A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy

Pearson, Stephen John; Hussain, Syed Robiul

doi:10.1007/s40279-014-0264-9

Cited by 592Cardiovascular and exercise physiologySports Performance and TrainingMuscle metabolism and nutrition

A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy

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Pearson, Stephen John, Hussain, Syed Robiul·2015·Sports Medicine

DOI 10.1007/s40279-014-0264-9

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Abstract

It has traditionally been believed that resistance training can only induce muscle growth when the exercise intensity is greater than 65% of the 1-repetition maximum (RM). However, more recently, the use of low-intensity resistance exercise with blood-flow restriction (BFR) has challenged this theory and consistently shown that hypertrophic adaptations can be induced with much lower exercise intensities (<50% 1-RM). Despite the potent hypertrophic effects of BFR resistance training being demonstrated by numerous studies, the underlying mechanisms responsible for such effects are not well defined. Metabolic stress has been suggested to be a primary factor responsible, and this is theorised to activate numerous other mechanisms, all of which are thought to induce muscle growth via autocrine and/or paracrine actions. However, it is noteworthy that some of these mechanisms do not appear to be mediated to any great extent by metabolic stress but rather by mechanical tension (another primary factor of muscle hypertrophy). Given that the level of mechanical tension is typically low with BFR resistance exercise (<50% 1-RM), one may question the magnitude of involvement of these mechanisms aligned to the adaptations reported with BFR resistance training. However, despite the low level of mechanical tension, it is plausible that the effects induced by the primary factors (mechanical tension and metabolic stress) are, in fact, additive, which ultimately contributes to the adaptations seen with BFR resistance training. Exercise-induced mechanical tension and metabolic stress are theorised to signal a number of mechanisms for the induction of muscle growth, including increased fast-twitch fibre recruitment, mechanotransduction, muscle damage, systemic and localised hormone production, cell swelling, and the production of reactive oxygen species and its variants, including nitric oxide and heat shock proteins. However, the relative extent to which these specific mechanisms are induced by the primary factors with BFR resistance exercise, as well as their magnitude of involvement in BFR resistance training-induced muscle hypertrophy, requires further exploration.

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Low-load BFR exercise activates mTORC1/p70S6K1 signalling to a degree comparable with high-load resistance training.
“low-load BFR exercise has been shown to activate mTORC1/p70S6K1 signalling to a degree comparable with high-load resistance training [155,156]”
From Ribosome Biogenesis as a Putative Bottleneck to Skeletal Muscle Hypertrophy: Mechanisms, Human Evidence, and Practical Modulators (2026) · cites this paper as [156]
The compensatory increase in cellular swelling and localized metabolic stress likely explains why high external loads are not necessary.
“likely due to the compensatory increase in cellular swelling and localized metabolic stress [156].”
From Ribosome Biogenesis as a Putative Bottleneck to Skeletal Muscle Hypertrophy: Mechanisms, Human Evidence, and Practical Modulators (2026) · cites this paper as [156]
BFR may provide a theoretically viable alternative for preserving or stimulating translational-capacity-related processes in clinical or sarcopenic cohorts.
“While BFR may provide a theoretically viable alternative for preserving or stimulating translational-capacity-related processes in these cohorts [155,156]”
From Ribosome Biogenesis as a Putative Bottleneck to Skeletal Muscle Hypertrophy: Mechanisms, Human Evidence, and Practical Modulators (2026) · cites this paper as [156]

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Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety
Patterson, S. D., Hughes, L., Warmington, S. A., Burr, J. F., Scott, B. R., Owens, J. G., Abe, T., Nielsen, J. L., Libardi, C. A., Laurentino, G. C., et al. (2019) · Frontiers in Physiology · doi:10.3389/fphys.2019.00533 · Cited by 950 · see citing works
Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis
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Effects of blood flow restriction training on muscular strength and hypertrophy in older individuals: a systematic review and meta-analysis.
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Blood Flow Restriction Training After Knee Arthroscopy
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Do metabolites that are produced during resistance exercise enhance muscle hypertrophy?
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Arthrogenic Muscle Inhibition: Best Evidence, Mechanisms, and Theory for Treating the Unseen in Clinical Rehabilitation
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Low-Intensity Sprint Training With Blood Flow Restriction Improves 100-m Dash
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Blood Flow Restriction Resistance Exercise Improves Muscle Strength and Hemodynamics, but Not Vascular Function in Coronary Artery Disease Patients: A Pilot Randomized Controlled Trial
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The Effects of Restriction Pressures on the Acute Responses to Blood Flow Restriction Exercise
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Cycling with blood flow restriction improves performance and muscle K + regulation and alters the effect of anti‐oxidant infusion in humans
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Effect of Low-Load Blood Flow Restriction Training After Anterior Cruciate Ligament Reconstruction: A Systematic Review
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Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction
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Strength Training: In Search of Optimal Strategies to Maximize Neuromuscular Performance
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Blood Flow–Restricted Training for Lower Extremity Muscle Weakness due to Knee Pathology: A Systematic Review
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Electrical stimulation and blood flow restriction increase wrist extensor cross-sectional area and flow meditated dilatation following spinal cord injury
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EFFECT OF BLOOD FLOW RESTRICTION TRAINING ON MUSCULAR PERFORMANCE, PAIN AND VASCULAR FUNCTION
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Oxygenation time course and neuromuscular fatigue during repeated cycling sprints with bilateral blood flow restriction
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Physiological responses to interval endurance exercise at different levels of blood flow restriction
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A SYSTEMATIC REVIEW OF THE EFFECTS OF BLOOD FLOW RESTRICTION TRAINING ON QUADRICEPS MUSCLE ATROPHY AND CIRCUMFERENCE POST ACL RECONSTRUCTION.
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Comparison of Blood Flow Restriction Training versus Non-Occlusive Training in Patients with Anterior Cruciate Ligament Reconstruction or Knee Osteoarthritis: A Systematic Review
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High-pressure blood flow restriction with very low load resistance training results in peripheral vascular adaptations similar to heavy resistance training
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The Role of Inflammation and Immune Cells in Blood Flow Restriction Training Adaptation: A Review
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Blood-flow restricted resistance training in patients with sporadic inclusion body myositis: a randomized controlled trial
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Upper-extremity blood flow restriction: the proximal, distal, and contralateral effects—a randomized controlled trial
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Blood Flow Restriction Training After Achilles Tendon Rupture
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Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial
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Short-Term Blood Flow Restriction Increases Power Output and Bar Velocity During the Bench Press
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Blood Flow Restriction Training Blunts Chronic Kidney Disease Progression in Humans
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Blood Flow Restriction Combined with Electrical Stimulation Attenuates Thigh Muscle Disuse Atrophy
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Acute cellular and molecular responses and chronic adaptations to low-load blood flow restriction and high-load resistance exercise in trained individuals
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Strengthening the Brain—Is Resistance Training with Blood Flow Restriction an Effective Strategy for Cognitive Improvement?
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Effects of drop sets with resistance training on increases in muscle CSA, strength, and endurance: a pilot study
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The effect of low‐load resistance training with blood flow restriction on chronic patellar tendinopathy — A case series
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Does a resistance exercise session with continuous or intermittent blood flow restriction promote muscle damage and increase oxidative stress?
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The Acute Effects of External Compression With Blood Flow Restriction on Maximal Strength and Strength-Endurance Performance of the Upper Limbs
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Blood Flow Restriction Therapy: Where We Are and Where We Are Going
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Low-Load Blood Flow Restriction and High-Load Resistance Training Induce Comparable Changes in Patellar Tendon Properties
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Muscle Adaptations to Heavy-Load and Blood Flow Restriction Resistance Training Methods
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Effects of Practical Blood Flow Restriction Training on Adolescent Lower-Body Strength
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The Acute Impact of External Compression on Back Squat Performance in Competitive Athletes
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Aerobic Training With Blood Flow Restriction for Endurance Athletes: Potential Benefits and Considerations of Implementation
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Effects of Blood Flow Restriction Training on Muscle Strength and Architecture
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Triceps brachii hypertrophy is substantially greater after elbow extension training performed in the overhead versus neutral arm position
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Clinical translation of myocardial conditioning
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Blood Flow Restriction Enhances Rehabilitation and Return to Sport: The Paradox of Proximal Performance
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Low-load blood flow restriction elicits greater concentric strength than non-blood flow restriction resistance training but similar isometric strength and muscle size
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Safety and efficacy of blood flow restriction exercise in individuals with neurological disorders: A systematic review
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Knee extension with blood flow restriction: Impact of cuff pressure on hemodynamics
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Low-Load Blood Flow Restriction and High-Load Resistance Training Induce Comparable Changes in Patellar Tendon Properties
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Blood Flow Restriction Training in Rehabilitation Following Anterior Cruciate Ligament Reconstructive Surgery: A Review
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Effects of training intensity in electromyostimulation on human skeletal muscle
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Efficacy and Safety of Blood Flow Restriction Training in Patients With Knee Osteoarthritis: A Systematic Review and Meta‐Analysis
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Blood Flow Restriction Training Reduces Blood Pressure During Exercise Without Affecting Metaboreflex Activity
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Blood Flow Restriction Therapy after Closed Treatment of Distal Radius Fractures
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EFFECTS OF LOW-INTENSITY RESISTANCE TRAINING WITH BLOOD- FLOW RESTRICTION ON MUSCLE
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Authors: Pearson, S. J., & Hussain, S. R.
Affiliations: University of Salford (GB)
Corresponding author: Pearson, Stephen John
ORCID: Pearson, Stephen John
Venue: Sports Medicine
Publisher: Springer Science and Business Media LLC
Published: 2014-09-24
Volume: 45
Issue: 2
Pages: 187-200
ISSN: 0112-1642 (ISSN-L)
1179-2035
DOI: 10.1007/s40279-014-0264-9
OpenAlex: W2087307311
Cited by: 592
References: 169
Citations by year: 2026: 86 · 2025: 103 · 2024: 62 · 2023: 64 · 2022: 65 · 2021: 47 · 2020: 52 · 2019: 35 · 2018: 36 · 2017: 22 · 2016: 13 · 2015: 6
FWCI: 3.77
Type: journal article
Language: en
Open access: green
usir.salford.ac.uk
Licence: cc-by
www.springer.com/tdm (tdm)
Locations: Sports Medicine (publishedVersion)
PubMed (publishedVersion)
University of Salford Institutional Repository (University of Salford) (submittedVersion, cc-by)
Topics: Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Muscle metabolism and nutrition
Keywords: blood flow restriction, resistance training, muscle hypertrophy, metabolic stress, mechanical tension, mechanotransduction, muscle damage, hormone production, reactive oxygen species, nitric oxide, heat shock proteins, cell swelling, autocrine and paracrine signaling, low-intensity exercise
MeSH terms: Adaptation, Physiological, Energy Metabolism, Hemodynamics, Humans, Regional Blood Flow, Muscle, Skeletal, Resistance Training

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A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy

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