Blood Flow Restriction (BFR) training in rehabilitation: A comprehensive review of safety, contraindications, dosageparameters, clinical effectiveness, and applications acrossdiverse patient populations

Abstract

Blood Flow Restriction (BFR) training has emerged as a transformative rehabilitation strategy that enables significant improvements in skeletal muscle strength, hypertrophy, and functional recovery while utilising substantially lower exercise loads than conventional resistance training. Originally developed in Japan as KAATSU training, BFR has evolved into an evidence-based intervention widely adopted in sports medicine, orthopaedic rehabilitation, neurological rehabilitation, geriatric care, and postoperative recovery programmes. By partially restricting arterial inflow while substantially limiting venous return through specialised pneumatic cuffs, BFR creates a hypoxic intramuscular environment that stimulates metabolic stress, cellular swelling, endocrine activation, and recruitment of fast-twitch muscle fibres. These physiological responses closely resemble those achieved through high-intensity resistance exercise despite the application of only 20–40% of one-repetition maximum (1RM), making BFR particularly valuable for individuals unable to tolerate heavy mechanical loading due to injury, surgery, pain, or chronic disease (Patterson et al., 2019). Although clinical evidence increasingly supports the efficacy of BFR training, concerns regarding patient safety, vascular complications, optimal cuff pressure, exercise dosage, contraindications, and implementation protocols continue to limit widespread clinical adoption. Improper application may increase the risk of nerve compression, excessive pain, tissue injury, or thrombotic events, particularly in patients with cardiovascular disease, peripheral vascular disorders, uncontrolled hypertension, or coagulation abnormalities (Hughes et al., 2017). Consequently, evidence-based screening, individualised occlusion pressure determination, and clinician supervision are essential components of safe practice. Recent systematic reviews and clinical guidelines demonstrate that appropriately prescribed BFR training significantly improves muscle strength, muscle cross-sectional area, functional mobility, pain reduction, and rehabilitation outcomes across diverse patient populations, including individuals recovering from anterior cruciate ligament reconstruction, total knee arthroplasty, osteoarthritis, sarcopenia, neurological disorders, and chronic musculoskeletal conditions (Scott et al., 2015; Centner et al., 2019). Emerging evidence also suggests potential applications in cardiovascular rehabilitation, intensive care unit recovery, and age-related muscle preservation. This review comprehensively examines the physiological mechanisms underlying BFR training, current evidence regarding safety and contraindications, recommended dosage parameters, clinical effectiveness across various rehabilitation settings, and future research directions. By synthesising contemporary literature, this review aims to provide healthcare professionals with practical guidance for integrating BFR safely and effectively into evidence-based rehabilitation programmes.