Blood Flow Restriction with Low-load Resistance Exercise Improves Strength in Adults with Risk Factors for Knee Osteoarthritis: A Double-Blind Randomized Controlled Trial

Sakolawat Jaroenpakdee; Rachawan  Suksathien; Pimpisa Vongvachvasin

Authors

Sakolawat Jaroenpakdee Department of Rehabilitation Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima
Rachawan Suksathien Department of Rehabilitation Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima https://orcid.org/0009-0000-2134-0328
Pimpisa Vongvachvasin Department of Rehabilitation Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima https://orcid.org/0000-0001-7303-7611

Keywords:

blood flow restriction therapy, resistance exercise, knee osteoarthritis, randomized controlled trial (RCT)

Abstract

Objectives: To assess the efficacy of blood flow restriction (BFR) with Low-load Resistance Exercise improving knee exten-sor strength in adults with risk factors for symptomatic knee osteoarthritis (OA)

Study design: Double-blind randomized controlled trial

Setting: Department of Rehabilitation Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand

Subjects: Forty-four adults aged ≥ 40 years who engaged in irregular physical activity and had at least one risk factor for symptomatic knee OA were enrolled. Participants were randomly assigned to either the BFR or the control group using stratified and mixed block randomization.

Methods: The study employed a double-blind, randomized, controlled trial design. The BFR group exercised twice a week for 4 weeks, performing knee extension exercises at 30% of their one-repetition maximum (1RM) (15 reps × 4 sets) with cuff pressure, while the control group performed the same exercises but without using the cuff protocol. The outcomes measured included 1RM isokinetic knee extension, 1RM isokinetic leg press, 30-second chair stand test, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Test results pre-exercise and post-exercise (3 days after the last exercise session) were recorded. Differences in results between groups were compared using the linear regression test.

Results: The post-test mean differences of 1RM isokinetic knee extensor, 1RM leg press, 30 second chair stand test, and KOOS between groups (adjusted mean difference, AMD) were 14.7 kg (95% confidence interval (95%CI) 4.0, 19.3; p < 0.001), 30.83 kg (95%CI: 18.0, 43.7; p < 0.001), 7.1 times (95%CI: 4.2, 10.1; p < .001) and 1.4 points (95%CI: 0.3, 2.5; p = 0.01) respectively, all of which were statistically significant (p < 0.05).

Conclusions: BFR can improve knee extensor strength in adults with risk factors for symptomatic knee OA compared to low-load resistance exercise alone without further worsening knee symptoms.

References

Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine [Internet]. 2020 [cited 2023 Sep 11];29-30:100587. Available from: https://doi.org/10.1016/j.eclinm.2020.100587

Segal NA, Glass NA, Felson DT, Hurley M, Yang M, Nevitt M, et al. Effect of quadriceps strength and proprioception on risk for knee osteoarthritis. Med Sci Sports Exerc [Internet]. 2010 [cited 2023 Sep 11];42:2081-8. Available from: https://doi.org/10.1249/MSS.0b013e3181dd902e

Liguori G. ACSM’s Guidelines for exercise testing and prescription. 11th ed. [Internet]. Scribd; 2021 [cited 2023 Sep 11]. Available from: https://www.scribd.com/document/630074012/ACSM-s-Guidelines-for-exercise-testing-and-prescription-11th-edition-pdf

Mujalli M, Zakarneh M, Aloyoun A. Common sports injuries among physical activities practitioners at the physical fitness centers in Jordan (comparative study). Asian Soc Sci [Internet]. 2016 [cited 2023 Sep 11];12(5):24. Available from: https://doi.org/10.5539/ass.v12n5p24

Kacin A, Rosenblatt B, Tomc Zargi T, Biswas A. Safety considerations with blood flow restricted resistance training. Ann Kinesiol [Internet]. 2016 [cited 2023 Sep 11];6:3-26.

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 [Internet]. 2017 [cited 2023 Jul 11];51:1003-11. Available from: https://doi.org/10.1136/bjsports-2016-097071

Miller BC, Tirko AW, Shipe JM, Sumeriski OR, Moran K. The systemic effects of blood flow restriction training: a systematic review. Int J Sports Phys Ther [Internet]. 2021 [cited 2023 Jul 11];16:978-90. Available from: https://doi.org/10.26603/001c.25791

Pearson SJ, Hussain SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med [Internet]. 2015 [cited 2023 Jul 11];45:187-200. Available from: https://doi.org/10.1007/s40279-014-0264-9

Jessee MB, Mattocks KT, Buckner SL, Dankel SJ, Mouser JG, Abe T, et al. Mechanisms of blood flow restriction: the new testament. Tech Orthop [Internet]. 2018 [cited 2023 Jul 11];33:72. Available from: https://doi.org/10.1097/BTO.0000000000000252

Lim ZX, Goh J. Effects of blood flow restriction (BFR) with resistance exercise on musculoskeletal health in older adults: a narrative review. Eur Rev Aging Phys Act [Internet]. 2022 [cited 2023 Jul 11];19:15. Available from: https://doi.org/10.1186/s11556-022-00294-0

Lorenz DS, Bailey L, Wilk KE, Mangine RE, Head P, Grindstaff TL, et al. Blood flow restriction training. J Athl Train [Internet]. 2021 [cited 2023 Jul 11];56:937-44. Available from: https://doi.org/10.4085/418-20

Aniceto RR, da Silva Leandro L. Practical blood flow restriction training: new methodological directions for practice and research. Sports Med Open [Internet]. 2022 [cited 2023 Jul 11];8:87. Available from: https://doi.org/10.1186/s40798-022-00475-2

Jones MT, Aguiar EJ, Winchester LJ. Proposed mechanisms of blood flow restriction exercise for the improvement of type 1 diabetes pathologies. Diabetology [Internet]. 2021 [cited 2023 Jul 11];2:176-89. Available from: https://doi.org/10.3390/diabetology2040016

Segal NA, Torner J, Felson D, Niu J, Sharma L, Lewis CE, et al. The effect of thigh strength on incident radiographic and symptomatic knee osteoarthritis in the multicenter osteoarthritis (MOST) study. Arthritis Rheum [Internet]. 2009 [cited 2023 Jul 11];61:1210-7. Available from: https://doi.org/10.1002/art.24541

Dong Y, Yan Y, Zhou J, Zhou Q, Wei H. Evidence on risk factors for knee osteoarthritis in middle-older aged: a systematic review and meta analysis. J Orthop Surg [Internet]. 2023 [cited 2023 Jul 11];18:634. Available from: https://doi.org/10.1186/s13018-023-04089-6

Sinusas K. Osteoarthritis: diagnosis and treatment. Am Fam Physician [Internet]. 2012 [cited 2023 Jul 11];85:49-56. Available from: https://www.aafp.org/pubs/afp/issues/2012/0101/p49.html

Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med [Internet]. 2020 [cited 2023 Jul 11];54:1451-62. Available from: https://doi.org/10.1136/bjsports-2020-102955

Tudor-Locke C, Craig C, Thyfault J, Spence J. A step-defined sedentary lifestyle index. Appl Physiol Nutr Metab [Internet]. 2013 [cited 2023 Jul 11];38:100-14. Available from: https://doi.org/10.1139/apnm-2012-0235

Bhat AG, Farah M, Szalai H, Lagu T, Lindenauer PK, Visintainer P, et al. Evaluation of the American Association of Cardiovascular and Pulmonary Rehabilitation exercise risk stratification classification tool without exercise testing. J Cardiopulm Rehabil Prev [Internet]. 2021 [cited 2023 Jul 11];41:257-63. Available from: https://doi.org/10.1097/HCR.0000000000000584

Segal NA, Williams GN, Davis M, Wallace RB, Mikesky. A. Efficacy of Blood Flow Restricted Low-Load Resistance Training in Women with Risk Factors for Symptomatic Knee Osteoarthritis. PM R [Internet]. 2015 [cited 2025 Jul 21];7:376-384. Available from: https://doi.org/10.1016/j.pmrj.2014.09.014

Bryk FF, Dos Reis AC, Fingerhut D, Araujo T, Schutzer M, Leite Cury RP, et al.. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc Off J ESSKA [Internet]. 2016 [cited 2025 Jul 21];24:1580-1586. Available from: https://doi.org/10.1007/s00167-016-4064-7

Mattar MA, Gualano B, Perandini LA, Shinjo SK, Lima FR, Lúcia Sá-Pinto A, et al.. Safety and possible effects of low-intensity resistance training associated with partial blood flow restriction in polymyositis and dermatomyositis. Arthritis Res Ther [Internet]. 2014 [cited 2025 Jul 21];16:473. Available from: https://doi.org/10.1186/s13075-014-0473-5

Vechin FC, Libardi CA, Conceição MS, Damas FR, Lixandrão ME, Berton RP, et al.. Comparisons between low-intensity resistance training with blood flow restriction and high-intensity resistance training on quadriceps muscle mass and strength in elderly. J Strength Cond Res [Internet]. 2015 [cited 2025 Jul 21];29:1071-1076. Available from: https://doi.org/10.1519/jsc.0000000000000703

Libardi CA, Chacon-Mikahil MPT, Cavaglieri CR, Tricoli V, Roschel H, Vechin FC, et al.. Effect of concurrent training with blood flow restriction in the elderly. Int J Sports Med [Internet]. 2015 [cited 2025 Jul 21];36:395-399. Available from: https://doi.org/10.1055/s-0034-1390496

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 [Internet]. 2016 [cited 2025 Jul 21];116:749-757. Available from: https://doi.org/10.1007/s00421-016-3328-8

Patterson SD, Ferguson RA. Enhancing strength and postocclusive calf blood flow in older people with training with blood-flow restriction. J Aging Phys Act [Internet]. 2011 [cited 2025 Jul 21];19:201-213. Available from: https://doi.org/10.1123/japa.19.3.201

Yasuda T, Fukumura K, Uchida Y, Koshi H, Iida H, Masamune K, et al. Effects of Low-Load, Elastic Band Resistance Training Combined With Blood Flow Restriction on Muscle Size and Arterial Stiffness in Older Adults. J Gerontol A Biol Sci Med Sci [Internet]. 2015 [cited 2025 Jul 21];70:950-958. Available from: https://doi.org/10.1093/gerona/glu084

Schoenfeld BJ, Ogborn D, Krieger JW. Effects of Resistance Training Frequency on Measures of Muscle Hypertrophy: A Systematic Review and Meta-Analysis. Sports Med Auckl NZ [Internet]. 2016 [cited 2025 Jul 21];46:1689-1697. Available from: https://doi.org/10.1007/s40279-016-0543-8

Cegielski J, Brook MS, Quinlan JI, Wilkinson DJ, Smith K, Atherton PJ, et al.. A 4-week, lifestyle-integrated, home-based exercise training programme elicits improvements in physical function and lean mass in older men and women: a pilot study. F1000Research [Internet]. 2017 [cited 2025 Jul 21];6:1235. Available from: https://doi.org/10.12688/f1000research.11894.2

Yokokawa Y, Hongo M, Urayama H, Nishimura T, Kai I. Effects of low-intensity resistance exercise with vascular occlusion on physical function in healthy elderly people. Biosci Trends [Internet]. 2008 [cited 2025 Jul 21];2:117-123.

Karabulut M, Abe T, Sato Y, Bemben MG. The effects of low-intensity resistance training with vascular restriction on leg muscle strength in older men. Eur J Appl Physiol [Internet]. 2010 [cited 2025 Jul 21];108:147-155. Available from: https://doi.org/10.1007/s00421-009-1204-5

Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. J Appl Physiol Bethesda Md [Internet]. 2006 [cited 2025 Jul 21];1985 100:1460-1466. Available from: https://doi.org/10.1152/japplphysiol.01267.2005

Ozaki H, Miyachi M, Nakajima T, Abe T. Effects of 10 weeks walk training with leg blood flow reduction on carotid arterial compliance and muscle size in the elderly adults. Angiology [Internet]. 2011 [cited 2025 Jul 21];62:81-86. Available from: https://doi.org/10.1177/0003319710375942

Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport [Internet]. 1999 [cited 2025 Jul 21];70:113-119. Available from: https://doi.org/10.1080/02701367.1999.10608028

Anderson KD, Rask DMG, Bates TJ, Nuelle JAV. Overall Safety and Risks Associated with Blood Flow Restriction Therapy: A Literature Review. Mil Med [Internet]. 2022 [cited 2025 Jul 21];187:1059-1064. Available from: https://doi.org/10.1093/milmed/usac055