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Acute Central Stiffness and Muscle Morphological Responses Following Blood Flow Restricted Resistance Exercise with Autoregulated and Non-Autoregulated Pressure Application




BFR training, autoregulation, safety, central stiffness, pulse wave velocity



To investigate the acute effects of autoregulated (AR) and non-autoregulated (NAR) blood flow restriction (BFR) resistance exercise to volitional fatigue on indices of arterial stiffness and muscle morphology using the Delfi Personalized Tourniquet System.


Following a randomized AR-BFR/NAR-BFR familiarization session, 20 physically active adults (23±5 years; 7 female) participated in 3 randomized treatment-order sessions with AR-BFR, NAR-BFR, and No-BFR.  Participants performed 4 sets of dumbbell wall squats to failure using 20% of 1 repetition maximum. BFR was performed with 60% of supine limb occlusion pressure. Testing before and immediately post-session included an ultrasonic scan of the carotid artery, applanation tonometry, and blood pressure acquisition. Vastus lateralis cross-sectional area (CSA), and echo intensity (EI) were also assessed via ultrasound before and after each session.


CF-PWV increased in the NAR-BFR and No-BFR groups following exercise while CR-PWV increased in the No-BFR group (all p < 0.05). CF-PWV exhibited an interaction effect between AR-BFR and NAR-BFR in favor of AR-BFR (p < 0.05).  There were significant main effects of treatment for CSA (p=0.016) and EI (p=0.019) with all conditions on CSA and EI, with a greater increase in NAR-BFR.


AR-BFR training does not influence indices of arterial stiffness while NAR-BFR and No-BFR training increases central stiffness.  Additionally, low-load resistance exercise to failure induces muscle swelling regardless of BFR. However, NAR-BFR increased CSA and EI compared to AR-BFR. These findings suggest that AR-BFR causes a lower fluid flux to the intracellular space, possibly inducing less muscle damage and swelling than NAR-BFR.


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Cuffe M, Novak J, Saithna A, Strohmeyer HS, Slaven E. Current trends in blood flow restriction. Front Physiol. 2022 Jul 6;13:882472.

Lixandrão ME, Ugrinowitsch C, Berton R, Vechin FC, Conceição MS, Damas F, et al. 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 [Internet]. Vol. 48, Sports Medicine. Springer International Publishing; 2018. p. 361–78. Available from:

Grønfeldt BM, Lindberg Nielsen J, Mieritz RM, Lund H, Aagaard P. Effect of blood-flow restricted vs heavy-load strength training on muscle strength: Systematic review and meta-analysis [Internet]. Vol. 30, Scandinavian Journal of Medicine and Science in Sports. Blackwell Munksgaard; 2020. p. 837–48. Available from:

Cristina-Oliveira M, Meireles K, Spranger MD, O’Leary DS, Roschel H, Peçanha T. Clinical safety of blood flow-restricted training? A comprehensive review of altered muscle metaboreflex in cardiovascular disease during ischemic exercise. Am J Physiol Heart Circ Physiol. 2020 Jan 1;318(1):H90–109.

Minniti MC, Statkevich AP, Kelly RL, Rigsby VP, Exline MM, Rhon DI, et al. The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: A systematic review. Am J Sports Med. 2020 Jun;48(7):1773–85.

Spranger MD, Krishnan AC, Levy PD, O’Leary DS, Smith SA. Blood flow restriction training and the exercise pressor reflex: A call for concern [Internet]. Vol. 309, American Journal of Physiology - Heart and Circulatory Physiology. American Physiological Society; 2015. p. H1440–52. Available from:

Pinto RR, Karabulut M, Poton R, Polito MD. Acute resistance exercise with blood flow restriction in elderly hypertensive women: haemodynamic, rating of perceived exertion and blood lactate. Clin Physiol Funct Imaging. 2018 Jan;38(1):17–24.

Pinto RR, Polito MD. Haemodynamic responses during resistance exercise with blood flow restriction in hypertensive subjects. Clin Physiol Funct Imaging. 2016 Sep;36(5):407–13.

Staunton CA, May AK, Brandner CR, Warmington SA. Haemodynamics of aerobic and resistance blood flow restriction exercise in young and older adults. Eur J Appl Physiol. 2015 Nov;115(11):2293–302.

Amorim S, Rolnick N, Schoenfeld BJ, Aagaard P. Low-intensity resistance exercise with blood flow restriction and arterial stiffness in humans: A systematic review. Scand J Med Sci Sports. 2021 Mar;31(3):498–509.

Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, et al. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006 Nov;27(21):2588–605.

Najjar SS, Scuteri A, Shetty V, Wright JG, Muller DC, Fleg JL, et al. Pulse wave velocity is an independent predictor of the longitudinal increase in systolic blood pressure and of incident hypertension in the Baltimore Longitudinal Study of Aging. J Am Coll Cardiol. 2008 Apr 8;51(14):1377–83.

Blacher J, Safar ME, Guerin AP, Pannier B, Marchais SJ, London GM. Aortic pulse wave velocity index and mortality in end-stage renal disease. Kidney Int. 2003 May;63(5):1852–60.

Bond V, Curry BH, Kumar K, Pemminati S, Gorantla VR, Kadur K, et al. Restricted blood flow exercise in sedentary, overweight African-American females may increase muscle strength and decrease endothelial function and vascular autoregulation. J Pharmacopuncture. 2017 Mar;20(1):23–8.

Groennebaek T, Sieljacks P, Nielsen R, Pryds K, Jespersen NR, Wang J, et al. Effect of blood flow restricted resistance exercise and remote ischemic conditioning on functional capacity and myocellular adaptations in patients with heart failure. Circ Heart Fail. 2019 Dec;12(12):e006427.

Fahs CA, Heffernan KS, Fernhall B. Hemodynamic and vascular response to resistance exercise with L-arginine. Med Sci Sports Exerc. 2009 Apr;41(4):773–9.

Tagawa K, Ra S-G, Choi Y, Yoshikawa T, Kumagai H, Maeda S. Regular resistance training favorably affects central artery stiffness response following transient resistance exercise. Sport Sci Health. 2021 Dec;17(4):901–9.

Miyachi M, Kawano H, Sugawara J, Takahashi K, Hayashi K, Yamazaki K, et al. Unfavorable effects of resistance training on central arterial compliance: a randomized intervention study. Circulation. 2004 Nov 2;110(18):2858–63.

Okamoto T, Masuhara M, Ikuta K. Effects of low-intensity resistance training with slow lifting and lowering on vascular function. J Hum Hypertens. 2008 Jul;22(7):509–11.

Jurik R, Żebrowska A, Stastny P. Effect of an acute resistance training bout and long-term resistance training program on arterial stiffness: A systematic review and meta-analysis. J Clin Med. 2021 Aug 7;10(16):3492.

Blacher J, Guerin AP, Pannier B, Marchais SJ, Safar ME, London GM. Impact of aortic stiffness on survival in end-stage renal disease. Circulation. 1999 May 11;99(18):2434–9.

Rolnick N, Kimbrell K, De Queiros V. Beneath the cuff [Internet]. 2022. Available from:

Hughes L, Rosenblatt B, Gissane C, Paton B, Patterson SD. Interface pressure, perceptual, and mean arterial pressure responses to different blood flow restriction systems. Scand J Med Sci Sports. 2018 Jul 1;28(7):1757–65.

Jacobs E, Rolnick N, Wezenbeek E, Stroobant L, Capelleman R, Arnout N, et al. Investigating the autoregulation of applied blood flow restriction training pressures in healthy, physically active adults: an intervention study evaluating acute training responses and safety. Br J Sports Med [Internet]. 2023 Jan 5 [cited 2023 Jan 12]; Available from:

Hirono T, Ikezoe T, Taniguchi M, Tanaka H, Saeki J, Yagi M, et al. Relationship between muscle swelling and hypertrophy induced by resistance training. J Strength Cond Res. 2022 Feb;36(2):359–64.

Masri BA, Day B, Younger ASE, Jeyasurya J. Technique for measuring limb occlusion pressure that facilitates personalized tourniquet systems: A randomized trial. J Med Biol Eng. 2016 Oct 4;36(5):644–50.

Essentials of strength training and conditioning, 4th edition. Med Sci Sports Exerc. 2016 Oct;48(10):2073.

Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005 Feb 8;111(5):697–716.

Segers P, Rietzschel ER, Chirinos JA. How to measure arterial stiffness in humans. Arterioscler Thromb Vasc Biol. 2020 May;40(5):1034–43.

Steele J, Fisher J, McKinnon S, McKinnon P. Differentiation between perceived effort and discomfort during resistance training in older adults:Reliability of trainee ratings of effort and discomfort,and reliability and validity of trainer ratings of trainee effort. J Trainology. 2016;6(1):1–8.

Lachenbruch PA, Cohen J. Statistical Power Analysis for the Behavioral Sciences (2nd ed.). J Am Stat Assoc. 1989 Dec;84(408):1096.

Tillin T, Chambers J, Malik I, Coady E, Byrd S, Mayet J, et al. Measurement of pulse wave velocity: site matters. J Hypertens. 2007 Feb;25(2):383–9.

Hametner B, Wassertheurer S, Mayer CC, Danninger K, Binder RK, Weber T. Aortic pulse wave velocity predicts cardiovascular events and mortality in patients undergoing coronary angiography: A comparison of invasive measurements and noninvasive estimates. Hypertension. 2021 Feb;77(2):571–81.

Arnadottir SA, Jonsson BG. Outpatient physical therapy population has been aging faster than the general population: a total population register-based study. BMC Health Serv Res. 2021 Jul 18;21(1):708.

Pierce DR, Doma K, Leicht AS. Acute effects of exercise mode on arterial stiffness and wave reflection in healthy young adults: A systematic review and meta-analysis. Front Physiol. 2018 Feb 13;9:73.

Machado-Vidotti HG, Mendes RG, Simões RP, Castello-Simões V, Catai AM, Borghi-Silva A. Cardiac autonomic responses during upper versus lower limb resistance exercise in healthy elderly men. Braz J Phys Ther. 2014 Jan;18(1):9–18.

Clark BC, Manini TM, Hoffman RL, Williams PS, Guiler MK, Knutson MJ, et al. Relative safety of 4 weeks of blood flow-restricted resistance exercise in young, healthy adults. Scand J Med Sci Sports. 2011 Oct;21(5):653–62.

Fahs CA, Rossow LM, Thiebaud RS, Loenneke JP, Kim D, Abe T, et al. Vascular adaptations to low-load resistance training with and without blood flow restriction. Eur J Appl Physiol. 2014 Apr;114(4):715–24.

Hunt JEA, Galea D, Tufft G, Bunce D, Ferguson RA. Time course of regional vascular adaptations to low load resistance training with blood flow restriction. J Appl Physiol. 2013 Aug 1;115(3):403–11.

Vlachopoulos C, Aznaouridis K, Stefanadis C. Prediction of cardiovascular events and all-cause mortality with arterial stiffness: a systematic review and meta-analysis. J Am Coll Cardiol. 2010 Mar 30;55(13):1318–27.

Cleary CJ, Herda TJ, Quick AM, Herda AA. Acute muscle swelling effects of a knee rehabilitation exercise performed with and without blood flow restriction. PLoS One. 2022 Dec 22;17(12):e0278540.

Damas F, Phillips SM, Lixandrão ME, Vechin FC, Libardi CA, Roschel H, et al. Early resistance training-induced increases in muscle cross-sectional area are concomitant with edema-induced muscle swelling. Eur J Appl Physiol. 2016 Jan;116(1):49–56.

Pillen S, Tak RO, Zwarts MJ, Lammens MMY, Verrijp KN, Arts IMP, et al. Skeletal muscle ultrasound: correlation between fibrous tissue and echo intensity. Ultrasound Med Biol. 2009 Mar;35(3):443–6.

Nieman DC, Shanely RA, Zwetsloot KA, Meaney MP, Farris GE. Ultrasonic assessment of exercise-induced change in skeletal muscle glycogen content. BMC Sports Sci Med Rehabil. 2015 Apr 18;7(1):9.

MacDougall JD, Ward GR, Sale DG, Sutton JR. Biochemical adaptation of human skeletal muscle to heavy resistance training and immobilization. J Appl Physiol. 1977 Oct;43(4):700–3.

Tesch PA. Skeletal muscle adaptations consequent to long-term heavy resistance exercise. Med Sci Sports Exerc. 1988 Oct;20(Sup 1):S132–4.

Hill JC, Millán IS. Validation of musculoskeletal ultrasound to assess and quantify muscle glycogen content. A novel approach. Phys Sportsmed. 2014 Sep;42(3):45–52.

Patterson SD, Hughes L, Warmington S, Burr J, Scott BR, Owens J, et al. Blood flow restriction exercise position stand: Considerations of methodology, application, and safety [Internet]. Vol. 10, Frontiers in Physiology. Frontiers Media S.A.; 2019. p. 533. Available from:

de Queiros VS, Rolnick N, Dos Santos ÍK, de França IM, Lima RJ, Vieira JG, et al. Acute effect of resistance training with blood flow restriction on perceptual responses: A systematic review and meta-analysis. Sports Health. 2022 Nov 22;19417381221131532.

Counts BR, Rossow LM, Mattocks KT, Mouser JG, Jessee MB, Buckner SL, et al. Let’s talk about sex: where are the young females in blood flow restriction research? Clin Physiol Funct Imaging. 2018 Jan;38(1):1–3.

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