The development of new exercise interventions aimed at enhancing physiological measures of aerobic fitness and associated aerobic performance outcomes is a far-reaching research effort that holds great value for coaches and practitioners alike. Maintaining a high degree of aerobic fitness can enhance sports performance (4,14,23) and improve recovery capabilities (37), while also having positive implications for health (18). However, it is commonly accepted that as aerobic fitness and performance capabilities improve, higher intensity training methods are required to elicit a training response (3,7). Therefore, the development of training methods that can assist in the maintenance and enhancement of aerobic capabilities during time when high-intensity training modalities are not suitable (such as rehabilitation scenarios or during planned periods of reduced training loads) is a valuable pursuit.
Undertaking exercise with blood flow restriction (BFR) has become an increasingly popular training method in athletic and rehabilitation settings to increase physiological stress while maintaining relatively low exercise intensities (22). Blood flow restriction training (also known as KAATSU training) involves exercising with an external constricting device (such as blood pressure cuffs, elasticated muscle wraps, or tourniquets) applied to the proximal limb musculature, with the intent to physically restrict arterial blood flow and occlude venous return (21). In doing so, BFR training may cause a decline in both oxygen delivery and metabolite clearance, thus creating a more stressful environment and stimulating physical adaptation (33). The observed effects of blood flow–restricted exercise include increases in exercising heart rate, enhanced muscle fiber recruitment, and intensified systemic hormone production (22,31). This suggests that the application of BFR with low-intensity exercise modalities may have the ability to stimulate physiological adaptation, while minimizing mechanical load.
Blood flow restriction training has been shown to enhance muscle hypertrophy and promote the development of muscular strength using loads as low as 20–50% of a subject's 1 repetition maximum in athletes (9,24), apparently healthy adults (20), older adults (39), and severely diseased individuals (25). This suggests that BFR training may allow for the development of muscular strength and size in populations where high load resistance training is unsuitable, such as with athletes during competitive season (32) and individuals in the postacute phase of musculoskeletal rehabilitation (15), while also indicating a place in more clinical settings (30). Furthermore, given its ease of application and relatively low cost, BFR seems to provide a simple and effective method of training with minimal barriers to its implementation.
In effect, the combination of BFR and aerobic exercise may offer a useful and practical method of training to improve cardiorespiratory fitness in clinical populations, while also offering a means of maintaining or improving aerobic performance in more athletic populations during times of reduced training intensity. Recent research has aimed to establish the effect that training with BFR has on aerobic fitness and exercise performance, with conflicting results (16,28), which provides an unclear picture of its role within exercise prescription.
This review aims to systematically identify and assess those studies that have combined BFR with aerobic exercise, and establish the effectiveness of BFR on aerobic fitness and performance.
Experimental Approach to the Problem
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines (26).
Only studies performed on humans were included. Articles were eligible for inclusion if they included the pre-training and post-training assessments of aerobic fitness (i.e., V[Combining Dot Above]O2max or V[Combining Dot Above]O2peak) or aerobic performance (i.e., time to exhaustion [TTE], 6-minute walk test), the training protocol consisted of exercise training with concurrent BFR, and the training protocol lasted a minimum of 2 weeks. Only studies using mechanical BFR through external applied pressure on the proximal point of a limb (i.e., blood pressure cuff or tourniquet) were included. All other mechanisms (e.g., hyperbaric chamber and hypoxic environment) were excluded. There were no inclusion criteria placed around the physical qualities of the occlusion cuffs (e.g., occlusion pressure and cuff width). Participants were not restricted by age, sex, fitness, or health status. Randomized controlled trials, matched controlled trials, and noncontrolled designs were included. To provide a full representation of the available research and assist guide future studies, articles were not excluded if they failed to report sufficient statistics for estimating effect sizes, did not justify the selected sample size, or on the basis of risk of bias assessment. Abstracts, reviews, meta-analyses, and other secondary sources were excluded. Moreover, studies examining the acute effects of BFR training during a single bout of exercise were also excluded. This brief review was approved by Alliance for Research in Exercise, Nutrition and Activity (ARENA) at the University of South Australia.
A systematic search was undertaken to identify all relevant studies assessing the effect of BFR training on aerobic fitness or performance. Candidate studies published between the year 1950 and 2018 were searched for between March 6, 2018, and March 9, 2018, by first searching a number of relevant online databases (Medline, Web of Science, SPORTDiscus, CINHAL, and ScienceDirect) using the following search terms: ((vascular occlusion*) OR (blood flow restrict*) OR (kaatsu*)) AND ((train*) OR (aerobic exercis*) OR (aerobic train*) OR (interval train*) OR (circuit train*) OR (walk*) OR (run*) OR (swim*) OR (cycl*) OR (ski*)) NOT ((rat*) OR (animal*)). Full-text articles published in the peer-reviewed literature in English between the years 1950 and 2018 were included. All titles and abstracts returned from the search were assessed to identify suitable studies. When the title and abstract provided insufficient data to ensure eligibility, the full-text article was retrieved.
Two authors independently conducted all literature searches and collated all abstracts. Those same authors then independently reviewed the abstracts and determined the suitability of the articles for full-text assessment, based on the inclusion and exclusion criteria. Discrepancies were resolved by discussion and reference to the initial article. The reference lists and citations (google scholar search, publications dated up to March 9, 2018) of included articles were checked for additional peer-reviewed articles meeting the inclusion criteria.
The Quality Assessment Tool for Quantitative Studies (36) was used to assess the risk of bias in each included study. This standardized critical appraisal tool consists of 6 sections: participant selection, study design, confounding factors, blinding, data collection method, and withdrawal. The tool can be adapted dependent on the type of quantitative study design used. For each individual study, each of the components was rated as “strong,” “moderate,” or “weak,” based on standardized criteria. These ratings are then combined to attain an overall rating for each study (“strong,” no weak ratings; “moderate,” one weak rating; and “weak,” 2 or more weak ratings).
The authors independently extracted the data (the quality criteria, participant details, validity measures, reliability measures, and main conclusion). Discrepancies were resolved by discussion and reference to the initial article.
The primary outcome measures used were the validity statistics between the actual measured maximal oxygen consumption (V[Combining Dot Above]O2max) or peak oxygen consumption (V[Combining Dot Above]O2peak), predicted V[Combining Dot Above]O2max/V[Combining Dot Above]O2peak values, and aerobic performance measures (i.e., TTE, 6-minute walk test, queen's college step test, time-trial time, and time to fatigue), and the reported direction of statistically significant difference between those measures. In the scenario where only absolute preintervention and postintervention measures were provided, percentage change was calculated.
The selection process is detailed in Figure 1. The combined database search yielded 2,104 unique results, of which 2,069 were excluded during the initial abstract screening. After full-text assessment, a further 27 studies were excluded based on the eligibility criteria detailed previously, leaving 8 articles that met the inclusion criteria. Two additional studies were located through the reference lists of the studies, whereas 5 were located through the citation search, leaving a total of 15 studies for analysis. On full-text analysis, one additional study was excluded because of plagiarism.
The characteristics of the 14 included studies are summarized in Table 1, including study sample information, method of intervention, and outcome measures. Sample sizes ranged from 7 to 49 participants. Seven study samples comprised only male participants (1,12,17,27,28,35,38), one did not state participant sex (19), and the remainder comprised both male and female subjects (2,8,10,11,16,29). The publication year ranged from 2010 to 2017.
The aim of this section is to summarize those studies that have evaluated the effectiveness on BFR training on aerobic capacity and aerobic exercise performance. Blood Flow Restricted Aerobic Exercise details the studies whose intervention used BFR combined with aerobic exercise, Blood Flow Restricted Resistance Exercise With Concurrent Aerobic Exercise those that involved BFR combined with resistance-based exercise, and Aerobic Interval Training With Blood Flow Restricted Recovery those that applied BFR during the rest periods of interval-based aerobic exercise. In Risk of Bias, the results of the risk of bias assessment are summarized.
Blood Flow Restricted Aerobic Exercise
Eleven of the included studies directly looked at the impact of BFR combined with aerobic exercise on aerobic capacity and performance (1,2,8,10,12,16,17,28,29,38).
Continuous cycle exercise combined with BFR in young healthy adults elicited measurable improvements in V[Combining Dot Above]O2peak (2.0%) (17), V[Combining Dot Above]O2max (6.4%), and TTE (15.4%) (1) when using low weekly training volumes of 45–60 total minutes per week, at low exercise intensities (30% of heart rate reserve or 40% of V[Combining Dot Above]O2max, respectively). In comparable population groups, continuous BFR treadmill-based exercise also demonstrated significant improvements in both V[Combining Dot Above]O2max (3.5–7.3%) and 1.5-mile time-trial performance (1.1%) (12,38). Alternatively, improvements in predicted V[Combining Dot Above]O2max and measured V[Combining Dot Above]O2max were not observed when combining continuous aerobic exercise with BFR in older adults (2,8); however, changes in aerobic-based measures of functional capacity were significantly larger than those reported in their respective control groups, suggesting a positive impact on aerobic performance (Table 2). Applied occlusion pressures were reported to be between 120 and 220 mm Hg (1,2,12,17), or at 60% of arterial occlusion (8).
The impact of low-intensity interval training combined with BFR in healthy young adults on V[Combining Dot Above]O2max has also been explored. Park et al. (28) first reported significant improvements in V[Combining Dot Above]O2max (11.6%) after 2 weeks of interval-based BFR walk training. This protocol required participants to perform a total of 15 minutes of BFR walking at low intensities (4–6 km·h−1, 5% grade) for 12 sessions per week over 2-week duration. Similarly, 2 further studies examined the effects 4 weeks of low-intensity (30% power max) and low-volume BFR aerobic interval training. The first demonstrated significant improvements in V[Combining Dot Above]O2max (6%) and onset of blood lactate accumulation (16%) (11) after the BFR training intervention, indicating enhanced aerobic capacity and performance. The second did not provide a direct measure of aerobic capacity but reported significant improvements in TTE (48.9%) after intervention (10). Occlusion pressures varied between 140 and 220 mm Hg (10,11,29).
The combination of BFR with high-intensity interval training has also been explored. Keramidas et al. (16) reported no change in V[Combining Dot Above]O2max after 6 weeks of BFR cycle-based interval training using occlusion pressures of 90 mm Hg in healthy young adults and training intensities of 90% of V[Combining Dot Above]O2max. However, a decline in the average oxygen uptake maintained during a 6-minute submaximal aerobic test (performed at 80% of V[Combining Dot Above]O2max), and time to fatigue at 150% of peak power output, led the authors to suggest improvements in aerobic performance parameters. Conversely, Paton et al. (29) saw significant improvements in both V[Combining Dot Above]O2max (6.3%) and TTE (26.9%) using a similar training protocol where running was the primary exercise modality (exercise performed at 80% of peak running velocity).
Blood Flow Restricted Resistance Exercise With Concurrent Aerobic Exercise
Two of the included studies aimed to establish the effect of endurance exercise performed concurrently with BFR resistance training on aerobic fitness in older adults (19,27).
Libardi et al. (19) demonstrated significant improvements in V[Combining Dot Above]O2peak (10.3%) after 12 weeks of aerobic exercise combined with BFR resistance training using an average occlusion pressure of 67 mm Hg. These improvements were not significantly different from the control group, who performed the same protocol using non–BFR-restricted training. Nakajima et al. (27) reported significant improvements in both V[Combining Dot Above]O2peak and oxygen uptake at anaerobic threshold (10.7 and 10.9%, respectively) in older adults with diagnosed ischemic heart disease in response to a 12-week aerobic and BFR resistance training program.
Aerobic Interval Training With Blood Flow Restricted Recovery
Taylor et al. (35) aimed to establish the effect of 4 weeks of sprint interval training combined with BFR rest periods on aerobic capacity and performance in healthy active adults. In this study, the participants performed 30-second bouts of sprints separated by 4-minute recovery periods, with the BFR group wearing an occlusion cuff on both limbs (occlusion pressure of 130 mm Hg) for 2 minutes of the 4-minute recovery periods. Measures of average training intensity and total training workload were significantly lower in the intervention group. Measures of V[Combining Dot Above]O2max were significantly improved after the training intervention (4.7%), while remaining unchanged in the control group. Fifteen-kilometer time-trial performance remained unchanged in both groups.
Risk of Bias
Table 3 depicts the results of the quality assessment for each study. Selection bias was high (receiving a “weak” rating) because most studies seemed to use a convenience sample rather than randomly selecting participants form the general population. The included articles were typically rated as “strong” across the categories pertaining to study design and confounders. Within this, 7 of the 9 studies (1,2,8,11,16,19,28) used a randomized design, accounting for confounders. Blinding was not reported in any of the articles, whereas withdrawals and dropouts were only reported in one (35). Thirteen of the included articles were rated globally as “weak,” whereas a single study was rated globally “moderate” (38).
A systematic search of the literature revealed 14 unique publications regarding the effects of blood flow–restricted exercise on aerobic capacity and performance. Eleven of these looked to determine the effectiveness of aerobic exercise with simultaneous application of BFR, 2 investigated the effectiveness of BFR resistance training with concurrent non-BFT aerobic exercise, whereas a single study demonstrated the effectiveness of sprint interval training in conjunction with BFR rest intervals, with conflicting results.
Of the 11 studies looking at aerobic exercise with BFR, 8 demonstrated improvements in measured V[Combining Dot Above]O2max (1,10–12,28,29) or V[Combining Dot Above]O2peak (17). Each of these was performed in young healthy adults and used relatively high occlusion pressures (when specifically reported, equal or greater than 160 mm Hg). Conversely, the 4 that did not report significant improvements in measured or predicted V[Combining Dot Above]O2max were either performed in older adults (2,8), used relatively low occlusion pressures (90 mm Hg) (16), or strictly reported measures of aerobic performance (38). The modality of exercise (cycle vs. treadmill-based) did not seem to influence the observed changes. Although this information would suggest that BFR aerobic exercise can strictly elicit improvements in aerobic capacity in younger individuals and when using occlusion pressures above at least 90 mm Hg, it is also important to note that, across all groups, improvements in aerobic performance measures were observed. As these performance improvements occurred irrespective of measured improvements in aerobic capacity, further exploration is required.
At a given exercise intensity, BFR exercise has been suggested to reduce arterial blood flow and increase venous pooling within the limb, decreasing stroke volume and causing a subsequent increase in heart rate, thus placing increased mechanical stress on the heart and driving cardiovascular adaptions (34). With this, BFR exercise has also been suggested to increase toxicity and metabolite accumulation within the working limb, leading to peripheral muscular adaptations (33). As declinations in muscle quality are observed with increase in age (13), it could be hypothesized that BFR aerobic exercise in older adults stimulates peripheral adaptations first. As these peripheral deficits are not typically observed in younger individuals, it would be reasonable to suggest that BFR aerobic exercise is therefore more likely induce more central cardiovascular adaptations in this population. This would help explain the improvements in aerobic performance measures observed in older individuals, without the same improvements in aerobic capacity.
While low-intensity BFR-resisted training combined with concurrent aerobic exercise was shown to elicit improvements in both aerobic capacity and performance in older individuals in 2 studies (19,27), neither included a control group that performed only aerobic exercise. As such, it cannot be determined whether the non-BFR aerobic exercise was responsible for these adaptations, or the BFR exercise did indeed play a role. Although the peripheral adaptations within the muscle tissue in response to BFR resistance exercise may result in enhanced aerobic capacity, more research is needed to determine whether this is indeed the case.
And finally, in trained individuals, the combination of sprint interval training and BFR (occlusion pressure of 130 mm Hg) rest periods was shown to stimulate large improvements in V[Combining Dot Above]O2max (4.7%) when compared with sprint interval training alone (0.7%). Although this increase did not correspond with an improvement in time-trial performance, it does suggest that combining sprint interval training with BFR may have positive implications for aerobic fitness. Although the exact mechanisms of this adaptation remain unclear, the authors hypothesized that training with the implementation of BFR during the recovery periods of sprint bouts may cause an increase in capillary density within the muscle tissue (35), leading to a subsequent increase in V[Combining Dot Above]O2max.
The results of this review indicate that BFR exercise is a viable method of improving aerobic capacity and performance despite relatively low training intensities. However, this does require further consideration. Exercise with BFR has been shown to increase ratings of perceived exertion and sensation of pain at given exercise intensities when compared with exercise without BFR (5). This seems to be combined with significantly higher delayed onset muscle soreness in BFR training groups up to 48 hours after exercise (6). As a result, although BFR exercise may reduce physical training load, it may not reduce exercise intensity per se. With this in mind, more research is needed before practical recommendations can be made around the use of BFR exercise in settings where high-intensity exercise is not suitable.
In addition, the studies included within this review had several limitations. First, in terms of their overall quality, 13 of the studies were rated globally as “weak” in accordance with the Quality Assessment Tool for Quantitative Studies (36). Within this, a number of important factors were not reported, and the participant selection seemed to be highly biased. As a result, we cannot be sure that the results truly represent those observed in the reported target population. Second, the studies used a variety of methods to apply BFR to their exercise regime, with vast differences in occlusion cuff widths, occlusion cuff pressures, exercise intensities, and exercise durations. This lack of similarity across methodologies makes it hard to compare the effectiveness of the interventions because many variables could have had an interaction with the outcome measures. Finally, each of the studies within this review had relatively small sample sizes, with no more than 11 participants within a single training group. Larger sample sizes may have provided more certainty around the results observed. Taking this into consideration, more high-level studies are required in this area before any definitive conclusions can be drawn.
Despite the potential limitations observed in the included studies, this review provides insight and guidance around the potential applications of BFR with respect to aerobic exercise: an area of research that is relatively new and shows promise in both clinical and athletic populations. Future studies in this area would benefit from increased sample sizes and more rigorous reporting methods.
Aerobic exercise is integral to the maintenance of cardiovascular health and function, while also playing a key role in enhancing athletic performance. This review demonstrates that the combination of BFR with aerobic exercise can elicit improvements in aerobic performance and aerobic fitness in various populations irrespective of training intensity, although certain considerations are required. BFR aerobic exercise at light intensities has been shown to cause improvements in both aerobic fitness and aerobic performance in young adults when using higher occlusion pressures (130 mm Hg or greater). Conversely, BFR combined with aerobic exercise seems to strictly enhance aerobic performance in older adults, without impacting physiological measures of aerobic fitness. The authors hypothesize that this may be due to BFR exercise eliciting predominantly peripheral adaptations in older individuals, where a combination of central and peripheral adaptions may be more likely to occur in young adults. Despite the limitations of the included studies, BFR aerobic exercise seems to have potential applications in settings where high-intensity training is not appropriate, although more high-quality research is needed to further demonstrate this.
This research was supported by an Australian Government Research Training Program (RTP) Scholarship. The protocol for this review was registered on the international prospective register for systematic reviews (PROSPERO), registration number (CRD42018090702). The authors declare that they have no conflict of interest.
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Keywords:Copyright © 2019 by the National Strength & Conditioning Association.
ischemic; exercise; maximal oxygen uptake; KAATSU