Knee extension with blood flow restriction: Impact of cuff pressure on hemodynamics

  • Tyler J. SingerEmail author
  • Jon Stavres
  • Steven J. Elmer
  • Matthew A. Kilgas
  • Brandon S. Pollock
  • Sarah G. Kearney
  • John McDaniel
Original Article



Blood flow restriction (BFR) exercise has emerged as a method of increasing muscle size and strength with low intensity resistance training. While the cuff pressures used during BFR are typically a percentage of resting arterial occlusion pressure (AOP), the impact these cuff pressures have on blood flow during lower body exercise is unknown.


To determine how various cuff pressures impact blood flow and tissue perfusion during exercise.


Eleven healthy male participants completed four sets of knee extension (30 reps per set at 30% max torque) with 0%, 60%, 80%, and 100% of arterial occlusion pressure (AOP) was applied to the proximal portion of the thigh. Femoral artery blood flow, tissue oxygenation, and central hemodynamics were continuously recorded before, during, and after exercise. Electromyography (EMG) amplitude was recorded from the vastus lateralis during exercise.


Blood flow increased during exercise compared to rest across all cuff pressures (p < 0.001), however compared to 0%, the absolute blood flow was reduced by 34 ± 17%, 45 ± 22%, and 72 ± 19% for 60, 80, and 100% AOP, respectively. Furthermore, each cuff pressure resulted in similar relative changes in blood flow before, during, and after exercise. During exercise, tissue saturation index (TSI) decreased as cuff pressure increased (p ≤ 0.005) with the exception of 80 to 100% AOP. Deoxyhemoglobin increased (p ≤ 0.001) with cuff pressure.


Our data indicate that while BFR knee extension elicits an absolute hyperemic response at cuff pressures up to 100% resting AOP, the relative reductions in blood flow are consistent across rest, exercise and recovery.


Arterial occlusion Resistance exercise Near inferred spectroscopy Blood flow restriction 



The authors would like to thank everyone who participated in this study.


No external funding was received for this work.

Compliance with ethical standards

Conflict of interest

The author declares that they have no competing interests.


  1. Braith RW, Stewart KJ (2006) Resistance exercise training. Circulation 113:2642–2650CrossRefGoogle Scholar
  2. Cook CJ, Kilduff LP, Beaven CM (2014) Improving strength and power in trained athletes with 3 weeks of occlusion training. Int J Sports Physiol Perform 9:166–172. CrossRefPubMedGoogle Scholar
  3. Counts BR, Dankel SJ, Barnett BE et al (2016) Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle Nerve 53:438–445. CrossRefPubMedGoogle Scholar
  4. Downs M, Hackney K, Martin D et al (2014) Acute vascular and cardiovascular responses to blood flow-restricted exercise. Med Sci Sports Exerc 46:1489–1497. CrossRefPubMedGoogle Scholar
  5. Fujita T, Brechue WF, Kurita K et al (2008) Increased muscle volume and strength following six days of low-intensity resistance training with restricted muscle blood flow. Int J KAATSU Train Res 4:1–8. CrossRefGoogle Scholar
  6. Ganesan G, Cotter JA, Reuland W et al (2015) Effect of blood flow restriction on tissue oxygenation during knee extension. Med Sci Sports Exerc 47:185–193. CrossRefPubMedPubMedCentralGoogle Scholar
  7. Habazettl H, Athanasopoulos D, Kuebler WM et al (2010) Near-infrared spectroscopy and indocyanine green derived blood flow index for noninvasive measurement of muscle perfusion during exercise. J Appl Physiol 108:962–967CrossRefGoogle Scholar
  8. Hass CJ, Feigenbaum MS, Franklin BA (2001) Prescription of resistance training for healthy populations. Sports Med 31:953–964CrossRefGoogle Scholar
  9. Inagaki Y, Madarame H, Neya M, Ishii N (2011) Increase in serum growth hormone induced by electrical stimulation of muscle combined with blood flow restriction. Eur J Appl Physiol 111:2715–2721CrossRefGoogle Scholar
  10. Jones G, Burnham V, Francis P, Johnson MI (2018) An investigation into the effect of blood flow restriction on pain and muscular endurance in healthy human participants. J Phys Med 1(1):1–9Google Scholar
  11. Kacin A, Strazar K (2011) Frequent low-load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scand J Med Sci Sports 21(6):231–241CrossRefGoogle Scholar
  12. Kilgas MA, McDaniel J, Stavres J et al (2019) Limb blood flow and tissue perfusion during exercise with blood flow restriction. Eur J Appl Physiol 119:377–387. CrossRefPubMedGoogle Scholar
  13. Kraemer WJ, Deschenes MR, Fleck SJ (1988) Physiological adaptations to resistance exercise. Sports Med 6:246–256CrossRefGoogle Scholar
  14. Laurentino GC, Ugrinowitsch C, Roschel H et al (2012) Strength training with blood flow restriction diminishes myostatin gene expression. Med Sci Sports Exerc 44:406–412CrossRefGoogle Scholar
  15. Lixandrão ME, Ugrinowitsch C, Laurentino G et al (2015) Effects of exercise intensity and occlusion pressure after 12 weeks of resistance training with blood-flow restriction. Eur J Appl Physiol 115:2471–2480. CrossRefGoogle Scholar
  16. Loenneke JP, Pujol TJ (2009) The use of occlusion training to produce muscle hypertrophy. Strength Cond J 31:77. CrossRefGoogle Scholar
  17. Loenneke JP, Fahs CA, Wilson JM, Bemben MG (2011) Blood flow restriction: the metabolite/volume threshold theory. Med Hypotheses 77:748–752. CrossRefPubMedGoogle Scholar
  18. MacDougall JD, Tuxen D, Sale DG et al (1985) Arterial blood pressure response to heavy resistance exercise. J Appl Physiol Bethesda Md 58:785–790. CrossRefGoogle Scholar
  19. Manini TM, Clark BC (2009) Blood flow restricted exercise and skeletal muscle health. Exerc Sport Sci Rev 37:78–85CrossRefGoogle Scholar
  20. Mouser JG, Dankel SJ, Jessee MB et al (2017a) A tale of three cuffs: the hemodynamics of blood flow restriction. Eur J Appl Physiol 117:1493–1499. CrossRefPubMedGoogle Scholar
  21. Mouser JG, Laurentino GC, Dankel SJ et al (2017b) Blood flow in humans following low-load exercise with and without blood flow restriction. Appl Physiol Nutr Metab Physiol Appl Nutr Metab 42:1165–1171. CrossRefGoogle Scholar
  22. Mouser JG, Ade CJ, Black CD et al (2018) Brachial blood flow under relative levels of blood flow restriction is decreased in a nonlinear fashion. Clin Physiol Funct Imaging 38:425–430. CrossRefPubMedGoogle Scholar
  23. Mouser JG, Mattocks KT, Buckner SL et al (2019a) High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training. Physiol Meas 40:035003. CrossRefPubMedGoogle Scholar
  24. Mouser JG, Mattocks KT, Dankel SJ et al (2019b) Very-low-load resistance exercise in the upper body with and without blood flow restriction: cardiovascular outcomes. Appl Physiol Nutr Metab Physiol Appl Nutr Metab 44:288–292. CrossRefGoogle Scholar
  25. Patterson SD, Ferguson RA (2010) Increase in calf post-occlusive blood flow and strength following short-term resistance exercise training with blood flow restriction in young women. Eur J Appl Physiol 108:1025–1033CrossRefGoogle Scholar
  26. Pearson SJ, Hussain SR (2015) A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med 45:187–200. CrossRefPubMedGoogle Scholar
  27. Poton R, Polito MD (2016) Hemodynamic response to resistance exercise with and without blood flow restriction in healthy subjects. Clin Physiol Funct Imaging 36:231–236. CrossRefPubMedGoogle Scholar
  28. Renzi CP, Tanaka H, Sugawara J (2010) Effects of leg blood flow restriction during walking on cardiovascular function. Med Sci Sports Exerc 42:726–732. CrossRefPubMedPubMedCentralGoogle Scholar
  29. Sallinen J, Fogelholm M, Volek JS et al (2007) Effects of strength training and reduced training on functional performance and metabolic health indicators in middle-aged men. Int J Sports Med 28:815–822. CrossRefPubMedGoogle Scholar
  30. Scott BR, Loenneke JP, Slattery KM, Dascombe BJ (2016) Blood flow restricted exercise for athletes: a review of available evidence. J Sci Med Sport 19:360–367. CrossRefPubMedGoogle Scholar
  31. Spranger MD, Krishnan AC, Levy PD et al (2015) Blood flow restriction training and the exercise pressor reflex: a call for concern. Am J Physiol-Heart Circ Physiol 309:H1440–H1452. CrossRefPubMedGoogle Scholar
  32. Stavres J, Singer TJ, Brochetti A et al (2018) The feasibility of blood flow restriction exercise in patients with incomplete spinal cord injury. PM&R 10:1368–1379. CrossRefGoogle Scholar
  33. Takarada Y, Nakamura Y, Aruga S et al (2000a) Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J Appl Physiol 88:61–65. CrossRefPubMedGoogle Scholar
  34. Takarada Y, Takazawa H, Ishii N (2000b) Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc 32:2035–2039. CrossRefGoogle Scholar
  35. Trappe S, Williamson D, Godard M (2002) Maintenance of whole muscle strength and size following resistance training in older men. J Gerontol Ser A 57:B138–B143. CrossRefGoogle Scholar
  36. Yasuda T, Abe T, Brechue WF et al (2010a) Venous blood gas and metabolite response to low-intensity muscle contractions with external limb compression. Metabolism 59:1510–1519. CrossRefPubMedGoogle Scholar
  37. Yasuda T, Abe T, Brechue WF et al (2010b) Venous blood gas and metabolite response to low-intensity muscle contractions with external limb compression. Metabolism 59:1510–1519. CrossRefPubMedGoogle Scholar
  38. Yasuda T, Loenneke JP, Thiebaud RS, Abe T (2012) Effects of blood flow restricted low-intensity concentric or eccentric training on muscle size and strength. PLoS One 7:e52843. CrossRefPubMedPubMedCentralGoogle Scholar
  39. Zou K, Meador BM, Johnson B et al (2011) The α7β1-integrin increases muscle hypertrophy following multiple bouts of eccentric exercise. J Appl Physiol 111:1134–1141. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Exercise PhysiologyKent State UniversityKentUSA
  2. 2.Heart and Vascular InstitutePenn State University College of MedicineHersheyUSA
  3. 3.Department of Kinesiology and Integrated PhysiologyMichigan Technological UniversityHoughtonUSA
  4. 4.School of Health and Human PerformanceNorthern Michigan UniversityMarquetteUSA
  5. 5.Exercise Science ProgramWalsh UniversityNorth CantonUSA

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