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https://doi.org/10.1007/s00113-020-00774-x
© Springer Medizin Verlag GmbH, part of
Springer Nature 2020
editorial staff
U. Tegtbur, Hanover
Strength training with the aim of
muscle hypertrophy should be carried
out with loads >70% of the personal
"one-repetition maximum" (1RM) [1].
In contrast, the combination of blood
flow reduction in the extremity with
strength training shows similar
improvements in muscle mass even at
lower intensities of between 20 and
30% of 1RM [11]. Blood flow restriction
(BFR) training, which was developed by
the Japanese doctor under the name
Kaatsu in the mid-1970s, is
increasingly being researched. BFR
training is used both in performance-
oriented sport and in the rehabilitation
of musculoskeletal disorders. By using
the BFR with a low training load,
training effects should be possible
with existing joint problems, which can
otherwise only be achieved by
accepting more severe pain.
application
Patterson et al. summarized criteria
for the implementation of the BFR
training in a current review. After
determining the full occlusal pressure
on the corresponding limb, it is
recommended to perform the BFR
training with 40–80% of this measured
pressure [16]. Measurement and
training should be done with the same
cuffs to prevent different pressures
with varying cuff widths. Loenneke et
al. recommend partial occlusion
pressures of around 50%, as high
anabolic training effects can already
be achieved with this [12]. With
increasing occlusion pressure, the risk
of thrombus formation and
U. Tegtbur1S. Haufe1· MW buses2
1 Institute for Sports Medicine, Hannover Medical School (MHH), Hannover, Germany
2 Institute for Sports Medicine and Prevention, University of Leipzig, Leipzig, Germany
Application and effects of "blood
flow restriction training"
microvascular damage would increase
and training effectiveness would
decrease. However, there are no long-
term studies on different occlusion
pressures to describe adaptations and
side effects in the chronic course [12].
Kilgas et al. investigated the extent to
which the BFR at rest can be transferred
to the conditions during and after BFR
training using "handgrip" loads: 30
repetitions were completed in 1 min with
30% of the 1RM [10]. Without BFR, the
resting blood flow in the forearm was
approx. 65 ml/min, rose to approx. 170
ml/min after 1 min during the handgrip
test and fell to approx. 125 ml/min 30 s
afterwards. During training with 60% of
the complete occlusal pressure (mean
81mmHg), the blood flow was reduced to
the same extent before and during
exercise (22%), and by 52% in the minute
of recovery after the end of the exercise.
At 80% BFR (mean 108mmHg), blood
flow was reduced by 47%, 48%, and 71%
before, during, and after exercise,
respectively. The results show that the
percent blood flow reductions measured
at rest at 60% and 80% BFR remain
nearly identical during exercise. An
adjustment of the cuff pressure during
exercise therefore does not seem
necessary. The O2-Saturation index in the
forearm during the hand grip loads was
68% without occlusion and was reduced
to about 60% at 60% BFR and to about
58% at 80% BFR as a sign of local hypoxia
[10].
Patterson et al. recommend the
following strategy for limb strength
training with a BFR at 40–80% of
occlusal pressure: Intensities should
be 20–40% of 1RM. For longer
Training programs should consist of
2 to 4 series with, for example,
30-15-15-15 repetitions (wh), a
contraction speed of 1-2s and a
30-60s break each, 2 to 3 times a
week. The BFR time should be 5–10
min and be intermittent or
continuous [16].
»
The recommended ones
Intensities at the BFR
Limb strength training is
20-40% of 1RM
The working group has also defined
training recommendations for cycling
or walking: With a BFR duration of
5-20 min with 40-80% of the maximum
occlusion pressure continuously or in
intervals, the endurance exercise
should be <50% of the maximum
oxygen uptake or <50% of the heart
rate (HR) reserve 2 - be completed up
to 3 times/week [16].
training effects
A new meta-analysis shows that strength
training at 10–40% of 1RM with BFR results
in a similarly good increase in muscle mass
as strength training at 70–92% of 1RM
without BFR. However, the improvement in
muscle strength from high-intensity
strength training was more pronounced
than after low-intensity training
interventions with BFR, which is probably
due to the stronger central nervous system
adaptation at high training loads [11].
Counts et al. compared 8 weeks of BFR
strength training in healthy subjects with 40
and 90%
The trauma surgeon
 main topic
the total occlusion pressure. Muscle
mass, strength and endurance
improved equally well in both groups.
Therefore, the authors recommended
applying lower partial occlusion
pressures, since the training effects
induced by BFR can already be
observed sufficiently strongly at lower
flow reductions (40%) [6].
Hughes et al. summarized in a
meta-analysis the effects of BFR
training from studies on
rehabilitation in gonarthrosis,
reconstruction of the anterior
cruciate ligament or in patients with
sarcopenia [9]. Again, low-intensity
BFR training achieved
improvements in strength and
function in 69% of participants
postoperatively or during
rehabilitation (in 76% of participants
after high-intensity training without
BFR). Since the risk of thrombosis,
muscle damage or undesirable
cardiovascular reactions appears to
be higher in patient groups than in
healthy exercisers, investigations
should be carried out with
significantly larger groups than
previously and guidelines for
indication-specific
recommendations for training with
BFR and for measuring the
maximum occlusion pressure should
be defined will [9].
»
The training effects
increased by BFR are
effects of local ischemia
and hypoxia
Numerous causes for the training
effects increased by BFR have been
described. The additional local
ischemia and hypoxia lead to
increased metabolic stimuli, swelling
of muscle cells and increased
oxidative stress. After a single low-
intensity strength training session
(20% of 1RM), muscle biopsy
samples showed an increase in
mRNA expression for muscle cell
adaptation caused by hypoxia and
cell stress (hypoxia-induced
The trauma surgeon
Factor-1 α, p21, myostatin, [8th]).
Christiansen et al. compared the effects
of BFR training on interval running with
those of systemic hypoxia (inspiratory
oxygen fraction [FIO2] 14%,
corresponding to 3250m altitude).
Measured in muscle biopsy samples,
there were comparably high increases in
the concentration of lactate and signal
proteins of muscle fibers types I and II
(“5' AMP-activated protein
kinase” [AMPK], “Ca2+/ calmodulin-
dependent protein kinase II” [CaMKII]) [3
]. After BFR training, increased levels of
heat shock protein27 [HSP27] and mRNA
transcripts of mitochondria and ion
transport were found in muscle cells
compared to hypoxic training. The
authors justified the better effects on the
mitochondria and the Na+K+ATPase due
to increased oxidative stress in BFR
training [3].
Few studies exist on the effects of
BFR endurance training. A surprising
result showed an 8-week cycle
endurance training with BFR
(endurance training with BFR in the
form of 80% of the maximum
occlusion pressure over 30 minutes
with 40% maximum oxygen uptake
[V̇O2 max] vs. strength training with
70% of 1RM vs. 30min endurance with
70% V̇O2 max; 4 times/week each, [5]).
The effects on muscle hypertrophy
from BFR endurance training (m.
vastus lateralis, +11%) and strength
training (+13%) were comparable. The
improvement in maximum endurance
performance after BFR endurance
training was 40% of the V̇O2 max
11%, after endurance training without BFR
at 70% of V̇O2 max 21%. Key genes involved
in angiogenesis were also activated after
BFR training. Clinical mechanisms of action
of endurance training with BFR seem to be
very pronounced and should be further
investigated.
safety
Miniti et al. examined in a
systematic review the safety of BFR
training in the therapy of various
musculoskeletal disorders [15]. In
168 patients pooled from 19
randomized trials that
ne BFR training therapy for up to 16
weeks, a thrombosis (axillary vein
after BFR arm training) and 2
rhabdomyolyses were diagnosed.
No major adverse events were
noted in the 154 patients in the no-
BFR control groups. Ten participants
in the BFR and 4 participants in the
control group training described
low-grade events such as acute
muscle pain and cuff-induced pain.
In the majority of studies, joint
discomfort was less in BFR training
at lower intensities. Very rarely did
the training intervention have to be
stopped because of the use of the
cuff. In the opinion of the authors, it
should be further investigated which
collectives have an increased risk in
BFR training therapy [15].
»
Patients at risk of BFR
training therapy need to
be identified in further
studies
acute effects: Because BFR training
limits venous return and leads to
blood pooling, Madarame et al. the
coagulation system of young healthy
volunteers. Between 10 minutes and
24 hours after BFR training (“leg press”
with 30% of 1RM, partial occlusion at
150–160 mmHg), there were no
increases in the concentration of D-
dimers, prothrombin fragments,
thrombin-antithrombin III complex
and fibrin degradation products [14].
Chronic Effects: Clark et al.
studied young adults. Over 4 weeks,
they compared BFR training at 30%
of 1RM with high-intensity strength
training at 80% of 1RM [4]. Knee
extension exercises were performed
three times a week until exhaustion.
BFR training cuff pressure at the leg
exceeded brachial systolic blood
pressure by 30%. Maximum
isometric strength increased by 8%
after BFR resistance training and by
13% after high-intensity training. No
significant differences showed

between the interventions in the pulse
wave transit time, in the ankle-brachial
index and in the concentrations of
fibrinogen, highly sensitive C-reactive
protein (hsCRP) or the D-dimers.
Immediately after training, tissue
plasminogen activator antigen was
elevated in both groups. The authors
concluded that effective strength
training with and without BFR
increases fibrinolytic activity without
affecting parameters of coagulation or
inflammation [4].
The vast majority of BFR intervention
studies have been conducted in healthy
subjects. Therefore, questions about
thrombotic events and BFR should be
conducted in long-term training studies
with larger (patient) collectives.
cardiovascular activation
BFR training leads to greater
activation of the muscular
metaboreflex than training without
BFR [7]. Muscle metabolites target
receptors in the muscle interstitium
and activate type IV afferent nerve
fibers. This leads to a reduction in the
parasympathetic and an increase in
the sympathetic autonomic response
to the training stimulus after central
switching. Heart rate, stroke volume,
blood pressure, vasoconstriction, and
peripheral vascular resistance increase
more with BFR. Therefore, during BFR
training with risk groups,
cardiovascular parameters should be
monitored during the sessions [7].
Scott et al. compared hemodynamic
responses in 63- to 75-year-old women
during low-intensity (NI; 20% of 1RM, 3
sets of 20 reps, 15 reps, 15 reps) and
high-intensity (HI; 70% of 1RM, 3 sets)
leg press training session à 10 Wh)
each without BFR with low-intensity
strength training with BFR (20% of
1RM, 20 Wh, 15 Wh, 15 Wh) [17]. The
low-intensity BFR training was
completed with a BFR of 50% of the
arterial occlusive pressure. The
subjective perception of stress on the
Borg scale [2] of 0-10 averaged 2-3 for
low-intensity exercise and was for
high-intensity exercise and
Abstract · Abstract
trauma surgeon https://doi.org/10.1007/s00113-020-00774-x ©
Springer Medizin Verlag GmbH, part of Springer Nature 2020
U. Tegtbur S. Haufe MW Busse
Application and effects of "blood flow restriction training"
summary
Blood flow restriction (BFR) limits
arterial and venous blood flow and
leads to blood pooling, which could
increase training-induced effects.
Strength training at lower intensities
(20-30% of maximum strength)
combined with BFR showed similar
effects on muscle hypertrophy as
training at 70% maximum strength
without BFR. Low-intensity cycling
endurance training with BFR improves
muscle hypertrophy and endurance
and activates angiogenesis. After
determining the total occlusal pressure
on the corresponding limb, it is
recommended to perform the BFR
training with 40-80% of the measured
pressure. During upper extremity
strength training, a 60–80% partial
occlusion results in a 20–50% reduction
in arterial blood flow volume.
Application and effects of blood flow restriction training
Abstracts
Blood flow restriction (BFR) limits arterial and
venous blood flow and leads to blood
pooling, which could increase exercise-
induced training effects. Strength training at
lower intensities (20-30% of maximum
strength) in combination with BFR showed
similar effects on muscle hypertrophy as
training with 70% without BFR. Low intensity
cycling endurance training with BFR improves
muscle hypertrophy and endurance
performance and activates angiogenesis.
After determination of the complete
occlusion pressure on the corresponding
extremity, it is recommended that BFR
training should be performed with 40–80% of
the measured occlusion pressure. During
strength training of the upper extremities, an
occlusion of 60–80% leads to a reduction in
the arterial blood flow by 20–50%. Local
ischemia and hypoxia, a stronger metabolic
stimulus,
stress discussed. In short-term studies,
comparable adjustments to parameters of
fibrinolytic activity, coagulation or
inflammation could be shown for strength
training with and without BFR. Thromboses
after BFR have only rarely been described to
date, but require further clarification through
appropriate studies. BFR training leads to
greater activation of the muscular
metaboreflex and thus to relatively greater
increases in exercise blood pressure, so
cardiovascular parameters should be
monitored during BFR training. First meta-
analyses in healthy people and patients with
low case numbers indicate the effectiveness
of BFR training. Standardizations or
guidelines for clinical use are still pending.
keywords
Kaatsu Therapeutic Occlusion Ischemia
Hypoxia Thrombosis
for the increased training effects due to BFR. In
short-term studies, comparable adjustments to
parameters of fibrinolytic activity, coagulation
and inflammation could be observed for strength
training with and without BFR. So far,
thromboses after BFR have been described only
rarely but need to be further clarified by
appropriate studies. The BFR training leads to a
stronger activation of the muscular metabolic
reflex and thus to a relatively greater increase in
exercise blood pressure, so that cardiovascular
parameters should be controlled during BFR
training. First meta-analyses with small numbers
of healthy people and patients indicate the
effectiveness of BFR training. Standardization or
guidelines for clinical use are still lacking.
keywords
Kaatsu Therapeutic occlusion Ischemia
Hypoxia Thrombosis
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 main topic
increased to 5 with low-intensity BFR
training. With low-intensity BFR
training, cardiac output, heart rate,
and blood pressure were
significantly higher than with
training at a comparable weight and
the same as with high-intensity
training at 70% of 1RM.
In patients with chronic coronary
artery disease (CHD), BFR strength
training (BFR with an occlusal pressure
of 200 mmHg, 4 times 15Wh knee
extension at 20% of 1RM) led to a
significantly greater increase in
norepinephrine concentration than
without BFR [13]. Sugawara et al.
studied 15 healthy volunteers, mean
age 27, with the aim of testing the
effects of BFR on the hemodynamic
response to endurance activity [18].
The protocol consisted of 5 intervals of
2 min each at a walking speed of 3.2
km/h. Peripheral systolic blood
pressure increased 43% to
approximately 173mmHg with BFR
(160mmHg) and 11% without BFR.
Aortic pressure increased by 43% with
BFR or remained unchanged without
BFR. The diastolic pressure changed
comparably. Heart rate increases in
the 5th interval were relatively small,
from 68 to 95 bpm with BFR and 67 to
81 bpm without BFR. Although walking
speeds were slow, BFR exposure
resulted in a marked increase in
central and peripheral blood pressure.
Low-dose strength training with BFR
and high-intensity strength training
without BFR show comparable high
cardiovascular activations. In BFR
endurance training, the increase in blood
pressure appears to be significantly
greater, but less so in HR. In contrast to
strength training, type I muscle fibers
are primarily recruited during moderate
endurance loads. The BFR, on the other
hand, leads to increased activation of
muscle fiber type II (strength, speed)
even with light exertion instead of the
endurance-specific muscle fiber type I
and thus to a relatively more
pronounced increase in blood pressure.
The trauma surgeon
conclusion for practice
4 The Blood flow restriction (BFR)
ning seems to lead to
significant improvements in
muscle strength, mass,
- function -metabolism and
cellular adaptation.
4 Even after minor restrictions
The training effects can be observed at
higher blood flow levels, such as 40% of
the maximum occlusion pressure.
4 High blood flow restrictions, the
may be associated with higher
rates of side effects or pain
should be avoided.
4 Recent studies show that
In addition to strength training using
the BFR, there could also be new
fields of application in BFR endurance
training.
4 First meta-analyses in healthy subjects
and patients demonstrate the
effectiveness of BFR training.
However, the number of cases is
still very low overall. For use in
clinical care, standardized
processes are required to
develop individual training
(therapy) programs.
correspondence address
Prof. U. Tegtbur
Institute for Sports
Medicine, Hannover
Medical School (MHH)
Carl-Neuberg-Str. 1,
30625 Hanover,
Germany
tegtbur.uwe@
mh-hannover.de
Compliance with ethical guidelines
conflict of interest.U. Tegtbur, S. Haufe,
and MW Busse declare no conflict of
interest.
No human or animal studies were
performed by the authors for this article.
The ethical guidelines specified there apply
to the listed studies.
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