Potential Moderators of the Effects of Blood Flow Restriction Training on Muscle Strength and Hypertrophy: A Meta-analysis Based on a Comparison with High-Load Resistance Training

Yu Geng; Xueping Wu; Yong Zhang; Meng Zhang

doi:10.1186/s40798-024-00719-3

. 2024 May 22;10:58. doi: 10.1186/s40798-024-00719-3

Potential Moderators of the Effects of Blood Flow Restriction Training on Muscle Strength and Hypertrophy: A Meta-analysis Based on a Comparison with High-Load Resistance Training

Yu Geng ^1,^✉, Xueping Wu ², Yong Zhang ³, Meng Zhang ⁴

PMCID: PMC11109065 PMID: 38773002

Abstract

Background

While it has been examined whether there are similar magnitudes of muscle strength and hypertrophy adaptations between low-load resistance training combined with blood-flow restriction training (BFR-RT) and high-load resistance training (HL-RT), some important potential moderators (e.g., age, sex, upper and lower limbs, frequency and duration etc.) have yet to be analyzed further. Furthermore, training status, specificity of muscle strength tests (dynamic versus isometric or isokinetic) and specificity of muscle mass assessments (locations of muscle hypertrophy assessments) seem to exhibit different effects on the results of the analysis. The role of these influencing factors, therefore, remains to be elucidated.

Objectives

The aim of this meta-analysis was to compare the effects of BFR- versus HL-RT on muscle adaptations, when considering the influence of population characteristics (training status, sex and age), protocol characteristics (upper or lower limbs, duration and frequency) and test specificity.

Methods

Studies were identified through database searches based on the following inclusion criteria: (1) pre- and post-training assessment of muscular strength; (2) pre- and post-training assessment of muscular hypertrophy; (3) comparison of BFR-RT vs. HL-RT; (4) score ≥ 4 on PEDro scale; (5) means and standard deviations (or standard errors) are reported or allow estimation from graphs. In cases where the fifth criterion was not met, the data were requested directly from the authors.

Results

The main finding of the present study was that training status was an important influencing factor in the effects of BFR-RT. The trained individuals may gain greater muscle strength and hypertrophy with BFR-RT as compared to HL-RT. However, the results showed that the untrained individuals experienced similar muscle mass gains and superior muscle strength gains in with HL-RT compared to BFR-RT.

Conclusion

Compared to HL-RT, training status is an important factor influencing the effects of the BFR-RT, in which trained can obtain greater muscle strength and hypertrophy gains in BFR-RT, while untrained individuals can obtain greater strength gains and similar hypertrophy in HL-RT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-024-00719-3.

Keywords: Blood flow restriction training, High-load resistance training, Training effect, Strength, Hypertrophy, Training status, Protocol characteristics, Test specificity, Meta-analysis

Key Points

Training status is an important factor influencing the effects of the BFR-RT.

Trained individuals may obtain greater muscle strength and hypertrophy gains in BFR-RT compared to HL-RT.

Untrained individuals may experience a smaller increase in strength and a similar increase in hypertrophy with BFR-RT compared to HL-RT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-024-00719-3.

Background

High-load resistance training (HL-RT) has long been considered as the “gold standard” protocol to increase muscle strength and mass. It has been suggested that ≥ 65% one-repetition maximum (1RM) is required to increase strength and hypertrophy [1–3]. However, mounting evidence indicates that the use of low-load resistance training (< 50% 1RM) combined with blood flow restriction (BFR-RT) results in strength and morphological responses [4]. The results of a previous study showed that low load resistance training with and without blood flow resulted in similar adaptations when sets of exercise were taken to failure [5], however the results of multiple studies showed the superiority of BFR-RT in terms of gains in muscle strength and hypertrophy when compared with similar low-load resistance training without blood flow restriction [6–8]. However, the literature is controversial about the magnitude of the adaptations when comparing BFR-RT to HL-RT. For example, some studies have reported greater increases in muscle strength for HL-RT when comparing to BFR-RT [9–13], while others have suggested similar gains between the two exercise protocols [14–17]. Moreover, some studies have reported that BFR-RT has higher muscle strength gains than HL-RT [18, 19]. Some studies compared the effects of BFR-RT and HL-RT through meta-analysis [20, 21]. In the meta-analysis by Lixandrão et al., they observed that BFR-RT and HL-RT have similar gains in muscle hypertrophy, while HL-RT is more effective in increasing muscle strength [20]. However, limited by the number of studies comparing BFR and HL-RT at that time, some important potential moderators (e.g., training frequency, etc.) could not be further explored [20].

The increase in muscle strength is the result of the coordination of nerve and muscle systems [22]. It is believed that neural adaptation dominates early in the training programme; later, as neural adaptations reach a plateau, muscular adaptation (hypertrophy) dominates [23]. At this stage, in intermediate and advanced training, progress is limited to the extent of muscular adaptation that can be achieved [23]. It has been believed that BFR-RT provides a potential time-effective approach to stimulate muscle adaptations [8, 24, 25], and even well-trained athletes may benefit from BFR-RT [26]. Thus, compared to HL-RT, training status and training duration may be a key factor affecting the effectiveness of BFR-RT. Additionally, the results of several studies have showed that compared with HL-RT, BFR-RT induced less hypertrophy in the proximal region [17, 27, 28]. Therefore, this regional specificity may be another influencing factor. Finally, HL-RT implies high-load exercise, which is similar to specific strength assessments (i.e., 1RM test), while during BFR-RT, participants are never exposed to high loads [29]. Thus, non-specific strength assessments (i.e., isometric or isokinetic tests) may more accurately reflect the response to the low-load training protocols [29]. In this regard, test specificity may also affect the results.

In short, the inconsistencies in the literature regarding effects of BFR-RT compared with HL-RT on the muscle strength and hypertrophy justify the need for synthesis and a comprehensive review of the available evidence. Therefore, based on previous studies, the purpose of this study was to conduct a meta-analysis comparing the responses of BFR-RT and HL-RT on muscle strength and hypertrophy. To further explore the effects on muscle strength and hypertrophy of these protocols, we will also consider potential influence factors such as population characteristics (i.e., training status, sex and age), protocol characteristics (i.e., upper or lower limbs, duration and frequency), test specificity (i.e., 1RM and spacing or equal speed testing), and region-specific adaptations in muscle mass.

Methods

Search Strategy and Study Selection

The articles were identified through the English databases Web of Knowledge, PubMed, EBSCO-SPORTDiscus from the earliest record up to February 2024, and the Chinese database WANFANG DATA, CNKI from the earliest record up to February 2024. The search strategy combined the English and Chinese terms (see Additional file 1: Table S1). Two reviewers (GY and ZY) evaluated the titles and abstracts of the retrieved articles to assessed their eligibility for the meta-analysis. In cases of differences, a consensus was adopted. If necessary, the third reviewer (WXP) evaluated the article. If the abstract did not provide sufficient information about the inclusion criteria, the reviewers read the full text.

Eligibility Criteria

Studies were considered for inclusion if they met the following criteria: (1) articles were published in English or Chinese; (2) subjects were healthy people, (3) pre- and post-intervention assessment of muscular strength (i.e., dynamic, isometric or isokinetic test); (4) pre- and post-intervention assessment of muscle hypertrophy (i.e., magnetic resonance imaging, computerized tomography, or ultrasonography); (5) comparisons between HL-RT (i.e., > 65%1RM) and BFR-RT (i.e., < 50%1RM); (6) score ≥ 4 on the Physiotherapy Evidence Database (PEDro) scale.

Study Quality

The quality of the study was determined by using the PEDro scale, based on the Delphi list [30]. Studies with a score ≥ 4 were included in this meta-analysis (see Additional file 1: Table S2). For each of the items (2–11) of the PEDro scale, two reviewers (GY and ZY) assessed the studies independently. In cases of disagreement, a consensus was adopted or a third reviewer (WXP) evaluated the study.

Data Extraction

After screening of the studies, all included studies were assessed for eligibility based on their full texts. Two reviewers (GY and ZY) extracted data from the articles independently; in cases of disagreement, if no consensus could be reached, a third reviewer (WXP) was consulted. The data extracted were recorded relating to (1) population characteristics (i.e., age, sex and training status); (2) intervention protocol characteristics (i.e., duration, frequency, training load, volume, exercises etc.); (3) pre- and post-intervention assessment of muscle strength (i.e., dynamic, isometric, or isokinetic test); (4) pre- and post-intervention assessment of muscle hypertrophy (cross-sectional area [CSA], muscle thickness and muscle mass). The trained individuals were defined as athletes or individuals who participated in regular resistance training protocols before the intervention. The untrained individuals were defined as individuals who were sedentary or did not participate in regular resistance training protocols before the interventions. In cases of incomplete data availability, we extrapolated the data from figures or contacted the corresponding author. The graphical data were extracted using the OriginPro 2021 (Version 2021. OriginLab Corporation, Northampton, MA, USA) graphical digitizing tool. Only the last was included as the post-intervention value for analysis, when intervention effects were assessed at multiple time points. When intervention effects were measured through multiple measurement methods (e.g., CSA and muscle thickness for muscle size), the multiple outcomes were combined (i.e., using the mean of the outcomes) [31]. The combination was performed by Comprehensive Meta-Analysis software (version 3.3, Biostat, Inc., Englewood, NJ, USA). The extracted data of included studies are provided in Tables 1 and 2.

Table 1.

Characteristics of studies included in the meta-analysis of muscle strength adaptations

References	Age	Training Status	N	Exercise	Protocol	Weeks (times/wk)	Exercise load	Occlusion pressure	Muscle strength assessment
Bjornsen et al. [26]	24	Trained	9	SQ	BFR-RT:30–15-12–8	2(5)	24–30%1RM	120mmHg	Dynamic SQ
	24	Trained	9	SQ	BFR-RT:30–15-12–8	2(5)	24–30%1RM	120mmHg	Isometric KE
	26		8		HL-RT:6–7 × 1–6	2(5)	74–76%1RM
Buckner et al. [32]	18–35	Untrained	20	BC	BFR-RT1:4 × failure	8(2)	15%1RM	57mmHg	Dynamic BC
									Isometric BC
									Isokinetic BC (60°/s, 180°/s)
	18–35		20		BFR-RT2:4 × failure	8(2)	15%1RM	110mmHg
	18–35		20		HL-RT:4 × failure	8(2)	70%1RM
Centner et al. [33]	27	Untrained	M11	CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	Isometric CR
Centner et al. [33]	26		M14		HL-RT:3 × 6–12	14(3)	70–80%1RM
Centner et al. [28]	28	Untrained	M14	LP, KE, CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	Dynamic LP & KE
Centner et al. [28]	28		M15		HL-RT:3 × 6–12	14(3)	70–85%1RM
Clark et al. [14]	24	Untrained	9	KE	BFR-RT:3 × 30–50	4(3)	30%1RM	170mmHg	Isometric KE
Clark et al. [14]	24		7		HL-RT:3 × 8–12	4(3)	80%1RM
Cook et al. [34]	77	Untrained	12	KE, KF, LP	BFR-RT: ~ 3 × 30	12(2)	30%1RM	184 ± 25mmHg	Dynamic KE, KF & LP
	77	Untrained	12	KE, KF, LP	BFR-RT: ~ 3 × 30	12(2)	30%1RM	184 ± 25mmHg	Isometric KE
	77		12		HL-RT: ~ 3 × 15	12(2)	70%1RM
Cook et al. [35]	18–22	Untrained	6	KE, LP	BFR-RT:2 × 25,1 × failure	6(3)	20%1RM	180-200mmHg	Dynamic KE
	18–22	Untrained	6	KE, LP	BFR-RT:2 × 25,1 × failure	6(3)	20%1RM	180-200mmHg	Isometric KE
	18–22		6		HL-RT:2 × 10,1 × failure	6(3)	70%1RM
Davids et al. [36]	24	Trained	11	SQ, LP, KE, SSQ	BFR-RT:30 + 2–3 × 15	9(3)	30–40%1RM	60%AOP	Dynamic SQ
	24	Trained	11	SQ, LP, KE, SSQ	BFR-RT:30 + 2–3 × 15	9(3)	30–40%1RM	60%AOP	Isometric KE & KF
	24		10		HL-RT:3–4 × 8	9(3)	75–80%1RM
de Lemos Muller et al. [37]	24	Untrained	M13	BC, KE	BFR-RT:4 × 22	8(3)	30%1RM	110-150mmHg	Dynamic BC & KE
de Lemos Muller et al. [37]	25		M13		HL-RT:4 × 8	8(3)	80%1RM
Ellefsen et al. [17]	23	Untrained	M12	KE	BFR-RT:5 × failure	12(2)	30%1RM	90-100mmHg	Dynamic KE
Ellefsen et al. [17]	23		M12		HL-RT:3 × 6–10	12(2)	75–90%1RM
Fernandes et al. [38]	20	Untrained	F14	GS	BFR-RT:3 × 15–25	4(3)	45%1RM	160mmHg	Isometric GS
Fernandes et al. [38]	20		F14		HL-RT:3 × 8–12	4(3)	75%1RM
Jessee et al. [39]	21	Untrained	10	KE	BFR-RT1:4 × failure	8(2)	15%1RM	40%AOP	Dynamic KE
									Isometric KE
									Isokinetic KE (60°/s, 180°/s)
	21		10		BFR-RT2:4 × failure	8(2)	15%1RM	80%AOP
	21		10		HL-RT:4 × failure	8(2)	70%1RM
Karabulut et al. [9]	57	Untrained	M13	LP, KE	BFR-RT:30–15-15	6(3)	20%1RM	205mmHg	Dynamic LP & KE
Karabulut et al. [9]	57		M13		HL-RT:3 × 8	6(3)	80%1RM
Kim et al. [40]	26	Untrained	M10	LP, KE, KF	BFR-RT:2 × 10	3(3)	20%1RM	178 ± 20mmHg	Dynamic LP, KE & KF
Kim et al. [40]	22		M10		HL-RT:2 × 10	3(3)	80%1RM
Kim et al. [41]	21	Untrained	M9	BC	BFR-RT:30–15-15–15	8(3)	30%1RM	72 ± 11mmHg	Dynamic BC
	21	Untrained	M9	BC	BFR-RT:30–15-15–15	8(3)	30%1RM	72 ± 11mmHg	Isometric BC
	21		M9		HL-RT:3 × 10	8(3)	75%1RM
Kim et al. [42]	63	Untrained	9	GS	BFR-RT:3 × failure	4(3)	20%1RM	160mmHg	Isometric GS
Kim et al. [42]	63		10		HL-RT:3 × failure	4(3)	75%1RM
Korkmaz et al. [43]	18	Trained	M11	KE	BFR-RT:30–15-15–15	6(2)	30%1RM	130-150mmHg	Isokinetic KE (60°/s, 80°/s)
Korkmaz et al. [43]	18		M12		HL-RT:4 × 12	6(2)	80%1RM
Kubo et al. [10]	25	Untrained	M9	KE	BFR-RT:25–18-15–12	12(3)	20%1RM	180-240mmHg	Isometric KE
Kubo et al. [10]	25		M9		HL-RT:4 × 10	12(3)	80%1RM
Laswati et al. [44]	33	Untrained	M6	BC	BFR-RT:30–15-15–15	5(2)	30%1RM	50mmHg	Isokinetic BC (60°/s)
Laswati et al. [44]	33		M6		HL-RT:3 × 12	5(2)	70%1RM
Laurentino et al. [15]	20	Untrained	M10	KE	BFR-RT:3–4 × 15	8(2)	20%1RM	95 ± 10mmHg	Dynamic KE
Laurentino et al. [15]	24		M9		HL-RT:3–4 × 8	8(2)	80%1RM
Letieri et al. [45]	68	Untrained	F11	SQ, LP, KE, KF	BFR-RT1:30–15-15	16(3)	20–30%1RM	188 ± 5mmHg	Isokinetic KE & KF (60°/s)
	69		F10		BFR-RT2:30–15-15	16(3)	20–30%1RM	105 ± 7mmHg
	67		F11		HL-RT:3–4 × 6–8	16(3)	70–80%1RM
Libardi et al. [46]	64	Untrained	10	LP	BFR-RT:30–15-15–15	12(2)	20–30%1RM	67 ± 8mmHg	Dynamic LP
Libardi et al. [46]	65		8		HL-RT:4 × 10	12(2)	70–80%1RM
Lixandrao et al. [47]	26	Untrained	M11	KE	BFR-RT1:2–3 × 15	12(2)	20%1RM	56 ± 8mmHg	Dynamic KE
	29		M14		BFR-RT2:2–3 × 15	12(2)	20%1RM	110 ± 9mmHg
	26		M8		BFR-RT3:2–3 × 15	12(2)	40%1RM	55 ± 5mmHg
	29		M10		BFR-RT4:2–3 × 15	12(2)	40%1RM	1055 ± 19mmHg
	29		M9		HL-RT:2–3 × 10	12(2)	80%1RM
Luebbers et al. [48]	16–17	Trained	M8	SQ	BFR-RT:30–15-15–15	6(2)	20%1RM		Dynamic SQ
Luebbers et al. [48]	16–17		M9		HL-RT:3 × 10	6(2)	78%1RM
Martin-Hernandez et al. [12]	20	Untrained	M10	KE	BFR-RT1:30–15-15–15	5(2)	20%1RM	110mmHg	Dynamic KE
	20	Untrained	M10	KE	BFR-RT1:30–15-15–15	5(2)	20%1RM	110mmHg	Isokinetic KE (60°/s, 80°/s)
	21		M10		BFR-RT2:2 × (30–15-15–15)	5(2)	20%1RM	110mmHg
	21		M11		HL-RT:3 × 8	5(2)	85%1RM
May et al. [49]	24	Untrained	M8	KE, KF	BFR-RT:30–15-15–15	7(3)	20%1RM	128mmHg	Dynamic KE & KF
May et al. [49]	24		M9		HL-RT:4 × 8	7(3)	70%1RM
Mendonca et al. [50]	22	Untrained	15	CR	BFR-RT:30–15-15–15	4(5)	20%1RM	60%AOP	Isometric CR
Mendonca et al. [50]	22		15		HL-RT:4 × 10	4(5)	75%1RM
Morley et al. [51]	24	Untrained	7	KE	BFR-RT1:3 × 10–12 + 1 × failure	8(3)	20%1RM	100%AOP	Dynamic KE
	24	Untrained	7	KE	BFR-RT1:3 × 10–12 + 1 × failure	8(3)	20%1RM	100%AOP	Isometric KE
	21		6		BFR-RT2:3 × 10–12 + 1 × failure	8(3)	20%1RM	50%AOP
	21		7		HL-RT:3 × 10–12 + 1 × failure	8(3)	70%1RM
Ozaki et al. [16]	23	Untrained	M10	BP	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160mmHg	Dynamic BP
Ozaki et al. [16]	24		M9		HL-RT:3 × 10	6(3)	75%1RM
Ramis et al. [52]	24	Untrained	M15	BC, KE	BFR-RT:4 × 23	8(3)	30%1RM	110-150mmHg	Isometric BC & KE
Ramis et al. [52]	25		M13		HL-RT:4 × 8	8(3)	80%1RM		Isokinetic BC & KE (60°/s)
Sharifi et al. [53]	21	Untrained	M8	LP, KE, KF, CP, BC	BFR-RT:9 × 20	6(3)	20–30%1RM	110-160mmHg	Dynamic LP & CP
	19		M8		HL-RT:9 × 10	6(3)	70–80%1RM
	21		M8		BFR-RT:9 × 20	6(6)	20–30%1RM	110-160mmHg
	19		M8		HL-RT:9 × 10	6(6)	70–80%1RM
Shiromaru et al. [54]	23	Untrained	M15	KE	BFR-RT:3 × 15	3(4)	30%1RM	80%AOP	Dynamic KE
Shiromaru et al. [54]	23		M15		HL-RT:3 × 10	6(2)	80%1RM
Sousa et al. [55]	24	Untrained	10	KE	BFR-RT:3 × failure	6(2)	30%1RM	142 ± 122mmHg	Isometric KE
Sousa et al. [55]	21		11		HL-RT:3 × failure	6(2)	80%1RM
Sugiarto et al. [56]	26–45	Untrained	M6	BC	BFR-RT:30–15-15–15	5(2)	30%1RM	50mmHg	Isokinetic KE (60°/s, 120°/s, 180°/s)
Sugiarto et al. [56]	26–45		M6		HL-RT:3 × 12	5(2)	75%1RM
Teixeira et al. [57]	24	Untrained	M8	KE	BFR-RT:3 × 15	8(2)	20%1RM	80%AOP	Dynamic KE
Teixeira et al. [57]	24		M8		HL-RT:3 × 8	8(2)	70%1RM
Thiebaud et al. [58]	59	Untrained	F6	CP, SR, SHP	BFR-RT:30–15-15	8(3)	10–30%1RM	80-120mmHg	Dynamic CP, SR & SHP
Thiebaud et al. [58]	62		F8		HL-RT:3 × 10	8(3)	70–90%1RM
Vechin et al. [13]	62	Untrained	M8	LP	BFR-RT:30–15-15–15	12(2)	20–30%1RM	71 ± 9mmHg	Dynamic LP
Vechin et al. [13]	65		M8		HL-RT:4 × 10	12(2)	70–80%1RM
Yasuda et al. [11]	22–32	Untrained	M10	BP, EE	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160mmHg	Dynamic BP
	22–32	Untrained	M10	BP, EE	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160mmHg	Isometric EE
	22–32		M10		HL-RT:3 × 10	6(3)	75%1RM
Che et al. [19]	18	Trained	F8	SQ	BFR-RT:30–15-15–15	6(3)	30%1RM	180mmHg	Dynamic SQ
	18	Trained	F8	SQ	BFR-RT:30–15-15–15	6(3)	30%1RM	180mmHg	Isokinetic KE & KF (60°/s, 180°/s)
	17		F8		HL-RT:4 × 8–10	6(3)	75%1RM
Shanghua et al. [59]	21	Trained	M12	LP	BFR-RT:5 × 12	8(3)	40%1RM	200mmHg	Isokinetic KE & KF (60°/s, 180°/s)
Shanghua et al. [59]	22		M12		HL-RT:5 × 12	8(3)	70%1RM
Li et al. [18]	22	Trained	M8	SQ, SSQ, DF	BFR-RT:30–15-15–15	4(3)	30%1RM	200mmHg	Dynamic SQ
	22	Trained	M8	SQ, SSQ, DF	BFR-RT:30–15-15–15	4(3)	30%1RM	200mmHg	Isokinetic KE & KF (60°/s)
	22		M8		HL-RT:4 × 8–12	4(3)	70%1RM
Li et al. [60]	20	Trained	M10	BP, SQ	BFR-RT:30–15-15–15	6(2)	30%1RM	160-200mmHg	Dynamic SQ & BP
Li et al. [60]	20		M10		HL-RT:4 × 12	6(2)	70%1RM
Wang et al. [61]	24	Trained	M9	SQ, SSQ, DF	BFR-RT:4 × 20–30	8(3)	30%1RM	200-220mmHg	Isokinetic KE & KF (60°/s)
Wang et al. [61]	24		M9		HL-RT:4 × 12	8(3)	70%1RM
Zhang et al. [62]	23	Trained	M8	SQ	BFR-RT1:5 × 10	5(2)	20%1RM	252mmHg	Dynamic SQ
	24		M8		BFR-RT2:5 × 11	5(2)	40%1RM	252mmHg
	23		M8		HL-RT:5 × 12	5(2)	75%1RM
Centner et al. [65]	28	Untrained	M14	CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	Dynamic CR
Centner et al. [65]	28		M15		HL-RT:3 × 6–12	14(30	70–80%1RM
De Araujo et al. [66]	23	Untrained	M10	BC	BFR-RT:30–15-15–15	6(2)	30%1RM	50%AOP	Dynamic BC
De Araujo et al. [66]	23		M10		HL-RT:3 × 10–12	6(2)	70%1RM
Horiuchi et al. [67]	18–30	Untrained	M12	LP, KE	BFR-RT:4 × 20	4(4)	30%1RM	130%AOP	Dynamic LP & KE
Horiuchi et al. [67]	18–30		M12		HL-RT:3 × 10	4(4)	75%1RM
Judd et al. [68]	20	Trained	M4	BC	BFR-RT: 4 × 5	6(2)	30%1RM	40%AOP	Dynamic BC
	20		M4		HL-RT: 4 × 5	6(2)	80%1RM
	20		F4		BFR-RT: 4 × 5	3(2)	30%1RM	40%AOP
	20		F5		HL-RT: 4 × 5	3(2)	80%1RM
Reece et al. [69]	21	Untrained	15	KE	BFR-RT: 3 × failure	6(3)	30%1RM	50%AOP	Dynamic KE
Reece et al. [69]	22		15		HL-RT:3 × failure	6(3)	80%1RM
Sousa-Silva et al. [70]	21	Untrained	M9	BC	BFR-RT:1 × 30 + 2–3 × 15	8(2)	30%1RM	50%AOP	Dynamic BC
Sousa-Silva et al. [70]	21		M9		HL-RT:3–4 × 10–12	8(2)	70%1RM
Wang et al. [71]	20	Trained	M8	SQ	BFR-RT: 30–15-15–15	4(3)	30%1RM	200mmHg	Dynamic SQ
Wang et al. [71]	20		M8		HL-RT;4 × 8–12	4(3)	70%1RM

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M male, F female

BC biceps curls, BP bench press, CP chest press, DF deadlift, EE elbow extension, GS grip strength, KE knee extension, KF knee flexion, LP leg press, SHP seated shoulder press, CR calf raises, SQ squat, SSQ split squat, SR Seated Rowing

Table 2.

Characteristics of studies included in the meta-analysis of muscle hypertrophy adaptations

References	Age	Training Status	N	Exercise	Protocol	Weeks (times/wk)	Exercise load	Occlusion pressure	Muscle mass assessment
References	Age	Training Status	N	Exercise	Protocol	Weeks (times/wk)	Exercise load	Occlusion pressure	Method	Muscle groups	Test site
Bjornsen et al. [26]	24	Trained	9	SQ	BFR-RT:30–15-12–8	2(5)	24–30%1RM	120 mmHg	US	Rectus femoris	Distal
										Vastus lateralis
										Vastus medialis
										Vastus intermedius
	26		8		HL-RT: 6–7 × 1–6	2(5)	74–76%1RM
Buckner et al. [32]	18–35	Untrained	20	BC	BFR-RT1: 4 × failure	8(2)	15%1RM	57 mmHg	US	Upper arm	Mid
	18–35	Untrained	20	BC	BFR-RT1: 4 × failure	8(2)	15%1RM	57 mmHg	US	Upper arm	Distal
	18–35		20		BFR-RT2: 4 × failure	8(2)	15%1RM	110 mmHg
	18–35		20		HL-RT: 4 × failure	8(2)	70%1RM
Centner et al. [33]	27	Untrained	M11	CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	US	Gastrocnemius
Centner et al. [33]	26		M14		HL-RT:3 × 6–12	14(3)	70–80%1RM
Centner et al. [28]	28	Untrained	M14	LP,KE,CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	MRI	Rectus femoris,	Proximal Mid
	28	Untrained	M14	LP,KE,CR	BFR-RT:30–15-15–15	14(3)	20–35%1RM	50%AOP	MRI	Rectus femoris,	Distal
	27		M15		HL-RT:3 × 6–12	14(3)	70–85%1RM
Cook et al. [34]	76	Untrained	12	KE,KF,LP	BFR-RT: ~ 3 × 30	12(2)	30%1RM	184 ± 25 mmHg	MRI	Quadriceps
Cook et al. [34]	77		12		HL-RT: ~ 3 × 15	12(2)	70%1RM
Cook et al. [35]	18–22	Untrained	6	KE,LP	BFR-RT:2 × 25, 1 × failure	6(3)	20%1RM	180-200 mmHg	MRI	Quadriceps
Cook et al. [35]	18–22		6		HL-RT:2 × 10, 1 × failure	6(3)	70%1RM
Davids et al. [36]	24	Trained	11	SQ,LP,KE,SSQ	BFR-RT:30 + 2–3 × 15	9(3)	30–40%1RM	60%AOP	MRI	Quadriceps
Davids et al. [36]	24		10		HL-RT:3–4 × 8	9(3)	75–80%1RM
Ellefsen et al. [18]	23	Untrained	M12	KE	BFR-RT: 5 × failure	12(2)	30%1RM	90-100 mmHg	MRI	Quadriceps	Proximal
	23	Untrained	M12	KE	BFR-RT: 5 × failure	12(2)	30%1RM	90-100 mmHg	MRI	Quadriceps	Distal
	23		M12		HL-RT:3 × 6–10	12(2)	75–90%1RM
Jessee et al. [41]	21	Untrained	10	KE	BFR-RT1: 4 × failure	8(2)	15%1RM	40%AOP	US	Quadriceps	Proximal
											Mid
											Distal
	21		10		BFR-RT2: 4 × failure	8(2)	15%1RM	80%AOP
	21		10		HL-RT: 4 × failure	8(2)	70%1RM
Kataoka et al. [65]	23	Untrained	27	CR	BFR-RT:4 × 16–39	6(3)	30%1RM	40%AOP	US	Gastrocnemius
Kataoka et al. [65]	23		27		HL-RT:4 × 12–19	6(3)	70%1RM			Soleus
Kim et al. [66]	26	Untrained	M10	LP,KE,KF	BFR-RT:2 × 10	3(3)	20%1RM	178 ± 20 mmHg	CT	Thigh	Mid
Kim et al. [66]	22		M10		HL-RT:2 × 10	3(3)	80%1RM
Kim et al. [41]	21	Untrained	M9	BC	BFR-RT:30–15-15–15	8(3)	30%1RM	72 ± 11 mmHg	US	Upper arm	Mid
	21	Untrained	M9	BC	BFR-RT:30–15-15–15	8(3)	30%1RM	72 ± 11 mmHg	US	Upper arm	Distal
	21		M9		HL-RT:3 × 10	8(3)	75%1RM
Korkmaz et al. [43]	18	Trained	M11	KE	BFR-RT:30–15-15–15	6(2)	30%1RM	130-150 mmHg	US	Rectus femoris	Mid
	18	Trained	M11	KE	BFR-RT:30–15-15–15	6(2)	30%1RM	130-150 mmHg	US	Vastus lateralis	Mid
	18		M12		HL-RT:4 × 12	6(2)	80%1RM
Kubo et al. [10]	25	Untrained	M9	KE	BFR-RT:25–18-15–12	12(3)	20%1RM	180-240 mmHg	MRI	Quadriceps
Kubo et al. [10]	25		M9		HL-RT:4 × 10	12(3)	80%1RM
Laurentino et al. [15]	20	Untrained	M10	KE	BFR-RT:3–4 × 15	8(2)	20%1RM	95 ± 10 mmHg	MRI	Quadriceps	Mid
Laurentino et al. [15]	23		M9		HL-RT:3–4 × 8	8(2)	80%1RM
Libardi et al. [46]	64	Untrained	10	LP	BFR-RT:30–15-15–15	12(2)	20–30%1RM	67 ± 8 mmHg	MRI	Quadriceps	Mid
Libardi et al. [46]	65		8		HL-RT:4 × 10	12(2)	70–80%1RM
Lixandrao et al. [47]	26	Untrained	M11	KE	BFR-RT1:2–3 × 15	12(2)	20%1RM	55.5 ± 8 mmHg	MRI	Quadriceps	Mid
	28		M14		BFR-RT2:2–3 × 15	12(2)	20%1RM	109 ± 9 mmHg
	26		M8		BFR-RT3:2–3 × 15	12(2)	40%1RM	54 ± 5 mmHg
	28		M10		BFR-RT4:2–3 × 15	12(2)	40%1RM	105 ± 19 mmHg
	29		M9		HL-RT:2–3 × 10	12(2)	80%1RM
Martin-Hernandez et al. [12]	20	Untrained	M10	KE	BFR-RT1:30–15-15–15	5(2)	20%1RM	110 mmHg	US	Rectus femoris	Mid
	20	Untrained	M10	KE	BFR-RT1:30–15-15–15	5(2)	20%1RM	110 mmHg	US	Vastus lateralis	Mid
	21		M10		BFR-RT2:2 × (30–15-15–15)	5(2)	20%1RM	110 mmHg
	20		M11		HL-RT:3 × 8	5(2)	85%1RM
May et al. [49]	24	Untrained	M8	KE,KF	BFR-RT:30–15-15–15	7(3)	20%1RM	128 mmHg	CT	Quadriceps	Mid
										Quadriceps	Distal
										Hamstrings	Distal
	24		M9		HL-RT:4 × 8	7(3)	70%1RM
Mendonca et al. [50]	22	Untrained	15	CR	BFR-RT:30–15-15–15	4(5)	20%1RM	60%AOP	US	Soleus
Mendonca et al. [50]	21		15		HL-RT:4 × 10	4(5)	75%1RM
Ozaki et al. [16]	23	Untrained	M10	BP	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160 mmHg	MRI	Triceps brachii
	23	Untrained	M10	BP	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160 mmHg	MRI	Pectoralis major
	24		M9		HL-RT:3 × 10	6(3)	75%1RM
Ramis et al. [52]	23	Untrained	M15	BC,KE	BFR-RT:4 × 23	8(3)	30%1RM	110-150 mmHg	US	Biceps brachii
Ramis et al. [52]	24		M13		HL-RT:4 × 8	8(3)	80%1RM			Quadriceps
Shiromaru et al. [54]	22	Untrained	M15	KE	BFR-RT:3 × 15	3(4)	30%1RM	80%AOP	MRI	Quadriceps	Mid
Shiromaru et al. [54]	22		M15		HL-RT:3 × 10	6(2)	80%1RM
Teixeira et al. [57]	24	Untrained	M8	KE	BFR-RT:3 × 15	8(2)	20%1RM	80%AOP	MRI	Quadriceps	Mid
Teixeira et al. [57]	24		M8		HL-RT:3 × 8	8(2)	70%1RM
Thiebaud et al. [58]	59	Untrained	F6	CP,SR,SHP	BFR-RT:30–15-15	8(3)	10–30%1RM	80-120 mmHg	US	Biceps brachii	Distal
	59	Untrained	F6	CP,SR,SHP	BFR-RT:30–15-15	8(3)	10–30%1RM	80-120 mmHg	US	Triceps brachii	Distal
	62		F8		HL-RT:3 × 10	8(3)	70–90%1RM
Vechin et al. [13]	62	Untrained	M8	LP	BFR-RT:30–15-15–15	12(2)	20–30%1RM	71 ± 9 mmHg	MRI	Quadriceps	Mid
Vechin et al. [13]	65		M8		HL-RT:4 × 10	12(2)	70–80%1RM
Yasuda et al. [11]	22–32	Untrained	M10	BP,EE	BFR-RT:30–15-15–15	6(3)	30%1RM	100-160 mmHg	MRI	Triceps brachii	Mid
Yasuda et al. [11]	22–32		M10		HL-RT:3 × 10	6(3)	75%1RM
Sousa-Silva et al. [70]	21	Untrained	M9	BC	BFR-RT: 1 × 30 + 2–3 × 15	8(2)	30%1RM	50%AOP	US	Biceps brachii	Distal
Sousa-Silva et al. [70]	21		M9	BC	HL-RT:3–4 × 10–12	8(2)	70%1RM

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M male, F female

1RM one-repetition maximum, AOP arterial occlusion pressure, CT Computed Tomography, MRI magnetic resonance imaging, US ultrasonography,

Distal > 50% of the thigh or upper arm length, Mid = 50% of the thigh or upper arm length, Proximal < 50% of the thigh or upper arm length

Statistical Analyses

All analyses were performed using Comprehensive Meta-Analysis software (version 3.3, Biostat, Inc., Englewood, NJ, USA). The comparisons (BFR-RT vs. HL-RT) were calculated as the effect size difference (ES_diff) using the difference in pre- and post- intervention mean and standard deviation values of muscle strength and mass, sample size and correlation between pre- and post-test for all groups. If the studies included in the meta-analysis did not report correlation between pre- and post-test, the following formula was used for estimation [20, 72]:

r = \frac{S_{pre}^{2} + S_{post}^{2} - S D^{2}}{2 \times S_{pre} \times S_{post}}

where S_pre and S_post are the standard deviation of pre-test and post-test, respectively. SD is the standard deviation of difference between pre- and post-test calculated using the following formula [1, 20]:

S D = \sqrt{\frac{S_{pre}^{2}}{n} + \frac{S_{post}^{2}}{n}}

Using the correction factor to correct the small sample size bias of all ES_diff [20, 31]. The correction factor is given by:

Correction factor = 1 - \frac{3}{4 \times (n_{1} + n_{2} - 2) - 1}

The subjects of the studies included in the present meta-analysis came from different populations. Moreover, different training protocols and various strength and hypertrophy measurements and variables were utilized in these studies. All factors may have an impact on the effect of the intervention. Thus, the random-effects model was used to perform the meta-analysis [73]. The I² statistics was used to assess heterogeneity. I² values of 25%, 50% and 75% were set as low, moderate and high levels of heterogeneity, respectively. [74].

The first step was to compare the effects of BFR-RT and HL-RT on muscle strength and muscle mass. Subsequently, subgroup analyses were conducted to examine the effects of training status (trained vs. untrained individuals), sex, age, upper and lower limbs, test specificity (i.e. 1RM test vs. isometric or isokinetic tests) and region-specific adaptations of muscle hypertrophy. Based on the average age reported by the included studies, the age subgroups were divided into young (≤ 33 year) and old (≥ 57 year). Finally, according to the measured position reported by the studies, the results for muscle hypertrophy were categorized into three subgroups: proximal, middle and distal, which were < 50%, = 50% and > 50% of the length of the femur or humerus, respectively.

To identify the presence of highly influential studies that might bias the analyses, a sensitivity analysis was performed. The analysis was therefore conducted by removing one study at a time and then examining its effect on comparisons. If removal changed the significance level of ES_diff (i.e., from P ≤ 0.05 to P > 0.05, or vice versa), the study was considered as influential. This method has been used elsewhere [75]. The funnel plot, and Begg and Egger’s test were used to consider and assess publication bias, respectively. All data are presented as mean ± standard error. The significance level was set at P ≤ 0.05.

Results

The initial search retrieved 2801 English studies and Chinese 361studies. Afterwards, 723 duplicated studies were excluded. After evaluation of titles and abstracts, 2376 studies were removed, while the remaining 63 studies were assessed through full texts. Finally, 53 studies were considered to meet the inclusion criteria (Fig. 1), 51 of which were included in the muscle strength analysis (Table 1) and 28 in the muscle hypertrophy analysis (Table 2). In addition, by contacting the authors, the muscle hypertrophy data of one study were obtained [28]. However, after multiple attempts to contact the author, the muscle strength and hypertrophy data for another study were not included as the author did not respond [76].

Fig. 1 — Flow diagram of the search and review process

Muscle Strength

Fifty-one studies involving 1164 participants were included in the present meta-analysis to compare muscle strength gains. In the studies that investigated the trained population, only one study adopted 9 weeks of training duration and one study adopted a training frequency of 5 sessions per week (Fig. 2).

Fig. 2 — Forest plot of the effect size difference between BFR-RT versus HL-RT for muscle strength. The different capital letters (i.e. A, B, C, D) after the reference number are used to represent different training protocols for the same study. Hedges’g represents effect size difference. Red diamond represents overall Hedges’g. *1rm* 1RM test, *BFR-RT* blood-flow restriction low-load resistance training, CI confidence interval, *Combined* mean of multiple outcomes from the same training protocol, *HL-RT* high-load resistance training, *mvc* isometric or isokinetic tests

The overall ES_diff demonstrated significantly lower gains in muscle strength for BFR-RT compared with HL-RT (ES_diff = − 0.335 ± 0.092, 95% confidence interval [CI] − 0.515 to − 0.156) (Fig. 2 and Table 3). However, when considering training status, the differences between trained and untrained subgroups were significant (Q = 29.39, P < 0.01) (Table 3). Significantly higher strength gains for BFR-RT were observed compared with HL-RT in the trained group (ES_diff = 0.491 ± 0.172, 95% CI 0.154 to 0.827) (Fig. 3 and Table 3). In contrast, the strength gains of HL-RT were significantly higher than that of BFR-RT in the untrained group (ES_diff = − 0.552 ± 0.087, 95%CL − 0.722 to − 0.382) (Fig. 3 and Table 3). In trained individuals, there were no significant differences between the different sexes, limbs, durations, frequency and test types (Table 3 and Additional file 1: Figs. S1–S5). In untrained individuals, there were also no significant differences between the different sexes, age, limbs, training duration and frequency (Table 3 and Additional file 1: Figs. S6–S11).

Table 3.

Summary of meta-analysis results for muscle strength

	Subgroups	N	ES_diff	Standard error	95% Confidence interval		P value	Between group		Heterogeneity
	Subgroups	N	ES_diff	Standard error	Lower limit	Upper limit	P value	Q-value	P value	Q-value	P value	I²
Overall effect
		63	− 0.335	0.092	− 0.515	− 0.156	< 0.01			157.542	< 0.01	60.65
Training status
	Trained	14	0.491	0.172	0.154	0.827	< 0.01	29.392	< 0.01	27.047	0.01	51.94
	Untrained	49	− 0.552	0.087	− 0.722	− 0.382	< 0.01			83.634	< 0.01	42.61
Trained
Sex	Female	2	0.682	0.572	− 0.440	1.804	0.23	0.014	0.91	3.896	0.05	74.33
Sex	Male	10	0.609	0.236	0.146	1.072	0.01			18.791	0.03	52.11
Limbs	Lower limb	12	0.391	0.198	0.003	0.779	0.05	1.495	0.22	18.374	0.07	40.13
Limbs	Upper limb	3	1.011	0.467	0.095	1.926	0.03			8.736	0.01	77.11
Duration	≤ 4wk	4	0.724	0.371	− 0.004	1.452	0.05	0.214	0.64	3.420	0.33	12.28
Duration	= 5–8wk	9	0.520	0.238	0.053	0.987	0.03			19.563	0.01	59.11
Frequency	2/wk	7	0.660	0.300	0.072	1.248	0.03	0.330	0.57	20.471	< 0.01	70.69
Frequency	3/wk	6	0.415	0.303	− 0.179	1.010	0.17			5.821	0.32	14.10
Test type	Non-specific test	6	0.541	0.282	− 0.011	1.094	0.05	0.352	0.55	11.211	0.05	55.40
Test type	Specific test	11	0.330	0.218	− 0.098	0.758	0.13			20.499	0.02	51.22
Untrained
Sex	Female	5	− 0.638	0.297	− 1.220	− 0.055	0.03	0.143	0.71	5.529	0.24	27.66
Sex	Male	31	− 0.516	0.120	− 0.751	− 0.282	< 0.01			68.109	< 0.01	55.95
Age	Old	8	− 0.714	0.205	− 1.115	− 0.312	< 0.01	0.573	0.45	7.159	0.41	2.22
Age	Young	40	− 0.544	0.091	− 0.721	− 0.367	< 0.01			69.180	< 0.01	43.63
Limbs	Lower limb	36	− 0.618	0.111	− 0.836	− 0.400	< 0.01	0.514	0.47	73.921	< 0.01	52.65
Limbs	Upper limb	17	− 0.477	0.162	− 0.794	− 0.160	< 0.01			38.871	< 0.01	58.84
Duration	≤ 4wk	7	− 0.493	0.216	− 0.916	− 0.070	0.02	0.278	0.87	5.107	0.53	0.00
	= 5–8wk	28	− 0.593	0.116	− 0.820	− 0.365	< 0.01			51.803	< 0.01	47.88
	≥ 9wk	14	− 0.507	0.158	− 0.816	− 0.198	< 0.01			25.833	0.02	49.68
Frequency	2/wk	21	− 0.596	0.131	− 0.853	− 0.339	< 0.01	0.795	0.67	35.971	0.02	44.40
	3/wk	25	− 0.560	0.121	− 0.797	− 0.323	< 0.01			44.477	0.01	46.04
	4/wk	2	− 0.231	0.388	− 0.991	0.528	0.55			0.683	0.41	0.00
Test specificity	Non-specific test	24	− 0.422	0.120	− 0.657	− 0.188	< 0.01	3.573	0.06	33.745	0.07	31.84
Test specificity	Specific test	37	− 0.715	0.099	− 0.909	− 0.522	< 0.01			70.945	< 0.01	49.26

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ES_diff effect size difference

Fig. 3 — Forest plot of the effect size difference between BFR-RT versus HL-RT for muscle strength according to training status. The different capital letters (i.e. A, B, C, D) after the reference number are used to represent different training protocols for the same study. Hedges’g represents effect size difference. Red diamonds represent overall Hedges’g of subgroups. *1rm* 1RM test, *BFR-RT* blood-flow restriction low-load resistance training, CI confidence interval, *Combined* mean of multiple outcomes from the same training protocol, *HL-RT* high-load resistance training, *mvc* isometric or isokinetic tests

The sensitivity analysis conducted by deleting one study at a time and re-analyzing the data showed that none of the studies had a significant impact on muscle strength results. Inspection of the funnel plots indicated no evidence of publication bias (Additional file 1: Fig. S12). The results of the Begg test showed that Kendall’s tau with continuity correction was equal to − 0.02 (P = 0.84), and Egger’s regression intercept was equal to 1.09 (P = 0.41).

Muscle Hypertrophy

Twenty-eight studies involving 703 participants were included in the present meta-analysis to compare muscle hypertrophy gains. However, only three studies investigated the trained population. In addition, of the studies that investigated the untrained population, only one included female subjects, and only one adopted a training frequency of 4 sessions per week.

The overall ES_diff suggested similar gains in muscle mass between BFR-RT and HL-RT (ES_diff = − 0.067 ± 0.070, 95% CI − 0.205 to 0.071) (Fig. 4 and Table 4). However, when considering training status, the differences between trained and untrained subgroups were significant (Q = 9.41, P < 0.01) (Table 4). Significantly higher muscle hypertrophy gains for BFR-RT were observed compared with HL-RT in the trained subgroup (ES_diff = 0.695 ± 0.258, 95% CI 0.189–1.200). In contrast, the muscle mass gains with BFR-RT were similar to those with HL-RT in the untrained subgroup (ES_diff = − 0.128 ± 0.073, 95% CI − 0.272 to 0.015) (Fig. 5 and Table 4). However, in untrained individuals, there were no significant differences between the different age, limbs, duration and frequency, and region-specific adaptations in muscle mass (Additional file 1: Figs. S13–S18 and Table 4).

Table 4.

Summary of meta-analysis results for muscle hypertrophy

		N	ES_diff	Standard error	95% CI		Between Group			Heterogeneity
		N	ES_diff	Standard error	Lower limit	Upper limit	P value	Q-value	P value	Q-value	P value	I²(%)
Overall effect
		34	− 0.067	0.070	− 0.205	0.071	0.34			29.578	0.64	0.00
Training status
	Trained	3	0.695	0.258	0.189	1.200	0.01	9.413	< 0.01	3.048	0.22	34.39
	Untrained	31	− 0.128	0.073	− 0.272	0.015	0.08			17.116	0.97	0.00
Untrained
Age	Old	4	0.096	0.226	− 0.346	0.538	0.67	1.106	0.29	0.265	0.97	0.00
Age	Young	27	− 0.155	0.077	− 0.306	− 0.003	0.05			15.746	0.94	0.00
Limbs	Lower limbs	24	− 0.053	0.084	− 0.217	0.111	0.52	3.398	0.07	10.961	0.98	0.00
Limbs	Upper limbs	8	− 0.354	0.140	− 0.628	− 0.080	0.01			3.231	0.86	0.00
Duration	≤ 4 wk	3	− 0.115	0.220	− 0.546	0.317	0.60	0.254	0.88	0.489	0.78	0.00
	= 5–8 wk	18	− 0.102	0.095	− 0.289	0.084	0.28			12.718	0.75	0.00
	≥ 9 wk	10	− 0.185	0.134	− 0.448	0.079	0.17			3.656	0.93	0.00
Frequency	2/wk	17	− 0.219	0.100	− 0.416	− 0.022	0.03	2.128	0.15	7.113	0.97	0.00
Frequency	3/wk	13	0.000	0.112	− 0.219	0.220	0.99			7.663	0.81	0.00
Assessment region (Thigh)	Distal	5	− 0.069	0.184	− 0.430	0.291	0.71	1.805	0.41	0.478	0.98	0.00
	Mid	16	− 0.149	0.107	− 0.359	0.062	0.17			4.550	0.99	0.00
	Proximal	4	− 0.417	0.203	− 0.816	− 0.018	0.04			0.470	0.93	0.00
Assessment region (Upper-arm)	Distal	5	− 0.242	0.172	− 0.579	0.094	0.16	1.762	0.18	1.912	0.75	0.00
Assessment region (Upper-arm)	Mid	4	− 0.577	0.184	− 0.938	− 0.216	< 0.01			3.881	0.28	22.70

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2/wk 2 sessions per week, 3/w 3 sessions per week, ES_diff effect size difference

Fig. 5 — Forest plot of the effect size difference between BFR-RT versus HL-RT for muscle hypertrophy according to training status. The different capital letters (i.e. A, B, C, D) after the reference number are used to represent different training protocols for the same study. Hedges’g represents effect size difference. Red diamonds represent overall Hedges’g of subgroups. *BFR-RT* blood-flow restriction low-load resistance training, CI confidence interval, *Combined* mean of multiple outcomes from the same training protocol, *CSA* cross-sectional area, *HL-RT* high-load resistance training, mt muscle thickness

The sensitivity analysis showed that muscle hypertrophic adaptation was not affected by any particular study. Inspection of the funnel plots indicated no evidence of publication bias (Additional file 1: Fig. S19). The results of the Begg test show that Kendall’s tau with continuity correction was equal to 0.17 (P = 0.16), and Egger’s regression intercept was equal to 0.52 (P = 0.65).

Discussion

The purpose of the current study was to compare the effects of BFR-RT and HL-RT on the muscle strength and hypertrophy, using HL-RT as a control to evaluate the effects and characteristics of BFR-RT. The main finding of the present study was that training status was an important influencing factor in the effects of BFR-RT. The trained individuals will get greater muscle strength and hypertrophy gains from BFR-RT as compared with HL-RT. However, in the untrained individuals, the results demonstrated that superior gains in muscle strength and similar muscle mass for HL-RT as compared with BFR-RT.

Effect of BFR-RT on Trained Individuals

The analysis results of trained individuals (ES_diff = 0.491) suggested that in the comparison of these two training modalities, 69% of trained individuals may obtain greater gains in muscle strength with BFR-RT [77].

Training is initially characterized by neural adaptations, however, later as neural adaptations reach a plateau, muscular adaptation (i.e., hypertrophy) dominates [23, 78]. In intermediate and advanced training, the progress of strength training is limited to the degree of muscle adaptation that can be achieved [23]. Hakkinen et al. reported that during one-year traditional strength training, advanced weight-lifters show limited potential for further neural adaptations, and the total mean muscle fiber area did not increase significantly [79]. However, mounting research indicates that BFR-RT can promote muscle hypertrophy in athletes [18, 26, 43, 80, 81], and even in elite powerlifters the muscle fiber CSA increased more with BFR-RT than with HL-RT [26].

Metabolic stress was believed to be one of the factors promoting muscle hypertrophy [82]. Compared with other strength training protocols, BFR-RT was believed to produce a higher level of metabolic stress [83]. Studies suggested that compared with normoxic conditions, resistance training under the hypoxic condition caused greater metabolic and hormonal responses [84, 85], whereas it was believed that blood flow restriction could cause similar muscle hypoxia as compared with systemic hypoxia [86]. In this study, the results (Table 4) showed that in the trained individuals, superior muscle hypertrophy gains were observed for BFR-RT as compared with HL-RT. Put another way, 76% of the trained population may obtain greater gains in muscle hypertrophy with BFR-RT [77]. In fact, our results showed that the average relative strength change [(pre-training − post-training)/pre-training × 100] with BFR-RT (8.4% ± 1.09) was twice that of HL-RT (3.96% ± 0.66) in the trained individuals.

Effect of BFR-RT on Untrained Individuals

Being different from the trained subjects, the analysis results for untrained individuals (ES_diff = − 0.552) suggested that about 70% of untrained individuals may experience greater gains in muscle strength with HL-RT [77].

However, previous studies have found that the muscle activation level of BFR-RT was higher than that of the same intensity (low load) resistance exercise [87–90], its muscle activation level is still low as compared with HL-RT [91–93]. For example, Cook et al. [92] reported that muscle activation level (according to surface electromyography) was greater in the HL-RT at the beginning and end of exercise compared with the BFR-RT. It has been suggested that increasing the occlusion pressure (from 40 to 60% occlusive pressure) could increase the activation level of muscle [94], but recent research showed that even with higher occlusive pressure (80%), the activation level of BFR-RT on muscle was also significantly lower than HL-RT [91]. While these findings were based on surface electromyography, BFR-RT may not achieve the same level of muscle activation and produce the same neural stimulation as HL-RT [83, 95].

Limitations

The current meta-analysis has some limitations. The lack of studies including females limited generalizability of the findings. Because of the sparse number of studies, the results comparing muscle hypertrophy in trained individuals should be interpreted with caution. In addition, the data from one study were not included [76]. However, the sensitivity analysis revealed that no single study had a significant impact on the analysis results. Therefore, the absence of these data would unlikely to have affected the current results and their interpretation.

Conclusion

The present meta-analysis indicates that training status is an important factor influencing the effects of BFR-RT. Compared to HL-RT, trained individuals can obtain greater strength and hypertrophy gains from BFR-RT. However, in untrained individuals, the results demonstrate that superior muscle strength and similar mass gains for HL-RT.

From a practical standpoint, BFR-RT could be a beneficial supplemental training protocol for trained population. It has been demonstrated that the combination of BFR- and HL-RT was more beneficial for the increase of muscle strength [97]. Thus, healthy individuals or athletes are likely to maximize their training adaptations by combining these two training methods [4, 98]. Finally, it is important to highlight that BFR-RT remains a valid and effective alternative for people who cannot perform high-load resistance training.

Supplementary Information

Additional file 1^{(3.3MB, pdf)}

Acknowledgements

Not applicable.

Abbreviations

1RM: One repetition maximum
BFR-RT: Low-load resistance training (< 50% 1RM) combined with blood flow restriction
CI: Confidence interval
CSA: Cross-sectional area
ES_diff: Effect size difference
HL-RT: High-load resistance training
PEDro: Physiotherapy Evidence Database

Author contributions

YG and XPW contributed to the study concept and design. YG, XPW and YZ performed the literature search. YG and YZ performed the data extraction and quality assessment. YG wrote the first draft of the manuscript. XPW, Y Z and MZ critically revised the draft of the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for this project.

Availability of Data and Materials

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics Approval and Consent to participate

Not applicable.

Consent for Publication

Not applicable.

Competing interests

Yu Geng, Xueping Wu, Yong Zhang and Meng Zhang declare that they have no conflict of interests relevant to the content of this review.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Additional file 1^{(3.3MB, pdf)}

Data Availability Statement

The datasets analysed during the current study are available from the corresponding author on reasonable request.

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PERMALINK

Potential Moderators of the Effects of Blood Flow Restriction Training on Muscle Strength and Hypertrophy: A Meta-analysis Based on a Comparison with High-Load Resistance Training

Yu Geng

Xueping Wu

Yong Zhang

Meng Zhang

Abstract

Background

Objectives

Methods

Results

Conclusion

Supplementary Information

Key Points

Supplementary Information

Background

Methods

Search Strategy and Study Selection

Eligibility Criteria

Study Quality

Data Extraction

Table 1.

Table 2.

Statistical Analyses

Results

Fig. 1.

Muscle Strength

Fig. 2.

Table 3.

Fig. 3.

Muscle Hypertrophy

Fig. 4.

Table 4.

Fig. 5.

Discussion

Effect of BFR-RT on Trained Individuals

Effect of BFR-RT on Untrained Individuals

Limitations

Conclusion

Supplementary Information

Acknowledgements

Abbreviations

Author contributions

Funding

Availability of Data and Materials

Declarations

Ethics Approval and Consent to participate

Consent for Publication

Competing interests

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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