tory of injuries to the lower extremities or serious medical
complaints. This study was approved by the Human Ethics
Committee of Juntendo University. Prior to the experiment,
the purpose of the study, contents, experimental protocol,
possible risk involved, and management or security offered
if an accident occurs were fully explained to these subjects.
Their consent in writing was obtained.
We investigated the effect of blood flow restriction by
application of external compressive forces of 50 mm Hg on
muscular weakness. For each subject, we measured muscle
strength and the circumference of the lower extremity at base-
line (before intervention). The muscle strength of the lower
extremities was measured as the torque of the knee and ankle
joints performing an isokinetic contraction. Details of these
measurements are described in the Measurement of muscle
strength section.
To determine changes in the volume of thigh and leg mus-
cles, we measured the circumference of the thigh region at
10 and 15 cm above the upper border of the patella (thigh 10
and 15) and the maximum circumference of the leg using a
tape while the subject was standing (n = 5 in the RBF group,
n = 5 in the CON group). The measurements of each region
were performed three times and the average values were used
for analysis.
For 2 weeks after all measurements, to induce muscu-
lar weakness, the left ankle joint of subjects was fixated
at the neutral position (ankle joint angle = 0◦ ) using a cast.
Subjects were required to use crutches to move without
weight bearing. Subjects were then divided randomly into
two groups: subjects who received repetitive blood flow
restriction with compressive force of 50 mm Hg (RBF group,
n = 5, age: 22.8 ± 0.8 year, height: 174.2 ± 5.9 cm, weight:
68.0 ± 3.7 kg) and subjects for whom blood flow was not
restricted (control group, CON group, n = 6, age: 22.8 ± 1.2
year, height: 174.8 ± 3.9 cm, weight: 70.3 ± 5.0 kg). During
the 2-week period, blood flow to the lower left extremity
was restricted by compressing the proximal end of the thigh
using a tourniquet (77 mm width, 770 mm length, MIZUHO
Co. Ltd., Tokyo) in subjects of the RBF group. A set consisted
of 5 min of applied blood flow restriction followed by 3 min
of rest (release of compression); each subject underwent five
sets twice a day (morning and afternoon) for 14 days. Our pre-
liminary data demonstrated that compared with the control
(before compression), the pulse wave velocity (PWV) mea-
sured with the second derivative plethysmograph (Fukuda
Denshi Co. Ltd., Tokyo) during the application of external
compression of 50, 100, 200 and 300 mm Hg was reduced
to 90.0 ± 23.1, 80.9 ± 26.4, 64.2 ± 26.3, 2.6 ± 7.3%, respec-
tively (n = 8). At the end of the 2-week period, muscle strength
was measured again.
The knee extensor–flexor torque under isokinetic and iso-
metric contraction and the ankle plantar flexor torques under
isokinetic contraction were measured quantitatively using an
apparatus that determines isokinetic muscle strength (System
3 Dynamometer; Biodex Medical Systems, Shirley, NY).
To determine the knee extensor–flexor torque, subjects
were seated; the measured femoral region and upper part of
the subject were constrained using 1–3 belts. The subject
extended and flexed the knee joints 3 or 5 times at an angular
speed of 60, 180, or 300◦ /s using a concentric contraction
(CC60, CC180, and CC300), and at angular speeds of 60 and
180◦ /s using an eccentric contraction (EC60 and EC180). Iso-
metric contractions were performed with the knee joint flexed
at an angle of 60◦ (IM). The subject continued extending or
flexing the knee joints for 5 s with a 10-s break between knee
extension and flexion. Following determination of the ankle
plantar flexor torque, the subject lay in a supine position and
the measurement limbs were fastened with a belt. The sub-
ject then extended and flexed the ankle joints three times at
CC60, CC120, EC60, and EC120.
All data were expressed as mean ± SD. Differences in
muscle strength at each angular speed and contraction pattern,
and circumference, before and after the intervention were
statistically analyzed using a paired t-test in the RBF and
CON groups respectively. In addition, percent changes cal-
culated from the muscle strength and circumference before
and after the intervention were tested using an unpaired t-test
between the RBF and CON groups. All p values less than
0.05 were inferred as demonstrating a statistically significant
difference.
3. Results
Table 1 shows the knee extensor–flexor muscle strength
before and after 2 weeks of immobilization without weight
bearing. Almost all muscle strength values had decreased
significantly in the CON after the protocol, while several mus-
cle strength values in the RBF group showed no significant
protection against such changes in muscle strength for both
the knee extensor and flexor muscles. The percent changes
in knee extensor torque showed significant differences in
EC60 and knee flexor torques in EC60, IM, CC60, and
CC300. Fig. 1 shows that the percent changes in knee extensor
torque at EC60 in the RBF group were significantly smaller
than in the CON group (−12.5 ± 10.7% and −30.1 ± 10.9%,
p = 0.025). Fig. 2 portrays that the percentage changes in
knee flexor torques at EC60, IM, CC60 and CC300 in the
RBF group were significantly smaller than those in the CON
group: EC60 (−3.5 ± 4.7% and −18.9 ± 9.6%, p = 0.0095),
 A. Kubota et al. / Journal of Science and Medicine in Sport 14 (2011) 95–99 97

Data are mean ± SD. EC180, 180◦ /s under eccentric contraction; EC60, 60◦ /s under eccentric contraction; IM, isometric contraction; CC60, 60◦ /s under concentric contraction; CC180, 180◦ /s under concentric
73.7 ± 18.2*
112.8 ± 24.7

121.6 ± 25.0
92.1 ± 11.6
Post
125.4 ± 24.0
87.5 ± 20.9

127.5 ± 18.2
95.7 ± 12.2
CC300 (N m)

Pre
Knee extensor–flexor torques at baseline and after a 2-week immobilization and non-weight bearing period combined with blood flow restriction (RBF) and no intervention (CON).

Fig. 1. Percent changes in knee extensor torque after a 2-week immobi-

138.4 ± 28.5*
82.9 ± 17.7

143.5 ± 28.4
99.5 ± 10.1
lization and non-weight bearing period, relative to baseline, combined with
blood flow restriction or no intervention. Data are mean ± SD. *p < 0.05.
EC180, 180◦ /s under eccentric contraction; EC60, 60◦ /s under eccentric
Post

contraction; IM, isometric contraction; CC60, 60◦ /s under concentric con-

traction; CC180, 180◦ /s under concentric contraction; CC300, 300◦ /s under
156.8 ± 28.2
99.3 ± 20.4

162.2 ± 21.4
101.0 ± 10.6
CC180 (N m)

concentric contraction.

IM (−3.7 ± 5.8% and −20.9 ± 13.7%, p = 0.029), CC60

Pre

(−6.9 ± 2.9% and −18.6 ± 11.0%, p = 0.047) and CC300

(−3.6 ± 4.6% and −15.4 ± 9.1%, p = 0.029).
172.3 ± 29.9**
105.4 ± 23.3*

195.9 ± 18.4*
123.8 ± 9.3*

All muscle strength values of the ankle plantar flexor

muscles had decreased significantly in the CON group
Post

after the protocol: EC120 (pre: 122.6 ± 27.3 N m and post:

104.1 ± 28.7 N m, p = 0.032), EC60 (pre: 133.1 ± 27.0 N m
222.5 ± 45.6
130.7 ± 30.0

234.6 ± 17.3
133.3 ± 13.7
CC60 (N m)

and post: 110.8 ± 18.5 N m, p = 0.004), CC60 (pre:

79.9 ± 18.3 N m and post: 59.5 ± 21.8 N m, p = 0.008) and
CC120 (pre: 57.2 ± 10.2 N m and post: 44.7 ± 13.7 N m,
Pre

p = 0.005). In the RBF group, the muscle strength value in

184.6 ± 26.3***
92.3 ± 17.4*

244.3 ± 20.6*
119.2 ± 17.8

CC60 had decreased significantly after the protocol (pre:

87.2 ± 15.5 N m and post: 68.0 ± 16.5 N m, p = 0.005), but
Post

RBF partially protected against such changes in muscle

strength. Specifically, the percentage change in ankle plantar
239.0 ± 38.9
117.8 ± 21.4

295.3 ± 11.6
124.0 ± 18.2

flexor torque at EC60 in the RBF group was significantly

less than that of the CON group (−0.2 ± 12.1% and
IM (N m)

−16.1 ± 6.3%, p = 0.020).

Pre

All circumferences of the lower extremities had decreased

143.5 ± 36.3**

significantly in the CON group after the protocol: thigh 10

203.3 ± 27.7*

309.9 ± 40.5
183.8 ± 27.3

(pre: 48.5 ± 2.8 cm and post: 47.2 ± 2.7 cm, p = 0.013), thigh
15 (pre: 52.6 ± 3.5 cm and post: 51.1 ± 2.9 cm, p = 0.012)
Post

and leg (pre: 38.5 ± 2.0 and post: 37.5 ± 2.1, p = 0.007).
In the RBF group, the circumferences in thigh 15 and leg
301.6 ± 92.6
177.3 ± 40.7

354.1 ± 11.2
190.1 ± 23.5
EC60 (N m)

had decreased significantly after the protocol: thigh 10 (pre:

contraction; CC300, 300◦ /s under concentric contraction.
Pre
185.7 ± 26.8**

247.2 ± 28.9**
140.6 ± 37.9*

171.4 ± 37.2
Post
255.7 ± 65.7
173.9 ± 39.7

321.3 ± 41.4
190.3 ± 22.8
EC180 (N m)

Pre

Fig. 2. Percent changes in knee flexor torque after a 2-week immobiliza-

tion and non-weight bearing period, relative to baseline, combined with
Extensor

Extensor

blood flow restriction or no intervention. Data are mean ± SD. *p < 0.05,
Flexor

Flexor

*** p < 0.001.

* p < 0.05.
** p < 0.01.

**p < 0.01. EC180, 180◦ /s under eccentric contraction; EC60, 60◦ /s under
eccentric contraction; IM, isometric contraction; CC60, 60◦ /s under con-
Table 1

Group

centric contraction; CC180, 180◦ /s under concentric contraction; CC300,

CON

RBF

300◦ /s under concentric contraction.

98 A. Kubota et al. / Journal of Science and Medicine in Sport 14 (2011) 95–99
48.2 ± 1.0 cm and post: 47.2 ± 1.2 cm, p = 0.051), thigh 15
(pre: 52.3 ± 1.2 cm and post: 51.5 ± 1.6 cm, p = 0.045) and
leg (pre: 37.5 ± 1.5 cm and post: 36.8 ± 1.6 cm, p = 0.005). In
addition, the differences between the RBF and CON groups
were not significant for all percent changes of circumfer-
ences.
4. Discussion
The main finding of this study is that repeated muscle
blood flow restriction at low pressure (50 mm Hg) mitigated
muscular weakness induced by immobilization and non-
weight bearing. This result suggests that mild blood flow
restriction, achieved by 50 mm Hg cuff pressure, has a mild
preventive effect on muscular atrophy and weakness induced
by chronic unloading.
We observed partial reduction of muscle weakness by
blood flow restriction with low cuff pressure (50 mm Hg).
Comparison with data from our previous report shows that
a 50 mm Hg cuff pressure program has a milder effect on
muscle weakness induced by chronic unloading than the
200 mm Hg cuff pressure program. Our previous study using
the same weight-bearing protocol described that less than
a 5% decrease of muscle strength was observed in the
200 mm Hg cuff pressure group, although 10–25% reduction
was observed in the control group.16 In the present study,
50 mm Hg cuff pressure had a preventive effect against the
knee flexor muscle strength decrease, in agreement with the
results of our previous study,16 but only a slight effect was
observed in the knee extensor muscle strength (Fig. 1). The
PWV data suggest that 50 mm Hg cuff pressure has a smaller
effect on arterial blood flow than 200 mm Hg cuff pressure.
Therefore, the level of blood flow restriction might be an
important factor to prevent muscle weakness by repetitive
blood flow restriction, especially in the knee extensor muscle.
It remains unclear how blood flow restriction with
50 mm Hg cuff pressure prevents muscle weakness induced
by chronic unloading. It has been reported that hemodynamic
responses to the blood flow restriction were less observed
in 50 mm Hg cuff pressure compared with 200 mm Hg cuff
pressure.23 Because 50 mm Hg is lower than the arterial
blood pressure, but higher than the venous blood pressure,
50 mm Hg cuff pressure might induce venous congestion in
lower extremities. This congestion might have some roles
to diminish muscle dysfunction. It has been reported that
the accumulation of intramuscular phosphate metabolites
and hydrogen ions influence the hypertrophic effects of
continuous muscle contraction.21 Consequently, blood flow
restriction with 50 mm Hg cuff pressure might prevent mus-
cle weakness through those underlying mechanisms.21,24 In
addition, the different effects of 50 mm Hg cuff pressure and
200 mm Hg cuff pressure programs are also explained by this
hypothesis because the PWV data suggest that 50 mm Hg cuff
pressure had less effect on arterial blood flow than 200 mm Hg
cuff pressure. Further studies are necessary to clarify the
underlying mechanisms of the effects of blood flow restric-
tion.
Results of this study did not clarify whether muscle
atrophy was prevented by blood flow restriction. We only
measured the respective circumferences of thigh and leg and
the data suggest that the circumferences of those muscles
were significantly but similarly decreased in both groups.
Therefore, it seems that a low cuff pressure program, in con-
trast to the high pressure program,16,24 might not be effective
for preventing muscle atrophy induced by chronic unloading.
Interestingly, muscle weakness was predominantly prevented
in knee flexor muscles, which suggests that a muscle specific
effect can occur by blood flow restriction, thereby necessi-
tating direct measurement (CT or MRI) to measure muscle
atrophy more precisely. In addition, it has been reported
that the maximum force production is directly dependent
on muscle cross-sectional area.25 It is also generally known
that neuromuscular coordination plays an intimate role in
the expression of muscle strength. These factors might con-
tribute to the inconsistent results between muscle weakness
and atrophy in the present study.
5. Conclusion
The repetitive restriction of blood flow with 50 mm Hg
cuff pressure to the lower extremity partially prevents
muscular weakness induced by chronic unloading. Further
investigation is necessary to clarify the underlying mecha-
nisms of the anti-atrophic effects of blood flow restriction.
Practical implications
• Blood flow restriction is a potential measures to pre-
vent muscle atrophy and weakness induced by chronic
unloading such as that which occurs as bed rest and cast
immobilization.
• Blood flow restriction may also be used as a medical treat-
ment in the rehabilitation of sports injury.
• The positive effect of blood flow restriction on the muscle
weakness depends on the external compressive force.
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