Blood Flow-Restricted Training in Older Adults: A Narrative Review
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Low-intensity resistance training (LI-RT) combined with blood flow restriction (BFR) is an alternative to traditional moderate–high-intensity resistance training to increase strength and muscle mass. However, the evidence about the efficacy of this novel training method to increase strength and muscle mass in healthy and older adults with pathologies is limited. Furthermore, the possible risk and adverse effects with BFR training methodology in older adults should be considered.
(1) To summarize the current evidence on training with BFR strategies in older adults aiming to improve strength and to increase muscle mass; and (2) to provide recommendations for resistance and aerobic training with BFR in older adults based on the studies reviewed.
Studies that investigated the chronic responses to resistance training or aerobic training with BFR related to strength and muscle mass changes in older adults were identified. Two independent researchers conducted the search in PubMed, Web of Science, and Google Scholar databases from their inception up to November 1, 2018.
Seventeen out of 35 studies, which performed resistance or aerobic training with BFR in older adults focused on strength and muscle mass outcomes, were included in this review. Studies performing resistance and aerobic training with BFR found better improvements in strength and higher increase in muscle mass compared to non-BFR groups that performed the same training protocol. High-intensity resistance training (HI-RT) without BFR provided greater improvements in strength and a similar increase in muscle mass compared to light-intensity resistance training (LI-RT) with BFR.
Current evidence suggests that LI-RT and/or aerobic training with BFR improves strength and increases muscle mass in older people. Light-intensity training without BFR would normally not obtain such benefits. Therefore, LI-RT and aerobic training with BFR is an alternative to traditional methods to improve strength and by way of an increase in muscle mass, which are important in the elderly who have progressive muscle atrophy and are at higher risk of falls.
KeywordsHypertrophy Strength Vascular occlusion Resistance training Elderly adults
The aging process is often characterized by a substantial decrease in muscle mass, strength and physical function [8, 9, 29]. This condition is considered a geriatric syndrome called sarcopenia . The presence of sarcopenia has been associated with several adverse consequences, such as disability, high risk of falling and bone fractures, poor quality of life, and a higher risk of mortality [21, 34, 35]. According to the European Group on Sarcopenia in older people (EWGSP), the prevalence of sarcopenia ranges from 17 to 33% among institutionalized older people [2, 20]. Thus, an increase in strength and muscle mass has clinical and public health consequences in this population, and resistance training currently represents an effective treatment to control and even reverts sarcopenia .
To generate desirable training adaptations, the American College of Sports Medicine recommendations for older adults suggests that resistance training should be performed at high intensity. The intensity should increase gradually from 60% to over 80% of the individual one repetition maximum (1RM) [4, 33]. Supporting these recommendations, several studies demonstrated that high-intensity resistance training (HI-RT), i.e., ≥ 70% of 1RM, are associated with improvements in strength and muscle mass in older adults [39, 42]. However, the training progression is usually compromised in advanced years of life due to injuries, orthopedic limitations, and other pathologies that negatively affect the musculoskeletal function .
A novel training alternative could be light-intensity resistance training (LI-RT) with partial blood flow restriction (BFR), i.e., 20–30% of 1RM. This type of training has been demonstrated to be an effective method to improve strength and to increase muscle mass compared to the classical HI-RT in athletes and young adults [47, 48]. High metabolic stress (i.e., accumulation of metabolites during exercise) could play a key role in the increase in strength and muscle mass observed with low-intensity BFR training, which acts via several unique mechanisms (e.g., increased fast-twitch fiber recruitment, muscle damage and systemic and localized hormone production) irrespective of lower training intensities . Also, LI-RT with BFR has shown to be safe in young healthy adults . However, little is known about the clinical application of resistance and aerobic training with BFR that leads to improve strength and muscle mass in healthy and older adults with pathologies. Likewise, potential risks and adverse effects of training with BFR in older adults should be discussed. This issue should be considered by professionals when applying this methodology of training with older adults in clinical settings and fitness centers.
Therefore, the aims of the present narrative review were (1) to provide an overview of the effects of resistance and aerobic training with BFR on strength and muscle mass and (2) to provide exercise recommendations of training with BFR in older adults based on the studies reviewed (i.e., type of exercise, duration, frequency, sets × repetitions, resting time, intensity, exercises).
Two independent researchers (AP-F and AP) conducted the search in PubMed, Web of Science, and Google Scholar databases from inception up to November 1, 2018. The keywords included blood flow restriction, occlusion, Kaatsu, vascular occlusion, ischemia, hypertrophy, resistance training, strength training, aerobic exercise, walking training, older people, and elderly people. We defined the inclusion criteria as follows: (1) participants ≥ 55 years old, (2) intervention studies using resistance training and/or aerobic training (walking/cycling) with BFR (specific duration was not selected for interventions) and (3) report any measurement of strength and/or muscle mass (i.e., isokinetic strength, increase in 1RM and the cross-sectional area, etc.).
Summary of studies examining the effects of combined BFR training on musculoskeletal health in older adults (n = 17)
Participants (age and sex)
Type of exercise
Intensity of exercise (set × rep)
Training frequency and duration
Cuff pressure (width)
Assessment technique (A) and results in the BFR group
Abe et al. 
19 (60–78 years old and 11 females)
45% of HR maximum reserve (average HR 104 beats/min). 20 min
5 × week
160–200 mmHg (training pressure was increased by 10 mmHg each week) (cuff width not reported)
A: IKS, MIKS, CSA
Isokinetic knee extension and flexion torques: ↑ 7% and ↑ 16%
Maximal isometric knee: ↑ 11%
Muscle-bone CSA: ↑ 5.8% and ↑ 5.1% thigh and lower leg, respectively
Ultrasound skeletal muscle mass: ↑ 6.0% and ↑ 10.7% for total and thigh, respectively
Cook et al. 
36 (73.4–78.5 years old and 21 females)
Resistance training: leg extension, leg curl, and horizontal leg press machine exercises
BFR LI-RT: 1–3 sets 30–50% RM; volitional failure
60-s rest between sets and 3 min between exercises
Non-BFR HI-RT: 70% RM
2 × week
1.5 times brachial systolic blood pressure and average pressure of 184 ± 25 mmHg
A: RM, CSA
1 RM leg extension and leg press: ↑ 24% and 12%
CSA: ↑ 4.3%
Gualano et al. 
1 (case report; sporadic inclusion body myositis)
(65 years old; male)
Resistance training: leg press, knee extension, and squat exercises
3 × 15 RM; 30-s rest cuff pressure maintained
2 × week
50% of total occlusion pressure (65 mmHg)
A: RM, CSA
Leg press: ↑ 15.9%
Thigh CSA: ↑ 4.7%
Jørgensen et al. 
1 (case report; sporadic inclusion body myositis; 74 years old; 1 male)
Resistance training: unilateral leg press, isolated knee extension, seated calf raise
3–4 sets, reps until exhaustion.
2 × week
100 mmHg (150 mm width)
A: MMF, MHGS
Mechanical muscle function (maximal isometric strength, rate of force development, and muscle power): ↑ 38–92%
Maximal horizontal gait speed: ↑ 19%
Libardi et al. 
25 (60.6–68.8 years old and not reported sex)
Endurance training and resistance training (leg press)
BFR LI-RT: endurance training: 50–80% VO2peak
(30–40 min), resistance training: 20–30% 1–RM (1 × 30 and 3 × 15)
60 s rest
Non-BFR HI-RT: endurance training: 50–80% VO2peak (30–40 min), resistance training: 70–80% 1–RM (4 × 10) 60 s rest
Endurance T: 2 days/week, resistance T: 2 days/week
50% RAOP: 67 ± 8.0 mmHg (175 mm width, 920 mm length)
A: RM, CSA
1 RM 45° leg press: no significant difference between-group
CSA: no significant difference between-group
Ozaki et al. 
23 (56–76 years old and 18 females)
4 × week
200 mmHg (5 cm)
A: IKS, CSA
Isokinetic knee extension: ↑ 8.7% (N/m)
Isokinetic knee flexion: ↑ 15% (N/m)
CSA ↑ 3.2% cm2
Ozaki et al. 
18 (57–73 years old and females)
45% of HRR; mean treadmill speed and grade were 4.5 ± 0.0 km/h and 1.6 ± 0.4
4 × week
140–200 mmHg; elastic cuff (5 cm wide)
A: IKS, MIS, CSA, MV (magnetic resonance imaging)
Isokinetic knee extension: ↑ 8% (N/m)
Isokinetic knee flexion: ↑ 22%
Maximal isometric strength: ↑ 5.9%
CSA thigh: 3.1%
MV thigh: 3.7%
Ozaki et al. 
26 (69 ± 1 years old and 11 females)
3 groups-walking training + stair-climbing: (WS), (WS-BFR1), (WS-BFR2)
70–85% of the age-predicted maximum heart rate
20–30 min per session
2–4 × week (without BFR)
Additionally, 1–2× week (BFR groups)
Based on the circumference of the right thigh (< 50 cm, 100 mmHg; and 50–55 cm, 120 mmHg. Cuff width 105 mm)
No significant differences between groups
Patterson et al. 
10 (62–73 years old and 2 females)
Resistance training: unilateral plantar flexion
25% 1 RM; (3× failure); 1 min rest
3 × week
A: RM; MVC; MIT
Plantar flexion: RM ↑ 14% kg
Plantar flexion: MVC ↑18%
MIT at 0.52 rad/s ↑ 20%
MIT at 1.05 rad/s ↑ 17%
Shimizu et al. 
40 (67–75 years old and 7 females)
Resistance training: leg extension, leg press, rowing, chest press
20% RM (3 × 20)
30 s rest
3 × week
Femoral SBP, brachial SBP (leg cuff width: 10 cm; arm cuff width: 7 cm)
Leg extension (before: 46.8 ± 11.1, after: 55.7 ± 16.7)
Leg press (before: 138.7 ± 35.7, after: 154.4 ± 36.8)
Rowing and chest press increased but not significantly
Silva et al. 
15 (62.2 ± 4.53 years old, female osteoporosis)
Resistance training: unilateral knee extensions
BFR LI-RT: 30% RM, 4× failure, 30-s rest
Non-BFR HI-RT: 80% RM, 4× failure, 2-min rest
2 × week
104.20 ± 7.88 mmHg (18 cm width)
Leg extension machine
BFR LI-RT (PRE = 35.85 ± 6.72, POST = 40.10 ± 7.39)
Non-BFR HI-RT (PRE = 27.78 ± 3,45, POST = 37.37 ± 4.58). No significant differences
Thiebaud et al. 
14 (61 ± 5 years old and female)
Upper body: seated chest press, seated row and seated shoulder press.
Lower body: knee extension, knee flexion, hip flexion, hip extension.
Non-BFR MHI: 70% to 90% 1 RM; 3 × 10, 1–2-min rest
BFR LI-RT 10–30% 1 RM, 3×30–15–15, 30-s rest
Elastics bands were used
3 × week
80–120 mmHg (width 3.3 cm). Only upper body
A: RM, MT
RM in Chest press, seated row, and shoulder press increased but there were no differences between groups
Muscle thickness the pectoralis major: ↑ 17%
Vechin et al. 
23 (60.23–67.85 years old and 9 females)
Resistance training: leg press
20–30% 1 RM (1 × 30 and 3 × 15)
2 × week
50% tibial SBP (18 cm)
A: RM, CSA
Leg press RM: ↑17%
Quadriceps CSA: ↑ 6.6%
Yasuda et al. 
19 (61–84 years old and 14 females)
Resistance training: knee extension and leg press
(1 × 30, 1 × 20, 1 × 15, 1 × 10)
30 s rest
2 × week
120–270 mmHg (50 mm)
A: RM, CSA
Leg press RM: ↑ 33.4%
Leg extension RM: ↑ 26.1%
Quadriceps CSA: ↑ 8%
Adductors CSA: ↑ 6.5%
Gluteus maximus CSA: ↑ 4.4%
Yasuda et al. 
17 (61–85 years old and 14 females)
Resistance training: arm curl and triceps pushdown
“Heavy (green)” band for men and “Thin (yellow)” band for women
(1 × 30 and 3 × 15)
30 s rest between sets, 90 s between exercises
2 × week
120–270 mmHg (30 mm)
A: MVIC, CSA
MVIC: ↑ 7.8%
MVIC: ↑ 16.1%
CSA elbow flexors ↑ 17.6%
CSA elbow extensor ↑ 17.4%
Yasuda et al. 
30 (61–86 years old and females)
Resistance training: squat and knee extension
5–9 OMNI (extremely easy 0 to extremely hard 10) elastic band (1 × 30 and 3 × 15)
30 s rest between sets, 90 s between exercises
2 × week
120–200 mmHg (50 mm)
A: MVIC, RM, CSA
Knee extension MVIC: ↑ 13.7%
Knee extension RM: ↑ 7.6%
Leg press RM: ↑ 16.4%
Quadriceps CSA: ↑ 6.9%
Yokokawa et al. 
51 (65 years old and 34 females)
BFR: half squats, forward lunges, calf raises, knee lifts, crunches, knee flexion and extension while seated
DBE: symmetrical and asymmetrical movements, forward and lateral reach, forward and backward steps, standing and walking on a reduced base of support, increasing the complexity of ambulatory tasks, and functional ankle strengthening
BFR: 3–5 sets, 10–15 reps, 20 s to 5 min rest
2 × week
70–150 mmHg (45 mm)
Left knee extension MVIC: ↑20.4%
Right knee extension MVIC: ↑ 6.9%
Changes in Strength-Associated Resistance and Aerobic Training with BFR
Concerning isometric knee strength, Yokokawa et al. reported around 20.4% of improvements in BFR condition . In regard to isokinetic strength, Patterson et al. showed around 20% of improvement in plantar isokinetic strength at 0.52 rad/s in BFR condition . Likewise, improvements in leg press exercise RM (1 repetition maximum) ranged from 12 to 33.4% [7, 15, 22, 37, 51, 52, 54], in leg extension RM from 7.6 to 26.1% [7, 37, 40, 52, 54] and increases of + 15.7 and + 8.9 kg in leg press RM and leg extension in BFR condition . However, one study did not report significant differences in rowing and chest press between BFR and non-BFR conditions . Plantar flexion RM showed increases of 14% . Light-intensity resistance training in non-BFR conditions did not show significant increases in strength measurements. However, similar improvements in strength between LI-RT in BFR condition and HI-RT non-BFR groups were also reported [40, 50, 51].
Related to the aerobic training programs with BFR, some studies [1, 26, 27] reported increases in the knee extension isometric strength ranging from 5.9 to 11.8%, the knee extension isokinetic strength (N/m) ranging from 7 to 8.7%, as well as in the knee flexion isokinetic strength (N/m) ranging from 16 to 22% [1, 26, 27].
Changes in Muscle Mass Associated with Resistance and Aerobic Training with BFR
Twelve articles out of the seventeen listed in Table 1 reported changes in muscle mass. Among the twelve studies, eight performed resistance training [7, 15, 22, 50, 51, 52, 53, 54] and four performed aerobic training [1, 26, 27, 28] with BFR. In general, the groups that performed LI-RT in BFR conditions showed a significant increase in muscle mass compared with LI-RT in non-BFR conditions. Some studies that performed LI-RT with BFR reported cross-sectional area (CSA) in the quadriceps from 6.9 to 8.0% of improvements [52, 54], with adductors 6.5% and gluteus maximus 4.4% . Also, it has been reported CSA increase of 17.6% in the elbow flexors and 17.4% in the extensors . However, other studies reported similar increases in quadriceps CSA between LI-RT with BFR and the HI-RT non-BFR groups [7, 22, 51]. Changes ranged from 3.6 to 7.9%. Likewise, Thiebaud et al.  reported a significant but similar increase in pectoral muscle thickness (17%) in LI-RT with BFR and HI-RT non-BFR groups.
Walking with BFR has a positive effect on muscle mass. Abe et al.  reported an increase in the thigh muscle–bone CSA of + 5.8% and +5.1% in the lower leg muscle–bone CSA. Also, Ozaki et al. [26, 27] observed that the walking BFR group increased their thigh muscle CSA (+ 3.2%)  and their muscle CSA (cm2) in the thigh and quadriceps (+ 3.1% and + 3.0%, respectively) . However, another study  reported no additional improvements in muscle thickness after the inclusion of 1–2 sessions per week of walking with BFR.
Light-intensity resistance training or walking with BFR seems to be more effective to increase strength and muscle mass than the same training methods without BFR. In addition, HI-RT non-BFR seems to provide higher improvements in strength compared to LI-RT with BFR. Furthermore, although the number of studies found was limited, similar increases in muscle mass occurred with HI-RT without BFR and LI-RT with BFR. Therefore, training with BFR may be a viable alternative to HI-RT to improve strength and increase muscle mass in older adults in scenarios where heavy loads may not be safe or suitable.
Effects of Changes in Strength Associated with Resistance and Aerobic Training with BFR
In general terms, participants in LI-RT in BFR condition improved their strength more than LI-RT non-BFR. However, Shimizu et al.  reported no differences between groups in 1 RM rowing and chest press exercises. A possible explanation for the lack of improvement in rowing and chest press is that the main muscles implicated in these exercises (latissimus dorsi and pectoralis, respectively) do not work under direct BFR, although increments in strength and gains in muscle mass related to muscles proximal to the applied pressure have been previously reported (chest, shoulder, back) .
Importantly, similar improvements in resistance training with BFR compared to the traditional HI-RT non-BFR groups have also been reported [40, 50, 51]. In the study of Silva et al. , conducted on women with osteoporosis, the HI-RT non-BFR group showed higher improvements in 1RM leg extension compared to the LI-RT group with BFR (HI-RT non-BFR group: mean increase post-intervention 9.59 kg; and LI-RT with BFR group: mean increase post-intervention 4.25 kg). Vechin et al.  also found that the HI-RT non-BFR group increased the RM leg press more than the LI-RT group with BFR (+ 54% and + 17%, respectively). These higher strength improvements in the HI-RT non-BFR groups can be due to predominant neural adaptations to higher intensities. In addition, the strength differences can also be influenced by the different resting time intervals between sets in the LI-RT with BFR groups (usually 30 s) and the HI-RT non-BFR groups (1–2 min). Hence, this aspect should also be taken into consideration .
Nevertheless, Thiebaud et al.  found no significant differences between healthy participants completing a LI-RT with BFR and a moderate-to-high resistance training non-BFR (70–90% RM, ranging from 7 to 9 on the OMNI Resistance Exercise Scale). It is also possible that, in this study, a different control of intensity (OMNI Resistance Exercise Scale) with elastic bands and modification of elongation might have produced similar improvements between groups and contradictory findings reported in other studies [40, 51].
Furthermore, some studies have investigated adaptations in older adults performing concurrent training with BFR . For instance, Libardi et al.  found no differences in lower body strength between the BFR and non-BFR groups. The endurance training was the same for both training groups, but strength training was different (BFR group: 1 × 30 sets and 3 × 15 sets at 30% RM, non-BFR group: 4 × 10 at 70% RM). The lack of differences between groups can be due to the fact that LI-RT with BFR has previously shown to increase the recruitment of type II muscle fibers [44, 45]. In addition, another study has shown similar recruitment of type II muscle fibers between LI-RT with BFR and HI-RT non-BFR . The physiological mechanism is not well understood, but it is suggested that partial BFR causes low oxygen supply to active muscles and an increase in metabolites and intramuscular pH . In fact, these results in altered recruitment patterns of the fibers  lead to neuromuscular adaptation. The combination of LI-RT with BFR and endurance training in the same microcycle can be an interesting approach to improve strength in older people with reduction of mechanical stress.
Changes in Muscle Mass Associated with Resistance and Aerobic Training with BFR
Some studies have found higher increments in the CSA of different muscles (e.g., quadriceps, adductors, gluteus maximus, elbow flexors and extensors) in the LI-RT with BFR groups with respect to LI-RT non-BFR groups [52, 54]. Similarly, Gualano et al.  found an increase in the thigh CSA (4.7%) in a case report with a participant aged 65 affected by inclusion body myositis. Nonetheless, Thiebaud et al.  did not show significant changes in biceps, triceps and deltoid muscle thickness, using a protocol of training with elastic bands.
Other studies reported similar increases in quadriceps CSA between LI-RT with BFR and the HI-RT non-BFR groups [7, 51]. Metabolic stress might be similar in LI-RT with BFR and HI-RT non-BFR, which can explain the similar increase in muscle mass . However, neural adaptations can determine differences in strength gains between the abovementioned groups . Likewise, some studies reported that walking with BFR has a positive effect on muscle mass while non-BFR conditions do not [1, 26, 27]. However, another study of Ozaki et al.  did not report additional improvements in muscle thickness after the inclusion of 1–2 sessions per week. Possibly, the frequency of walking with BFR conducted in this intervention might have not been sufficient compared to higher frequency used in other studies (frequency of 4–5 days per week) [1, 27].
Light-intensity resistance training and walking with BFR seem to be more effective to increase strength and muscle mass than the same protocol without BFR. Fry et al.  suggested some physiological mechanisms that could explain this increment in older people. They found that a single session of LI-RT with BFR increased muscle protein synthesis by 56% 3 h after the end of the session, while muscle protein synthesis did not increase performing the same intervention without BFR. Likewise, they observed increases in the phosphorylation of the ribosomal protein S6 kinase beta-1 (S6K1) in the BFR condition, suggesting enhanced mammalian target of rapamycin (mTORC1) signaling following exercise. This could explain the increase in protein synthesis after exercise observed in the BFR group. Also, Gualano et al.  found a 3.97-fold increment in the mechano growth factor and a 40% reduction in atrogin-1 gene expression. This suggests an increase in muscle protein synthesis. Likewise, Santos et al.  found a 25% reduction of the myostatin mRNA level, which could explain the physiological mechanisms by which LI-RT with BFR produces an increase in muscle mass.
In conclusion, LI-RT or walking with BFR seems to be more effective to improve strength and increase muscle mass than the same training protocols in non-BFR conditions. Therefore, resistance training with BFR may be an alternative to HI-RT to increase strength and muscle mass in older adults compared to the same training protocol without BFR. However, to interpret these findings, it should be taken into account the differences in the methods used in the studies in cuff pressure, different strength measures, differences in training modalities (i.e., failure and non-failure), and different characteristics of the samples (not all the old participants included in the studies were healthy, or suffered from osteoporosis or from sporadic inclusion body myositis) between studies.
Notwithstanding, a systematic review has been published recently on this topic in healthy older adults . In brief, although many of the articles reviewed were similar in both reviews, we did not exclude studies with older adults presenting any pathology (e.g., body myositis, osteoporosis) as Centner et al. did. Furthermore, Center et al. mention that taking a thorough cardiovascular disease history from each individual is important to avoid adverse events . In this regard, we reviewed and discussed potential risks and adverse effects of occlusive training in older adults (“Risks, side effects, and contraindications of BFR in older adults”). This issue should be considered by professionals when applying this methodology of training to older adults in clinical settings and fitness centers.
Exercise Recommendations Using Resistance and Aerobic Training with BFR in Older Adults
Characteristics of combined BFR training in older adults based on the studies reviewed
Type of exercise
Duration of program
2–3 sessions/week in resistance training programs and 4–5 sessions/week in walking programs
Sets × repetitions, durations of walking session
3–4 sets of 15–30 repetitions; 20 min walking sessions
Rest interval between sets
20–30% of 1 RM for LI-RT and 45% HRR for walking
Leg press, knee extension, squat for the lower body and chest press, rowing, arm curl, and triceps pushdown exercises in the upper limbs
We found it is important to highlight the methodological differences between studies regarding the cuff pressure. While some studies applied cuff pressure arbitrarily [12, 28], others controlled its application as a percentage of systolic blood pressure or as a percentage of resting arterial occlusion pressure . It is especially important to bear in mind the considerations of Loenneke et al. , who reported that wide cuffs restrict the arterial blood flow at lower pressures than narrow cuffs (wide cuffs 13.5 cm and narrow cuffs 5 cm). Also, limbs with a larger circumference require higher occlusive pressures to reach the same level of arterial occlusion . Regarding pressure control, studies should take into consideration the type of cuff used (wide or narrow), trying to adjust the cuff to the limb circumference. All aspects related to cuff width and pressure have been explained in detail in a recent position stand, which focused on the methodology for BFR training . Detailed information about methodological differences in cuff pressure can be found in Table 1.
We encourage exercise professionals and physical therapists to implement LI-RT with BFR to improve strength and muscle mass (mainly in lower limbs) in older adults. The performance of movements involving major muscle groups, e.g., leg press, leg extension, and squat, has shown the most significant improvements in strength and muscle mass. Furthermore, beneficial muscular adaptations have been reported with BFR training using absolute pressure values ranging from 60 to 270 mmHg based on the studies included in our review. Higher BFR pressures can induce discomfort and augment cardiovascular response  and, therefore, they are not recommended in this population. Using wide cuffs may limit movement during the exercise . Thus, we recommend using low pressures and not extremely wide cuffs to increase the adherence to exercise and avoid possible risk with the implementation of training with BFR in older adults. The cuff material (nylon vs. elastic) used is not a relevant issue as it could not have a relevant effect on muscular adaptations . The pressure should be relative to the individual based on the cuff used during the exercise (40–80% of the arterial occlusion pressure). We should inflate the cuff (i.e., the same cuff used during exercise), stopping before blood flow ceases (100% of arterial occlusion pressure) and using a 40–80% of that pressure during exercise .
Risks, Side Effects, and Contraindications of BFR in Older Adults
The studies included in the present review did not report adverse consequences of training with BFR in older adults. In this context, Nakajima et al.  gave questionnaires to instructors or leaders of 105 facilities to learn the side effects while of training with BFR in all generations of people (healthy and with pathology). They reported a reduced number of side effects. The main negative effects reported were venous thrombus (0.055%), pulmonary embolism (0.008%), and rhabdomyolysis (0.008%). In addition, Clark et al.  reported safety (markers of coagulation and inflammation) in LI-RT with BFR in young healthy adults. Nonetheless, exercise pressor reflex can markedly increase the sympathetic neural activity in several cardiovascular diseases , and training with BFR does not have this possible response in older adults.
Kacin et al.  points to contraindications when training with BFR: (1) having a family history of clotting disorders (hemophilia, high platelets); (2) suffering from hypertension I (SBP ≥ 140 mmHg); (3) having a past history of pulmonary embolus; (4) having suffered from a hemorrhagic or thrombotic stroke. These contraindications should be taken into consideration when using resistance and aerobic training with BFR in older adults. In summary, training with BFR is relatively safe, but caution should be used by personal trainers and health care professionals when implementing this novel training approach in older adults. Several studies have shown that training with BFR can lead to high creatine kinase values [16, 38], indicating that potential risk for rhabdomyolysis could exist even in healthy young people.
The loss of strength and muscle mass with aging may result in poor quality of life and impaired performance of daily living activities [14, 46]. Training with BFR uses less mechanical stress and may be an alternative to high-intensity training to improve strength and increase muscle mass in older adults. Furthermore, not only improvements in strength and muscle mass have been reported in older adults with BFR training, but also the physical function has shown significant improvement with BFR training in older adults . This review contains useful information about the characteristics of training with BFR in older adults (studies including adults over 55 years of age) that lead to improvements in strength and increases in muscle mass, based on available evidence. Furthermore, we propose exercise recommendations for health professional and personal trainers who use resistance and aerobic training with BFR in older adults. The goal is to provide guidance to those training with BFR and recommendations for the correct implementation of resistance training or walking with BFR in older adults. Moreover, this review sheds light on the characteristics that training with BFR should have to achieve considerable changes in strength and muscle mass, which are precisely negatively affected with age.
Importantly, the recommendations provided in our review should be considered with caution due to the lack of randomized controlled trials in older adults training with BFR and the heterogeneity of the interventions. Furthermore, the optimal level of pressure and cuff width cannot be addressed in the present narrative review due to wide ranges provided (i.e., 60–270 mmHg and 3–18 cm, respectively). In this regard, a recent position stand explains in detail methodological aspects (cuff width and pressure among other aspects) of BFR training . More interventions employing training with BFR in older adults followed by systematic reviews and meta-analysis will provide further insights into this topic. Likewise, we think that this narrative review is practical and useful to provide a general overview of the current literature in this topic for clinical professionals and personal trainers while more randomized controlled trials are to be carried out.
Limitations and Strengths
The major limitation of the present review is the reduced number of studies in older adults. Also, a narrative review was performed instead of a systematic review. Unlike the narrative review, systematic reviews are based on the findings of comprehensive and systematic literature searches with minimization of bias. Likewise, the quality assessment of the studies was not performed.
Our narrative review provides practical recommendations for resistance training or aerobic training with BFR in healthy and older adults with pathologies based on the studies reviewed, although it should be taken into account cautiously due to the heterogeneity related to the methodological issues about BFR pressures and cuff width reported in the different studies.
Evidence suggests the effectiveness of resistance and aerobic training with BFR interventions in older adults to increase strength and muscle mass using low intensities as an alternative to the HI-RT. Improvements in strength and muscle mass have important consequences in this population, who is characterized by a progressive muscle atrophy and high risk of falls. The information provided in this review could be useful for clinical professionals and personal trainers for the correct and successful implementation of resistance and aerobic training with BFR in older adults.
CC-S is supported by a grant from the Spanish Ministry of Economy, Industry and Competitiveness (BES-2014-068829). A P-F, JHM, and J M-G are supported by the Spanish Ministry of Education, Culture and Sport (FPU 16/02760, FPU15/02645, and FPU14/06837, respectively). FBO is supported by a grant from the Spanish Ministry of Science, Innovation and Universities (RYC-2011-09011). I E-C is supported by a grant from the Alicia Koplowitz Foundation. M R-A is supported by the National Operational Programme on Youth Employment. Additional support was obtained from the Scientific Excellence Unit on Exercise and Health (UCEES) and EXERNET Research Network on Exercise and Health in Special Populations (DEP2005-00046/ACTI). This study has been partially funded by the University of Granada, Research and Knowledge Transfer Fund 2016, Excellence actions: Scientific Units of Excellence; Unit of Excellence on Exercise and Health (UCEES), and by the Andalusian Regional Government, Consejería de Conocimiento, Investigación y Universidades and European Regional Development Fund (ERDF), ref.SOMM17/6107/UGR. We are grateful to Ms. Carmen Sainz-Quinn and Ms. Ana Yara Postigo-Fuentes for assistance with the English language.
Compliance with Ethical Standards
Conflict of interest
The authors do not have any conflict of interest to disclose.
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