Chronic Blood Flow Restriction Exercise Improves Objective Physical Function: A Systematic Review

Efficacy of Blood Flow Restriction Exercise for Improving Lower Limb Muscle Strength and Function in Chronic Spinal Cord Injury: A Randomized Controlled Trial

The objective of the present study was to evaluate the efficacy of low-load (LL) blood flow restriction exercise (BFRE) for improving lower limb muscle strength, muscle thickness and physical function in individuals with spinal cord injury (SCI). In a randomized sham-controlled trial, 21 participants (age ≥ 18 years, SCI duration ≥ 1 year, knee extensor strength grade 2-4, ASIA A-D) were randomized to either 45-min LL-BFRE (n = 11) or sham BFRE (n = 10) twice/week for 8 weeks. The exercise protocol consisted of four sets (30 × 15 × 15 × 15 repetitions) of unilateral seated leg extensions and leg curls at 30%-40% of 1RM performed with pneumatic cuffs applied proximally on the trained limb and inflated to 40% of total arterial occlusion pressure (BFRE) or non-inflated (sham exercise). Maximal voluntary isometric quadriceps and hamstring muscle strength, quadriceps muscle thickness, thigh circumference, and physical function were assessed at baseline, after 4 and 8 weeks of training and at 4-week follow-up. No significant between-group differences were found between BFRE and sham exercise in quadriceps or hamstring muscle strength, 10-m walking test, timed up & go, 6-min walking test or the spinal cord independence measure. In contrast, a significant between-group difference favoring BFRE was present for muscle thickness and thigh circumference from baseline to 4-week follow-up (0.76 cm (95% CI: 0.32; 1.20, p = 0.002) and 2.42 cm (0.05; 4.79, p = 0.05), respectively). In conclusion, there was no significant difference in the effect of LL-BFRE and sham exercise on muscle strength and physical function in individuals with SCI. However, significant increases in muscle thickness and thigh circumference were observed in favor of BFRE. Trial Registration: ClinicalTrials.gov identifier: NCT03690700.

An Updated Panorama of Blood-Flow-Restriction Methods

BACKGROUND

Exercise with blood-flow restriction (BFR) is being increasingly used by practitioners working with athletic and clinical populations alike. Most early research combined BFR with low-load resistance training and consistently reported increased muscle size and strength without requiring the heavier loads that are traditionally used for unrestricted resistance training. However, this field has evolved with several different active and passive BFR methods emerging in recent research.

PURPOSE

This commentary aims to synthesize the evolving BFR methods for cohorts ranging from healthy athletes to clinical or load-compromised populations. In addition, real-world considerations for practitioners are highlighted, along with areas requiring further research.

CONCLUSIONS

The BFR literature now incorporates several active and passive methods, reflecting a growing implementation of BFR in sport and allied health fields. In addition to low-load resistance training, BFR is being combined with high-load resistance exercise, aerobic and anaerobic energy systems training of varying intensities, and sport-specific activities. BFR is also being applied passively in the absence of physical activity during periods of muscle disuse or rehabilitation or prior to exercise as a preconditioning or performance-enhancement technique. These various methods have been reported to improve muscular development; cardiorespiratory fitness; functional capacities; tendon, bone, and vascular adaptations; and physical and sport-specific performance and to reduce pain sensations. However, in emerging BFR fields, many unanswered questions remain to refine best practice.

Blood flow restriction as a potential therapy to restore physical function following COVID-19 infection

Accumulating evidence indicates that some COVID-19 survivors display reduced muscle mass, muscle strength, and aerobic capacity, which contribute to impairments in physical function that can persist for months after the acute phase of illness. Accordingly, strategies to restore muscle mass, muscle strength, and aerobic capacity following infection are critical to mitigate the long-term consequences of COVID-19. Blood flow restriction (BFR), which involves the application of mechanical compression to the limbs, presents a promising therapy that could be utilized throughout different phases of COVID-19 illness. Specifically, we hypothesize that: 1) use of passive BFR modalities can mitigate losses of muscle mass and muscle strength that occur during acute infection and 2) exercise with BFR can serve as an effective alternative to high-intensity exercise without BFR for regaining muscle mass, muscle strength, and aerobic capacity during convalescence. The various applications of BFR may also serve as a targeted therapy to address the underlying pathophysiology of COVID-19 and provide benefits to the musculoskeletal system as well as other organ systems affected by the disease. Consequently, we present a theoretical framework with which BFR could be implemented throughout the progression from acute illness to outpatient rehabilitation with the goal of improving short- and long-term outcomes in COVID-19 survivors. We envision that this paper will encourage discussion and consideration among researchers and clinicians of the potential therapeutic benefits of BFR to treat not only COVID-19 but similar pathologies and cases of acute critical illness.

Acute physiological responses to steady-state arm cycling ergometry with and without blood flow restriction

PURPOSE

To compare heart rate (HR), oxygen consumption (VO₂), blood lactate (BL), and ratings of perceived exertion (RPE) during arm cycling with and without a blood flow restriction (BFR).

METHODS

Twelve healthy males (age: 23.9 ± 3.75 years) completed four, randomized, 15-min arm cycling conditions: high-workload (HW: 60% maximal power output), low-workload (LW: 30% maximal power output), low-workload with BFR (LW-BFR), and BFR with no exercise (BFR-only). In the BFR conditions, cuff pressure to the proximal biceps brachii was set to 70% of occlusion pressure. HR, VO₂, and RPE were recorded throughout the exercise, and BL was measured before, immediately after, and five minutes post-exercise. Within-subject repeated-measures ANOVA was used to evaluate condition-by-time interactions.

RESULTS

HW elicited the greatest responses in HR (91% of peak; 163.3 ± 15.8 bpm), VO₂ (71% of peak; 24.0 ± 3.7 ml kg^-1 min^-1), BL (7.7 ± 2.5 mmol L^-1), and RPE (14 ± 1.7) and was significantly different from the other conditions (p < 0.01). The LW and LW-BFR conditions did not differ from each other in HR, VO₂, BL, and RPE mean of conditions: ~ 68%, 41%, 3.5 ± 1.6 mmol L^-1, 10.4 ± 1.6, respectively; p > 0.05). During the BFR-only condition, HR increased from baseline by ~ 15% (on average) (p < 0.01) without any changes in VO₂, BL, and RPE (p > 0.05).

CONCLUSIONS

HW arm cycling elicited the largest and most persistent physiological responses compared to LW arm cycling with and without a BFR. As such, practitioners who prescribe arm cycling for their clients should be advised to augment the demands of exercise via increases in exercise intensity (i.e., power output), rather than by adding BFR.

Blood Flow Restricted Cycling Impairs Subsequent Jumping But Not Balance Performance Slightly More Than Non-Restricted Cycling: An Acute Randomized Controlled Cross-Over Trial

Chronic blood flow restriction (BFR) training has been shown to improve drop jumping (DJ) and balance performance. However, the acute effects of low intensity BFR cycling on DJ and balance indices have not yet been examined. 28 healthy young adults (9 female; 21.8 ± 2.7years; 1.79 ± 0.08m; 73.9 ± 9.5kg) performed DJ and balance testing before and immediately after 20min low intensity cycling (40% of power at maximal oxygen uptake) with (BFR) and without BFR (noBFR). For DJ related parameters, no significant mode × time interactions were found (p ≥ 0.221, η_p ² ≤ 0.06). Large time effects for DJ heights and the reactive strength index were observed (p < 0.001, η_p ² ≥ 0.42). Pairwise comparison revealed notably lower values for both DJ jumping height and reactive strength index at post compared to pre (BFR: -7.4 ± 9.4%, noBFR: -4.2 ± 7.4%). No statistically significant mode × time interactions (p ≥ 0.36; η_p ² ≤ 0.01) have been observed for balance testing. Low intensity cycling with BFR results in increased (p ≤ 0.01; SMD ≥ 0.72) mean heart rate (+14 ± 8bpm), maximal heart rate (+16 ± 12 bpm), lactate (+0.7 ± 1.2 mmol/L), perceived training intensity (+2.5 ± 1.6au) and pain scores (+4.9 ± 2.2au) compared to noBFR. BFR cycling induced acutely impaired DJ performance, but balance performance was not affected, compared to noBFR cycling. Heart rate, lactate, perceived training intensity, and pain scores were increased during BFR cycling.

Effectiveness of Blood Flow Restriction on Functionality, Quality of Life and Pain in Patients with Neuromusculoskeletal Pathologies: A Systematic Review

BACKGROUND

Blood flow restriction is characterized as a method used during exercise at low loads of around 20-40% of a repetition maximum, or at a low-moderate intensity of aerobic exercise, in which cuffs that occlude the proximal part of the extremities can partially reduce arterial flow and fully restrict the venous flow of the musculature in order to achieve the same benefits as high-load exercise.

OBJECTIVE

The main objective of this systematic literature review was to analyze the effects of BFR intervention on pain, functionality, and quality of life in subjects with neuromusculoskeletal pathologies.

METHODS

The search to carry out was performed in PubMed, Cochrane, EMBASE, PEDro, CINHAL, SPORTDiscus, Trip Medical Database, and Scopus: "kaatsu" OR "ischemic training" OR "blood flow restriction" OR "occlusion resistance training" OR "vascular occlusion" OR "vascular restriction".

RESULTS

After identifying 486 papers and eliminating 175 of them due to duplication and 261 after reading the title and abstract, 50 papers were selected. Of all the selected articles, 28 were excluded for not presenting a score equal to or higher than 6 points on the PEDro scale and 8 for not analyzing the target outcome variables. Finally, 14 papers were selected for this systematic review.

CONCLUSIONS

The data collected indicate that the blood flow restriction tool is a therapeutic alternative due to its effectiveness under different exercise modalities. The benefits found include decreases in pain thresholds and improvement in the functionality and quality of life of the neuro-musculoskeletal patient during the first six weeks. However, the results provided by this tool are still not clear for medium- and long-term interventions.

Beneath the cuff: Often overlooked and under-reported blood flow restriction device features and their potential impact on practice-A review of the current state of the research

Training with blood flow restriction (BFR) has been shown to be a useful technique to improve muscle hypertrophy, muscle strength and a host of other physiological benefits in both healthy and clinical populations using low intensities [20%-30% 1-repetition maximum (1RM) or <50% maximum oxygen uptake (VO_2max)]. However, as BFR training is gaining popularity in both practice and research, there is a lack of awareness for potentially important design characteristics and features associated with BFR cuff application that may impact the acute and longitudinal responses to training as well as the safety profile of BFR exercise. While cuff width and cuff material have been somewhat addressed in the literature, other cuff design and features have received less attention. This manuscript highlights additional cuff design and features and hypothesizes on their potential to impact the response and safety profile of BFR. Features including the presence of autoregulation during exercise, the type of bladder system used, the shape of the cuff, the set pressure versus the interface pressure, and the bladder length will be addressed as these variables have the potential to alter the responses to BFR training. As more devices enter the marketplace for consumer purchase, investigations specifically looking at their impact is warranted. We propose numerous avenues for future research to help shape the practice of BFR that may ultimately enhance efficacy and safety using a variety of BFR technologies.

Effects of low-intensity resistance exercise with blood flow restriction after high tibial osteotomy in middle-aged women

BACKGROUND

High tibial osteotomy (HTO) is an effective surgical method for treating medial compartment osteoarthritis. However, in most cases after surgery, muscle strength is decreased, and rapid muscle atrophy is observed. Therefore, the purpose of this study is to verify the effects of low-intensity resistance exercise (LIE) with blood flow restriction (BFR) on the cross-sectional area (CSA) of thigh muscles, knee extensor strength, pain, and knee joint function and investigate proper arterial occlusion pressure (AOP) in middle-aged women who underwent HTO.

METHOD

This study was designed as a prospective randomized controlled trial. Forty-two middle-aged women who underwent HTO were randomly divided into three groups and participated in LIE with (40% or 80% AOP applied) or without BFR. The main outcome was the measurement of the CSA of thigh muscles (at 30% and 50% distal length of the femur) before and 12 weeks after treatment. Additionally, knee extension muscle strength, pain, and joint function were evaluated before and 6 and 12 weeks after treatment.

RESULTS

CSA of thigh muscles at 30% and 50% distal length of the femur decreased in the AOP 40% and control groups and was the largest in the AOP 80% group 12 weeks after treatment. Knee extension strength increased in all groups and was the highest in the AOP 80% group 6 and 12 weeks after treatment. Pain improved in all groups, with no intergroup differences. Knee joint function improved in all groups and was superior in the 80% AOP group 12 weeks after treatment.

CONCLUSION

LIE with BFR at 80% AOP was effective in preventing atrophy of the thigh muscle, increasing muscle strength, and improving function. BFR at 40% AOP had no difference in the results when compared with the group in which BFR was not applied. Therefore, LIE with an AOP of 80% is recommended for patients undergoing HTO.

A call to action for blood flow restriction training in older adults with or susceptible to sarcopenia: A systematic review and meta-analysis

Background: The extent to which exercise training with blood flow restriction (BFR) improves functional performance (FP) in people with sarcopenia remains unclear. We performed a comprehensive search of BFR training in subjects with sarcopenia or susceptible to sarcopenia hoping to perform a systematic review and meta-analysis on the effects of BFR on FP in older adults without medical disorders, but with or susceptible to sarcopenia.

Methods: PubMed and the Cochrane library were searched through February 2022. Inclusion criteria were: 1) the study examined older adults (&gt;55 years of age) with or susceptible to sarcopenia and free of overt acute or chronic diseases, 2) there was a random allocation of participants to BFR and active control groups, 3) BFR was the sole intervention difference between the groups, and 4) the study provided post-intervention measures of skeletal muscle and physical function which were either the same or comparable to those included in the revised European Working Group on Sarcopenia in Older People (EWGSOP) diagnostic algorithm.

Results: No studies of BFR training in individuals with sarcopenia were found and no study included individuals with FP values below the EWGSOP criteria. However, four studies of BFR training in older adults in which FP was examined were found. BFR training significantly improved the timed up and go (MD = −0.46, z = 2.43, p = 0.02), 30-s chair stand (MD = 2.78, z = 3.72, p &lt; 0.001), and knee extension strength (standardized MD = 0.5, z = 2.3, p = 0.02) in older adults.

Conclusion: No studies of BFR exercise appear to have been performed in patients with or suspected sarcopenia based on latest diagnostic criteria. Despite the absence of such studies, BFR training was found to significantly improve the TUG, 30-s chair stand, and knee extension strength in older adults. Studies examining the effects of BFR in subjects below EWGSOP cut-off points are needed.

Blood-flow restricted exercise following ankle fractures - A feasibility study

BACKGROUND

The objective was to investigate the feasibility of blood flow restricted exercise (BFRE) as a rehabilitation modality in patients with a unilateral ankle fracture.

METHODS

Feasibility study with a prospective cohort design. Inclusion criteria were above 18 years of age and unilateral ankle fractures.

EXCLUSION CRITERIA

history of cardiac or embolic diseases, cancer, diabetes, hypertension and family history of cardio or vascular diseases. The predefined feasibility outcome was based on three criteria regarding patients experience with participating in the BFRE protocol and the absence of any serious adverse events.

RESULTS

Eight patients were included. Median age was 33 years (range: 23-60). All eight patients reported maximum satisfaction on the two questions regarding patient's perception of the overall experience with BFRE training and the feasibility to introduce BFRE as an intervention.

CONCLUSION

Early use of BFRE in patients with unilateral ankle fractures seems feasible in patients without comorbidity.

Low- to Moderate-intensity Blood Flow Restricted Walking is not an Acute Equivalent for Unrestricted Jogging in Young Active Adults

This study investigated whether walking with blood flow restriction (BFR) increases acute cardio-respiratory demands to the point that it can be considered an alternative for jogging. Sixteen physically active adults completed five experimental sessions (order randomised), comprising 10 min of treadmill exercise. Two sessions included unrestricted walking, two sessions required walking with BFR cuffs positioned on the lower limbs inflated to 60% of individualised arterial occlusion pressure, and one session was conducted at a jogging pace. Comfortable walking and jogging speeds were calculated during the familiarisation session. Walking speeds were individualised to either 100% (speed: 6.0 ± 0.3km·h^-1[low-intensity]) or 120% (speed: 7.2 ± 0.3km·h^-1[moderate-intensity]) of comfortable walking speed. The jogging session was unrestricted (speed: 9.1 ± 0.7km·h^-1). Initial analysis compared walking conditions across heart rate, left cardiac work index, systolic blood pressure, relative oxygen consumption, minute ventilation, rating of perceived exertion and limb discomfort. Secondary analysis compared the walking session with the highest cardio-respiratory demands to jogging. Initial analysis identified that moderate-intensity with BFR induced the highest cardio-respiratory and perceptual responses compared with any other walking sessions (p < 0.01). Secondary analysis revealed that all cardio-respiratory measures were higher during jogging when compared with moderate-intensity with BFR (p < 0.01), except systolic blood pressure (p = 0.10). All perceptual measures were higher during moderate-intensity with BFR (p < 0.01) compared with jogging. Low- to moderate-intensity BFR-walking produces lower acute cardio-respiratory responses at higher ratings of perceived exertion and discomfort compared with jogging. Overall, BFR-walking does not seem to provide an equivalent exercise modality for unrestricted jogging in physically active adults.

An Overview of Blood Flow Restriction Physiology and Clinical Considerations

ABSTRACT

The utilization of blood flow restriction has garnished considerable attention due to its widespread application and benefits that include strength enhancement, muscle hypertrophy, and increased level of function for specific populations. Blood flow restriction induces a hypoxic environment within a muscle group, initiating a metabolic cascade that stimulates muscle protein synthesis, altered gene regulation of muscle satellite cells, and increased muscle fiber recruitment, ultimately resulting in improved strength and endurance. When using blood flow restriction, consideration of the individual patient, occlusion pressure, cuff width, and cuff size are paramount. Blood flow restriction has been proven to be a consistently safe and effective tool for augmenting rehabilitative regimens for the upper and lower extremity.

Effect of Blood Flow Restriction on Functional, Physiological and Structural Variables of Muscle in Patients with Chronic Pathologies: A Systematic Review

The main objective of this systematic review of the current literature is to analyze the changes that blood flow restriction (BFR) causes in subjects with neuro-musculoskeletal and/or systemic pathologies focusing on the following variables: strength, physiological changes, structural changes and cardiocirculatory variables. The search was carried out in seven databases, including randomized clinical trials in which therapeutic exercise was combined with the blood flow restriction tool in populations with musculoskeletal pathologies. Outcome variables are strength, structural changes, physiological changes and cardiocirculatory variables. Twenty studies were included in the present study. Although there is a lot of heterogeneity between the interventions and evaluation instruments, we observed how the restriction of blood flow presents significant differences in the vast majority of the variables analyzed. In addition, we observed how BFR can become a supplement that provides benefits when performed with low intensity, similar to those obtained through high-intensity muscular efforts. The application of the BFR technique can provide benefits in the short and medium term to increase strength, muscle thickness and cardiovascular endurance, even improving the physiological level of the cardiovascular system. In addition, BFR combined with low-load exercises also achieves benefits comparable to high-intensity exercises without the application of BFR, benefiting patients who are unable to lift high loads.

Effects of Low-Load Blood-Flow Restricted Resistance Training on Functional Capacity and Patient-Reported Outcome in a Young Male Suffering From Reactive Arthritis

Introduction: Reactive arthritis (ReA) is a chronic inflammatory disease usually caused by a preceding gastrointestinal or genitourinary bacterial infection. ReA usually occurs in the lower limbs causing joint pain and joint swelling. Physiotherapy-led exercise is recommended to prevent muscle atrophy. The purpose of this case report is to describe the outcome after 12 weeks of low-load blood flow restricted resistance training (BFR-RT) as a rehabilitation method for a young male suffering from ReA.

Methods and materials: A 17-year-old male suffered from ReA in the both knee joints and the left hip joint. 36 months after the incident, he suffered from another ReA incident in his right knee. Non-steroid anti-inflammatory drugs and a new arthrocentesis added with corticosteroid injection was unsuccessful in treating the ReA. The patient performed 12 weeks of BFR-RT on the right lower limb with a low amount of supervision after the first week of training. Assessment of unilateral 30-sec chair stand test (u30-sec CST), low-thigh circumference above apex patella, The Knee Injury and Osteoarthritis Outcome Score (KOOS), The Forgotten Knee Joint Score (FJS), and Numeric Ranking Scale for pain (NRS) was performed at baseline and after 3,6,9, and 12 weeks of BFR-RT.

Results: The patient completed all planned exercise sessions. u30-sec CST improved with 7 repetitions (reps) on the right limb and 5 reps on the left leg. Low-thigh circumference decreased 1.1 cm on the right leg and 1.0 on the left leg. KOOS symptoms, ADL, quality of life and FJS demonstrated a clinically relevant change on 10, 14 and 23 points.

Conclusion: The present case study indicates that even with low amounts of supervision BFR-RT could increase functional performance, reduce knee joint swelling and improve key patient-reported outcome.

Is there rationale for the cuff pressures prescribed for blood flow restriction exercise? A systematic review

BACKGROUND

Blood flow restriction exercise has increasingly broad applications among healthy and clinical populations. Ensuring the technique is applied in a safe, controlled, and beneficial way for target populations is essential. Individualized cuff pressures are a favored method for achieving this. However, there remains marked inconsistency in how individualized cuff pressures are applied.

OBJECTIVES

To quantify the cuff pressures used in the broader blood flow restriction exercise literature, and determine whether there is clear justification for the choice of pressure prescribed.

METHODS

Studies were included in this review from database searches if they employed an experimental design using original data, involved either acute or chronic exercise using blood flow restriction, and they assessed limb or arterial occlusion pressure to determine an individualized cuff pressure. Methodologies of the studies were evaluated using a bespoke quality assessment tool.

RESULTS

Fifty-one studies met the inclusion criteria. Individualized cuff pressures ranged from 30% to 100% arterial occlusion pressure. Only 7 out of 52 studies attempted to justify the individualized cuff pressure applied during exercise. The mean quality rating for all studies was 11.1 ± 1.2 out of 13.

CONCLUSIONS

The broader blood flow restriction exercise literature uses markedly heterogeneous prescription variables despite using individualized cuff pressures. This is problematic in the absence of any clear justification for the individualized cuff pressures selected. Systematically measuring and reporting all relevant acute responses and training adaptations to the full spectrum of BFR pressures alongside increased clarity around the methodology used during blood flow restriction exercise is paramount.

Hemodynamic and perceptual responses to blood flow-restricted exercise among patients undergoing dialysis

End-stage kidney disease is associated with reduced exercise capacity, muscle atrophy, and impaired muscle function. While these may be improved with exercise, single modalities of exercise do not traditionally elicit improvements across all required physiological domains. Blood flow-restricted exercise may improve all of these physiological domains with low intensities traditionally considered insufficient for these adaptions. Investigation of this technique appeals, but is yet to be evaluated, in patients undergoing dialysis. With the use of a progressive crossover design, 10 satellite patients undergoing hemodialysis underwent three exercise conditions over 2 wk: two bouts (10 min) of unrestricted cycling during two consecutive hemodialysis sessions (condition 1), two bouts of cycling with blood flow restriction while off hemodialysis on 2 separate days (condition 2), and two bouts of cycling with blood flow restriction during two hemodialysis sessions (condition 3). Outcomes included hemodynamic responses (heart rate and blood pressure) throughout all sessions, participant-perceived exertion and discomfort on a Borg scale, and evaluation of ultrafiltration rates and dialysis adequacy (Kt/V) obtained post hoc. Hemodynamic responses were consistent regardless of condition. Significant increases in heart rate, systolic blood pressure, and mean arterial blood pressure (P < 0.05) were observed postexercise followed by a reduction in blood pressures during the 60-min recovery (12, 5, and 11 mmHg for systolic, diastolic, and mean arterial pressures, respectively). Blood pressures returned to predialysis ranges following the recovery period. Blood flow restriction did not affect ultrafiltration achieved or Kt/V. Hemodynamic safety and tolerability of blood flow restriction during aerobic exercise on hemodialysis is comparable to standard aerobic exercise.

Effect of blood-flow restriction exercise on falls and fall related risk factors in older adults 60 years or above: a systematic review

This systematic review investigated the effect of low-load resistance training combined with blood-flow restriction (LL-BFR) on falls in older adults ≥60 years of age. The databases Embase, Medline, and Cochrane Library were searched from inception to October 1^st, 2019 and reference lists of retrieved publications. Main outcomes were fall rates or proportion of fallers. Additional outcomes were physical performance, lower extremity muscle strength or function, and balance. Mean difference ±SD on falls and fall related outcomes were reported and Cochrane Collaboration's risk of bias tool was used to evaluate quality of evidence. Eight RCT-studies met the inclusion criteria. None reported falls data. Assessing physical performance tests (n=12), 8/12 of the LL-BFR groups showed a significant within-group improvement and 5/12 significant between-group effects comparing LL-BFR to respective controls. For muscle strength tests (n=16), 9/16 showed significant positive within-group improvement and 3/16 significant between-group effects. One study reported data on balance with conflicting results. In conclusion, LL-BFR might increase physical performance and muscle strength in older adults ≥60 years of age. None of the included studies investigated the effect on falls. Larger adequately powered studies are required before introducing LL-BFR as an alternative exercise modality to decrease fall risk.