Blood Flow Restriction Training: Physiological Mechanisms & Effects in the Management of Osteoporosis

Osteoporosis is a disease characterized by low bone mass, that occurs when the body loses too much bone, makes too little bone, or both.1,2 As a result, bones suffer microarchitectural deterioration and become weak and frail. 1,2 Osteoporotic bones are more likely to break from falls or even minor incidents.1,2 

A 2018 survey reported a 12.6% prevalence of osteoporosis and a 43.1% prevalence of low bone mass in the United States.Over the next 4 decades the number of individuals 65 years and older will double in the United States, increasing from over 40 million in 2010 to more than 88 million by 2050.4 Thus, the burden of osteoporosis and age-related fractures is estimated to increase by almost 50%, growing from 2.1 million in 2005 to over 3 million in 2025.4,5 The increase in the cumulative cost of osteoporosis is projected to rise from $209 billion (2006-2015) to $228 billion (2016-2025).


Blood flow restriction (BFR) has its roots in Japan, originating in the 1960s as “Kaatsu training” (“training with pressure”).6,7,8 BFR training utilizes a tourniquet-style cuff to the proximal aspect of the targeted limb in order to occlude venous flow and allow arterial inflow. 8,9 BFR has been called a developing clinical tool which can be used to attain physiological adaptations in populations who may not be able to tolerate or perform high resistance training.8 BFR can be applied during voluntary resistance exercise (BFR-RE), aerobic exercise (BFR-AE), and passively without exercise (BFR-P).  Notably, much of the recent research has focused on the effects of BFR during whole-body vibration and neuromuscular electrical stimulation.10


BFR with low mechanical load has been found to achieve significant gains in muscle hypertrophy and strength within a short-term exercise period. 11 Several mechanical changes have been found in the BFR training group, including: elevated Serum GH concentration, increased hematocrit, increased mean VO2 max, increased muscle-bone cross-sectional area (CSA), increased mid-thigh quadriceps and hamstrings muscle CSA, and increased leg press and leg curl 1-Rep Max (RM) strength.12 It has been proposed that elevated metabolic stress is an essential factor in achieving hypertrophy outcomes; in addition, “enhanced intramuscular metabolic stress triggers muscle adaptations”.11

Some of the suggested mechanisms for Low-Load BFR (LL-BFR) include a metabolic “overload” which is typically achieved with high resistance training.13,14 More recently, it has been proposed that the gains related to BFR resistance exercise may be associated with a decrease in the mRNA gene expression of MURF-1, atrogin, and myostatin.15,16

The range of physiological mechanisms for BFR’s capacity to provoke hypertrophy are likely yet to be fully identified and understood.  Notably, two primary physiologic mechanisms for the effects of BFR training have been proposed: 1. biochemical responses that stimulate muscle hypertrophy 17, 18, 19, 20, 21,22,23,24 and 2. heightened muscular functioning due to shifts in fiber type recruitment associated with hypoxia.24, 25, 26

The American College of Sports Medicine (ACSM) recommends strength training at 60% of 1RM for novice individuals, 80% 1RM for trained individuals,27 and 85% 1RM for athletes.28 Moreover, according to ACSM, resistance training at 80% 1RM achieves the highest gains in muscular strength and endurance.29 

It is common for patients in rehabilitation settings to not tolerate heavy resistance training due to pain, injury, illness, or safety concerns. BFR with low load training (LL-BFR) has been found to attenuate the effects of sarcopenia along with possible benefits of improving bone health.30 BFR without exercise can be used in early rehabilitation to diminish atrophy and facilitate strength, along with a progressive effect on muscle size.30  

A 2011 meta-analysis concluded that low intensity resistance training (without muscular failure) was not sufficient to stimulate muscle hypertrophy.6 However, it was determined that LL-BFR stimulated significant increases in strength and muscle hypertrophy.6 Similarly, a 2008 clinical trial found BFR with simple aerobic exercise (i.e., slow walking) was beneficial for muscle hypertrophy without signs of muscle damage, indicating a likely useful tool for a large range of populations including the frail and elderly.12 Many injuries and illnesses can give way to disuse atrophy and dysfunction. More specifically, patients suffering from disuse atrophy secondary to immobilization, bed rest, unilateral limb unloading, or casting, may benefit from BFR training to attenuate atrophy, recuperate muscle strength, and improve endurance.31


The safety of BFR training has been extensively studied. 8,10,12,24,32-49 One proposed risk is excessive muscle damage; however, it turns out BFR has been found to pose minimal risk of muscle damage with similar effects as LL-RT.8,10,12,24,35,40 Nevertheless, practitioners should be mindful of those patients who may inherently be at higher risk of sarcoidosis.8,10,12,24,35,40 Thrombus formation (i.e. a blood clot) has been raised as a theoretical risk for BFR training; however, the incidence of adverse events is very low and numerous studies have found no significant changes in blood markers for thrombus formation.8,10, 37-39, 48 

Cardiovascular responses to BFR training have been extensively analyzed. 8,10,32-34,36,41-48 Overwhelmingly, these the large majority of studies found, that when applied properly, BFR is not associated with increased cardiovascular risk. 8,10,32-34,36,41-48 Notably, “proper application” include the cuff size, pressure, duration, rest, and intensity; moreover, these factors should be tailored specifically to each patient and account for their specific health presentation to best avoid adverse events. 8,10,32-34,36,41-48 

A potential side effect of BFR is numbness;8,38 however, the incidence is low and most likely associated with excessive cuff pressure which can likely be prevented by the selection and application of an appropriate cuff size and pressure.8,38 Notably, numbness during BFR training has been reported as transient in nature and is most often relieved with adjustments to the cuff application or pressure level.8,38


Increased muscle strength and muscle mass are associated with increased bone mass and decreased bone fragility.50,53-57Therefore, increasing muscle mass and muscle strength may be a valuable tool in the prevention, deceleration, or even reversal of the bone loss associated with osteoporosis.50, 53-56 It has been recommended that older adults maintain higher muscle strength to slow down the loss of muscle mass and prevent balance impairments.50 Furthermore, it is beneficial to include activities which improve body balance and proprioception as well and osteogenic exercises to prevent falls and fractures associated with osteoporosis.50-57

While research on BFR in older populations is still emerging, the existing literature does support the use of BFR training for muscle strength, muscle hypertrophy and increased functional performance in older populations.34, 58-62 BFR is an effective training strategy which uses less mechanical stress and produces similar improvements in muscle strength and muscle mass as high resistance training.34, 58-62 Notably, older adults are commonly found to suffer muscle atrophy and are at a higher risk of falling; therefore, improving muscle strength and muscle mass can produce vital benefits.58

Bone mass is determined by two metabolic processes which are highly influenced by the body’s functional environment; most notably, loading stimulates bone building and bed rest or inactivity can induce bone loss.63-71 Numerous studies have found aerobic and anaerobic exercise with BFR can stimulate enhanced bone biomarkers and can therefore be part of the management for improving bone diseases such as osteoporosis.63,65-71


There are several physiological mechanisms that may explain why BFR training stimulates bone production. The following are possible mechanisms: improved bone metabolism (as noted by analysis of alkaline phosphate and amino-terminal telopeptides), increased intramedullary pressure and interstitial fluid within the bone, activation of hypoxia-induced transcription factor (HIF), increased expression of vascular endothelial growth factor (VEGF), the formation of micro-blood vessels in bone, increased secretion of growth hormone (GH), enhanced endocrine responses, and improved bone-ALP concentrations indicating increased bone production activity.24, 63-71

While many studies have reported the benefit of BFR training for muscle hypertrophy, muscle mass, and bone mass in young and elderly populations,6-71 the evidence to support BFR training in patients with osteoporosis is emerging. Following the addition of BFR low load training, a 2015 clinical trial found a significant improvement in maximal dynamic strength of women with osteoporosis at 6 and 12 weeks.72 In postmenopausal women with low bone density, LL-BFR was recently found to be superior to low intensity resistance training for improving muscle strength, lactate concentration, bone formation markers and balance.73 BFR training appears to be a beneficial intervention for those with osteoporosis, while avoiding the risks associated with heavy resistance training.70-74


In a recent literature review of the varied interventions for osteoporosis, many pharmacological options were presented; notably, bisphosphonates remain the first line treatment option for osteoporosis.75 Within this 13-page review article, it is rather odd that the word ‘exercise’ is only mentioned in one sentence; however, the conclusion states, “osteoporosis is preventable with proper management of diet, lifestyle and fall prevention interventions”.75

If medical physicians are to continue pushing bisphosphonates, then it is up to physical therapists to advise patients in physical exercise as the first line of defense for the treatment of osteoporosis and osteopenia. Interestingly, the American College of Sports Medicine reports that physical activity is the only intervention that can potentially increase bone mass/strength and reduce the risk of falling in older populations.53 BFR training is an emerging intervention in patients with osteoporosis that uses less mechanical stress and produces similar improvements in muscle strength and muscle mass while avoiding the risks associated with high resistance training.


Brittany A. Forbes, PT, DPT, OCS, FAAOMPT, Dip. Osteopractic
Physical Therapist, Axis Physical Therapy, Jacksonville, NC
Graduate, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Casey Charlebois, PhD(c), DPT, MSc, FAAOMPT, Dip. Osteopractic
Director of Clinical Research, AAMT Fellowship in Orthopaedic Manual Physical Therapy
PhD Candidate, Nova Southeastern University, Fort Lauderdale, FL

James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL

Paul Bliton, DPT, OCS, SCS, FAAOMPT, Dip. Osteopractic
Associate Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
William S. Middleton VA Hospital, Madison, WI

Patrick Gorby, DPT, FAAOMPT, Dip. Osteopractic
Assistant Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Gorby Osteopractic Physical Therapy, Phoenix, AZ


  1. Consensus development conference: prophylaxis and treatment of osteoporosis. Osteoporos Int. 1991;1(2):114-117.
  2. National Osteoporosis Foundation. (n.d.). What is Osteoporosis and What Causes It? Retrieved July 23, 2021, from
  3. Sarafrazi N, Wambogo EA, Shepherd JA. Osteoporosis or Low Bone Mass in Older Adults: United States, 2017-2018. NCHS Data Brief. 2021 Mar(405):1-8. PMID: 34029181.
  4. Lewiecki EM, Leader D, Weiss R, Williams SA. Challenges in osteoporosis awareness and management: results from a survey of US postmenopausal women. J Drug Assess. 2019;8(1):25-31. Published 2019 Feb 6. doi:10.1080/21556660.2019.1579728
  5. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. doi:10.1359/jbmr.061113
  6. Loenneke JP, Wilson JM, Marín PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol. 2012;112(5):1849-1859. doi:10.1007/s00421-011-2167-x
  7. Wernbom, M., J. Augustsson, and T. Raastad. “Ischemic Strength Training: a Low-Load Alternative to Heavy Resistance Exercise?” Scandinavian Journal of Medicine & Science in Sports 18.4 (2008): 401–416. Web.
  8. Vanwye, W & Weatherholt, A & Mikesky, A. (2017). Blood Flow Restriction Training: Implementation into Clinical Practice. International Journal of Exercise Science. 10. 649-654. 
  9. Scott, Brendan R. et al. “Exercise with Blood Flow Restriction: An Updated Evidence-Based Approach for Enhanced Muscular Development.” Sports Medicine 45.3 (2014): 313–325. Web.
  10. Patterson SD, Hughes L, Warmington S, et al. Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety [published correction appears in Front Physiol. 2019 Oct 22;10:1332]. Front Physiol. 2019;10:533. Published 2019 May 15. doi:10.3389/fphys.2019.00533
  11. Takada S, Okita K, Suga T, et al. Low-intensity exercise can increase muscle mass and strength proportionally to enhanced metabolic stress under ischemic conditions. J Appl Physiol (1985). 2012;113(2):199-205. doi:10.1152/japplphysiol.00149.2012
  12. Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training [published correction appears in J Appl Physiol. 2008 Apr;104(4):1255]. J Appl Physiol (1985). 2006;100(5):1460-1466. doi:10.1152/japplphysiol.01267.2005
  13. Takarada, Y., Takazawa, H., Sato, Y., Takebayashi, S., Tanaka, Y., and Ishii, N. (2000b). Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J. Appl. Physiol. 88, 2097–2106.
  14. Suga T, Okita K, Morita N, et al. Dose effect on intramuscular metabolic stress during low-intensity resistance exercise with blood flow restriction. J Appl Physiol (1985). 2010;108(6):1563-1567. doi:10.1152/japplphysiol.00504.2009
  15. Manini, T. M., Vincent, K. R., Leeuwenburgh, C. L., Lees, H. A., Kavazis, A. N., Borst, S. E., et al. (2011). Myogenic and proteolytic mRNA expression follow- ing blood flow restricted exercise. Acta Physiol. (Oxf.) 201, 255–263. 
  16. Laurentino, G. C., Ugrinowitsch, C., Roschel, H., Aoki, M. S., Soares, A. G., Neves, M. Jr. et al. (2012). Strength training with blood flow restriction diminishes myostatin gene expression. Med. Sci. Sports Exerc. 44, 406–412. 
  17. Fry CS, Glynn EL, Drummond MJ, Timmerman KL, Fujita S, Abe T, Dhanani S, Volpi E, Rasmussen BB. Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men. J Appl Physiol. 2010;108: 1199–1209. 
  18. FujitaS,AbeT,DrummondMJ,CadenasJG,DreyerHC,SatoY, Volpi E, Rasmussen BB. Blood flow restriction during low- intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis. J Appl Physiol. 2007;103:903–910. 
  19. Gentil P, Oliveira E, Bottaro M. Time under tension and blood lactate response during four different resistance training methods. J Physiol Anthropol. 2006;25:339–344.
  20. Kawada S, Ishii N. Skeletal muscle hypertrophy after chronic restriction of venous blood flow in rats. Med Sci Sports Exerc. 2005;37:1144–1150. 
  21. Laurentino GC, Ugrinowitsch C, Roschel H, Aoki MS, Soares AG, Neves M Jr, Aihara AY, Fernandes Ada R, Tricoli V. Strength training with blood flow restriction diminishes myo- statin gene expression. Med Sci Sports Exerc. 2012;44: 406–412.
  22. Reeves GV, Kraemer RR, Hollander DB, Clavier J, Thomas C, Francois M, Castracane VD. Comparison of hormone responses following light resistance exercise with partial vascular occlusion and moderately difficult resistance exercise without occlusion. J Appl Physiol. 2006;101:1616–1622. 
  23. Takano H, Morita T, Iida H, Asada K-i, Kato M, Uno K, Hirose K, Matsumoto A, Takenaka K, Hirata Y. Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. Eur J Appl Physiol. 2005;95:65–73. 
  24. Takarada Y, Nakamura Y, Aruga S, Onda T, Miyazaki S, Ishii N. Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J Appl Physiol. 2000;88:61–65. 
  25. Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusions diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc. 2000;32:2035–2039. 
  26. 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.
  27. Rhea MR, Alvar BA, Burkett LN, Ball SD. A meta-analysis to determine the dose response for strength development. Med Sci Sports Exerc. 2003;35:456–64. 
  28. Peterson MD, Rhea MR, Alvar BA. Maximizing strength development in athletes: a meta-analysis to determine the dose– response relationship. J Strength Cond Res. 2004;18:377–82.
  29. Ratamess, Nicholas & Alvar, Brent & Evetoch, TK & Housh, TJ & Kibler, WB & Kraemer, William. (2009). Progression models in resistance training for healthy adults [ACSM position stand]. Medicine &amp Science in Sports &amp Exercise. 41. 687-708. 
  30. Peterson, Mark & Rhea, Matthew & Alvar, Brent. (2004). Maximizing Strength Development in Athletes: A Meta-Analysis to Determine the Dose-Response Relationship. Journal of strength and conditioning research / National Strength & Conditioning Association. 18. 377-82. 10.1519/R-12842.1.
  31. Cook SB, Brown KA, DeRuisseau K, Kanaley JA, Ploutz- Snyder LL. Skeletal muscle adaptations following blood flow- restricted training during 30 days of muscular unloading. J Appl Physiol. 2010;109:341–349.
  32. Hughes, L., Paton, B., Rosenblatt, B., Gissane, C., & Patterson, S. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal of Sports Medicine, 51, 1003 – 1011.
  33. Loenneke JP, Wilson JM, Wilson GJ, Pujol TJ, Bemben MG. Potential safety issues with blood flow restriction training. Scand J Med Sci Sports. 2011;21(4):510-518. doi:10.1111/j.1600-0838.2010.01290.x
  34. Baker BS, Stannard MS, Duren DL, Cook JL, Stannard JP. 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(3):593-606. doi:10.1097/CORR.0000000000001090
  35. Clarkson PM, Hubal MJ. Exercise-induced muscle damage in humans. Am J Phys Med Rehabil 81(11 Suppl): S52-69, 2002. doi:10.1097/01.PHM.0000029772.45258.43.
  36. Jessee MB, Buckner SL, Mouser JG, Mattocks KT, Loenneke JP. Letter to the editor: Applying the blood flow restriction pressure: the elephant in the room. Am J Physiol Heart Circ Physiol 310(1): H132-H133, 2016. doi:10.1152/ajpheart.00820.2015.
  37. Madarame H, Kurano M, Fukumura K, Fukuda T, Nakajima T. Haemostatic and inflammatory responses to blood flow-restricted exercise in patients with ischaemic heart disease: a pilot study. Clin Physiol Funct Imaging 33(1): 11-17, 2013. doi:10.1111/j.1475-097X.2012.01158.x.
  38. Nakajima T, Kurano M, Iida H, et al. Use and safety of KAATSU training: results of a national survey. Int J KAATSU Training Res 2(1): 5-13, 2006. doi:10.3806/ijktr.2.5.
  39. Patterson SD, Brandner CR. The role of blood flow restriction training for applied practitioners: a questionnaire-based survey. J Sports Sci 2017: 1-8, 2017. doi:10.1080/02640414.2017.1284341.
  40. Sieljacks P, Matzon A, Wernbom M, Ringgaard S, Vissing K, Overgaard K. Muscle damage and repeated bout effect following blood flow restricted exercise. Eur J Appl Physiol 116(3): 513-525, 2016. doi:10.1007/s00421-015-3304-8.
  41. Waclawovsky G, Lehnen AM. Hemodynamics of aerobic and resistance
blood flow restriction exercise in young and older adults. Eur J Appl Physiol
2016;116:859–60. 82
  42. Fitzgibbons PG, Digiovanni C, Hares S, et al. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg 2012;20:310–9. 

  43. Manini TM, Clark BC. Blood flow restricted exercise and skeletal muscle health. Exerc Sport Sci Rev 2009;37:78–85. 

  44. Pope ZK, Willardson JM, Schoenfeld BJ. Exercise and blood flow restriction. J Strength Cond Res 2013;27:2914–26. 

  45. Ozaki H, Miyachi M, Nakajima T, Abe T. Effects of 10 weeks walk training with leg blood flow reduction on carotid arterial compliance and muscle size in the elderly adults. Angiology. 2011;62:81–86.
  46. Iida H, Nakajima T, Kurano M, Yasuda T, Sakamaki M, Sato Y, Yamasoba T, Abe T. Effects of walking with blood flow restriction on limb venous compliance in elderly subjects. Clin Physiol Funct Imaging. 2011;31:472–476. 
  47. Heitkamp H. Training with blood flow restriction. Mechanisms, gain in strength and safety. J Sports Med Phys Fitness. 2015;55: 446–456. 
  48. Clark B, Manini T, Hoffman R, Williams P, Guiler M, Knutson M, McGlynn M, Kushnick M. Relative safety of 4 weeks of blood flow‐restricted resistance exercise in young, healthy adults. Scand J Med Sci Sports. 2011;21:653–662. 
  49. Shimizu R, Hotta K, Yamamoto S, Matsumoto T, Kamiya K, Kato M, Hamazaki N, Kamekawa D, Akiyama A, Kamada Y. Low-intensity resistance training with blood flow restriction improves vascular endothelial function and peripheral blood circulation in healthy elderly people. Eur J Appl Physiol. 2016; 116:749–757.
  50. Gouveia ÉR, Ihle A, Gouveia BR, Kliegel M, Marques A, Freitas DL. Muscle Mass and Muscle Strength Relationships to Balance: The Role of Age and Physical Activity. J Aging Phys Act. 2020;28(2):262-268. Published 2020 Apr 24. doi:10.1123/japa.2018-0113
  51. Moreira LD, Oliveira ML, Lirani-Galvao AP, Marin-Mio RV, Santos RN, Lazaretti- Castro M. Physical exercise and osteoporosis: effects of different types of exercises on bone and physical function of postmenopausal women. Arq Bras Endocrinol Metabol. 2014;58:514e522.
  52. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. doi:10.1249/MSS.0b013e318213fefb
  53. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR, American College of Sports Medicine. Position Stand: physical activity and bone health. Med Sci Sports Exerc. 2004;36(11): 1985–96. 
  54. Maïmoun L, Sultan C. Effects of physical activity on bone remodeling. Metabolism. 2011;60(3):373-388. doi:10.1016/j.metabol.2010.03.001
  55. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115(12):1643–55. 
  56. Russo CR. The effects of exercise on bone. Basic concepts and implications for the prevention of fractures. Clin Cases Miner Bone Metab. 2009;6(3):223-228.
  57. Russo CR, Lauretani F, Seeman E, et al. Structural adaptations to bone loss in aging men and women. Bone. 2006; 38:112-8. 
  58. Plaza-Florido, Abel & Migueles, Jairo & Piepoli, Antonio & Molina-Garcia, Pablo & Rodriguez-Ayllon, María & Cadenas-Sanchez, Cristina & Mora-Gonzalez, Jose & Esteban-Cornejo, Irene & Ortega, Francisco. (2019). Blood Flow-Restricted Training in Older Adults: A Narrative Review. 10.1007/s42978-019-00034-4. 
  59. Vechin, F. C., Libardi, C. A., Conceição, M. S., Damas, F. R., Lixandrão, M. E., Berton, R. P., Tricoli, V. A., Roschel, H. A., Cavaglieri, C. R., Chacon-Mikahil, M. P., & Ugrinowitsch, C. (2015). Comparisons between low-intensity resistance training with blood flow restriction and high-intensity resistance training on quadriceps muscle mass and strength in elderly. Journal of strength and conditioning research, 29(4), 1071–1076.
  60. 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 [published correction appears in Sports Med. 2018 Nov 9;:]. Sports Med. 2019;49(1):95-108. doi:10.1007/s40279-018-0994-1
  61. Karabulut M, Abe T, Sato Y, Bemben MG. The effects of low-intensity resistance training with vascular restriction on leg muscle strength in older men. Eur J Appl Physiol. 2010;108(1):147-155. doi:10.1007/s00421-009-1204-5
  62. Araújo JP, Neto GR, Loenneke JP, et al. The effects of water-based exercise in combination with blood flow restriction on strength and functional capacity in post-menopausal women. Age(Dordr). 2015;37(6):110. doi:10.1007/s11357-015-9851-4
  63. Bittar ST, Pfeiffer PS, Santos HH, Cirilo-Sousa MS. Effects of blood flow restriction exercises on bone metabolism: a systematic review [published online ahead of print, 2018 Mar 2]. Clin Physiol Funct Imaging. 2018;10.1111/cpf.12512. doi:10.1111/cpf.12512
  64. Fritton SP, Weinbaum S. Fluid and Solute Transport in Bone: Flow-Induced Mechanotransduction. Annu Rev Fluid Mech. 2009;41:347-374. doi:10.1146/annurev.fluid.010908.165136
  65. Loenneke JP, Abe T, Wilson JM, et al. Blood flow restriction: An evidence based progressive model (Review). Acta Physiol Hung (2012a); 99: 235–250. 
  66. Loenneke JP, Young KC, Fahs CA, et al. Blood flow restriction: Rationale for improving bone. Med Hypotheses (2012b); 78: 523–527. 
  67. Beekley MD, Sato Y, Abe T. KAATSU-walk training increases serum bone-specific alkaline phosphatase in young men. Int J KAATSU Training Res (2005); 1: 77–81. 
  68. Bemben DA, Palmer IJ, Abe T, et al. Effects of a single bout of low intensity KAATSU resistance training on markers of bone turn- over in young men. Int J KAATSU Training Res (2007); 3: 21–26. 
  69. Araldi E, Schipani E. Hypoxia, HIFs and bone development. Bone (2010); 47: 190–196. 
  70. Fujimura R, Ashizawa N, Watanabe M, Mukai N, Amagai H, Fukubayashi T, Hayashi K, Tokuyama K, Suzuki M (1997) Effect of resistance exercise training on bone formation and resorption in young male subjects assessed by biomarkers of bone metabolism. J Bone Miner Res 12:656–662
  71. Karabulut M, Bembem DA, Sherk VD, Anderson MA, Abe T, Bembem MG. Effects of high- intensity resistance training and low-intensity resistance training with vascular restriction on bone markers in older men. Eur J Appl Physiol. 2011;111:1659-1667.
  72. Silva, Julio & Neto, Gabriel & Freitas, Eduardo & Pereira Neto, Elisio & Batista, Gilmário & Torres, Monica & Sousa, Maria. (2015). Chronic effect of strength training with blood flow restriction on muscular strength among women with osteoporosis. Journal of Exercise Physiologyonline. 18. 33-41. 
  73. Linero C, Choi SJ. Effect of blood flow restriction during low-intensity resistance training on bone markers and physical functions in postmenopausal women. J Exerc Sci Fit. 2021;19(1):57-65. doi:10.1016/j.jesf.2020.09.001
  74. Pereira Neto, Elisio & Bittar, Simoni & Silva, Julio & Pfeiffer, Patrick & Santos, Heleodório & Sousa, Maria. (2018). Walking with blood flow restriction improves the dynamic strength of women with osteoporosis. Brazilian Journal of Sports Medicine. 24. 135-139. 10.1590/1517-869220182402175290. 
  75. Tu KN, Lie JD, Wan CKV, et al. Osteoporosis: A Review of Treatment Options. P T. 2018;43(2):92-104