Effectiveness of blood flow restriction exercise on pain and disability in patients with low back pain: A systematic review

Abstract

Objective

To systematically evaluate the effectiveness of blood flow restriction exercise (BFRE) on disability and pain in individuals with chronic non-specific low back pain CNSLBP.

Methods

A systematic review of randomized controlled trials was conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Web of Science were searched up to September 2025. Eligible studies compared therapeutic exercise programs incorporating BFRE with identical or conventional exercise interventions without BFRE. Oswestry Disability Index or its modified version was the primary outcome. Risk of bias was evaluated using the Cochrane RoB 2 tool. The study protocol was registered in PROSPERO with the identification code CRD420261283862.

Results

Three randomized controlled trials involving 104 participants were included. All studies reported significant within-group improvements in disability following BFRE-based interventions. In two trials, reductions in disability were significantly greater in the BFRE groups compared with control interventions, despite the use of lower external loads. In the remaining trial, between-group differences did not reach statistical significance, although absolute improvements favored BFRE. Pain intensity generally improved to a greater extent in BFRE groups. Nevertheless, overall risk of bias was low, with some concerns related to missing outcome data in one study.

Conclusions

BFRE may represent a potential adjunct to exercise-based rehabilitation for CNSLBP; however, current evidence remains preliminary, heterogeneous, and insufficient to establish clear superiority over standard exercise interventions. Further adequately powered randomized controlled trials with standardized protocols are needed to clarify its effectiveness, safety, and optimal application parameters.

Keywords

blood flow restriction chronic low back pain disability therapeutic exercise rehabilitation

Introduction

Low back pain is defined as pain localized between the lower rib margins and the gluteal folds, with or without leg pain.¹ Globally, it affects around 12% of adults at any given time, and up to 40% over the lifetime, with higher prevalence in women and increasing incidence with age. It represents the leading cause of years lived with disability worldwide, with high rates of chronicity and recurrence and a substantial socioeconomic burden. Key risk factors include prior episode of back pain, heavy physical workload, obesity, smoking, depressive symptoms, and lower educational level.²

Low back pain encompasses a broad spectrum of etiologies, including both specific causes such as: herniated disc, spinal stenosis, fracture, malignancy, infection, or inflammatory disorders, to non-specific causes, in which no clear pathoanatomical source can be identified.³ Chronic non-specific low back pain (CNSLBP) might represent a distinct subgroup, characterized by pain persisting for more than 12 weeks, in the absence of identifiable spinal or nonspinal pathology including radiculopathy, fracture, malignancy, or infection.⁴ In this scenario, the diagnosis is made by exclusion, after ruling out specific causes through history, physical examination, and imaging. CNSLBP is a multifactorial condition, resulting from complex interactions among biological, psychological, and social factors, frequently involving nociplastic pain mechanisms.⁵

A frequently reported feature in individuals with CNSLBP is morphological and functional deconditioning of the trunk extensor musculature, particularly the lumbar multifidus.⁶ This latter is essential for segmental spinal stability, yet it is especially vulnerable to disuse atrophy and increased intramuscular fat, especially in the deep fascicles at L4-L5 and L5-S1, that are strongly associated with pain severity and adjacent disc degeneration, independent of age, sex, or BMI.⁶ Importantly, these alterations are not merely epiphenomena but are strongly associated with pain persistence, recurrent episodes, and poor functional outcomes; thus, restoration of trunk extensor strength and endurance is therefore a key therapeutic target in these patients rehabilitation path. Management aims primarily at alleviating pain and mitigating its functional and psychosocial consequences, including associated disability.

Exercise-based interventions and nutritonal supplementation (e.g., amino acids, vitamin D, etc.) have demonstrated efficacy in improving pain and disability in these subjects, particluarly in elderly.^7–12

However, a fundamental paradox exists in the rehabilitation of patients with CNSLBP. On the one hand, sufficient mechanical and metabolic stimulus is required to reverse muscle atrophy, improve neuromuscular function, and restore segmental spinal control; on the other hand, traditional high-load resistance training, known to be most effective for inducing muscle hypertrophy and strength gains, may be poorly tolerated or contraindicated in this population due to pain exacerbation, fear-avoidance behaviors, and concerns regarding spinal loading.¹³

While safer, these approaches may provide an insufficient stimulus to induce meaningful morphological adaptation of the trunk extensor muscles, potentially limiting long-term functional recovery.

In this context, blood flow restriction (BFR) has emerged as a promising strategy in musculoskeletal rehabilitation. BFR exercise (BFRE) is a resistance training technique in which a pneumatic cuff or band is applied proximally around a limb to partially restrict arterial inflow and fully restrict venous outflow during low-load exercise, thereby creating a hypoxic and metabolically stressful environment in the working muscle.¹⁴ BFRF offers a compelling solution to this clinical dilemma. By partially restricting arterial inflow and occluding venous outflow during low-load exercise, BFR induces a localized hypoxic and metabolically stressful environment within the working musculature.^15,16 This condition leads to accelerated metabolite accumulation, enhanced motor unit recruitment, particularly of fast-twitch fibers, and robust activation of anabolic signaling pathways, including increases in growth hormone secretion and intracellular pathways associated with muscle protein synthesis.¹⁷ Critically, these adaptations can be achieved using loads as low as 20–40% of one-repetition maximum, thereby markedly reducing mechanical stress on joints and spinal structures.¹⁸

From a pathophysiological perspective, BFRE is uniquely suited to address the core impairments observed in CNSLBP. First, it provides a sufficient anabolic and neuromuscular stimulus to counteract multifidus atrophy and fatty infiltration without imposing excessive spinal compression or shear forces.¹⁹ Second, the metabolic stress induced by BFR may enhance central motor drive and improve neuromuscular activation in muscles affected by pain-related inhibition, potentially breaking the vicious cycle of pain, disuse, and degeneration.²⁰ Third, emerging evidence suggests that BFR may exert analgesic effects through both peripheral and central mechanisms, including altered pain modulation and improved exercise tolerance, which may further facilitate patient adherence and engagement in rehabilitation programs.²¹

Although the majority of BFR research has been conducted in athletic populations or focused on the appendicular musculature, preliminary investigations in individuals with low back pain have yielded promising results.^22,23 Studies incorporating BFR into functional or stabilization exercises, such as sit-to-stand tasks or core training, have reported improvements in pain intensity, disability, and trunk muscle performance.^24,25 These findings suggest that BFR may amplify the therapeutic effects of conventional exercise by enhancing muscle adaptation and functional gains at loads that are otherwise insufficient to induce structural change. However, the extent to which adaptations induced by limb-based BFRE transfer to axial musculature remains unclear.

In addition, existing evidence remains limited by small sample sizes, heterogeneity in training protocols, and inconsistent application of BFR specifically targeting the trunk extensor musculature. Moreover, some randomized controlled trials have reported an absence of cross-transfer effects from limb-based BFR exercise to lumbar muscle adaptations, highlighting the need for a clearer understanding of how BFR should be integrated into low back pain rehabilitation to achieve clinically meaningful benefits.^26,27

Taken together, these considerations highlight important uncertainties regarding the effectiveness of BFRE in individuals with CNSLBP. Although BFRE has been proposed as a strategy to overcome the limitations of both low-load and high-load resistance training by providing a potent anabolic and neuromuscular stimulus while minimizing spinal stress, its clinical effectiveness in this population remains unclear. Therefore, a systematic synthesis of randomized controlled trials is warranted to determine whether BFRE provides clinically meaningful benefits in terms of disability and pain, and to identify current gaps in the literature.

Building on this background, the present systematic review of randomized controlled trials (RCTs) aims to summarize the available evidence on the use of BFR exercise as a therapeutic treatment in the management of low back pain.

Methods

Search strategy

A systematic literature search was conducted across the PubMed, Scopus, and Web of Science databases for studies published up to September 2025. The search strategy combined keywords and MeSH terms related to “blood flow restriction”, “low back pain”, and “rehabilitation”.

The full search strategies for each database are reported in Table 1.

Table 1.

Search strategy.

Electronic database	Search terms	Results
Pubmed	(“blood flow restriction” OR “Kaatsu” OR “Kaatsu training” OR “BFR” OR “low-load resistance training” OR “LLRT” OR “High-load Resistance Training” OR “HLRT” OR “ischemic training” OR “occlusion resistance training” OR “vascular occlusion” OR “vascular restriction”) AND (“back pain” OR “low back pain” OR “spine” OR “spine injury” OR “LBP” OR “spine instability” OR “lumbar instability”). Filtered from 1967-2025 and RCT	77
Scopus	TITLE-ABS-KEY ((“blood flow restriction” OR “Kaatsu” OR “Kaatsu training” OR “BFR” OR “low-load resistance training” OR “LLRT” OR “High-load Resistance Training” OR “HLRT” OR “ischemic training” OR “occlusion resistance training” OR “vascular occlusion” OR “vascular restriction”) AND (“back pain” OR “low back pain” OR “spine” OR “spine injury” OR “LBP” OR “spine instability” OR “lumbar instability”)). AND PUBYEAR > 1967 AND PUBYEAR < 2025	106
Web of Science	(“blood flow restriction” OR “Kaatsu” OR “Kaatsu training” OR “BFR” OR “low-load resistance training” OR “LLRT” OR “High-load Resistance Training” OR “HLRT” OR “ischemic training” OR “occlusion resistance training” OR “vascular occlusion” OR “vascular restriction”) AND (“back pain” OR “low back pain” OR “spine” OR “spine injury” OR “LBP” OR “spine instability” OR “lumbar instability”).	340

Reference lists of relevant articles and previous reviews were also screened manually to identify additional studies. This systematic review was performed in accordance with the PRISMA 2020 statement guidelines. The study protocol was registered in PROSPERO with the identification code CRD420261283862.

Selection criteria

Following the initial search, two reviewers (AA and GMG) independently screened all retrieved records for eligibility. Any discrepancies were resolved through discussion, and when necessary, adjudication by a third reviewer (EP). Study selection was guided by predefined inclusion criteria structured according to the following PICO framework:

P (Participants): adult patients (≥18 years) diagnosed with low back pain.

I (Intervention): therapeutic exercise protocols with BFR.

C (Comparison): standard rehabilitation or exercise interventions performed without BFR.

O (Outcomes): primary outcome: disability assessed through the Oswestry Disability Index (ODI); secondary outcomes: pain assessed through visual analogue scale (VAS); trunk muscle strength assessed through isokinetic dynamometer, muscle mass measured through ultrasound imaging; core endurance assessed using the McGill endurance test.

We included RCTs with two study arms and full-text available in English were included.

We excluded: 1) studies using BFR modalities not combined with active exercise or multimodal therapies, 2) full-text unavailability (i.e., posters and conference abstracts); 3) reviews, case reports, articles without outcomes or results, technical notes, editorials, letters to the editor, and expert opinions were excluded from the analysis. 4) Severe Comorbidities: Patients with absolute contraindications to BFR training, including a history of deep vein thrombosis (DVT), severe peripheral vascular disease, uncontrolled hypertension, or pregnancy. 5) Specific Spinal Pathologies: Subjects presenting with “Red Flags” (e.g., recent vertebral fractures, tumors, infections such as discitis, or cauda equina syndrome) or acute radicular pain requiring immediate surgical intervention. 6) Concomitant Interventions: Studies where BFR was combined with other physical therapies (e.g., electrical stimulation, tecar therapy) that prevented the isolation of the specific effect of BFR exercise compared to the control group. 7) Previous Surgical Interventions: Patients who had undergone spinal surgery within the 6–12 months prior to the study.

Data extraction

Two reviewers independently extracted main data from the included studies, utilizing a customized data extraction sheet on Microsoft Excel. In case of disagreement, a consensus was obtained asking an opinion of another reviewer.

We extracted the following data: 1) first author; 2) publication year; 3) nationality; 4) age of study participants; 5) population and the number of patients included; 6) intervention characteristics including frequency, intensity, and total duration (weeks); 7) type of control treatment, outpatient therapeutic exercise administration; 8) disability, pain scores, trunk muscle strength or endurance; 9) main findings.

Results

Study characteristics

The database search identified 523 records. After removing 91 duplicates, 432 articles were screened by title and abstract, leading to the exclusion of 424 records. Following full-text assessment, five additional studies were excluded. Ultimately, three randomized controlled trials (RCTs)^28–30 were included in the qualitative synthesis. The PRISMA Flow Diagram is shown in Figure 1.

All included studies were randomized controlled trials comparing an exercise protocol BFRE to an identical exercise program performed without BFR or to an alternative resistance training modality. Disability was assessed in all three studies using validated self-administered questionnaires. Lee et al.²⁹ and Liu et al.²⁸ used the ODI, whereas Werasirirat et al.³⁰ employed the Modified Oswestry Disability Questionnaire (MODQ). Changes were interpreted using the minimal clinically important difference (MCID) thresholds for low back pain, approximately 10 points or a 30% reduction. These thresholds were used to contextualize clinical relevance, while between-group differences were considered more informative for assessing the specific added effect of BFRE. The main characteristics of the included studies are summarized in Table 2, while intervention protocols and comparator details are reported in Table 3.

Table 2.

Characteristics of the included studies.

Author (year)	Country	N (TR/Control)	Sex (M/F) experimental and control
Lee K. et al., 2023	South Corea	20/20	7/13 and 8/12
Liu Y. et al., 2024	Cina	13/13	13/0 and 13/0
Werasirirat P. et al., 2025	Thailand	19/19	5/14 and 3/16

Table 3.

Characteristics of the interventions and controls in the included studies.

Author (year)	Intervention (TR)	Dose (Frequency/Duration)	Control	Primary outcomes	Secondary outcomes
Lee K. et al, 2023	STS exercise with BFRE: low-intensity BFRE, an exercise intensity of 20-30% of 1 repetition maximum (1RM) was applied; control group: STS exercise without BFRE.	The exercise was performed 20 times in the first set and 10 times in the second to fourth sets, with a 30-s break between sets, and applied for a total of 10 min (the correct rhythm of the STS was at a rate of 1 s down and 1 s up using the metronome).	Pre intervention and During intervention. NA where (non specifica, forse Department of Physical Therapy, College of Medical Science, Konyang University, Daejeon, South Korea).	Oswestry Disability Index (ODI).	1) Visual Analog Scale (VAS); 2) Systolic blood pressure (SBP) and Diastolic blood pressure (DBP); 3) Body composition; 4) Saturation of percutaneous oxygen (SpO2); 5) Ultrasounf imaging: assessment of QMM (rectus femoris, vastus intermedius, vastus medialis and vastus lateralis).
Liu Y. et al., 2024	LL-BFRT was done at 30% 1-repetition maximum (1RM) with 70% arterial occlusion pressure (AOP). HL-RT was done at 70% 1- RM.	4 sessions per week (Mondays, Wednesdays, Fridays and Sundays), held in the morning, for 4 weeks (16 sessions). Each exercise consisted of 4 sets. The first set was repeated 30 times, and the others were repeated 15 times.	Pre-training and post-training (4 weeks): baseline and follow-up tests were conducted at 24 h before and after formal training. NA where.	Oswestry Disability Index (ODI).	1) VAS; 2) Isometric core endurance test (McGill endurance Test); 3) Isokinetic core strength test.
Werasirirat P. et al., 2025	BFR + Core Stabilization exercice group; Core Stabilization exercice group.	Supervised rehabilitation sessions 3 times/week over a period of 4 consecutive weeks.	Muscle activity, muscle thickness, and disability were assessed before and after the four-week intervention. Physical Therapy Laboratory, Burapha University, Thailand.	Modified Oswestry Disability Questionnaire (MODQ).	1) EMG activity of: multifidus (MF), transversus abdominis (TrA), and gluteus maximus (Gmax); 2) Muscle thickness at rest and during maximal isometric contraction (for 10 s) using a B-mode diagnostic ultrasound system (MF, TrA, Gmax).

Across the included studies, different muscle groups were investigated depending on the site of blood flow restriction and the exercise modality. Werasirirat et al.³⁰ assessed neuromuscular activation and muscle thickness of trunk and hip stabilizers, specifically the transversus abdominis, multifidus, and gluteus maximus. Lee et al.²⁹ focused on morphological adaptations of the quadriceps muscles, including the rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius. Liu et al.²⁸ primarily evaluated trunk muscle function, with a specific emphasis on the endurance and strength of the trunk extensor muscles.

A relevant source of clinical heterogeneity across the included studies was the type of exercise intervention combined with blood flow restriction. Specifically, two studies implemented BFRE in conjunction with lower-limb or functional exercises, such as sit-to-stand movements and resistance training targeting the quadriceps musculature, whereas one study applied BFRE within a core stabilization exercise program specifically targeting trunk muscles, including the transversus abdominis and multifidus. As a result, the target musculature (limb versus trunk) and the exercise modalities differed substantially between studies, potentially engaging distinct neuromuscular and physiological mechanisms. This variability should be considered when interpreting the pooled findings, as it may influence the magnitude and nature of the observed effects.

Lee et al.²⁹ conducted a trial in South Korea including 40 participants (20 per group), using a low-intensity sit-to-stand exercise (20–30% 1RM) with elastic cuffs applied to both lower limbs for approximately 10 min. Regarding the evaluation of the primary outcome, ODI scores did not differ significantly between the BFRE group (28.30 ± 2.73) and the control group (27.85 ± 3.46; p = 0.651). Following the intervention, both groups demonstrated significant reductions in ODI scores. In the BFRE group, ODI decreased from 28.30 ± 2.73 to 13.10 ± 3.46 (p < 0.001), while in the control group it decreased from 27.85 ± 3.46 to 16.15 ± 2.30 (p < 0.001). Post-intervention comparison showed significantly lower ODI scores in the BFRE group (p < 0.001). The percentage change analysis revealed a greater reduction in disability in the BFRE group (–53.35 ± 10.03%) compared with the control group (−41.30 ± 10.04%; p = 0.001).

Liu et al.²⁸ performed a study in China with 26 male participants, comparing low-load BFR training (30% 1RM, 70% arterial occlusion pressure) with high-load resistance training (70% 1RM) over four weeks (16 sessions). Concerning the primary outcome, at baseline ODI scores were comparable between groups (LL-BFRT: 28.85 ± 6.82; HL-RT: 29.38 ± 7.90). After the intervention, both groups exhibited significant improvements. ODI decreased to 21.62 ± 4.94 in the LL-BFRT group (p = 0.001; effect size [ES] = 1.84) and to 27.38 ± 6.85 in the HL-RT group (p = 0.024; ES = 0.71). Although both interventions were effective, the magnitude of improvement was greater in the LL-BFRT group.

Werasirirat et al.³⁰ investigated BFRE combined with a core stabilization exercise (CSE) program versus CSE alone in Thailand, enrolling 38 participants over a four-week intervention. At baseline MODQ scores were similar between groups (BFRE + CSE: 25.17 ± 15.22; CSE: 25.06 ± 9.59; p = 0.979). Post-intervention, both groups demonstrated reductions in disability. MODQ scores decreased by 8.43 points (95% CI: 6.89–18.31) in the BFRE + CSE group and by 4.28 points (95% CI: 1.83–8.69) in the CSE group. Although the between-group difference favored BFRE + CSE (mean difference: 4.15 points), it did not reach statistical significance.

Overall, improvements in disability were observed in both BFRE and control groups across all included studies. However, between-group comparisons revealed a more nuanced pattern. Two randomized controlled trials reported statistically significant greater reductions in disability in the BFRE groups compared with control interventions, despite the use of lower external loads. In contrast, in the remaining study, the between-group difference did not reach statistical significance, although the magnitude of improvement favored the BFRE group.

These findings indicate that improvements over time were observed in both groups, but between-group comparisons suggest that BFRE may provide additional benefits beyond standard exercise in some contexts. However, this effect was not consistently demonstrated across all included studies.

Regarding pain intensity, improvements were observed in both intervention and control groups. Importantly, in the studies^28,29 reporting between-group analyses, reductions in pain were greater in the BFRE groups compared with controls, supporting a potential additive effect of BFRE beyond general exercise-related improvements.

Regarding neuromuscular outcomes, Lee et al.²⁹ reported increases in quadriceps muscle mass without adverse cardiovascular effects. Liu et al.²⁸ observed improvements in core strength and endurance in both training groups. Werasirirat et al.³⁰ demonstrated increased electromyographic activation and muscle thickness of the multifidus, transversus abdominis, and gluteus maximus muscles in the BFRE + CSE group.

Risk of bias

The overall risk of bias was low in most included studies. Two trials were judged at low risk across all RoB 2 domains, while one study was rated as “some concerns”, primarily due to issues related to missing outcome data. In this study, incomplete outcome data were reported, with limited information regarding the reasons for drop-out and the handling of missing data. In particular, the use of appropriate statistical methods, such as intention-to-treat analysis, was not clearly described, raising uncertainty about the potential influence of attrition on the estimated treatment effects. No major sources of bias related to randomization, deviations from intended interventions, or outcome measurement were identified, as depicted in Figure 2.

Discussion

This systematic review aimed to evaluate the effects of BFRE as an adjunct to exercise-based rehabilitation in individuals with CNSLBP, considering disability as the primary outcome of interest.

Although all included studies reported significant within-group improvements in disability and pain, these findings should be interpreted with caution, as they may reflect non-specific effects such as natural recovery, placebo responses, or the general benefits of exercise. For this reason, between-group comparisons represent the most appropriate approach to determine the specific effectiveness of BFRE. In the present review, two of the three included randomized controlled trials demonstrated significantly greater improvements in disability in the BFRE groups compared with control interventions, while the remaining study showed a non-significant between-group difference with results favoring BFRE. From a clinical perspective, these findings should be interpreted in light of the MCID for the ODI, typically estimated at approximately 10 points or a 30% improvement. In this context, BFRE-based interventions generally exceeded or approached this threshold in most studies, suggesting that the observed changes may be clinically meaningful. However, this pattern was not consistent across all trials, and in one study the between-group difference did not reach clinically meaningful levels.

Importantly, interpretation of these findings is further complicated by the clinical heterogeneity of the included interventions. The studies differed substantially in terms of target musculature (limb versus trunk muscles) and exercise modalities, ranging from functional lower-limb exercises to trunk-specific core stabilization programs. These differences likely involve distinct neuromuscular and physiological mechanisms, which may influence treatment effects and limit comparability across studies. Consequently, it remains difficult to determine whether the observed benefits are attributable specifically to BFRE or to the interaction between BFRE and the underlying exercise intervention. Taken together, while BFRE may represent a potential adjunct to exercise-based rehabilitation in individuals with CNSLBP, the limited number of studies, their heterogeneity, and the inconsistency of between-group findings warrant a cautious interpretation of the current evidence.

These findings are consistent with the broader blood flow restriction literature in musculoskeletal rehabilitation, which demonstrates that low-load BFR training can elicit strength and hypertrophy adaptations comparable to traditional high-load resistance training, while substantially reducing mechanical stress on joints and passive tissues.^22,27,31 This characteristic is particularly relevant in individuals with CNSLBP, where pain-related inhibition, fear-avoidance behaviors, and reduced tolerance to high external loads frequently limit the feasibility of conventional high-load strengthening programs.^32–37 Within this context, BFRE may help address the well-recognized “rehabilitation paradox” of providing a sufficient training stimulus to counteract trunk muscle deconditioning without exacerbating symptoms.^22,26

Overall, the available evidence suggests that BFRE may have a potential adjunctive role in CNSLBP rehabilitation; however, this interpretation remains uncertain. The limited number of studies, differences in target musculature, and inconsistent between-group findings prevent definitive conclusions regarding whether BFRE provides clinically meaningful advantages over conventional exercise.^32–37

Reductions in pain intensity paralleled improvements in disability across studies. Trials assessing pain outcomes reported greater pain reductions in the BFRE groups compared with control conditions, supporting a potential analgesic effect of BFRE when integrated into therapeutic exercise. This observation is in line with previous evidence suggesting that BFR training can induce hypoalgesic responses in musculoskeletal pain conditions possibly mediated by metabolic stress, altered afferent input, and central pain modulation.^32–37 Although pain was not uniformly assessed across all included trials, the consistency in the direction of effect reinforces the clinical relevance of BFRE in low back pain rehabilitation.

Secondary outcomes further suggest that BFRE may induce beneficial neuromuscular and morphological adaptations. While direct comparison across trials was limited by heterogeneity in outcome measures, convergent evidence points toward enhanced muscle activation, increased muscle thickness, and improved neuromuscular performance. These adaptations are consistent with established physiological mechanisms of BFRE, such as increased motor unit recruitment and anabolic signaling under low-load conditions and provide a plausible mechanistic explanation for the observed improvements in pain and disability.^20,21

Both Liu et al.²⁸ and Werasirirat et al.³⁰ reported improvements in neuromuscular function, despite assessing different anatomical regions and using different methodologies. In Liu et al.,²⁸ BFRE enhanced isometric core endurance, particularly in the trunk extensors, and increased isokinetic peak torque at higher angular velocities, suggesting improved recruitment of type II muscle fibers and faster force generation.

This interpretation is consistent with mechanistic evidence indicating that low-load BFR can increase neuromuscular demand through metabolite accumulation and accelerated fatigue, thereby promoting recruitment of higher-threshold motor units even at relatively low external loads.¹⁶

Similarly, Werasirirat et al.³⁰ showed that BFRE combined with core stabilization exercises led to significantly greater EMG activity of the transversus abdominis, multifidus, and gluteus maximus compared with stabilization exercises alone. Importantly, hypertrophy and functional restoration of deep trunk and hip muscles represent a key therapeutic target in CNSLBP. Structural alterations of the multifidus and transversus abdominis, including reduced muscle size, fatty infiltration, and impaired activation, have been consistently associated with altered spinal stability and persistence of symptoms.^32–37 Enhancing muscle mass and neuromuscular capacity of these stabilizing muscles is therefore considered central to restoring lumbar load-sharing and motor control.³⁸ Within this framework, BFRE may facilitate a hypertrophic and neuromuscular stimulus under low-load conditions, potentially overcoming pain-related inhibition and limited tolerance to high mechanical loads.³⁹

These findings align with the broader BFR literature suggesting that BFR can modulate motor unit behavior and activation strategies, potentially via increased central motor drive and altered afferent feedback during metabolically stressful contractions.^16,26,40 Taken together, the available evidence supports the hypothesis that BFRE may augment neuromuscular activation and coordination, which could contribute to improved motor control in individuals with low back pain.

Structural adaptations emerged consistently across studies using ultrasound imaging. Although Lee et al. assessed quadriceps morphology rather than trunk musculature, the greater increase observed in the BFRE group is consistent with the established capacity of low-load BFR to induce hypertrophy comparable to higher-load training, largely mediated by metabolic stress and downstream anabolic signaling.^16,22

Werasirirat et al. found parallel improvements in the thickness of deep stabilizing muscles (TrA, MF) and the gluteus maximus, both at rest and during contraction, and these adaptations were more pronounced when BFRE was added to core stabilization training. This pattern aligns with mechanistic models of BFR-induced hypertrophy emphasizing hypoxia, cell swelling, metabolite accumulation, and increased recruitment of fast-twitch fibers as key drivers of structural change under low-load conditions.¹⁷ Although direct between-study comparisons remain limited, the convergence of ultrasound-based findings supports the plausibility that BFRE may promote structural adaptations that contribute to functional capacity and spinal stability improvements in CNSLBP.¹⁷

Only Lee et al. assessed cardiovascular responses, reporting modest increases in systolic and diastolic blood pressure and a slight reduction in peripheral oxygen saturation during BFRE. These changes are consistent with the expected physiological response to blood flow restriction and remain within safe limits. No adverse cardiovascular or systemic events were documented in any study, supporting the feasibility and safety of low-load BFRE protocols in individuals with CNSLBP. This observation is broadly consistent with safety evidence from clinical musculoskeletal populations, where adverse events appear uncommon when BFR is appropriately prescribed and monitored, although rare events have been reported and careful screening is recommended.⁴¹

Thus, considering that nowadays there are several studies on the role of physical exercise on muscle mass and function in chronic musculoskeletal diseases,^42–45 the present findings on the role of BFR in CNSLBP are intriguing but should be interpreted with caution due to the limited number of trials, small sample size, and short term follow-up.

This systematic review has several limitations that should be considered when interpreting the findings. First, the small number of included randomized controlled trials and their limited sample sizes reduce the robustness and generalizability of the evidence. In addition, one study raised some concerns in the risk of bias assessment, mainly related to missing outcome data. The limited reporting of drop-out rates, reasons for missing data, and handling strategies (e.g., intention-to-treat analysis) may introduce uncertainty in estimating treatment effects.

Second, substantial heterogeneity was observed across studies in BFRE protocols, including cuff placement, occlusion pressure, exercise selection, and training duration, as well as in comparator interventions. Variability in target musculature and exercise type (e.g., lower limb versus trunk/core training) likely reflects different neuromuscular mechanisms, limiting comparability and making it difficult to determine whether effects are attributable to BFRE or the exercise modality.

Third, outcome measures, particularly for secondary outcomes, were not fully standardized, precluding quantitative synthesis and subgroup analyses. Sex distribution was inconsistently reported, with one study including only male participants, limiting generalizability. Finally, follow-up durations were short, preventing conclusions on long-term effects.

Despite these promising findings, the strength of evidence remains limited. The small number of included studies and their methodological and clinical heterogeneity reduce the certainty of conclusions regarding the superiority of BFRE. Moreover, the inconsistency in between-group significance across studies indicates that the added value of BFRE is not yet definitively established.

Another limitation might be the PROSPERO registration after initiation of the review process albeit before completion of data extraction and qualitative synthesis. No deviations from the registered protocol were made regarding eligibility criteria, primary outcome, or planned qualitative synthesis.

Accordingly, the interpretation of the present findings should primarily rely on between-group differences rather than within-group improvements, as only the former allows isolation of the specific contribution of BFRE beyond general exercise-related effects.

Future research should prioritize well-designed, adequately powered randomized controlled trials with standardized BFRE protocols specifically targeting trunk musculature in individuals with CNSLBP. Greater consistency in outcome measures, including disability, pain, neuromuscular function, and imaging-based structural outcomes, would facilitate comparison across studies and meta-analytic synthesis. Long-term follow-up is needed to determine the durability of clinical benefits, and systematic assessment of safety outcomes should be incorporated. Additionally, future studies should explore dose–response relationships and identify patient subgroups most likely to benefit from BFRE-based interventions.

Conclusion

Taken together, the findings of this systematic review suggest that BFRE may represent a potential adjunct to exercise-based rehabilitation in individuals with chronic non-specific low back pain, with possible benefits in terms of disability and pain reduction.

However, the current evidence remains preliminary and should be interpreted with caution due to the small number of included randomized controlled trials, their limited sample sizes, methodological heterogeneity, and the inconsistency of between-group effects. Therefore, no definitive conclusions can be drawn regarding the superiority of BFRE over standard exercise interventions.

Further high-quality, adequately powered RCTs with standardized protocols are required to confirm these findings, establish optimal application parameters, and clarify the clinical role and long-term effectiveness of BFRE in this population.

Footnotes

List of abbreviations

Acknowledgments

None.

ORCID iD

Antonio Ammendolia

Ethical approval

Not applicable due to the study design.

Informed consent

Not applicable due to the study design.

Author contribution

Conceptualization, AdS; methodology, AdS, NM, AA; validation, EP, AD, AA; formal analysis, EP, AA, GMG; investigation, EP, AA, GMG data curation, EP, NM, AdS; writing—original draft preparation, AdS, EP, AD, AA; writing—review and editing, GR, NM, AA; visualization, AP, GMG, PEF; supervision, AdS. All authors have read and agreed to the published version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

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