Advertisement

Potential Implications of Blood Flow Restriction Exercise on Vascular Health: A Brief Review

  • Dahan da Cunha NascimentoEmail author
  • Brad J. Schoenfeld
  • Jonato Prestes
Review Article

Abstract

Blood flow restriction (BFR) exercise (a.k.a. occlusion training) has emerged as a viable surrogate to traditional heavy-load strength rehabilitation training for a broad range of clinical populations including elderly subjects and rehabilitating athletes. A particular benefit of BFR exercise is the lower stress upon the joints as compared to traditional heavy resistance training, with similar gains in muscle strength and size. The application of an inflatable cuff to the proximal portion of the limbs increases the pressure required for venous return, leading to changes in venous compliance and wall tension. However, it is not known if long-term benefits of BFR exercise on muscle strength and size outweigh potential short and long-term complications on vascular health. BFR exercise could lead to clinical deterioration of the vasculature along with sympathetic overactivity and decreased vascular function associated with retrograde shear stress. This raises a fundamental question: Given the concern that excessive restriction could cause injury to endothelial cells and might cause detrimental effects on endothelial function, even in healthy individuals, should we critically re-evaluate the safety of this method for the general population? From this perspective, the purpose of this manuscript is to review the effects of BFR exercise on vascular function, and to provide relevant insights for training practice as well as future directions for research.

Notes

Acknowledgements

The first author would like to thank his family and in particular his mother Rita Cunha and his son Nicolas Cunha.

Author contributions

All authors contributed article preparation; took part in drafting the article and reviewing critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Compliance with ethical standards

Funding

No sources of funding were received for the preparation of this article.

Conflict of interest

Dahan da Cunha Nascimento, Brad J. Schoenfeld and Jonato Prestes have no conflicts of interest directly relevant to the content of this article.

References

  1. 1.
    Centner C, Wiegel P, Gollhofer A, Konig D. Effects of blood flow restriction training on muscular strength and hypertrophy in older individuals: a systematic review and meta-analysis. Sports Med. 2019;49(1):95–108.  https://doi.org/10.1007/s40279-018-0994-1.CrossRefPubMedGoogle Scholar
  2. 2.
    Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: a systematic review & meta-analysis. J Sci Med Sport. 2016;19(8):669–75.  https://doi.org/10.1016/j.jsams.2015.09.005.CrossRefPubMedGoogle Scholar
  3. 3.
    Bittar ST, Pfeiffer PS, Santos HH, Cirilo-Sousa MS. Effects of blood flow restriction exercises on bone metabolism: a systematic review. Clin Physiol Funct Imaging. 2018.  https://doi.org/10.1111/cpf.12512.CrossRefPubMedGoogle Scholar
  4. 4.
    Lixandrao ME, Ugrinowitsch C, Berton R, Vechin FC, Conceicao MS, Damas F, et al. Magnitude of muscle strength and mass adaptations between high-load resistance training versus low-load resistance training associated with blood-flow restriction: a systematic review and meta-analysis. Sports Med. 2018;48(2):361–78.  https://doi.org/10.1007/s40279-017-0795-y.CrossRefPubMedGoogle Scholar
  5. 5.
    Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51(13):1003–11.  https://doi.org/10.1136/bjsports-2016-097071.CrossRefPubMedGoogle Scholar
  6. 6.
    Mouser JG, Mattocks KT, Buckner SL, Dankel SJ, Jessee MB, Bell ZW, et al. High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training. Physiol Meas. 2019.  https://doi.org/10.1088/1361-6579/ab0d2a.CrossRefPubMedGoogle Scholar
  7. 7.
    Hudlicka O, Wright AJ, Ziada AM. Angiogenesis in the heart and skeletal muscle. Can J Cardiol. 1986;2(2):120–3.PubMedGoogle Scholar
  8. 8.
    Larkin KA, Macneil RG, Dirain M, Sandesara B, Manini TM, Buford TW. Blood flow restriction enhances post-resistance exercise angiogenic gene expression. Med Sci Sports Exerc. 2012;44(11):2077–83.  https://doi.org/10.1249/MSS.0b013e3182625928.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ferguson RA, Hunt JEA, Lewis MP, Martin NRW, Player DJ, Stangier C, et al. The acute angiogenic signalling response to low-load resistance exercise with blood flow restriction. Eur J Sport Sci. 2018;18(3):397–406.  https://doi.org/10.1080/17461391.2017.1422281.CrossRefPubMedGoogle Scholar
  10. 10.
    Thijssen DH, Dawson EA, Tinken TM, Cable NT, Green DJ. Retrograde flow and shear rate acutely impair endothelial function in humans. Hypertension. 2009;53(6):986–92.  https://doi.org/10.1161/HYPERTENSIONAHA.109.131508.CrossRefPubMedGoogle Scholar
  11. 11.
    Jenkins NT, Padilla J, Boyle LJ, Credeur DP, Laughlin MH, Fadel PJ. Disturbed blood flow acutely induces activation and apoptosis of the human vascular endothelium. Hypertension. 2013;61(3):615–21.  https://doi.org/10.1161/HYPERTENSIONAHA.111.00561.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Paiva FM, Vianna LC, Fernandes IA, Nobrega AC, Lima RM. Effects of disturbed blood flow during exercise on endothelial function: a time course analysis. Braz J Medi Biol Res. 2016;49(4):e5100.  https://doi.org/10.1590/1414-431x20155100.CrossRefGoogle Scholar
  13. 13.
    Tinken TM, Thijssen DH, Hopkins N, Dawson EA, Cable NT, Green DJ. Shear stress mediates endothelial adaptations to exercise training in humans. Hypertension. 2010;55(2):312–8.  https://doi.org/10.1161/HYPERTENSIONAHA.109.146282.CrossRefPubMedGoogle Scholar
  14. 14.
    Kim J, Lang JA, Pilania N, Franke WD. Effects of blood flow restricted exercise training on muscular strength and blood flow in older adults. Exp Gerontol. 2017;99:127–32.  https://doi.org/10.1016/j.exger.2017.09.016.CrossRefPubMedGoogle Scholar
  15. 15.
    Schreuder TH, Green DJ, Hopman MT, Thijssen DH. Impact of retrograde shear rate on brachial and superficial femoral artery flow-mediated dilation in older subjects. Atherosclerosis. 2015;241(1):199–204.  https://doi.org/10.1016/j.atherosclerosis.2015.04.017.CrossRefPubMedGoogle Scholar
  16. 16.
    Ozawa Y, Koto T, Shinoda H, Tsubota K. Vision loss by central retinal vein occlusion after kaatsu training: a case report. Medicine. 2015;94(36):e1515.  https://doi.org/10.1097/MD.0000000000001515.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Nakajima T, Kurano M, Iida H, Takano H, Oonuma H, Morita T, et al. Use and safety of KAATSU training: results of a national survey. Int J KAATSU Train Res. 2006;2(1):5–13.  https://doi.org/10.3806/ijktr.2.5.CrossRefGoogle Scholar
  18. 18.
    Yasuda T, Meguro M, Sato Y, Nakajima T. Use and safety of KAATSU training: results of a national survey in 2016. Int J KAATSU Train Res. 2017;13(1):1–9.  https://doi.org/10.3806/ijktr.13.1.CrossRefGoogle Scholar
  19. 19.
    Patterson SD, Brandner CR. The role of blood flow restriction training for applied practitioners: A questionnaire-based survey. J Sports Sci. 2018;36(2):123–30.  https://doi.org/10.1080/02640414.2017.1284341.CrossRefPubMedGoogle Scholar
  20. 20.
    Nascimento DDC, Petriz B, Oliveira SDC, Vieira DCL, Funghetto SS, Silva AO, et al. Effects of blood flow restriction exercise on hemostasis: a systematic review of randomized and non-randomized trials. Int J Gen Med. 2019;12:91–100.  https://doi.org/10.2147/IJGM.S194883.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Madarame H, Kurano M, Fukumura K, Fukuda T, Nakajima T. Haemostatic and inflammatory responses to blood flow-restricted exercise in patients with ischaemic heart disease: a pilot study. Clin Physiol Funct Imaging. 2013;33(1):11–7.  https://doi.org/10.1111/j.1475-097X.2012.01158.x.CrossRefPubMedGoogle Scholar
  22. 22.
    Montgomery R, Paterson A, Williamson C, Florida-James G, Ross MD. Blood flow restriction exercise attenuates the exercise-induced endothelial progenitor cell response in healthy, young men. Front Physiol. 2019;10:447.  https://doi.org/10.3389/fphys.2019.00447.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Spranger MD, Krishnan AC, Levy PD, O’Leary DS, Smith SA. Blood flow restriction training and the exercise pressor reflex: a call for concern. Am J Physiol Heart Circ Physiol. 2015;309(9):H1440–52.  https://doi.org/10.1152/ajpheart.00208.2015.CrossRefGoogle Scholar
  24. 24.
    Shimizu R, Hotta K, Yamamoto S, Matsumoto T, Kamiya K, Kato M, et al. Low-intensity resistance training with blood flow restriction improves vascular endothelial function and peripheral blood circulation in healthy elderly people. Eur J Appl Physiol. 2016;116(4):749–57.  https://doi.org/10.1007/s00421-016-3328-8.CrossRefPubMedGoogle Scholar
  25. 25.
    Iida H, Kurano M, Takano H, Kubota N, Morita T, Meguro K, et al. Hemodynamic and neurohumoral responses to the restriction of femoral blood flow by KAATSU in healthy subjects. Eur J Appl Physiol. 2007;100(3):275–85.  https://doi.org/10.1007/s00421-007-0430-y.CrossRefPubMedGoogle Scholar
  26. 26.
    Iida H, Takano H, Meguro K, Asada K, Oonuma H, Morita T, et al. Hemodynamic and autonomic nervous responses to the restriction of femoral blood flow by KAATSU. Int J KAATSU Train Res. 2005;1(2):57–64.CrossRefGoogle Scholar
  27. 27.
    Takano H, Morita T, Iida H, Asada K, Kato M, Uno K, et al. Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. Eur J Appl Physiol. 2005;95(1):65–73.  https://doi.org/10.1007/s00421-005-1389-1.CrossRefPubMedGoogle Scholar
  28. 28.
    Takano H, Morita T, Iida H, Kato M, Uno K, Hirose K, et al. Effects of low-intensity “KAATSU” resistance exercise on hemodynamic and growth hormone responses. Int J KAATSU Train Res. 2005;1(1):13–8.  https://doi.org/10.3806/ijktr.1.13.CrossRefGoogle Scholar
  29. 29.
    Pinto RR, Karabulut M, Poton R, Polito MD. Acute resistance exercise with blood flow restriction in elderly hypertensive women: haemodynamic, rating of perceived exertion and blood lactate. Clin Physiol Funct Imaging. 2018;38(1):17–24.  https://doi.org/10.1111/cpf.12376.CrossRefPubMedGoogle Scholar
  30. 30.
    Pinto RR, Polito MD. Haemodynamic responses during resistance exercise with blood flow restriction in hypertensive subjects. Clin Physiol Funct Imaging. 2016;36(5):407–13.  https://doi.org/10.1111/cpf.12245.CrossRefPubMedGoogle Scholar
  31. 31.
    Araujo JP, Silva ED, Silva JC, Souza TS, Lima EO, Guerra I, et al. The acute effect of resistance exercise with blood flow restriction with hemodynamic variables on hypertensive subjects. J Hum Kinet. 2014;43:79–85.  https://doi.org/10.2478/hukin-2014-0092.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Bond V, Curry BH, Kumar K, Pemminati S, Gorantla VR, Kadur K, et al. Restricted Blood Flow Exercise in Sedentary, Overweight African-American Females May Increase Muscle Strength and Decrease Endothelial Function and Vascular Autoregulation. Journal of pharmacopuncture. 2017;20(1):23–8.  https://doi.org/10.3831/KPI.2017.20.002.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Renzi CP, Tanaka H, Sugawara J. Effects of leg blood flow restriction during walking on cardiovascular function. Med Sci Sports Exerc. 2010;42(4):726–32.  https://doi.org/10.1249/MSS.0b013e3181bdb454.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Laurentino GC, Ugrinowitsch C, Roschel H, Aoki MS, Soares AG, Neves M Jr, et al. Strength training with blood flow restriction diminishes myostatin gene expression. Med Sci Sports Exerc. 2012;44(3):406–12.  https://doi.org/10.1249/MSS.0b013e318233b4bc.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Credeur DP, Hollis BC, Welsch MA. Effects of handgrip training with venous restriction on brachial artery vasodilation. Med Sci Sports Exerc. 2010;42(7):1296–302.  https://doi.org/10.1249/MSS.0b013e3181ca7b06.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Storch AS, Mattos JDd, Alves R, Galdino IdS, Rocha HNM. Methods of endothelial function assessment: description and applications. Int J Cardiovasc Sci. 2017;30(3):262–73.Google Scholar
  37. 37.
    Phillips SA, Andaku DK, Mendes RG, Caruso FR, Cabiddu R, Jaenisch RB, et al. Exploring vascular function biomarkers: implications for rehabilitation. Braz J Cardiovasc Surg. 2017;32(2):125–35.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Ghiadoni L, Salvetti M, Muiesan ML, Taddei S. Evaluation of endothelial function by flow mediated dilation: methodological issues and clinical importance. High Blood Press Cardiovasc Prev. 2015;22(1):17–22.  https://doi.org/10.1007/s40292-014-0047-2.CrossRefPubMedGoogle Scholar
  39. 39.
    Phillips SA, Mahmoud AM, Brown MD, Haus JM. Exercise interventions and peripheral arterial function: implications for cardio-metabolic disease. Prog Cardiovasc Dis. 2015;57(5):521–34.  https://doi.org/10.1016/j.pcad.2014.12.005.CrossRefPubMedGoogle Scholar
  40. 40.
    Alhejily W, Aleksi A, Martin BJ, Anderson TJ. The effect of ischemia-reperfusion injury on measures of vascular function. Clin Hemorheol Microcirc. 2014;56(3):265–71.  https://doi.org/10.3233/CH-131741.CrossRefPubMedGoogle Scholar
  41. 41.
    Gross GJ, Auchampach JA. Reperfusion injury: does it exist? J Mol Cell Cardiol. 2007;42(1):12–8.  https://doi.org/10.1016/j.yjmcc.2006.09.009.CrossRefPubMedGoogle Scholar
  42. 42.
    Schreuder TH, Green DJ, Hopman MT, Thijssen DH. Acute impact of retrograde shear rate on brachial and superficial femoral artery flow-mediated dilation in humans. Physiol Rep. 2014;2(1):e00193.  https://doi.org/10.1002/phy2.193.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Fahs CA, Rossow LM, Thiebaud RS, Loenneke JP, Kim D, Abe T, et al. Vascular adaptations to low-load resistance training with and without blood flow restriction. Eur J Appl Physiol. 2014;114(4):715–24.  https://doi.org/10.1007/s00421-013-2808-3.CrossRefPubMedGoogle Scholar
  44. 44.
    Kacin A, Strazar K. Frequent low-load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scand J Med Sci Sports. 2011;21(6):e231–41.  https://doi.org/10.1111/j.1600-0838.2010.01260.x.CrossRefPubMedGoogle Scholar
  45. 45.
    Oyama J, Node K. Sympathetic nerve activity and endothelial function. Hypertens Res. 2014;37(12):1035–6.  https://doi.org/10.1038/hr.2014.142.CrossRefPubMedGoogle Scholar
  46. 46.
    Magda SL, Ciobanu AO, Florescu M, Vinereanu D. Comparative reproducibility of the noninvasive ultrasound methods for the assessment of vascular function. Heart Vessels. 2013;28(2):143–50.  https://doi.org/10.1007/s00380-011-0225-2.CrossRefPubMedGoogle Scholar
  47. 47.
    Patterson SD, Ferguson RA. Increase in calf post-occlusive blood flow and strength following short-term resistance exercise training with blood flow restriction in young women. Eur J Appl Physiol. 2010;108(5):1025–33.  https://doi.org/10.1007/s00421-009-1309-x.CrossRefPubMedGoogle Scholar
  48. 48.
    Patterson SD, Ferguson RA. Enhancing strength and postocclusive calf blood flow in older people with training with blood-flow restriction. J Aging Phys Act. 2011;19(3):201–13.CrossRefGoogle Scholar
  49. 49.
    Hunt JE, Galea D, Tufft G, Bunce D, Ferguson RA. Time course of regional vascular adaptations to low load resistance training with blood flow restriction. J Appl Physiol. 2013;115(3):403–11.  https://doi.org/10.1152/japplphysiol.00040.2013.CrossRefPubMedGoogle Scholar
  50. 50.
    Mouser JG, Mattocks KT, Buckner SL, Dankel SJ, Jessee MB, Bell ZW, et al. High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training. Physiological Meas. 2019;40(3):035003.  https://doi.org/10.1088/1361-6579/ab0d2a.CrossRefGoogle Scholar
  51. 51.
    Jurva JW, Phillips SA, Syed AQ, Syed AY, Pitt S, Weaver A, et al. The effect of exertional hypertension evoked by weight lifting on vascular endothelial function. J Am Coll Cardiol. 2006;48(3):588–9.  https://doi.org/10.1016/j.jacc.2006.05.004.CrossRefPubMedGoogle Scholar
  52. 52.
    Dyson KS, Shoemaker JK, Hughson RL. Effect of acute sympathetic nervous system activation on flow-mediated dilation of brachial artery. Am J Physiol Heart Circ Physiol. 2006;290(4):H1446–53.  https://doi.org/10.1152/ajpheart.00771.2005.CrossRefPubMedGoogle Scholar
  53. 53.
    Hijmering ML, Stroes ES, Olijhoek J, Hutten BA, Blankestijn PJ, Rabelink TJ. Sympathetic activation markedly reduces endothelium-dependent, flow-mediated vasodilation. J Am Coll Cardiol. 2002;39(4):683–8.CrossRefGoogle Scholar
  54. 54.
    Navar LG. Physiology: hemodynamics, endothelial function, renin-angiotensin-aldosterone system, sympathetic nervous system. J Am Soc Hypertens. 2014;8(7):519–24.  https://doi.org/10.1016/j.jash.2014.05.014.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Nielsen JL, Aagaard P, Prokhorova TA, Nygaard T, Bech RD, Suetta C, et al. Blood flow restricted training leads to myocellular macrophage infiltration and upregulation of heat shock proteins, but no apparent muscle damage. J Physiol. 2017;595(14):4857–73.  https://doi.org/10.1113/JP273907.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Rossow LM, Fahs CA, Loenneke JP, Thiebaud RS, Sherk VD, Abe T, et al. Cardiovascular and perceptual responses to blood-flow-restricted resistance exercise with differing restrictive cuffs. Clin Physiol Funct Imaging. 2012;32(5):331–7.  https://doi.org/10.1111/j.1475-097X.2012.01131.x.CrossRefPubMedGoogle Scholar
  57. 57.
    Spitz RW, Chatakondi RN, Bell ZW, Wong V, Dankel SJ, Abe T, et al. The impact of cuff width and biological sex on cuff preference and the perceived discomfort to blood-flow-restricted arm exercise. Physiol Meas. 2019;40(5):055001.  https://doi.org/10.1088/1361-6579/ab1787.CrossRefPubMedGoogle Scholar
  58. 58.
    Mouser JG, Dankel SJ, Jessee MB, Mattocks KT, Buckner SL, Counts BR, et al. A tale of three cuffs: the hemodynamics of blood flow restriction. Eur J Appl Physiol. 2017;117(7):1493–9.  https://doi.org/10.1007/s00421-017-3644-7.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sports Med. 2015;45(3):313–25.  https://doi.org/10.1007/s40279-014-0288-1.CrossRefPubMedGoogle Scholar
  60. 60.
    Counts BR, Dankel SJ, Barnett BE, Kim D, Mouser JG, Allen KM, et al. Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle Nerve. 2016;53(3):438–45.  https://doi.org/10.1002/mus.24756.CrossRefGoogle Scholar
  61. 61.
    Sprick JD, Rickards CA. Cyclical blood flow restriction resistance exercise: a potential parallel to remote ischemic preconditioning? Am J Physiol Regul Integr Comp Physiol. 2017;313(5):R507–17.  https://doi.org/10.1152/ajpregu.00112.2017.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903–12.  https://doi.org/10.1007/s00421-011-2266-8.CrossRefGoogle Scholar
  63. 63.
    Brandner CR, May AK, Clarkson MJ, Warmington SA. Reported side-effects and safety considerations for the use of blood flow restriction during exercise in practice and research. Tech Orthopaedics. 2018;33(2):114–21.  https://doi.org/10.1097/BTO.0000000000000259.CrossRefGoogle Scholar
  64. 64.
    Kacin A, Rosenblatt B, Žargi TG, Biswas A. Safety considerations with blood flow restricted resistance training. Annales Kinesiologiae. 2015;6(1):3–26.Google Scholar
  65. 65.
    Nakajima T, Morita T, Sato Y. Key considerations when conducting KAATSU training. Int J KAATSU Train Res. 2011;7(1):1–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Physical EducationCatholic University of Brasilia (UCB)BrasiliaBrazil
  2. 2.Department of Physical EducationUniversity Center of the Federal District (UDF)BrasiliaBrazil
  3. 3.Department of Health SciencesCUNY Lehman CollegeBronxUSA

Personalised recommendations