- Published: December 28, 2021
- Updated: October 12, 2022
- University / College: The Scripps Research Institute (TSRI)
- Language: English
- Downloads: 45
A Commentary on
Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety
by Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., et al. (2019). Front. Physiol. 10: 1332. doi: 10. 3389/fphys. 2019. 00533
Blood flow restriction (BFR) training is a bourgeoning exercise modality which promotes increases in skeletal muscle mass and strength during resistance exercise ( Sato, 2005 ). In practice, prior to a bout of exercise, a pneumatic cuff (or tourniquet) is inflated around the limb proximal to the muscle to be trained thereby restricting its blood flow. During exercise with BFR, the ischemic working muscle inordinately accumulates metabolites (e. g., proton and lactate) which promote muscle strength and hypertrophy ( Slysz et al., 2016 ). The metabolic environment of the muscle interstitium during non-restricted, high-intensity resistance exercise can be simulated by performing blood flow-restricted low-intensity resistance exercise ( Kim et al., 2017 ). BFR resistance exercise (BFR-RE) is employed by bodybuilders, athletes, and is also intriguing for individuals with limited or incapacity of performing high-intensity resistance exercise: elderly ( Centner et al., 2019 ) and clinical populations such as orthopedic ( Hughes et al., 2017 ) and cardiac rehabilitation ( Madarame et al., 2013 ; Kambic et al., 2019 ) patients.
Spranger et al. (2015) offered caution to a hasty, wholesale implementation of BFR training from gym to clinic. The exercise pressor reflex (EPR—muscle metaboreflex and muscle mechanoreflex) was the primary basis of this concern. As previously stated, metabolites accumulate in the muscle interstitium during exercise. The muscle interstitium contains chemically sensitive receptors within group IV afferent nerve fibers which respond to these metabolites, reflexively engaging the metaboreflex. In turn, the metaboreflex increases sympathetic outflow leading to marked increases in hemodynamics such as heart rate and arterial blood pressure ( Boushel, 2010 ). Ischemic exercise, such as BFR-RE, inordinately accumulates metabolites within the muscle interstitium ( Takarada et al., 2000 ; Takada et al., 2012 ), supporting the contention that BFR-RE leads to exaggerated metaboreflex activation.
Several studies in young, healthy individuals have shown that BFR-RE exacerbates cardiovascular responses. Downs et al. (2014) reported that BFR-RE raised systolic blood pressure (SBP) (156 ± 7 mmHg) by ~29 mmHg vs. exercise without BFR (127 ± 4 mmHg). Prodel et al. (2016) reported that BFR-RE raised SBP (191 ± 8 mmHg) by ~38 mmHg vs. exercise without BFR (153 ± 7 mmHg). Thomas et al. (2018) reported that BFR-RE increased mean arterial pressure (MAP) by ~20 mmHg vs, exercise without BFR. Importantly, they further showed that low-intensity, BFR-RE increased MAP (124. 2 ± 2. 3 mmHg) by ~10 mmHg vs. high-intensity, exercise without BFR (113. 9 ± 2. 5 mmHg). They concluded that practitioners should use caution if prescribing this BFR exercise modality within a vascular compromised population. Recently, Hori et al. (2020) reported that BFR-RE exaggerated SBP from rest to exercise (52. 4 ± 6. 9 mmHg) vs. exercise in the absence of BFR (27. 0 ± 3. 1 mmHg). Moreover, they provided the first evidence that the BFR-RE-induced exaggeration in SBP can be explained by the SBP response to post-exercise muscle ischemia, which elicits the metaboreflex ( Crisafulli et al., 2018 ). These data, and other ( Domingos and Polito, 2018 ; Scott et al., 2018 ; Cristina-Oliveira et al., 2020 ), demonstrate that BFR-RE can exacerbate metaboreflex activation leading to abnormal increases in hemodynamic responses during exercise.
While caution is warranted even in healthy individuals, the primary concern of Spranger et al. (2015) specifically pertained to patients with cardiac and vascular diseases, as metaboreflex hemodynamics are exaggerated in subjects with heart failure, hypertension, and peripheral artery disease during exercise. Therefore, caution is heightened when considering a BFR-RE regimen for these clinical populations ( Spranger et al., 2015 ). In response to Spranger et al. (2015), Jessee et al. (2016) acknowledged this concern and proposed that making the arterial occlusion pressure relative to the cuff and individual may help reduce the risk of any adverse cardiovascular events associated with the EPR. Pope et al. (2013) furthered this sentiment, not only advocating that caution should be exercised for individuals with any form of cardiovascular disease, but also suggesting that BFR protocols for these individuals should employ reduced external cuff pressure, time under pressure, and physical exertion.
A few studies have employed BFR-RE in populations with cardiovascular disease with generally favorable conclusions. However, these conclusions were drawn despite the fact that either hemodynamics were not assessed in the study ( Madarame et al., 2013 ; Groennebaek et al., 2019 ) or they were only assessed before and after, but not during the exercise ( Barili et al., 2018 ; Kambič et al., 2020 ). For example, Kambič et al. (2020) assessed the safety of BFR-RE in patients with stable coronary artery disease. While they did not measure hemodynamics in these patients during exercise, they nonetheless concluded that BFR-RE exhibited favorable hemodynamic responses in patients with CAD, and therefore was proven to be safe. When considering the safety of BFR-RE for individuals with cardiovascular disease, it is paramount to understand what hemodynamic changes are occurring in the individual during the exercise. It is this ischemic maneuver, BFR, coupled with the resistance exercise, which leads to the increased accumulation of metabolites in the muscle interstitium which reflexively engage the metaboreflex leading to exaggerated increases in hemodynamics. Indeed, Pinto and Polito (2016) measured hemodynamics in hypertensive women with and without BFR. They reported that BFR-RE exaggerated the rise in SBP from rest to exercise (52. 4 ± 6. 9 mmHg) vs. exercise without BFR (27. 0 ± 3. 1 mmHg).
Patterson et al. (2019), proffers a prescription for BFR training for practitioners. Importantly, this review addresses several potential safety concerns to consider when coupling BFR to exercise. However, I am very concerned that Patterson et al. (2019) fail to mention and acknowledge the EPR, and even more specifically the metaboreflex, when addressing potential safety concerns regarding cardiovascular responses to BFR-RE. The studies provided in this commentary, and those thoroughly outlined by Cristina-Oliveira et al. (2020), clearly demonstrate that BFR-RE can markedly increase hemodynamic parameters, likely owing to exaggerated metaboreflex activity. This concern is amplified when considering the prescription of BFR-RE to individuals with cardiovascular disease.
Patterson et al. (2019) intend for their review to be a research-informed guide to BFR training for practitioners. I applaud the authors for their efforts and support Patterson et al. (2019) as “ the guide to BFR exercise” moving forward. However, I contend that this “ guide” is deficient in important safety information regarding BFR exercise and its interaction with the EPR. This is essential and vital knowledge for BFR practitioners, and thus, as in Vanwye et al. (2017), must be provided in the consequential review by Patterson et al. (2019).
Author Contributions
The author confirms being the sole contributor of this work and has approved it for publication.
Conflict of Interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
Barili, A., Corralo, V. D. S., Cardoso, A. M., Mânica, A., Bonadiman, B., Bagatini, M. D., et al. (2018). Acute responses of hemodynamic and oxidative stress parameters to aerobic exercise with blood flow restriction in hypertensive elderly women. Mol. Biol. Rep. 45, 1099–1109. doi: 10. 1007/s11033-018-4261-1
PubMed Abstract | CrossRef Full Text | Google Scholar
Boushel, R. (2010). Muscle metaboreflex control of the circulation during exercise. Acta Physiol. 199, 367–383 doi: 10. 1111/j. 1748-1716. 2010. 02133. x
PubMed Abstract | CrossRef Full Text | Google Scholar
Centner, C., Wiegel, P., Gollhofer, A., and Konig, D. (2019). Effects of blood flow restriction training on muscular strength and hypertrophy in older individuals: a systematic review and meta-analysis. Sports Med. 49, 95–108. doi: 10. 1007/s40279-018-0994-1
CrossRef Full Text | Google Scholar
Crisafulli, A., de Farias, R. R., Farinatti, P., Lopes, K. G., Milia, R., Sainas, G., et al. (2018). Blood flow restriction training reduces blood pressure during exercise without affecting metaboreflex activity. Front. Physiol. 9: 1736. doi: 10. 3389/fphys. 2018. 01736
PubMed Abstract | CrossRef Full Text | Google Scholar
Cristina-Oliveira, M., Meireles, K., Spranger, M. D., O’Leary, D. S., Roschel, H., and Peçanha, T. (2020). Clinical safety of blood flow-restricted training? A comprehensive review of altered muscle metaboreflex in cardiovascular disease during ischemic exercise. Am. J. Physiol. Heart Circ. Physiol. 318, H90–H109. doi: 10. 1152/ajpheart. 00468. 2019
PubMed Abstract | CrossRef Full Text | Google Scholar
Domingos, E., and Polito, M. D. (2018). Blood pressure response between resistance exercise with and without blood flow restriction: a systematic review and meta-analysis. Life Sci. 209, 122–131. doi: 10. 1016/j. lfs. 2018. 08. 006
PubMed Abstract | CrossRef Full Text | Google Scholar
Downs, M. E., Hackney, K. J., Martin, D., Caine, T. L., Cunningham, D., O’Connor, D. P., et al. (2014). Acute vascular and cardiovascular responses to blood flow-restricted exercise. Med. Sci. Sports Exerc. 46, 1489–1497. doi: 10. 1249/MSS. 0000000000000253
PubMed Abstract | CrossRef Full Text | Google Scholar
Groennebaek, T., Sieljacks, P., Nielsen, R., Pryds, K., Jespersen, N. R., Wang, J., et al. (2019). Effect of blood flow restricted resistance exercise and remote ischemic conditioning on functional capacity and myocellular adaptations in patients with heart failure. Circ. Heart Fail. 12: e006427. doi: 10. 1161/CIRCHEARTFAILURE. 119. 006427
PubMed Abstract | CrossRef Full Text | Google Scholar
Hori, A., Hasegawa, D., Suijo, K., Nishigaki, K., Ishida, K., and Hotta, N. (2020). Exaggerated pressor response to blood flow restriction resistance exercise is associated with a muscle metaboreflex-induced increase in blood pressure in young, healthy humans. Appl. Physiol. Nutr. Metab . doi: 10. 1139/apnm-2020-0491. [Epub ahead of print].
PubMed Abstract | CrossRef Full Text | Google Scholar
Hughes, L., Paton, B., Rosenblatt, B., Gissane, C., and Patterson, S. D. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br. J. Sports Med. 51, 1003–1011. doi: 10. 1136/bjsports-2016-097071
PubMed Abstract | CrossRef Full Text | Google Scholar
Jessee, M. B., Buckner, S. L., Mouser, J. G., Mattocks, K. T., and Loenneke, J. P. (2016). Letter to the editor: applying the blood flow restriction pressure: the elephant in the room. Am. J. Physiol. Heart Circ. Physiol. 310, H132–H133. doi: 10. 1152/ajpheart. 00820. 2015
PubMed Abstract | CrossRef Full Text | Google Scholar
Kambič, T., Novaković, M., TomaŽin, K., Strojnik, V., BoŽič-Mijovski, M., and Jug, B. (2020). Hemodynamic and hemostatic response to blood flow restriction resistance exercise in coronary artery disease: a pilot randomized controlled trial. J. Cardiovasc. Nurs . doi: 10. 1097/JCN. 0000000000000699. [Epub ahead of print].
PubMed Abstract | CrossRef Full Text | Google Scholar
Kambic, T., Novakovic, M., Tomazin, K., Strojnik, V., and Jug, B. (2019). Blood flow restriction resistance exercise improves muscle strength and hemodynamics, but not vascular function in coronary artery disease patients: a pilot randomized controlled trial. Front. Physiol. 10: 656. doi: 10. 3389/fphys. 2019. 00656
CrossRef Full Text | Google Scholar
Kim, D., Loenneke, J. P., Ye, X., Bemben, D. A., Beck, T. W., Larson, R. D., et al. (2017). Low-load resistance training with low relative pressure produces muscular changes similar to high-load resistance training. Muscle Nerve 56, E126–E133. doi: 10. 1002/mus. 25626
PubMed Abstract | CrossRef Full Text | Google Scholar
Madarame, H., Kurano, M., Fukumura, K., Fukuda, T., and Nakajima, T. (2013). Haemostatic and inflammatory responses to blood flow-restricted exercise in patients with ischaemic heart disease: a pilot study. Clin. Physiol. Funct. Imaging 33, 11–17. doi: 10. 1111/j. 1475-097X. 2012. 01158. x
PubMed Abstract | CrossRef Full Text | Google Scholar
Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., et al. (2019). Blood flow restriction exercise: considerations of methodology, application, and safety. Front. Physiol. 10: 533. doi: 10. 3389/fphys. 2019. 00533
CrossRef Full Text | Google Scholar
Pinto, R. R., and Polito, M. D. (2016). Haemodynamic responses during resistance exercise with blood flow restriction in hypertensive subjects. Clin. Physiol. Funct. Imaging 36, 407–413. doi: 10. 1111/cpf. 12245
PubMed Abstract | CrossRef Full Text | Google Scholar
Pope, Z. K., Willardson, J. M., and Schoenfeld, B. J. (2013). Exercise and blood flow restriction. J. Strength Cond. Res. 27, 2914–2926. doi: 10. 1519/JSC. 0b013e3182874721
PubMed Abstract | CrossRef Full Text | Google Scholar
Prodel, E., Balanos, G. M., Braz, I. D., Nobrega, A. C. L., Vianna, L. C., and Fisher, J. P. (2016). Muscle metaboreflex and cerebral blood flow regulation in humans: implications for exercise with blood flow restriction. Am. J. Physiol. Heart Circ. Physiol. 310, H1201–H1209. doi: 10. 1152/ajpheart. 00894. 2015
PubMed Abstract | CrossRef Full Text | Google Scholar
Sato, Y. (2005). The history and future of KAATSU training. Int. J. Kaatsu Train Res. 1, 1–5. doi: 10. 3806/ijktr. 1. 1
CrossRef Full Text | Google Scholar
Scott, B. R., Peiffer, J. J., Thomas, H. J., Marston, K. J., and Hill, K. D. (2018). Hemodynamic responses to low-load blood flow restriction and unrestricted high-load resistance exercise in older women. Front. Physiol. 9: 1324. doi: 10. 3389/fphys. 2018. 01324
PubMed Abstract | CrossRef Full Text | Google Scholar
Slysz, J., Stultz, J., and Burr, J. F. (2016). The efficacy of blood flow restricted exercise: a systematic review and meta-analysis. J. Sci. Med. Sport 19, 669–675. doi: 10. 1016/j. jsams. 2015. 09. 005
PubMed Abstract | CrossRef Full Text | Google Scholar
Spranger, M. D., Krishnan, A. C., Levy, P. D., O’Leary, D. S., and Smith, S. A. (2015). Blood flow restriction training and the exercise pressor reflex: a call for concern. Am. J. Physiol. Heart Circ. Physiol. 309, H1440–H1452. doi: 10. 1152/ajpheart. 00208. 2015
PubMed Abstract | CrossRef Full Text | Google Scholar
Takada, S., Okita, K., Suga, T., Omokawa, M., Kadoguchi, T., Sato, T., et al. (2012). Low-intensity exercise can increase muscle mass and strength proportionally to enhanced metabolic stress under ischemic conditions. J. Appl. Physiol. 113, 199–205. doi: 10. 1152/japplphysiol. 00149. 2012
PubMed Abstract | CrossRef Full Text | Google Scholar
Takarada, Y., Nakamura, Y., Aruga, S., Onda, T., Miyazaki, S., and Ishii, N. (2000). Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J. Appl. Physiol. 88, 61–65. doi: 10. 1152/jappl. 2000. 88. 1. 61
PubMed Abstract | CrossRef Full Text | Google Scholar
Thomas, H. J., Scott, B. R., and Peiffer, J. J. (2018). Acute physiological responses to low-intensity blood flow restriction cycling. J. Sci. Med. Sport 21, 969–974. doi: 10. 1016/j. jsams. 2018. 01. 013
PubMed Abstract | CrossRef Full Text | Google Scholar
Vanwye, W. R., Weatherholt, A. M., and Mikesky, A. E. (2017). Blood flow restriction training: implementation into clinical practice. Int. J. Exerc. Sci. 10, 649–654.
