Next Article in Journal
Advances in Bio-Hydrogen Production: A Critical Review of Pyrolysis Gas Reforming
Previous Article in Journal
Determination of the Social Contribution of Sustainable Additives for Asphalt Mixes Through Fuzzy Cognitive Mapping
Previous Article in Special Issue
Assessment of Limb Imbalance in Professional Soccer Players
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Applied Sciences
Volume 15
Issue 7
10.3390/app15073996
applsci-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Systematic Review

Effects of Low Load Blood Flow Restriction Training on Post-Surgical Musculoskeletal Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

by
Diego Santos-Pérez
1,
Nicolae Ochiana
2,*,
Luis Carrasco-Páez
3 and
Inmaculada C. Martínez-Díaz
4
1
Medical Department Cádiz Football Club Academy, 11010 Cádiz, Spain
2
Department of Physical Education and Sports Performance, Vasile Alecsandry University of Bacau, 600115 Bacau, Romania
3
Department of Physical Education and Sport, University of Seville, 41005 Seville, Spain
4
Department of Human Movement and Sports Performance, University of Seville, 41005 Seville, Spain
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(7), 3996; https://doi.org/10.3390/app15073996
Submission received: 20 November 2024 / Revised: 11 March 2025 / Accepted: 25 March 2025 / Published: 4 April 2025
(This article belongs to the Special Issue Advances in Sports Science and Movement Analysis)
Browse Figures
Review Reports Versions Notes

Abstract

:
Objective: Low-Load Blood Flow Restriction Training (LLBFRT) is an emerging approach in order to increase muscle endurance and muscle volume, as well as decrease pain in the early rehabilitation phase. The purpose of this review was to analyze the published literature on the effects of this intervention on musculoskeletal postsurgical rehabilitation. Methods: Six electronic databases (Cochrane Library, PubMed, SPORTDiscus, SCOPUS, CINAHL, and Web of Science) were searched from 2004 to 2024. Articles including adults who underwent any type of musculoskeletal surgery were screened. The Risk of Bias and Quality of Evidence were assessed using the Cochrane Risk-of-Bias Tool (RoB 2) and GRADE-CERQual scale. A meta-analysis was performed on the identified studies using RevMan version 5.4. The analysis model was synthesized as a random effects model, and the standard mean difference (SMD) was used as the effect measure. Results: Thirteen articles fulfilled the selection criteria and were included in this review. Muscle strength, muscle volume, and perceived pain had positive results in almost all studies; however, the meta-analysis reported a lack of overall effect in favor of LLLBFRT vs. control interventions in both lower and upper limb evaluations. Conclusions: Although some studies indicate positive effects of LLBFRT on strength, muscle size, and pain perception in operated lower and upper limbs, these results must be interpreted carefully since the overall effects are unclear. Nonetheless, the selected studies did not report discomfort claims; therefore, the LLBFRT could be a safe recovery strategy to use when rehabilitation programs need to gain variety.

1. Introduction

Musculoskeletal disorders (MD) are common injuries characterized by clinical features such as pain, limited mobility, functional disability, and reduced quality of life [1]. In recent years, the prevalence of these injuries has increased by 58% [2], mainly affecting the lower limbs in all types of populations [3,4], and they are currently the main cause of disability worldwide [5]. One of the most widely used treatments for MD is trauma surgery [6], which is a surgical procedure frequently performed in hospitalized and outpatient settings in the USA, France, Germany, and Spain [7].
However, these invasive procedures can have negative consequences. Muscle Weakness (MW), muscle atrophy (MA) and sometimes arthrogenic muscle inhibition (AMI) -especially after ACL reconstruction—are the most common consequences after musculoskeletal surgery [8,9,10]. During the postoperative period, MW, MA, and AMI can develop rapidly; for example, even short periods of immobilization can cause a 20–30% decrease in thigh volume after knee arthroscopy [11,12]. Therefore, it is essential for physical therapists to incorporate analytical strength work in the early stages of the rehabilitation process [13,14]. Thus, if there are no post-surgical complications, it is imperative to minimize the extent of knee extensor weakness during the early-stage post-ACL reconstruction [15]. Moreover, knee extensor maximal and explosive strength at 6-weeks post-ACL reconstruction has been shown to predict hop and jump performance at 6-months post-ACL surgery [16]. For these reasons, post-operative strength training should be initiated as soon as possible.
Over the last few decades, some studies have suggested the potential for low-load exercise (i.e., <25% maximal capacity) to stimulate significant muscular adaptations when the blood flow to a muscle or muscle group is restricted or fully occluded [17]. In fact, comparing blood flow-restricted exercise to a non-occluded exercise control group, a 14% increase in knee extensor strength of young subjects engaging in strength training at 50% of maximal capacity was observed [18]. Thus, Blood Flow Restriction therapy, combined with low-load strength exercise (<30% Maximum Repetition (RM) [19]—Low-Load Blood Flow Restriction Training (LLBFRT) -, has emerged as a therapeutic alternative with great clinical potential, as it causes neuromuscular adaptations and improves muscle volume in a manner similar to Heavy Load Training (HLT) [13,20,21]. The basis of the adaptations caused by the use of LLBFRT are all the physiological changes, which comprise the increase in cellular swelling, systemic hormone production (GH, IGF1, and MGF), myogenic stem cell proliferation, protein synthesis (mTOR and MAPK signalling pathways), and recruitment of type II fibers [22,23,24,25]. These changes result from metabolic cascades activated by mechanical tension and metabolic stress, the primary factors of hypertrophy [14,18,19,20,21,22,23,24,25,26], which occur after the ischemic situation produced during the method application.
LLBFRT has increased its use in rehabilitation and injury recovery areas [8,24], since the above-mentioned responses and adaptations lead to mitigate MA and MW [23,27] without overloading the tissue that must heal [16] and reducing the stress suffered by joints and bones [28]. Furthermore, it has a positive effect on postoperative pain management, as it has been shown to produce generalized hypoalgesia [29]. Research supports this, suggesting that working with this methodology favors strength and muscle mass increase, improves muscle and joint function, and sometimes reduces pain during exercise [8,27,28,30,31]. It is also known as a safe practice [11,26,32] that does not have more risks than traditional endurance training methods [8,10].
In recent years, clinicians have started to implement LLBFRT in musculoskeletal postoperative settings [32,33], where patients normally do not allow them to work with high exercise loads [22,24]. Nevertheless, the articles published so far have only focused on specific structures, such as the knee, or on variables related to the safety of the interventions. This study aimed to go a little further to investigate this issue. Hence, the following question was formulated: What are the effects of low-load blood flow restriction endurance training on post-surgical musculoskeletal patients? To answer this question, this systematic review analyzed the current scientific evidence on the effects of LLBFRT in patients after any musculoskeletal surgical process, verifying the effectiveness of this method specifically on (1) muscle strength, (2) muscle volume, and (3) perceived pain.

2. Materials and Methods

2.1. Study Design

We used the PRISMA guidelines for the development of this systematic review [34], which is also registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the following number: CRD42023481320.

2.2. Data Sources and Search Strategy

Six electronic databases (Cochrane Library, PubMed, CINAHL, SPORTDiscus (EBSCO), SCOPUS, and Web of Science) were searched from January 2004 to December 2024. A four-tier approach was used with search terms for intervention (e.g., “Blood flow restriction therapy” or “blood flow restricted exercise”), for population (e.g., “Musculoskeletal diseases” or “Orthopedic procedures”), study design (randomized controlled trial), and language (English, Spanish, or French). The search strategy contained both terminologies included in DeCS/MesH and synonyms in order to recruit as many publications as possible related to the topic. Full search strategy is attached on Appendix A.

2.3. Study Selection

Table 1 presents the study eligibility criteria for this review according to the PICO method. RCT or RCPT published during the last two decades (between 2004 and 2024), including adults (16–75 years old) who underwent any type of musculoskeletal surgery and received a postoperative LLBFRT intervention, were screened.
The management of the articles selected for screening was carried out with the Rayyan QCRI application [35] by both investigators by reading the title, abstract, and keywords. The potentially eligible studies for review were obtained in full text and then examined. Articles selected by both reviewers were included, while those selected by only one reviewer were discussed until a consensus was reached.

2.4. Data Extraction

Data from 13 articles were extracted and summarized in an Excel® spreadsheet by one author (DSP): author, year of publication, journal, study design, clinical characteristics of the population, sample size, and intervention protocol (occlusion percentage, exercise typology, series, repetitions, rest time, frequency, and duration) were recorded (Table 2 and Table 3). Means, standard deviations, and confidence intervals for the selected outcomes were also extracted for further analysis.

2.5. Risk of Bias and Quality Assessment

Risk-of-Bias Tool (RoB 2) guidelines were followed to analyze the risk of bias of each clinical trial [36], allowing to classify each article as “low”, “some concerns” and “high” risk of bias. Moreover, evidence quality evaluation was conducted using the Cochrane Collaboration Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) [37], which rates the level of evidence and the degree of recommendation as “high”, “moderate”, “low” or “very low”.

2.6. Data Synthesis and Analysis

Data regarding leg extensor and flexor strength and thigh muscle size were extracted from studies focusing on the lower limbs; when studies addressed the upper limbs, grip and wrist flexion-extension strength and wrist and forearm muscle volumes were evaluated. Simultaneously, pain experienced by the patient during the rehabilitation process was assessed. A narrative approach to the results was conducted, and a meta-analysis was performed using RevMan 5.4, a software developed by The Cochrane Collaboration, Oxford, England. Heterogeneity between studies was assessed using the chi-square test and the I2 test. The interpretation of the I2 results was as follows: values greater than 75% indicated a high level of heterogeneity, while values below 40% suggested a low level of heterogeneity [38]. Considering the heterogeneity among the included studies, a random effects model was employed for the analysis. Effect sizes were assessed using the standardized mean difference (SMD).
Table 2. Main characteristics of the included studies.
Table 2. Main characteristics of the included studies.
Author and YearStudy DesignGRADEJournal (JCI)NN (Intervention—Control) and %AOPSurgery
Hughes et al., 2019 [32]RCTHighSports Medicine (2.11)24I (LL-BFR 80% AOP n = 12) and C (HLT n = 12)ACL
reconstruction
Vieira de Melo et al., 2022 [39]RCTHighJournal of Rehabilitation Medicine (1.03)24I (LL-BFR 80% AOP n = 12) and C (HLT n = 12)ACL
reconstruction
Jack et al., 2023 [40]RCTHighSports Health32I (LL-BFR 80% AOP n = 17) and C (LLT n = 15)ACL
reconstruction
Li et al., 2023 [41]RCPTHigh *BMC Musculoskeletal Disorders (0.77)23I (LL-BFRT 80%AOP n = 8 and 40%AOP n = 9) and C (RT n = 6)ACL
reconstruction
Park et al., 2022 [42]RCTHighMedicine (0.38)42I (LL-BFRT 80%AOP n = 13 and 40%AOP n = 14) and C (LLT n = 15)High tibial osteotomy
Ke et al., 2022 [43]RCTHighFrontiers in Physiology (1.00)38I (LL-BFRT 80% AOP n = 19) and C (LLT n = 19)Knee arthroscopy (meniscectomy)
Mason et al., 2022 [44]RCTHigh *Journal of Sport
Rehabilitation (0.92)		17I (LLBFRT 80% AOP n = 8) and C (LLT n = 9)Knee arthroscopy (meniscal repair or chondral surgery)
Tennent et al., 2017 [45]RCPTHighClinical Journal of Sport Medicine (1.27)17I (LL-BFRT 80% AOP n = 10) and C (Protocol of Standard Physical Therapy n = 7)Knee arthroscopy
Fan et al., 2023 [46]RCTHigh *Annals of Medicine (0.98)35I (LLBFRT 40–80%AOP n = 17) and C (LLT n = 18)ORIF for distal radius fracture
Sgromolo et al., 2020 [47]RCTModerateJournal of Wrist Surgery (0.29)9I (LL-BFRT 50%AOP n = 5) and C (Standard Protocol of Physical Therapy n = 4)ORIF for distal radius fracture
Erickson et al., 2024 [48]RCTHighMedicine and Science in Sports and Exercise48I (LL-BFRT 60%AOP n = 23) and C (RT n = 25)ACL
reconstruction
Jung et al., 2022 [49]RCTHighApplied Sciences24I (LL-BFRT 40%AOP n = 12) and Standard Protocol of Physical Therapy n = 12)ACL
reconstruction
Okoroha et al., 2023 [50]RCTHighThe Orthopaedic Journal of Sport Medicine38I (LL-BFRT 80%AOP n = 16) and C (Standard Protocol of Physical Therapy n = 22)ACL
reconstruction
I: Intervention; C: Control; JCI: Journal Citation Indicator; RCT: Randomized Controlled Trial; RCPT: Randomized Controlled Pilot Trial; LLBFRT: Low Load Blood Flow Restriction Training; HLT: High Load Training; LLT: Low Load Training; RT: Resistance Training; ACL: Anterior Cruciate Ligament; AOP: Arterial Occlusion Pressure; ORIF: Open reduction and internal fixation. * The article presents items that can lower the initially allocated level of quality.
Table 3. Description of the intervention protocols carried out in each study.
Table 3. Description of the intervention protocols carried out in each study.
Author and YearProtocol of BFR Training
(Exercise, Sets and Repetitions)		LoadRest Frequency of Sessions and Length of Intervention
Hughes et al., 2019 [33]Unilateral Leg Press 0–90° ROM 4 × (30,15,15,15)30% RM30 s between sets16 sessions in 8 weeks
(2 times/week)
Vieira de Melo et al., 2022 [39]Leg Press and Knee Flexion on chair 4 × (30,15,15,15)30% RM30 s between sets24 sessions in 12 weeks
(2 times/week)
Jack et al., 2023 [40]W2-W5: Quadriceps contractions, CKC Knee extensions and bilateral leg press 4 × (30,15,15,15)
W5-W12: Single leg hamstring curl, single leg press, ball squat, split lunge and box step-up 4 × (30,15,15,15)		30% RM30 s between sets24 sessions in 12 weeks
(2 times/week)
Li et al., 2023 [41]2 Quadriceps exercises with elastic bands and barbells (30,15,15,15)30% RM30 s between sets16 sessions in 8 weeks
(2 times/week)
Park et al., 2022 [42]NWB (W0-W6): Quadriceps and Hamstring “Setting”,
Four-Way Straigh, Quadriceps Extension with Theraband and Hamstring Curl with Theraband 4 × (30,15,15,15)
FWB (W6-W12): Leg Extension with machine,
Hamstring Curl with machine, Leg Press, Squat and Lunge 4 × (30,15,15,15)		30% RM3 min of perfusion between 5 sets24 sessions in 12 weeks (2 times/week)
Ke et al., 2022 [43]Knee Flexion and Extension sliding leg and Squat 0–90° 4 × (30,15,15,15)30% RM30 s between sets16 sessions in 8 Weeks
(2 times/week)
Mason et al., 2022 [44]W1-W2: Isometric Quadriceps until 10 times straight leg and Straigh Leg Flexion/Extension/Aduction and Abduction 4 × (30,15,15,15)
W3-W4: Knee Extension (90–45°) 4 × (30,15,15,15)
W5-W6: Hamstrings Curl 4 × (30,15,15,15)
W7-W12: Squat and Unilateral Leg Press (to 60° flexion) 4 × (30,15,15,15)		30%RM30 s between sets and 2 min between exercises (without occlusion)24–36 sessions in 12 weeks (2–3 times/week)
Tennent et al., 2017 [45]Leg Press, Knee Extension and Reverse Press
4 × (30,15,15,15)		30% RM30 s between sets and 1 min between exercises12 sessions in 6 weeks
Fan et al., 2023 [46]Griping, pinching, Wrist flexion and extension (30,15,15,15)20% RM30 s between sets and 1 min between exercises20 sessions in 4 weeks (5 times/week)
Sgromolo et al., 2020 [47]Wrist Flexion/Extension over a foam wedge, Forearm pronation/supination with arm at side and elbow at 90°,
Pinch strength with PG-60 Pinch Gauge and Grip Strength with JAMAR dynamometer
4 × (30,15,15,15)		30% RM30 s between sets and 1 min between exercises16–24 sessions in 8 weeks (2–3 times/week)
Erikson et al., 2024 [48]Knee extension, leg press, box step up/down, double limb squat
(30,20,10)		30% RM30 s between sets and 1–2 min between exercises48 sessions in 16 weeks (3 times/week)
Jung et al., 2022 [49]FWB (wall squat, mini squat, half squat, lunge, step-up), leg extension and leg curl
4 × (30,15,15,15)		10–30% RM30 s between sets and 2 min between exercises36 sessions in 12 weeks (3 times/week)
Okoroha et al., 2023 [50]Supine quadriceps sets, side-lying hip abduction, calf raises, supine straight-leg raises, long-arc quadriceps sets (90–45° knee flexion) and quarter squats
(30,15,15,15)		-30 s between sets24 weeks (2–3 times/week)
NWB: Non-Weight Bearing; FWB: Full Weight Bearing.

3. Results

3.1. Characteristics of the Study

A total of 1591 articles were identified in the six databases (Cochrane Library, PubMed, SPORTDiscus, SCOPUS, CINAHL, and Web of Science), and 843 duplicate studies were eliminated. After title and abstract screening meeting inclusion criteria, 57 articles remained for full-text review. Later, 44 studies were ruled out because of the exclusion criteria; therefore, only 13 articles complied with all the established criteria and were included in the present systematic review (Figure 1). Although the search was open to studies published as early as 2010, the selected articles were published between 2017 and 2024, in English, and had an RCT or RCPT design. The main characteristics of the selected studies are summarized in Table 2.

3.2. Participants Characteristics

A total of 323 patients who underwent musculoskeletal surgery were assessed. The LLBFRT group comprised 195 patients; 115 of them underwent LLBFRT interventions at 80% of individuals’ arterial occlusion pressure (AOP), 63 at 40–60% AOP, and 17 at increasing AOP strategy (between 40 and 80%). On the other hand, 176 subjects formed the control group (24 HLT, 76 LLT, 31 RT, and 45 a specific physical therapy protocol). The average age of the patients in the intervention group was 38.5 ± 12.4 y, while the average age of the control group was 36.2 ± 10.6 y.
Of the 13 selected articles, 11 (around 85%) addressed lower limbs [33,40,41,42,43,44,45,46,48,49,50], while the remaining two (around 15%) dealt with upper limb patients [46,47]. Specifying the type of surgery, ACL reconstruction was the most frequent surgery included in this review, representing more than 50% of the included studies [33,39,40,41,48,49,50]. The clinical data are shown in Table 2.

3.3. Intervention Characteristics

The intervention protocols applied in each study are listed in Table 3. The basis of the LLBFRT intervention lies in the workload, occlusion pressure (AOP mentioned above), and volume of exercise performed. All studies worked with <30% RM load and mainly with one to four sets of 30,15,15, and 15 repetitions [33,39,40,41,42,43,44,45,46,47,49,50]. The rest period between sets was 30 s in all studies, with the exception of Park et al. [42], who allowed three minutes of reperfusion between sets of five minutes. The length of the intervention ranged between 4–24 weeks, and the number of sessions performed was about 12–48. Sixteen sessions for 8 weeks (2 times/week) [33,41,43] and 24 sessions for 12 weeks (2 times/week) were the most frequently used protocols [39,40,42].

3.4. Outcomes Assessment

Muscle strength was evaluated in all studies using isokinetic dynamometry (peak torque, N·m) for the knee extensor and flexor muscles at angular velocities ranging from 60 to 300°/s [33,39,41,42,43,44,45,48,49,50], although maximal loads (Kg) in leg press and hamstring curl were also used. On the other hand, grip and pinch strength and wrist flexor and extensor muscles strength were assessed for the analysis of upper limbs [50]. Moreover, muscle strength indexes (quadriceps and hamstrings) were used to compare the operated and non-operated limbs [44,50].
Muscle size was assessed in 10 of the selected studies [33,40,41,42,43,44,45,46,48,50] using thigh circumference [43,45], cross-sectional area (CSA; 30–50% distal femur) [42], thigh lean mass [40], thigh thickness [33,41], and thigh symmetry [44,50] as the main outcomes.
Pain perception was assessed in eight studies [33,39,42,43,44,45,47] using both the visual analog scale (VAS) and the Knee Injury and Osteoarthritis Outcome Score (KIOOS) pain scale. It is important to note that only data from the affected limb were included in the analysis.

3.5. Risk of Bias and Quality of Evidence Assessment

Only one study was considered to have a “low risk of bias” [43], whereas ten presented “some concerns about risk of bias” [33,39,40,41,42,44,45,46,47,48,49,50] and one study with “high risk of bias” (Figure 2). It is important to note that the most frequent biases observed were related to deviations from the intended interventions and missing outcome data. Considering the type of participants (surgical patients), sample sizes, and the lack of intention to treat in most of these studies, the nature of these risks is not surprising. Nevertheless, it is worth noting that no article presented a “high risk of bias”.
According to the GRADE system, all the articles included in the RCT started with a “high quality” rating. However, after applying the factors determining the level of quality, three studies [41,44,46] presented some items that could lower the initially allocated level of “high quality”. Lastly, on this basis, only one article was classified as “moderate quality” [47].
Applsci 15 03996 g002
Figure 2. Risk of bias assessment using the Cochrane RoB2 tool [32,39,40,41,42,43,44,45,46,47,48,49,50].
Figure 2. Risk of bias assessment using the Cochrane RoB2 tool [32,39,40,41,42,43,44,45,46,47,48,49,50].
Applsci 15 03996 g002

3.6. Muscle Strength

Muscle strength was assessed in all studies (23 cases). A total of 324 participants underwent LLBFRT interventions, whereas 336 subjects served as controls. Isokinetic evaluation (peak torque) of the knee flexors and extensor muscles using angular velocities between 60°/s and 300°/s, and the interlimb symmetry index calculated from isokinetic peak torques, were mainly used to determine the effects of LLBFRT on strength in the affected lower limbs. Pinch and grip strength, as well as wrist extensor and flexor muscle strength, were used to evaluate the effects of LLBFRT on the upper limbs. Conversely, the control groups underwent different therapy strategies: (a) standard protocols of physical therapy (four studies: [45,47,49,50]), (b) low-load resistance training (seven studies: [40,41,42,43,44,46,48]), and (c) high-load resistance training (two studies: [33,39]).
According to the meta-analysis results, the control groups showed significant changes in lower extremity strength compared to the LLBFRT groups (SMD = 0.64; 95% CI: 0.29 to 0.99; heterogeneity: χ2 = 95.56, df = 22, I2 = 77%; and overall effect: Z = 3.62, p = 0.0003) (Figure 3). Only four studies (less than 20% of total cases) reported some improvements in strength, with significant differences in favor of the LLBFRT group [40,44,49,50]. Increases in quadriceps peak torque [49,50], quadriceps strength symmetry index and hamstring strength [40], and hamstring peak torque [44] were observed in the lower extremities after LLBFRT interventions, whereas Fan et al. [46] showed an increase in the grip strength of the affected upper limb. In these cases, intragroup differences in LLBFRT were observed after twelve weeks of LLBFRT intervention after surgery (between 24 and 36 sessions) using 80% AOP, as highlighted by two studies [41,42]. However, as mentioned before, the meta-analysis’ overall effect size showed significant differences between the LLBFRT and control groups, favoring the latter. The greatest effects were observed in those studies where low-load resistance training was used as a control strategy [41,42,46], although Tennent et al. [45] reported significant effects using a standard protocol of physical therapy. Lastly, several studies (or cases) failed to report significant effects favoring LLBFRT or any control strategy [44,46,50].
Applsci 15 03996 g003
Figure 3. Forest plot displaying the difference in muscle strength between the experimental (LLBFRT) and control groups [40,41,42,43,44,45,46,48,49,50]. Letters (a–c) indicate different outcome assessments in the same study (cases).
Figure 3. Forest plot displaying the difference in muscle strength between the experimental (LLBFRT) and control groups [40,41,42,43,44,45,46,48,49,50]. Letters (a–c) indicate different outcome assessments in the same study (cases).
Applsci 15 03996 g003

3.7. Muscle Size

Muscle size was measured in 10 selected studies (13 cases). A total of 196 participants from the LLBFRT group and 204 who underwent the control strategies were included. Thigh thickness, circumference, lean mass, and quadriceps cross-sectional area were used to assess the muscle size of the affected lower limbs. In contrast, wrist and forearm circumferences were used to evaluate the effects of the interventions on the upper-limb muscles. Although four studies [33,45,46,48] (six cases) reported increases in muscle volume after LLBFRT, the results of our meta-analysis revealed no significant effects (SMD = 0.34; 95% CI: −0.28 to 0.95; heterogeneity: χ2 = 96.42, df = 12, I2 = 88%; and overall effect: Z = 1.08, p = 0.28) (Figure 4). In fact, five other studies [40,41,42,43,44] (6 cases) found significant effects favoring control interventions, while the remaining study did not show any effect [50].
Regarding the lower limbs, significant increases in quadriceps CSA [48], thigh thickness [33], and thigh circumference [45] were observed after LLBFRT programs of at least 6 weeks (12 sessions) using 80% AOP. The same effects were found on upper limbs since wrist and forearm circumferences increased after 4-weeks of LLBFRT programs in which incremental AOP (40–80%) was performed [46]. In contrast, the effects on muscle size were not significant for LLBFRT-based interventions compared with similar programs (8 to 16 weeks of low-load resistance training) without blood flow restriction. Specifically, the effects on thigh lean mass [40], thigh circumference [43,44], thigh thickness [41], and quadriceps CSA [42] were evaluated.
Applsci 15 03996 g004
Figure 4. Forest plot displaying differences in muscle size between the experimental (LLBFRT) and control groups [32,40,41,42,43,44,45,46,48,50]. Letter (a) indicates different outcome assessments in the same study (cases).
Figure 4. Forest plot displaying differences in muscle size between the experimental (LLBFRT) and control groups [32,40,41,42,43,44,45,46,48,50]. Letter (a) indicates different outcome assessments in the same study (cases).
Applsci 15 03996 g004

3.8. Perceived Pain

Pain perception was evaluated in eight of the selected studies [33,39,42,43,45,46,47,50] whose intra-group contrasts showed a positive effect on LLBFRT-related pain. After conducting an individualized review of these manuscripts, a significant decrease in pain perception was observed during the intervention, with differences between groups (LLBFRT vs. control) from the first two weeks [46] until the twelfth week [33,39,43,45,47]. However, the results of our meta-analysis do not reflect such effects on pain perception (SMD = 0.40; 95% CI: −0.85 to 1.65; heterogeneity: χ2 = 94.93, df = 6, I2 = 94%; and overall effect: Z = 0.62, p = 0.53) (Figure 5). In fact, the findings of three studies show effects in favor of control strategies, including high-load resistance training [33,39,50].
Applsci 15 03996 g005
Figure 5. Forest plot displaying differences in pain perception between the experimental (LLBFRT) and control groups [32,39,42,43,45,46,50].
Figure 5. Forest plot displaying differences in pain perception between the experimental (LLBFRT) and control groups [32,39,42,43,45,46,50].
Applsci 15 03996 g005

4. Discussion

This systematic review and meta-analysis performed qualitative and quantitative analyses and syntheses of RCTs in which patients who underwent musculoskeletal surgery were enrolled in LLBFRT-based therapy interventions. This review aimed to investigate the effects of LLBFRT programs on the strength and muscle size of operated limbs. Moreover, pain perception associated with LLBRFT was evaluated.
LLBFRT appears to be a good therapeutic approach for endurance training in postoperative patients with muscle weakness who cannot tolerate high loads [14]. It can also improve muscle development after surgery [14,51] and reduce recovery time [52]. Nevertheless, to our knowledge, it was not until 2003 that the efficacy of LLBFRT as a therapy strategy was evaluated in an RCT [30]; therefore, it is important to review and summarize the main findings reported in studies performed during the last years to confirm the potential of LLBRFT in postsurgical musculoskeletal rehabilitation, regardless of the limb or tissues repaired.

4.1. Low-Load Blood Flow Restriction Training and Muscle Strength

Considering the results reported by each of the selected studies individually, it can be stated that the knee extensor muscle strength improved after the LLBFRT intervention. Significant intragroup differences in quadriceps strength supporting the LLBFRT group were observed between four and twelve weeks post-intervention in five studies [33,39,41,42,43]. Similarly, positive effects were reported for knee flexor strength, with improvements in hamstring peak torque (p < 0.05) at eight weeks [33] or twelve weeks [39] after LLBFRT intervention. Moreover, other studies have also highlighted findings such as a 78% or 39% increase in both knee extensor and knee flexor isokinetic strength [45]. On the whole, it is observed that the greatest muscle strength enhancement occurred in the LLBFRT groups at 80% AOP, in some cases even finding significant intragroup differences with the 40% AOP group [41,42].
These results support the hypothesis that LLBFRT has greater positive effects on muscle strength than conventional resistance training in the initial postsurgical phase. This is mainly sustained by the published literature on LLBFRT and knee surgery, particularly after ACL reconstruction. Koc et al. [53] and Spada et al. [54] stated the beneficial effects of LLBFRT, preserving or even increasing quadriceps strength. More specifically, Kilgas et al. [55] and Noyes et al. [56] confirmed this improvement in their trials, which resulted in significant increases quantified between 20 ± 14% and 84 ± 47% in the post-intervention knee extension strength. Conversely, some studies also support our findings regarding hamstring strength. For example, Ohta et al. [30] reported a positive variation in the knee flexor peak concentric torque at 60° and 180° (p < 0.05) after the intervention. Noyes et al. [56] noted an improvement in mean peak knee flexor strength (p < 0.01) after nine LLBFRT sessions. However, other studies have questioned these results. A recent publication stated that there is no solid evidence of the positive effects of LLBFRT on knee extensor muscle endurance [57]. Although differences in intervention protocols and variability in post-surgical patients’ conditions could affect the results, the findings of our meta-analysis support this statement. In fact, the overall effect for the selected studies (i.e., cases) was opposite to the predictions. This contrary effect was more remarkable in the studies performed by Li [41] (SMD between 2.41 and 2.74; p < 0.001) and Park [42] (SMD = 1.49; p < 0.001), in which low-load resistance training (without blood flow restriction) was used as a control strategy.
Nevertheless, few studies have assessed the effects of LLBFRT on upper limb muscle strength after surgical intervention. Previous studies reported increases in external and internal shoulder rotation as well as shoulder abduction strength after twelve weeks of LLBFRT intervention (p < 0.01) [58]. Similar results were found by Wentzell et al. [59], who evaluated the effects of a 10-wk LLBFRT program on upper limb strength in a postsurgical biceps brachial patient.
Two of our selected articles focused on the effects of LLBFRT on operated upper limb muscles. The cases extracted from the study by Fan et al. [46] showed remarkable effects in favor of the control intervention (SMD between 2.48 and 2.95; p < 0.001), especially when pinch strength and wrist extension and flexion were tested. For their part, Sgromolo et al. [47], whose study could not be finally included in our meta-analysis, did not find significant differences between the intervention and control groups after an 8-wk LLBFRT program focused on grip and pinch strength.
Thus, considering the above, it is not possible to provide meta-analytic evidence of the differential benefits of LLBFRT as a therapy strategy focused on the strength of the operated muscles.

4.2. Low-Load Blood Flow Restriction Training and Muscle Volume

The ten articles that assessed muscle volume reported improvements in this outcome after the LLBFRT intervention [33,40,41,42,43,44,45,46,48,50]. These results align with those obtained in other studies not included here. Wengle et al. [31], Charles et al. [60], and Lu et al. [61], all of whom studied knee surgery, demonstrated the beneficial effect of LLBFRT on muscle volume during post-surgical trauma rehabilitation. However, other studies have failed to show the positive effects of LLBFRT on muscle size, refuting its efficacy in the recent literature. For example, Noyes et al. [56] found small and non-significant increases in thigh circumference (15 cm above the patella) after 18 LLBFRT sessions as a post-surgery rehabilitation therapy. Iversen et al. [62] reported a 13.8 ± 1.1% loss of quadriceps muscle area in the LLBFRT group after two weeks of intervention.
According to our meta-analysis, only four studies (less than 50% of the total cases) showed positive effects in favor of the LLBFRT intervention groups [33,45,46,48]. In fact, the non-significant overall effect was also in favor of controls, which calls into question the effectiveness of LLBFRT on hypertrophy, especially in thigh muscles. Nevertheless, regarding upper limb muscles, Fan et al. [46] showed greater increases in wrist and forearm circumferences in participants who performed a LLBFRT rehabilitation program than those who participated as controls.
Considering the heterogeneity observed in our analysis, the lack of an LLBFRT effect on muscle size could also be explained from different perspectives. First, the duration of early postoperative rehabilitation programs based on LLBFRT therapy seems to be a key factor for inducing hypertrophy, since the loads used (<30% RM) are not the most suitable for stimulating muscle growth. Thus, the number of sessions, especially their frequency (sessions per week), could be a determinant. Accordingly, two of the selected studies in which a greater effect of LLBFRT on muscle size was observed reported both a greater number of sessions and a higher weekly frequency. Moreover, the total number of exercises included in the program could be decisive, since a greater number and diversity of exercises could limit the focus on the muscles that are finally evaluated. Lastly, according to the basis of blood flow restriction, the AOP level could influence the effects of LLBFRT on muscle size. As confirmed in previous studies, metabolic stress related to blood flow restriction promotes the response of anabolic hormones, myogenic stem cell proliferation, and protein synthesis [24], some of the physiological pathways that stimulate muscle growth. In our analysis, LLBFRT-related ischemia was induced mainly by 80% AOP, as only two studies used a lower AOP [46,48]. Nevertheless, contrary to the expected results, these two studies reported the greatest hypertrophic effects, making it difficult to draw consistent conclusions.

4.3. Influence of Low-Load Blood Flow Restriction Training on Perceived Pain

Pain is a direct consequence of surgical intervention and always appears in the postoperative phase. Therefore, pain management during the rehabilitation process is a key objective of any therapeutic approach. Under this premise, it seems that LLBFRT has a positive effect on pain perception in operated patients. This has been confirmed by some studies that have focused on knee pain after surgical intervention. A meta-analysis by Li et al. [41] supported that knee pain perception is reduced in LLBFRT programs compared to RT rehabilitation therapy. In addition, Hughes et al. [63] reported a reduction in knee pain perception during and 24 h after an LLBFRT session in an eight-week LLBFRT therapy program.
In line with the above, all the studies selected for our analysis reported that LLBFRT was well tolerated by participants, showing significant reductions in pain during and at the end of the interventions [33,39,42,43,45,46,50]. However, as was the case with the previous outcomes, the overall effect found in our meta-analysis was not significant, with an SMD slightly favoring the control interventions. Only the studies conducted by Ke et al. [43] and Fan et al. [46] showed clear and significant effects of LLBFRT on pain perception compared to the control interventions. On the contrary, the studies of Hughes et al. [33] and Vieira de Melo et al. [39] found SMD favoring controls, and a lack of effect was observed in the studies performed by Park et al. [42], Tennent et al. [45], and Okoroha et al. [50]. Thus, considering all of the above, LLBFRT is a well-tolerated therapy for patients who undergo lower or upper limb surgery; however, we cannot state that it has a clear effect on pain perception.

4.4. Strength and Limitations

To our knowledge, this is the first systematic review and meta-analysis focusing on RCT studies in which the efficacy of LLBFRT therapy programs in musculoskeletal patient care has been analyzed. Moreover, we selected studies that were exclusively performed on patients in post-surgery recovery, analyzing the effects of LLBRT on strength, muscle size, and pain perception in the operated lower or upper limbs.
However, this study had some potential limitations. Regardless of the risk of bias already mentioned, and although all selected studies were RCT (only one of them was an RCPT), we found high levels of heterogeneity in the assessment methods used to evaluate the effects of LLBRT on strength and muscle size. Additionally, several studies could not be included in our meta-analysis because they did not adequately express strength-related outcomes [33,39,47]. A lack of homogeneity was also observed in the intervention protocols (especially regarding the number of sessions, program duration -from four to 24 weeks, and type of exercises performed) and controls (HRT, LLRT, and specific physical therapy protocols). However, curiously, the training workloads used (sets, repetitions, and rest intervals) were very similar between studies, with sets of 30-15-15-15 repetitions and 30 s of rest between sets being predominant. Additionally, nine of the selected studies used an arterial occlusion pressure of 80%, and three used pressures between 60 and 40%. This imbalance was even more pronounced when data were grouped by outcomes (strength: nine articles, seven used 80% of AOP, one used 40%, and one used incremental pressures—between 40 and 80%; muscle size: ten articles, eight used 80% of AOP and two used incremental pressures; pain perception: seven articles, six used 80% of AOP, and one used incremental pressures). Therefore, despite being a pooled-type analysis, moderation tests were not performed.

4.5. Future Prospective

RCT studies assessing the effects of LLBFRT in a clinical setting, specifically in postsurgical musculoskeletal rehabilitation, are insufficient. After evaluating controlled studies conducted over the last 20 years, a lack of evidence regarding the effectiveness of LLBFRT on strength, muscle size, and pain perception in postsurgical patients seems evident. Part of this lack of evidence could be explained by the use of very similar strength training protocols and arterial occlusion pressures. Thus, future studies comparing the effects of different LLBFRT characteristics on functional outcomes in these patients are needed, especially on upper limb rehabilitation.

5. Conclusions

The results of this systematic review and meta-analysis do not allow us to state that early implementation of low-load strength training combined with blood flow restriction therapy during the postoperative recovery phase is more effective than other therapies in inducing functional and structural muscular adaptations in postoperative musculoskeletal patients. Although some studies have indicated positive effects of LLBFRT on strength, muscle size, and pain perception in the operated lower and upper limbs, these results must be interpreted with caution, as the overall effects are unclear. Nonetheless, the selected studies did not report discomfort claims, so LLBFRT could be a safe recovery strategy when rehabilitation programs need to gain variety.

Author Contributions

Conceptualization, D.S.-P. and I.C.M.-D.; methodology, L.C.-P., D.S.-P. and I.C.M.-D.; software, D.S.-P. and I.C.M.-D.; validation, D.S.-P., N.O., L.C.-P. and I.C.M.-D.; formal analysis, D.S.-P.; investigation, D.S.-P. and I.C.M.-D.; resources, D.S.-P., L.C.-P. and I.C.M.-D.; data curation, D.S.-P.; writing—original draft preparation, D.S.-P.; writing—review and editing, D.S.-P., N.O., L.C.-P. and I.C.M.-D.; visualization, N.O. and I.C.M.-D.; supervision, D.S.-P. and N.O.; project administration, D.S.-P., N.O. and I.C.M.-D.; funding acquisition, N.O., L.C.-P. and I.C.M.-D. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Search Strategy

The search strategy used was: (“blood flow restriction therapy” OR “blood flow restriction training” OR “blood flow restricted exercise” OR “blood flow restriction”) AND (“rehabilitation” OR “musculoskeletal diseases” OR “orthopedic procedures” OR “postoperative period” OR “muscle weakness”). The same approach was used for all databases.

References

  1. Brych, V.; Vasylynets, M.; Dub, M. Some aspects of the potential adherence to rehabilitation of patients with musculoskeletal injuries. Wiad. Lek. 2022, 75, 1998–2002. [Google Scholar] [CrossRef] [PubMed]
  2. Jin, Z.; Wang, D.; Zhang, H.; Liang, J.; Feng, X.; Zhao, J.; Sun, L. Incidence trend of five common musculoskeletal disorders from 1990 to 2017 at the global, regional and national level: Results from the Global Burden of Disease Study 2017. Ann. Rheum. Dis. 2020, 79, 1014–1022. [Google Scholar] [CrossRef]
  3. Xu, D.; Zhou, H.; Quan, W.; Ma, X.; Chon, T.E.; Fernandez, J.; Gusztav, F.; Kovács, A.; Baker, J.S.; Gu, Y. New Insights Optimize Landing Strategies to Reduce Lower Limb Injury Risk. Cyborg Bionic Syst. 2024, 5, 0126. [Google Scholar] [CrossRef]
  4. Mason, J.S.; Owens, J.G.; Brown, W.J. Blood flow restriction training: Current and future applications for the rehabilitation of musculoskeletal injuries. Tech. Orthop. 2018, 33, 71. [Google Scholar] [CrossRef]
  5. Cieza, A.; Causey, K.; Kamenov, K.; Hanson, S.W.; Chatterji, S.; Vos, T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020, 396, 2006–2017. [Google Scholar] [CrossRef]
  6. Gehrig, L.M.B. Orthopedic surgery. Am. J. Surg. 2011, 202, 364–368. [Google Scholar] [CrossRef]
  7. Angelliaume, A.; Legallois, Y.; Harly, E.; Dartus, J.; Lavignac, P.; Chammas, P.-E.; Meynard, P. Orthopaedic and trauma surgery in the time of COVID-19 in France: A nationwide survey. Orthop. Traumatol. Surg. Res. 2023, 109, 103423. [Google Scholar] [CrossRef]
  8. Hughes, L.; Paton, B.; Rosenblatt, B.; Gissane, C.; Patterson, S.D. Blood flow restriction training in clinical musculoskeletal rehabilitation: A systematic review and meta-analysis. Br. J. Sports Med. 2017, 51, 1003–1011. [Google Scholar] [CrossRef]
  9. Norte, G.; Rush, J.; Sherman, D. Arthrogenic muscle inhibition: Best evidence, mechanisms, and theory for treating the unseen in clinical rehabilitation. J. Sport Rehabil. 2022, 31, 717–735. [Google Scholar] [CrossRef]
  10. Pietrosimone, B.; Lepley, A.S.; Kuenze, C.; Harkey, M.S.; Hart, J.M.; Blackburn, J.T.; Norte, G. Arthrogenic muscle inhibition following anterior cruciate ligament injury. J. Sport Rehabil. 2022, 31, 694–706. [Google Scholar] [CrossRef]
  11. Wilkinson, B.G.; Donnenwerth, J.J.; Peterson, A.R. Use of Blood Flow Restriction Training for Postoperative Rehabilitation. Curr. Sports Med. Rep. 2019, 18, 224–228. [Google Scholar] [CrossRef] [PubMed]
  12. Gerber, J.P.; Marcus, R.L.; Leland, E.D.; Lastayo, P.C. The use of eccentrically biased resistance exercise to mitigate muscle impairments following anterior cruciate ligament reconstruction: A short review. Sports Health 2009, 1, 31–38. [Google Scholar] [CrossRef] [PubMed]
  13. Nitzsche, N.; Stäuber, A.; Tiede, S.; Schulz, H. The effectiveness of blood-flow restricted resistance training in the musculoskeletal rehabilitation of patients with lower limb disorders: A systematic review and meta-analysis. Clin. Rehabil. 2021, 35, 1221–1234. [Google Scholar] [CrossRef]
  14. Watson, R.; Sullivan, B.; Stone, A.; Jacobs, C.; Malone, T.; Heebner, N.; Noehren, B. Blood Flow Restriction Therapy: An Evidence-Based Approach to Postoperative Rehabilitation. JBJS Rev. 2022, 10, e22.00062. [Google Scholar] [CrossRef]
  15. Buckthorpe, M.; Gokeler, A.; Herrington, L.; Hughes, M.; Grassi, A.; Wadey, R.; Patterson, S.; Compagnin, A.; La Rosa, G.; Della Villa, F. Optimising the Early-Stage Rehabilitation Process Post-ACL Reconstruction. Sports Med. 2024, 54, 49–72. [Google Scholar] [CrossRef]
  16. Pua, Y.H.; Mentiplay, B.F.; Clark, R.A.; Ho, J.Y. Associations Among Quadriceps Strength and Rate of Torque Development 6 Weeks Post Anterior Cruciate Ligament Reconstruction and Future Hop and Vertical Jump Performance: A Prospective Cohort Study. J. Orthop. Sports Phys. Ther. 2017, 47, 845–852. [Google Scholar] [CrossRef]
  17. Slysz, J.T.; Burr, J.F. The Effects of Blood Flow Restricted Electrostimulation on Strength and Hypertrophy. J. Sport Rehabil. 2018, 27, 257–262. [Google Scholar] [CrossRef] [PubMed]
  18. Takarada, Y.; Takazawa, H.; Sato, Y.; Takebayashi, S.; Tanaka, Y.; Ishii, N. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J. Appl. Physiol. 2000, 88, 2097–2106. [Google Scholar] [CrossRef]
  19. Ladlow, P.; Coppack, R.J.; Dharm-Datta, S.; Conway, D.; Sellon, E.; Patterson, S.D.; Bennett, A.N. Low-load resistance training with blood flow restriction improves clinical outcomes in musculoskeletal rehabilitation: A single-blind randomized controlled trial. Front. Physiol. 2018, 9, 1269. [Google Scholar] [CrossRef]
  20. Lixandrão, M.E.; Ugrinowitsch, C.; Berton, R.; Vechin, F.C.; Conceição, M.S.; Damas, F.; Libardi, C.A.; Roschel, H. Magnitude of muscle strength and mass adaptations between high-load resistance training versus low-load resistance training associated with blood-flow restriction: A systematic review and meta-analysis. Sports Med. 2018, 48, 361–378. [Google Scholar] [CrossRef]
  21. Loenneke, J.P.; Wilson, J.M.; Marín, P.J.; Zourdos, M.C.; Bemben, M.G. Low intensity blood flow restriction training: A meta-analysis. Eur. J. Appl. Physiol. 2012, 112, 1849–1859. [Google Scholar] [CrossRef]
  22. Lorenz, D.S.; Bailey, L.; Wilk, K.E.; Mangine, R.E.; Head, P.; Grindstaff, T.L.; Morrison, S. Blood flow restriction training. J. Athl. Train. 2021, 56, 937–944. [Google Scholar] [PubMed]
  23. Saraf, A.; Goyal, M.; Goyal, K. Blood Flow Restriction Training—An Overview and Implication in New Generation Physical Therapy: A Narrative Review. J. Lifestyle Med. 2022, 12, 63–68. [Google Scholar] [CrossRef] [PubMed]
  24. Slysz, J.; Stultz, J.; Burr, J.F. The Efficacy of Blood Flow Restricted Exercise: A Systematic Review & Meta-analysis. J. Sci. Med. Sport 2016, 19, 669–675. [Google Scholar] [CrossRef]
  25. Vopat, B.G.; Vopat, L.M.; Bechtold, M.M.; Hodge, K.A. Blood Flow Restriction Therapy: Where We Are and Where We Are Going. J. Am. Acad. Orthop. Surg. 2020, 28, E493–E500. [Google Scholar] [CrossRef]
  26. Miller, B.C.; Tirko, A.W.; Shipe, J.M.; Sumeriski, O.R.; Moran, K. The systemic effects of blood flow restriction training: A systematic review. Int. J. Sports Phys. Ther. 2021, 16, 978–990. [Google Scholar] [CrossRef]
  27. Cognetti, D.J.; Sheean, A.J.; Owens, J.G. Blood flow restriction therapy and its use for rehabilitation and return to sport: Physiology, application, and guidelines for implementation. Arthrosc. Sports Med. Rehabil. 2022, 4, e71–e76. [Google Scholar] [CrossRef] [PubMed]
  28. Centner, C.; Wiegel, P.; Gollhofer, A.; König, D. Effects of blood flow restriction training on muscular strength and hypertrophy in older individuals: A systematic review and meta-analysis. Sports Med. 2019, 49, 95–108. [Google Scholar] [CrossRef]
  29. Song, J.S.; Spitz, R.W.; Yamada, Y.; Bell, Z.W.; Wong, V.; Abe, T.; Loenneke, J.P. Exercise-induced Hypoalgesia and Pain Reduction Following Blood Flow Restriction: A Brief Review. Phys. Ther. Sport 2021, 50, 89–96. [Google Scholar]
  30. Ohta, H.; Kurosawa, H.; Ikeda, H.; Iwase, Y.; Satou, N.; Nakamura, S. Low-Load Resistance Muscular Training with Moderate Restriction of Blood Flow After Anterior Cruciate Ligament Reconstruction. Acta Orthop. Scand. 2003, 74, 62–68. [Google Scholar] [CrossRef]
  31. Wengle, L.; Migliorini, F.; Leroux, T.; Chahal, J.; Theodoropoulos, J.; Betsch, M. The Effects of Blood Flow Restriction in Patients Undergoing Knee Surgery: A Systematic Review and Meta-analysis. Am. J. Sports Med. 2022, 50, 2824–2833. [Google Scholar] [CrossRef]
  32. Minniti, M.C.; Statkevich, A.P.; Kelly, R.L.; Rigsby, V.P.; Exline, M.M.; Rhon, D.I.; Clewley, D. The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: A systematic review. Am. J. Sports Med. 2020, 48, 1773–1785. [Google Scholar] [CrossRef]
  33. Hughes, L.; Rosenblatt, B.; Haddad, F.; Gissane, C.; McCarthy, D.; Clarke, T.; Ferris, G.; Dawes, J.; Paton, B.; Patterson, S.D. Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service randomized controlled trial. Sports Med. 2019, 49, 1787–1805. [Google Scholar] [CrossRef] [PubMed]
  34. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef] [PubMed]
  35. Ouzzani, M.; Hammady, H.; Fedorowicz, Z.; Elmagarmid, A. Rayyan—A web and mobile app for systematic reviews. Syst. Rev. 2016, 5, 210. [Google Scholar] [CrossRef] [PubMed]
  36. Sterne, J.A.C.; Savović, J.; Page, M.J.; Elbers, R.G.; Blencowe, N.S.; Boutron, I.; Cates, C.J.; Cheng, H.Y.; Corbett, M.S.; Eldridge, S.M.; et al. RoB 2: A Revised Tool for Assessing Risk of Bias in Randomised Trials. BMJ 2019, 366, l4898. [Google Scholar] [CrossRef]
  37. Lewin, S.; Bohren, M.; Rashidian, A.; Munthe-Kaas, H.; Glenton, C.; Colvin, C.J.; Garside, R.; Noyes, J.; Booth, A.; Tunçalp, Ö.; et al. Applying GRADE-CERQual to qualitative evidence synthesis findings—Paper 2: How to make an overall CERQual assessment of confidence and create a Summary of Qualitative Findings table. Implement. Sci. 2018, 13, 68. [Google Scholar] [CrossRef]
  38. Deeks, J.J.; Higgins, J.P.; Altman, D.G.; Group, C.S.M. Analysing data and undertaking meta-analyses. In Cochrane Handbook for Systematic Reviews of Interventions; Wiley: Hoboken, NJ, USA, 2019; pp. 241–284. [Google Scholar]
  39. Vieira de Melo, R.F.; Komatsu, W.R.; de Freitas, M.S.; Vieira de Melo, M.E.; Cohen, M. Comparison of Quadriceps and Hamstring Muscle Strength after Exercises with and without Blood Flow Restriction Following Anterior Cruciate Ligament Surgery: A Randomized Controlled Trial. J. Rehabil. Med. 2022, 54, jrm00337. [Google Scholar] [CrossRef]
  40. Jack, R.A.; Lambert, B.S.; Hedt, C.A.; Delgado, D.; Goble, H.; McCulloch, P.C. Blood flow restriction therapy preserves lower extremity bone and muscle mass after ACL reconstruction. Sports Health A Multidiscip. Approach 2023, 15, 361–371. [Google Scholar] [CrossRef]
  41. Li, X.; Li, J.; Qing, L.; Wang, H.; Ma, H.; Huang, P. Effect of quadriceps training at different levels of blood flow restriction on quadriceps strength and thickness in the mid-term postoperative period after anterior cruciate ligament reconstruction: A randomized controlled external pilot study. BMC Musculoskelet. Disord. 2023, 24, 360. [Google Scholar] [CrossRef]
  42. Park, H.-S.; Song, J.-S.; Kim, E.-K. Effects of low-intensity resistance exercise with blood flow restriction after high tibial osteotomy in middle-aged women. Medicine 2022, 101, e32294. [Google Scholar] [CrossRef] [PubMed]
  43. Ke, J.; Zhou, X.; Yang, Y.; Shen, H.; Luo, X.; Liu, H.; Gao, L.; He, X.; Zhang, X. Blood flow restriction training promotes functional recovery of knee joint in patients after arthroscopic partial meniscectomy: A randomized clinical trial. Front. Physiol. 2022, 13, 1015853. [Google Scholar] [CrossRef]
  44. Mason, J.S.; Crowell, M.S.; Brindle, R.A.; Dolbeer, J.A.; Miller, E.M.; Telemeco, T.A.; Goss, D.L. The effect of blood flow restriction training on muscle atrophy following meniscal repair or chondral restoration surgery in active duty military: A randomized controlled trial. J. Sport Rehabil. 2022, 31, 77–84. [Google Scholar] [CrossRef] [PubMed]
  45. Tennent, D.J.; Hylden, C.M.; Johnson, A.E.; Burns, T.C.; Wilken, J.M.; Owens, J.G. Blood Flow Restriction Training after Knee Arthroscopy: A Randomized Controlled Pilot Study. Clin. J. Sport Med. 2017, 27, 245–252. [Google Scholar] [CrossRef]
  46. Fan, Y.; Bai, D.; Cheng, C.; Tian, G. The effectiveness and safety of blood flow restriction training for the post-operation treatment of distal radius fracture. Ann. Med. 2023, 55, 2240329. [Google Scholar] [CrossRef]
  47. Sgromolo, N.M.; Cancio, J.M.; Rhee, P.C. Safety and Efficacy of Blood Flow Restriction Therapy after Operative Management of Distal Radius Fractures: A Randomized Controlled Study. J. Wrist Surg. 2020, 9, 345–352. [Google Scholar] [CrossRef]
  48. Erickson, L.N.; Owen, M.K.; Casadonte, K.R.; Anatova, T.; Lucas, K.; Spencer, K.; Brightwell, B.D.; Graham, M.C.; White, M.S.; Thomas, N.T.; et al. The Efficacy of Blood Flow Restriction Training to Improve Quadriceps Muscle Function after ACL Reconstruction. Med. Sci. Sports Exerc. 2024, 57, 227–237. [Google Scholar] [CrossRef] [PubMed]
  49. Jung, W.S.; Kim, S.H.; Nam, S.S.; Kim, J.W.; Moon, H.W. Effects of Rehabilitation Exercise with Blood Flow Restriction after Anterior Cruciate Ligament Reconstruction. Appl Sci. 2022, 12, 12058. [Google Scholar] [CrossRef]
  50. Okoroha, K.R.; Tramer, J.S.; Khalil, L.S.; Jildeh, T.R.; Abbas, M.J.; Buckley, P.J.; Lindell, C.; Moutzouros, V. Effects of a Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction. Orthop. J. Sports Med. 2023, 11, 23259671231209694. [Google Scholar] [CrossRef]
  51. Curley, A.J.; Conroy, C.M.; West, R.V.; Chang, E.S. Postoperative use of blood flow restriction in orthopedics. Orthopedics 2021, 44, e694–e698. [Google Scholar] [CrossRef]
  52. Baker, B.S.; Stannard, M.S.; Duren, D.L.; Cook, J.L.; Stannard, J.P. Does blood flow restriction therapy in patients older than age 50 result in muscle hypertrophy, increased strength, or greater physical function? A systematic review. Clin. Orthop. Relat. Res. 2020, 478, 593–606. [Google Scholar] [CrossRef] [PubMed]
  53. Koc, B.B.; Truyens, A.; Heymans, M.J.L.F.; Jansen, E.J.P.; Schotanus, M.G.M. Effect of Low-Load Blood Flow Restriction Training After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Int. J. Sports Phys. Ther. 2022, 17, 334–346. [Google Scholar] [CrossRef]
  54. Spada, J.M.; Paul, R.W.; Tucker, B.S. Blood Flow Restriction Training Preserves Knee Flexion and Extension Torque Following Anterior Cruciate Ligament Reconstruction: A Systematic Review. J. Orthop. 2022, 34, 233–239. [Google Scholar] [CrossRef]
  55. Kilgas, M.A.; Lytle, L.L.M.; Drum, S.N.; Elmer, S.J. Exercise with Blood Flow Restriction to Improve Quadriceps Function Long After ACL Reconstruction. Int. J. Sports Med. 2019, 40, 650–656. [Google Scholar] [CrossRef] [PubMed]
  56. Noyes, F.R.; Barber-Westin, S.D.; Sipes, L. Blood Flow Restriction Training Can Improve Peak Torque Strength in Chronic Atrophic Postoperative Quadriceps and Hamstrings Muscles. Arthrosc. J. Arthrosc. Relat. Surg. 2021, 37, 2860–2869. [Google Scholar] [CrossRef]
  57. Colapietro, M.; Portnoff, B.; Miller, S.J.; Sebastianelli, W.; Vairo, G.L. Effects of blood flow restriction training on clinical outcomes for patients with ACL reconstruction: A systematic review. Sports Health A Multidiscip. Approach 2023, 15, 260–273. [Google Scholar] [CrossRef]
  58. McGinniss, J.H.; Mason, J.S.; Morris, J.B.; Pitt, W.; Miller, E.M.; Crowell, M.S. The Effect of Blood Flow Restriction Therapy on Shoulder Function Following Shoulder Stabilization Surgery: A Case Series. Int. J. Sports Phys. Ther. 2022, 17, 1144–1155. [Google Scholar] [CrossRef]
  59. Wentzell, M. Post-operative rehabilitation of a distal biceps brachii tendon reattachment in a weightlifter: A case report. J. Can. Chiropr. Assoc. 2018, 62, 193–201. [Google Scholar]
  60. Charles, D.; White, R.; Reyes, C.; Palmer, D. A systematic review of the effects of blood flow restriction training on quadriceps muscle atrophy and circumference post ACL reconstruction. Int. J. Sports Phys. Ther. 2020, 15, 882–891. [Google Scholar] [CrossRef]
  61. Lu, Y.; Patel, B.H.; Kym, C.; Nwachukwu, B.U.; Beletksy, A.; Forsythe, B.; Chahla, J. Perioperative Blood Flow Restriction Rehabilitation in Patients Undergoing ACL Reconstruction: A Systematic Review. Orthop. J. Sports Med. 2020, 8, 232596712090682. [Google Scholar] [CrossRef]
  62. Iversen, E.; Røstad, V.; Larmo, A. Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. J. Sport Health Sci. 2016, 5, 115–118. [Google Scholar] [CrossRef] [PubMed]
  63. Hughes, L.; Patterson, S.D.; Haddad, F.; Rosenblatt, B.; Gissane, C.; McCarthy, D.; Clarke, T.; Ferris, G.; Dawes, J.; Paton, B. Examination of the comfort and pain experienced with blood flow restriction training during post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service trial. Phys. Ther. Sport 2019, 39, 90–98. [Google Scholar] [CrossRef] [PubMed]
Applsci 15 03996 g001
Figure 1. PRISMA Flowchart Diagram.
Figure 1. PRISMA Flowchart Diagram.
Applsci 15 03996 g001
Table 1. Study eligibility criteria.
Table 1. Study eligibility criteria.
Inclusion CriteriaExclusion Criteria
(P) ParticipantsPatients who underwent musculoskeletal surgeryChildren (<16 years) and the elderly (>75 years)
Heterogeneous sample of patients
(I) InterventionsLow Load (<30% RM) Blood Flow Restriction TrainingHeterogeneous sample of surgical interventions
Home-based intervention
Presurgical Intervention
(C) Comparisons--
(O) OutcomesTwo variables at least, between muscle strength, muscle volume and pain, were analysed
Study characteristicsRandomized Controlled Trial (RCT) or Randomized Controlled Pillot Trial (RCPT)Conference posters or incomplete articles
Missing relevant data
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Santos-Pérez, D.; Ochiana, N.; Carrasco-Páez, L.; Martínez-Díaz, I.C. Effects of Low Load Blood Flow Restriction Training on Post-Surgical Musculoskeletal Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Appl. Sci. 2025, 15, 3996. https://doi.org/10.3390/app15073996

AMA Style

Santos-Pérez D, Ochiana N, Carrasco-Páez L, Martínez-Díaz IC. Effects of Low Load Blood Flow Restriction Training on Post-Surgical Musculoskeletal Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Applied Sciences. 2025; 15(7):3996. https://doi.org/10.3390/app15073996

Chicago/Turabian Style

Santos-Pérez, Diego, Nicolae Ochiana, Luis Carrasco-Páez, and Inmaculada C. Martínez-Díaz. 2025. "Effects of Low Load Blood Flow Restriction Training on Post-Surgical Musculoskeletal Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials" Applied Sciences 15, no. 7: 3996. https://doi.org/10.3390/app15073996

APA Style

Santos-Pérez, D., Ochiana, N., Carrasco-Páez, L., & Martínez-Díaz, I. C. (2025). Effects of Low Load Blood Flow Restriction Training on Post-Surgical Musculoskeletal Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Applied Sciences, 15(7), 3996. https://doi.org/10.3390/app15073996

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop